Midterm Flashcards
Role of report
Record findings
Documentation in med-legal circumstances
Provide a permanent record in case films lost or damaged
Provide communication with other health care professionals
Assist with indications, contra-indications, and prognosis for care
The global fee consists of
A technical component and a professional component
The technical fee is approximately
2/3 of the global fee
The professional comoponent is approximately
1/3 of the global fee
Time spent marking films and/or discussing the patient’s findings ___ part of the global fee
IS NOT
Technical component
Represents the production of the radiograph
The technical component includes
Equipment costs, time to position the patient, and time to create the image
The professional component is a full written typed reports
In the ABCS format as will be presented in this class
Check list type sheets ____ constitute a written report to satisfy the professional component
DO NOT
When using the global fee, there is a legal obligation to
Have a written report - otherwise, constitutes fraud
Failure to report an imaging study is analogous to
Performing a physical exam but not recording the findings
In order to meet requirement GA law states
You must make an appropriate diagnosis or at least a differential diagnosis
You are responsible for evaluating
The area of chief complaint
Local defense - NOT THE CASE
The idea that you will only be held to teh same standard as another DC in your locale
An action brought by the patient or when deceased the family against the practitioner for a crime of omission or comission - may result in punitive damages
Covered by malpractice insurance
MALPRACTICE
Any complaint to the board must be investigated
May or may not also have a malpractice claim
Often board complaints are not covered by malpractice insurance
Adverse decisions lead to licensure penalties to include revocation of the license
Board action
Responsibilities/liabilities when using an outside source
No opinion
Second opinion
Share the professional component
Things that alter liability even if films are sent out for review
Bad quality
Lack of opposing views
Failure to follow through on radiologist’s recommendations
Reasons to get a second opinion on x-ray
Red flags Complicated history or exam Failure to respond to care as expected Unexplained deterioration of the condition Confirming the DC’s interpretation Medicolegal support
Red flag indicators are often associated with
Significant underlying disease
Complicated history or exam
When patient aren’t like everybody else
Failure to respond to care as expected may point to
Misdiagnosis, or overlooked subtle finding
May lead to a decision on the next best step and the second opinion provider can assist even if not part of the report
Unexplained deterioration of the condition
Worsening of symptoms especially with care is often associated with significant underlying condiitons
Confirming the DC’s interpretation
When you have come to a diagnosis that isn’t an everyday finding a second opinion to confirm the interpretation is warranted
Medicolegal support
In personal injury and worker’s compensation cases confirmation of findings is vital to teh outcome of the case
Digital transmission to send films out for review
Direct software to software connection
Transferring through the receiver’s VPN
Taking a digital photo and sending as an email
Is not really legal on both ends
Snail mail sending films
Purchase mailing envelopes thorugh film suppliers
Pertinent clinical information
Recent trauma (when, where, etc)
Significant past history (tumor, metabolic disease, etc)
Exam findings that aren’t like everybody else
You have a quesiton area on the film
Identify the finding with an arrow, circle, etc
Or write a brief note noting your exact question like on the lateral film what is the transverse lucency through the posterior inferior body of L4
Comopnents of the radiology report
Biographical information History Body of report Conclusions/impressions Recommendations Signature
Biographical information
Patient name Patient age Patient number Date of exam Views taken
History
Optional
Helpful when clinically significant
Should be brief (inversion injury with pain at the base of the 5th metatarsal)
Body of report
Meat of the report Descriptions, NOT conclusions Precise descriptions Brief but complete Complete grammatically correct sentences
Body of report parts
A - alignment
B - bone density
C - cartilage
S - soft tissue
Alignment
Not listings
Pelvic inferiority, left or right curves, anterolisthesis, retrolisthesis, basilar invagination, dislocations/separations, valgus/varus, etc
Be specific
Bone density
Hardest part
Cartilage
Changes around joint space
Changes to joint space
Anterior osteophytes are noted at C5/C6
Cartilage
Moderate disc narrowing is noted at C5/6
Cartilage
Anterior soft tissue markings are within normal limits
Soft tissues
Brief
Phrases when possible
(Degenerative disc disease C5/6)
Conclusions (impressions)
Some radiologists combine with conclusions
Clearly identify what and why
Recommendations
A universal compression fracture is noted at L3. Continued assessment with MRI or a combination of bone scan and lab work is necessary to differentiate osteoporosis, metastasis or multiple myeloma as the cause
Recommendations
Definitions for guidelines
Acute
Subacute
Chronic
1-4 weeks
5-12 weeks
Greater than 12 weeks
