amser.doc

NMSCR 4/9/2023

AMSER

National Medical Student Curriculum in Radiology

Edited by:Kitt Shaffer M.D.

Petra Lewis M.D.

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Table of ContentsTable of Contents_______________________________________________________________________________________2

Key Concepts__________________________________________________________________________________________3

Curricular Framework___________________________________________________________________________________4

1. Core radiology topics________________________________________________________________________________4

2. Detailed organ-based curriculae_______________________________________________________________________4

3. Curriculum resources_______________________________________________________________________________5

4. Diagnostic short-list_________________________________________________________________________________5

Core Topics____________________________________________________________________________________________6

1. Physics concepts important to the clinician______________________________________________________________6

2. Orientation to radiology department (specific to individual programs)_________________________________________7

3. Use of PACS system (specific to individual programs)______________________________________________________7

4. Radiation safety and risks____________________________________________________________________________7

5. Imaging in pregnancy and breast feeding________________________________________________________________8

6. Other ‘risks’ of radiology_____________________________________________________________________________9

7. Financial costs____________________________________________________________________________________10

Chest Imaging________________________________________________________________________________________11

Abdominal Imaging____________________________________________________________________________________16

Musculoskeletal Radiology______________________________________________________________________________19

Interventional Radiology________________________________________________________________________________23

Emergency Radiology__________________________________________________________________________________26

Women’s Imaging_____________________________________________________________________________________30

Neuroimaging_________________________________________________________________________________________35

Nuclear Medicine______________________________________________________________________________________38

Pediatrics____________________________________________________________________________________________41

Curriculum Resources__________________________________________________________________________________44

1. Teaching Methods_________________________________________________________________________________44

2. Websites_________________________________________________________________________________________46

3. CDROM based programs____________________________________________________________________________48

4. Textbooks________________________________________________________________________________________48

Diagnostic Shortlist : The “Must See” Images________________________________________________________________49

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Key Concepts

This document is not intended to serve as a definitive list of all material that should be included in every radiology clerkship. Because of the wide range of variation between schools in the way radiology is taught, each individual school will likely have unique needs in terms of material to be covered. This document was written to be as inclusive as possible, and should serve as a starting point for a clerkship director looking for opportunities of expanding their course. The material listed in each area is more than could realistically be covered in a single month or less. It is hoped that most of the core or essential material in each section will be covered at some point in the four years of medical school, but not necessarily during a dedicated radiology clerkship. In particular, the section on core topics and curricular resources is intended to expand the horizons of educators and to offer new methods or sources of information that they may want to add to existing clerkships. This document is thus intended as an overarching compendium of possible topics and resources from which educators can pick and choose those portions that best suit their needs.

Aim: These could be used as guidelines for those programs that wish to develop their own curriculum.

Outline: Philosophy behind a student rather than resident based curriculum in Radiology.

These students will be our clinical colleagues. What do we want the internist utilizing radiology for the care or his or her patients to know about the practice of radiology and how can we teach it in the time we have available?

General concepts about the medical student curriculum in radiology (all areas):

This should not be a “watered down” radiology resident curriculum. It should be a realistic curriculum – most students spend no more than 4 weeks in radiology. It should include radiological topics that will be covered while on clinical services as well as on dedicated

radiology rotations. It should aim at those skills that are required by students entering general medicine or surgery rather than

students entering radiology. It should be flexible enough to be incorporated into a variety of different program formats It should identify for students critical areas to focus on during their rotations

It should include the following general areas: Exposure to the scope of radiology Imaging management skills – appropriate image ordering – cost effective, evidence based medicine,

tailoring studies to patient and case specifics Management of negative or equivocal imaging Concepts of positive and negative predictive values of imaging methods Knowledge of how procedures and imaging are performed (i.e. see imaging performed not just images) Image interpretation: Should focus on plain films and to lesser extent CT

Should focus on emergency radiology and common conditions Use of PACS Utility of image guided procedures Access to radiology ordering and reporting systems The risks of medical imaging (e.g. radiation induced cancer, incidental findings requiring additional

evaluation) Clinician-radiology interactions

ConsultationsImportance of providing clinical information

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Curricular Framework

1. Core radiology topics

Aim: This curriculum covers topics common to several imaging modalities and organ systems to avoid repetition. Topics could be covered separately or integrated into specialist areas.