Adult patient acute neck injury x-rays indicated when any are present
Over 65 Paraesthesias in extremities Not a simple rear end collision Immediate cervical pain onset Presence of midline cervical tenderness Patient unable to actively turn head to 45 degrees in both directions
Acute neck injury x-rays NOT indicated when ALL of these are fulfilled
Simple rear end collision
Delayed cervical pain onset
Absence of midline cervical tenderness
X-rays ___ indicated in acute uncomplicated neck pain
ARE NOT
Uncomplicated means
Nontraumatic without underlying neurological findings or red flags
Acute neck pain is generally not due to
Conditions that can be seen on x-ray
X-rays are indicated in acute uncomplicated neck pain in certain circumstances
If prior to seeing you the patient has had treatment with no success take x-rays
Consider x-ray or other tests in the absence of expected response to your care or if there is worsening of symptoms
BE SURE TO RECOGNIZE RECURRENT PAIN VERSUS ACUTE PAIN
X-rays ____ indicated in nontraumatic neck pain AND arm pain or paraesthesia
ARE
X-rays ___ indicated in uncomplicated subacute and chronic neck pain with or without radicular symptoms
ARE
4 weeks or longer
X-rays ___ indicated with complicated (red flags) neck pain
ARE
Patient less than 20 and over 50, particularly with S and S suggesting systemic disease
x-rays YES
Significant activity restriction greater than 4 weeks
YES x-rays
No resaponse to care after 4 weeks
X-rays YES
Intractable pain, constant or progressive S&S
X-rays YES
Neck rigidity in the sagittal plane in the absence of trauma
X-rays YES
Intractable pain - doesn’t go away, no position to releave the pain. Consistent or progressive signs and symptoms - hurts all the time no matter what
X-rays YES
2 things create dysphagia
OA and a tumor
Dysphagia
YES
Impaired consciousness
YES
Cranial n signs, pathological reflexes, long tract signs
YES
High risk lig laxity populations/suspected atlantoaxial instability
YES
Arm or leg pain with movement
YES
Cancer phobia
YES
Suspected neoplasm
YES
Suspected infection
YES
Suspected failed surgical fusion
YES
Progressive painful or structural deformity
YES
Elevated lab exam and positive S&S
YES
X-rays ____ indicated with recent (<2 weeks) acute T, L, or T/L trauma with ANY of these
ARE
Moderate to severe localized back pain
YES
Midline tenderness on palpation
Yes
Neurological deficits
Yes
MVA >50 mph
YES
Fall of 10 ft or more
YES
X-rays ARE NOT indicated with recent (<2 weeks) acute T, L, or T/L trauma with
Absence of pain
Normal ROM
Absence of neurological deficits
X-rays ____ indicated in acute patients with uncomplicated LBP, T pain
ARE NOT
Uncomplicated means
Nontraumatic
No neurological deficits
No red flags
X-rays ____ initially indicated with subacute or chronic LBP, T pain AND no previous treatment trial
ARE NOT
When no prior treatment has been attempted, a trial period of 4-6 weeks is suggested
Prior to radiographs
X-rays are indicated in the absence of expected treatment response or worsening after
4-6 weeks
X-rays ___ initally indicated with nontraumatic acute LBP AND sciatic (suspicion of disc herniation
ARE NOT
X-rays are not initially indicated with nontraumatic acute LBP and sciatic (suspicion of disc herniation) unless
Patient is >50 Or has progressive neurological deficits Or has unexpected response to care after 4-6 weeks Or worsens with care MRI would be of value
Signs of disc herniation - need 3 of 5 (consistent to same N level)
Primarily leg pain
Leg pain confined to dermatome
Neural stretch tests recreate or exacerbate the leg pain
At least 2/4 neurologic findings consistent with dermatome - muscle weakness, decreased reflex, abnormal pinwheel, atrophy
MR or CT correlating to dermatome
X-rays ____ indicated with suspected degenerative spondylolisthesis/lateral recess stenosis
ARE
Signs of degenerative spondylolisthesis in lumbar spine
Primarily scleratogenous leg pain (one or both legs)
Comes and goes
Often reduced by leanign forward or sitting down
No neurologic findings
Very common
4 F’s: fat, female, forty, L4
X-rays ____ indicated in complicated (red flag) thoracic and lumbar pain
ARE
S&S of systemic disease especially <20 or >50
Yes
Absence of expected treatment results or worsening avter 4-6 weeks
Yes
Significant activity restriction > 4 weeks
Yes
Unrelenting pain at rest
Yes
Constant or progressive S&S
Yes
Suspected inflammatory spondyloarthropathy
Yes
Suspected compression fracture
Yes
Suspected neoplasm
Yes
Suspected infection
Yes
Suspected failed surgical fusion
Yes
Progressive or painful structural deformity
Yes
Elevated lab and positive S&S
Yes
Criteria for inflammatory back pain
Morning stiffness for > 30 min
Improvement of back pain with exercise but not resat
Awakening in the second half of the night due to back pain
Alternating buttock pain
Signs of suspected neoplasm
Considerable LBP >50 Hx of CA Unexplained weight loss Failure of conservative care Intractable pain ESR >50mm/hr Systemically unwell Lymphadenopathy
Special circumstances for x-ray
Pt unable to give a reliable Hx
Crippling cancer phobia
Need for immediate decision about career or athletic future or legal evaluation
Hx of significant radiographic abnormalities elsewhere
Hx of finding from outside study (abdomen, etc) that requires spine evaluation
X-rays ___ indicated with non painful non progressive adult scoliosis
ARE NOT
In a skeletally mature patient, scoliosis is
> 10 degrees