Outline: Physics concepts important to clinicians Densities, silhouette signsTerminology used in radiologyKey modality comparisons, advantages and limitations (modality and patient specific)Use of contrast media, types, advantages

Orientation to radiology department Ordering urgent/routine studiesGetting wet readings, accessing reports

Use of PACS system Radiation safety

Risks associated with radiation exposureCXR equivalents of common examinationsPediatric exposure

Imaging in pregnancyOther complications of radiology

Contrast media (complications, high risk groups, prophylaxis)Interventional proceduresMRISocietal and emotional impact

Comparative modality costs

2. Detailed organ-based curriculae

Aim: To provide more details of the topics that ideally should be covered during a 4-week elective, or incorporated into a integrated radiology curriculum. These utilize a common structured format and will be outlines rather than text-book replacements. These also contain suggestions for students who may be undertaking a speciality-dedicated radiology elective.

Outline: Curriculae developed:

ChestMusculoskeletalNeuroimagingPediatricsWoman’s imagingAbdominalNuclear MedicineEmergency RadiologyInterventional Radiology

Curricular topics:

Technical aspectsTechniques used to image this anatomical/physiological area

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Patient preparation and educationStudies that should be visualized during elective

Normal anatomyStructures that should be identified on common modalitiesEmphasis on cross-modality correlation

Pathological conditionsCommon pathological conditions/findings that the student should recognizeIatrogenic pathology Emergency “don’t miss” findings Diagnostic situations/conditions that do NOT require imaging

Invasive proceduresIdentify clinical scenarios where image-guided procedures are beneficial

Imaging algorithms (appropriateness criteria)Appropriate imaging management algorithms for common diagnostic situationsCost-effective imagingIncorporating pre-test probabilities

3. Curriculum resources

Aim: To provide guidance on how the curriculum may be incorporated into various program formats, with suggestions for teaching methods and educational resources.

Outline: Teaching methods:

Group based conferencesStudent presentationsOne-on-one teachingInformal quizzesFormal examsGamesSelf-learning exercisesPractical experience

WebsitesCasefilesTutorialsGeneral information and portals

CDROM based programsTextbooks

4. Diagnostic short-list

Aim: To provide a limited list of diagnoses that all students must be able to recognize. This should be covered during the radiology course, but could be used as a basis for a quiz, game or other format.

Outline: 30-40 common diagnoses with an emphasis on ‘don’t miss’ or emergency findings covering all organ systems. Mostly plain films, some CT.. These images could be collated by AMSER as a shared resource.

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Core Topics

1. Physics concepts important to the clinician

1.1. What produces density differences on radiographs

1.2. Terminology used in radiology (reports)

Plain films/fluoroscopy:Lucency, opacity, interstitial, reticular, linear, nodule, mass, atelectasis, alveolar (incorrect terms inc. lung field, infiltrate)CT:Attenuation, enhancement, density, Hounsfield unitsUltrasound:Hyper and hypoechoic, attenuationMRI:Increased and decreased signalNuclear medicine

Hot spots, cold spots, radiotracer, radioisotope

1.3. Silhouette signs on CXR/KUB

1.4. Key modality differences

Anatomical resolution versus soft tissue contrast

Fluoroscopy: Concept of dynamic imaging with Xrays and contrast

CT : Concept of tomography, high resolution, fast, best anatomic resolution, CTA, CT fluoroscopy, multiplanar through reconstruction

Ultrasound: Concepts of sound reflection as imaging agent, portable scanner, multiplanar

MRI: Concepts of magnetic resonance, multiplanar imaging, best soft tissue resolution, limited access to patient in scanner, details of physics beyond student level

Nuclear medicine: Concept of anatomical versus physiological imaging, internal administration of radioisotopes

1.5. Limitations of modalities Obese patients (weight limits, ultrasound)Acoustic windows in ultrasound (lung, bowel gas)Claustrophobia (MRI>CT and PET)Immobile/elderly/sick patients (MRI, fluoro)CT and MRI may require sedation esp. in children

1.6. Contrast media Types of contrast media

Intracavitary:Bowel

RationaleTypes (barium, water soluble, gastrograffin)

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Double contrast versus single contrastUse of water soluble agents versus barium GI studiesBenefits of oral contrast on CTTube placement/sinus studies

IntrathecalIndications (myelography, CSF leak studies)Low osmolar

IntraarticularIndicationsMR/CT

IV:Iodine based (non-ionics, ionic agents)Gadolinium(Other MR agents)Uses:

Improving soft tissue contrastSolid organsVascular structuresInflammationRenal collecting systemsBladder

I

2. Orientation to radiology department (specific to individual programs)

2.1. Ordering urgent/routine studies Institutional methods of ordering routine studiesInstitutional methods of ordering urgent studiesImportance of clinical information (protocoling, interpretation, billing)Request legibilityContact information

2.2. Getting wet readings Office hours/on call

2.3. Accessing reports Dictation system/writtenPreliminary versus final reports

3. Use of PACS system (specific to individual programs)

Accessing imagesManipulating imagesDownloading images for presentationsImportance of reading reportsConfidentiality/legal issues

4. Radiation safety and risks

4.1. Risks associated with radiation exposure Hematological malignanciesSolid organ malignancies

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Local skin effectsTeratogenetic effectsALARA principle

4.2. CXR equivalents of common examinations (or use period natural exposure) Lumbar spine films 20KUB 75VQ scan 80Bone scan 180Myocardial perfusion250Chest CT 400 (approx. 20 yrs of 2 view mammograms)Abdo/Pelvic CT 750

4.3. Methods to reduce radiation exposure Reduction in unnecessary examinations (e.g. daily ICU films)Dose reduction (CT)Exposure time reduction (fluoroscopy)Use of US and MRI

4.4. Age dependance of radiation sensitivity Cancer incidence with age exposure Importance of reducing pediatric radiation exposure

5. Imaging in pregnancy and breast feeding

No proven risk to fetus of ultrasoundNo proven risk to fetus of MRI, but avoid in first trimester if possibleImportance of performing examinations if medically necessaryImportance of re-evaluating “set protocols” e.g. trauma protocols in a pregnant patientDose reductionShieldingTc99m tracers safe in pregnancy, other tracers avoidedShielding unhelpful in nuclear medicine, hydration and bladder emptyingBreast feeding withheld for at least 4 half-lives of tracerUse of intravenous iodine based contrast agents not contraindicated when required for diagnosis of maternal condition. After the 1st trimester, gadolinium occassionally used for strong indications (e.g ovarian tumors)

5.1. Preferred studies (limitations):

Dysnea – CXR (shielded)Fetal scanning – ultrasound, MRI for evaluation complex fetal anomaliesRenal stones – ultrasound. Limited by physiological hydro. Low dose spiral CT may be used if indicated within fetal dose guidelines Trauma - MRI or ultrasound for first choice, but CT if needed.Suspected appendicitis: ultrasound, but maybe limited by fetal position/maternal size, low dose spiral CT, (laparoscopy may be study of choice in high suspicion case)Suspected PE – CXR then perfusion scan +/- ventilation scan if abnormal

5.2. Studies that should be performed if absolutely necessary with shielding if possible

KUB Limited IVPCT, but limited dose

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5.3. Contraindicated studies (except in very rare life threatening cases)

AngiographyCT pelvis (except rare cases)GI Fluoroscopy (except in very rare cases)131I therapeutic or diagnostic dose201Tl scans67Ga111In white cell and other scans

6. Other ‘risks’ of radiology

6.1. Contrast media Complications

Local pain and vomitingExtravasations with tissue necrosisAllergic reactions

Incidence (minor 3+%, severe <0.5%, fatal 1:150,000)Renal failureAspiration (barium vs ionic vs non-ionic)Low risk of intra-luminal contrast

High risk groupsAllergy (asthma, previous reaction, not shellfish or iodine allergy)Renal failure Age > 65Diabetic (hydrate, consider avoiding if >1.6)) Increased creatinine (>1.6 hydrate if necessary, >2.0 contraindicated)Myeloma (contraindicated in the presence of proteinuria)Metformin therapy (withhold 2 days after contrast)

Methods to reduce/manage contrast complicationsLow osmolar contrast media (cost implications)Gadolium MRISteroid and antihistamine protocolsPre and post hydrationN-acetyl cysteineCO2 angiography

6.2. Risks of percutaneous biopsies and drainage procedures

Bleeding, infection, organ damage, pneumothorax

6.3. Claustrophobia

MRI>CT>nucs or fluoro

6.4. Complications specific to fluoroscopy

Bowel perforationBarium impactionBarium mediastinitis and peritonitisAspiration of contrast media (barium vs. ionic vs. non-ionic contrast media

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6.5. Complications specific to nuclear medicine

Allergic reactions extremely rare except antibody studiesPersantine/adenosine reactions

6.6. Complications specific to MRI

Ferromagnetic displacement (eye debris, aneurysm clips, objects)Electrical interference (pacemakers, defibrillators, neuro-stimulators)Artifacts from metallic prostheses and debris

6.7. Complications specific to pulmonary angiography

Risk of pulmonary angiography I(R) (approx. 0.2% fatal, 2% serious adverse events)Contraindications: severe pulmonary htn, recent MI, LBBB, contrast allergy

6.8. False positive and negative studies

Additional physical and financial risks of further imaging or biopsyEmotional risks (e.g. screening mammography)Risks of non-treatment in false negative cases

7. Financial costs

Patient and societyComparative charges for common examinations at student’s institution Example:

Examination $ charged as multiples of X (global fee)

CXR 1Abdominal series 2CT chest with contrast 10Chest, abdomen, pelvic CT 17CT abdomen with contrast 9MRI abdomen with contrast 12MRI of lumbar spine, no contrast 12Abdominal US 4UGI series with SBFT 4IVP 4Barium enema 3Colonoscopy 16Bone scan 5PET scan 16VQ scan 6

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Chest Imaging

Items that are grayed may be considered too comprehensive for a general radiology elective but are suggested for students who are taking specialized imaging electives.

1. Technical aspects

1.1. Techniques used to image this anatomical/physiological area

CXR: PA, lat, AP, decubitus views, lordotic view, expiratory view, supine (limitations)

CT: When contrast helps, definition and use of: high resolution CT, CT pulmonary and aortic angiography

MRI: Pulmonary angiographyNuclear medicine:

(FDG lung cancer) – covered under nucs curriculumVQ scans- covered under nucs curriculum

1.2. Patient preparation and education

Fasting 6hr for PET FDG scanNeed to hold breath for CT, respiratory gating MR

1.3. Studies that ideally should be watched during elective period or clinical rotations

PA and lateral CXRPortable CXRChest CTChest tube insertion and/or thoracocentesis

2. Normal anatomy

2.1. Structures that should be identified on each modality (Emphasis on cross-modality correlation)

CXR (PA and lateral) and CT Lungs:

RUL, RLL, RML, LLL, LULCostophrenic and cardiophrenic anglesMinor and major fissuresTrachea and carinaRight and left main bronchiRetrosternal clear space

Heart:RV, RA, LV, LAAorta, pulmonary outflow trackPericardiumPulmonary veinsPosition of heart valves

Mediastinum:SVCCarotid and subclavian vessels

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Aortic knob, AP windowRight paratracheal lineAzygous veinCarinaRight and left main pulmonary arteriesAzygo-esophageal lineRight paraspinal lineLeft paraaortic line

Bone and soft tissuesShoulders, C spine, thoracic spineScapulaeClaviclesSternumDiaphragmsLiverStomachColon

Common normal variantsAzygous lobeCervical ribsMediastinal lipomatosisPericardial fat pads

Pulmonary angiogram (CT and conventional) and MRI

Right and left main pulmonary arteriesAscending and descending aortaTake off of great vessels

3. Pathological conditions

The student should be taught a system (chosen by the tutor) of surveying every CXR for abnormalities to ensure that they do not ‘gestalt’ films.

3.1. Common pathological conditions/findings that the student should recognize or at least see examples of:

Atelectasis:LinearLobar: LLL, LUL, RLL, RML, RULIndirect signs (mediastinal, hilar, diaphragmatic and fissure shift)Total lung atelectasis

Pneumonia:Appearance of and DDX of consolidation (fluid, blood, malignancy, pus)Silhouette and spine signsAir bronchogramsLobar patterns: LLL, LUL, RLL, RML, RULViral/atypical patterns: mycoplasma, PCP

Vascular abnormalitiesRecognition and differential of dilated aortaAppearance of great vessel ectasiaThoracic aortic aneurysmRuptured aortaAortic dissection

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Pulmonary hypertensionPE (CXR, CT)

Pleural abnormalitiesPleural effusion (small, large, subpulmonic, decub films, supine and upright)Pneumothorax (small, large, supine and upright, decub and expiratory films, tension)PneumomediastinumPleural thickening and calcifications (asbestos exposure)Pseudotumor Empyema

Cardiac abnormalitiesCardiomegaly (individual chamber enlargement, generalized cardiomegaly)Cardiac failure (pulmonary venous hypertension, interstitial edema, alveolar edema)Aortic and mitral valve and annulus calcifications

Masses‘Danger zones’ for missing tumorsNon-small cell lung cancer (hilar mass, parenchymal tumor)Anterior mediastinal mass (Hodgkins, goiter, thymoma etc)Cavitating massGoitreGranulomaDistinguishing which mediastinal compartment masses are in

AdenopathyLymphomaSarcoidosis

Interstitial abnormalitiesInterstitial edemaEmphysemaExtensive fibrosis (honeycombing, cystic fibrosis)

OtherDistinguishing causes of hemithorax opacification (effusion, vs atelectasis vs pneumonia vs pneumonectomy).Meaning of ‘ground glass opacity’ on CXR/CT

3.2. Iatrogenic pathology Malplaced Dobhoff/NG (eg. esophagus, trachea, bronchus)Malplaced central venous catheters (jugular, subclavian, right atrium)Malplaced endotracheal tube (too high, low, esophageal)Other misplaced wires, catheters

3.3. Emergency “don’t miss” findings (CXR)

Tension pneumothoraxSupine pneumothorax (deep sulcus sign)LUL collapsePulmonary edema (interstitial and alveolar)Sub-diaphragmatic airPneumomediastinumSigns of aortic dissection Aortic rupture (supine CXR, CT)Dobhoff in trachea/bronchus

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3.4. Diagnostic situations/conditions that do NOT require imaging

Suspected rib fractures (unless complications then PA/Lat CXR, not rib films)Pre-op CXR in assymptomatic individuals

4. Invasive procedures

4.1. Identify clinical scenarios where image-guided procedures are beneficial

Pigtail chest tubes (when are they appropriate) for effusions and pneumothoraxThoracocentesis (when is image guidance not needed), ultrasound, CT, FluoroLung biopsy (CT, fluoro). Risk of pneumothoraxLung abscess (when percutaneous drainage is required)

5. Imaging algorithms (appropriateness criteria)

5.1. Appropriate imaging management algorithms for common diagnostic situations

Screening for metastases (CXR vs CT)Staging for lung cancer (CXR vs CT vs PET)Appropriate imaging for suspected pulmonary embolus (CT pulmonary angiography vs VQ vs angio vs leg venous doppler)Appropriate imaging in trauma (when to do C/A/P CT scan)Appropriate imaging for suspected aortic trauma (when to do CT angiogram, alternatives)Appropriate imaging for suspected aortic dissection (CT vs MRI vs TEE)Appropriate imaging for suspected small pneumothorax (use of expiratory/decubitus views)Appropriate imaging for suspected foreign body aspiration (kids, decub, expiratory views, fluoro)Appropriate imaging for SPN seen on CXR (old films, follow up, CT, PET, biopsy)Appropriate imaging for pneumonia (importance of follow up films, when to consider neoplasm workup)Appropriate imaging for pneumomediastinum (when is additional imaging required)Appropriate imaging for dysnea in non-immunocomprised patientAppropriate imaging for dysnea in immunocompromised patient (CXR vs CT)Appropriate imaging for suspected interstitial lung disease (CXR vs regular CT vs high res CT) Appropriate imaging for total hemithorax opacification (not decubs)

5.2. Cost-effective imaging

Value of obtaining older studiesCXR vs CT for metastatic evaluationCXR vs CT for lung cancer follow upDaily ICU film indicationsLung cancer screening controversiesPET for lung cancer diagnosis and staging

5.3. Incorporating imaging findings into patient management

Effects of pre-test probabilities Management of the low or intermediate probability VQ scan in high suspicion patientManagement of the negative CT pulmonary angiogram in the high suspicion patient, problems with limited quality studiesManagement of the benign appearing SPN in low risk patientManagement of the benign appearing SPN in high risk patient

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Management of the normal supine CXR in high risk trauma patient

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Abdominal Imaging



1.1. Techniques used to image this anatomical/physiological area KUB – upright, supine, use of decubitus viewsBarium swallow (and modified) Upper GISmall bowel follow throughDouble and single contrast enemasWater soluble enemaIVPCystogram/VCUGRUQ ultrasound“Abdominal” ultrasoundPelvic ultrasoundCT abdomen and pelvisHepatobiliary study (see nucs section)Renal scintigraphy (see nucs section)MRI abdomen and pelvis

1.2. Patient preparation and education Bowel preparation for enemas (elderly patient risks)Oral contrast for CT (diabetic contrast)Hydration following barium studiesHydration pre and post IV contrastRationale for bladder filling for pelvic ultrasoundUse of transvaginal/rectal ultrasoundClaustrophobia (MR>CT)

1.3. Studies that should be watched during elective period UGIBarium enemaCT scanRUQ ultrasoundPelvic ultrasoundVCUG

2. Normal anatomy

2.1. Structures that should be identified on each modality (where visible) with emphasis on cross- modality correlation especially CT-Ultrasound-Fluoro-KUB

EsophagusStomachDuodenumSmall bowelColonLiverGallbladderSpleen

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PancreasAortaIVCKidneysUretersBladderUterusOvaries



KUB:Free air (see below)Small bowel obstructionColonic obstructionCecal and sigmoid volvulusIlleusRenal and ureteric calculiGallstonesCalcified aortic aneurysmBenign calcifications (phleboliths, vascular etc)

Fluoroscopic studies:Malignant colonic stricture (obvious)Hiatal herniaEsophageal tumor (obvious)Gastric ulcer

Ultrasound:HydronephrosisBiliary obstructionGallstonesAcute cholecystitis

CT:Liver metastasesAAA (with and without rupture)HydronephrosisTraumatic liver and splenic rupturesAscites

3.2. Emergency “don’t miss” findings

Free air – upright chest, supine, decubitus and upright KUB, CTSBO Cecal and sigmoid volvulusFree fluid on CT

3.3. Diagnostic situations/conditions unlikely to benefit from imaging Ultrasound unhelpful for non-localizable abdominal painRenal failure in the setting of ICU patient (R/O hydronephrosis)

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Advantages and disadvantages of CT vs US guided proceduresHydronephrosisAbscess drainageWhen US required for paracentesisLiver and renal biopsiesBiliary obstruction (ERCP guided stenting vs percutaneous)TIPS proceduresAAA endovascular graftsRenal stents

5. Imaging management (appropriateness criteria)

5.1. Appropriate imaging algorithms for common diagnostic situations including cost-effective imagingWhen to order the barium swallow versus upper GIWhen to order the small bowel follow throughDouble versus single contrast enemas – discuss with radiologistAppropriate imaging for suspected renal calculi (KUB vs IVP vs non-contrast CT)Appropriate imaging for painless hematuriaAppropriate imaging for suspected acute cholecystitis (US vs CT vs hepatobiliary study)Staging for malignant disease (CT vs MRI)Appropriate imaging for acute pancreatitis (US vs CT, unhelpful in early disease)Appropriate imaging for suspected appendicitis in adults/children (ultrasound vs CT vs KUB)Appropriate imaging for rectal bleeding (acute vs chronic, barium enema vs colonoscopy)Appropriate imaging for upper GI bleeding (acute vs chronic, UGI vs endoscopy)Appropriate imaging for female pelvic pain (pregnant versus non-pregnant)Appropriate imaging for suspected ruptured AAAAppropriate imaging for SBOAppropriate imaging for colonic obstruction/illeus Appropriate imaging for suspected diverticulitisAppropriate imaging for jaundiceAppropriate imaging for renal failure

5.2. Incorporating imaging findings into patient management including impact of pre-test probabilities Management of the image negative, high pretest probability suspected acute cholecystitis patient Management of the image negative patient with suspected ectopic pregnancy

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Musculoskeletal Radiology




Plain filmsImportance of different projections, fractures may be occult if not displaced, difficulties in complex bones, importance of focused study, important views including scaphoid view, radial head view)

CTGood for bone detail, calcificationsUse of intravenous and intra-articular contrast

MRGood for soft tissues, marrow, ligaments, multiple plains, marrow edema for occult fracturesUse of intravenous and intra-articular contrast

FluoroscopyGuidance for biopsy, analysis of motion

UltrasoundSuperficial tendons, ligaments, foreign bodies, superficial infections, joint effusions

DEXA for bone mineral density


No driving after shoulder arthrogramPost-procedure pain managementImportance of holding still during CT/MR

1.3. Studies that should be watched during elective period or clinical rotations

Extremity plain filmArthrogramShoulder/hip/knee MRTrauma seriesFluoroscopy for assessment of stability/motion

2. Normal anatomy


Identification of major parts of : Humerus, radius, ulna, carpal bones, metacarpals and phalanges, femur, fibula, tibia, tarsal bones, calcaneus, metatarsals, vertebrae, ribs, pelvis, clavicles and scapulae.

Structure of long bones: Diaphysis, metaphysis, epiphysis

Common normal variants:

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Cervical ribs, extra lumbar vertebra, bipartite patellaSoft tissues

Identification of and significance of normal soft-tissue fat interface, fat padsIdentification of major muscle groups felt to be beyond medical student level


3.1. Common pathological conditions/findings that the student should recognize or at least see examples of :

Trauma:Joint effusions

KneeElbow

Appendicular Fractures

Descriptive words for fracture orientation, displacement and angulation Significance of intraarticular displacementSignificance of physeal plate involvementFracture ‘evolution’ on delayed filmsDisuse osteopeniaFemoral neck, intertrocanteric fractureMedial and lateral malleolar fracturesBase of 5th metatarsal fractureLisfranc fracture/dislocationSpinal compression fracturesSpinal burst fractureMetacarpal/phalangeal fractures Scaphoid fracture (importance of scaphoid view)Colles/Smith fractureRadial head (signs elbow effusion)Distal humeral fracture in a child (signs elbow effusion)Humeral head fractureClavicle fractureMetaphyseal corner factures (bucket handle) in child abuseTibial plateau fractureToddler fracture tibia

Common Spinal Fractures

Compression fractures thoracic and lumbar spinesBurst fractures (signs canal narrowing)Importance of identifying cervical lines and soft tissues on lateral filmC1 Jefferson fractureC2 fractures, dens and Hangman’sAnterior subluxation flexion injuryPosterior ligamentous injury (subtle signs of)Spinous process fractureBilateral jumped facets

Dislocations

Anterior shoulder dislocation and Hill Sachs fracturePhalangeal dislocations

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Hip dislocation

Soft tissue injuries

Rotator cuff injuryKnee meniscal injury

Arthritis:

OsteoarthritisInflammatory arthritisSeptic arthritis

Tumors:

Primary osteosarcomaBone metastasis - blastic vs lytic (significance for bone scan)Myeloma

Metabolic bone disease:

Osteoporosis

Infections:OsteomyelitisCellulitis


Septic jointFracture with extension into jointElbow joint effusion, radial head fractureShoulder dislocationAbnormalities of spinal-laminar lines/alignment of the c-spine e.g. posterior ligamentous injury(Child abuse see pediatric section)

3.3. Diagnostic situations/conditions unlikely to benefit from imaging

Ankle sprain


4.1. Identify clinical scenarios where image-guided procedures may be beneficial

Osteopenic vertebral collapse – vertebroplastyBone biopsy for suspected tumorsJoint aspiration for suspected septic jointsArthrography (CT or not) for suspected rotator cuff disease


5.1. Appropriate imaging management algorithms for common diagnostic situations including cost-effective imaging

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Appropriate imaging for chronic back pain in an adult (no imaging vs plain films vs CT vs MR vs myelography)Appropriate imaging for chronic back pain in a child (as above, plus bone scan)Appropriate imaging for acute back pain Use of the ‘trauma series”, indications for further imagingIndications for plain films of the neck in traumaIndications for CT of the neck in traumaIndications for MR of the neck in traumaAppropriate imaging for metastatic disease, plain film correlation with bone scanAppropriate imaging for shoulder pain (plain films vs CT arthrogram vs MR+/- arthrogram vs fluoroscopic arthrography)Appropriate imaging for suspected occult hip fracture (CT vs MRI vs bone scan)Appropriate imaging for the diabetic foot (plain films vs MR vs bone scan vs white cell scan)Appropriate imaging for suspected osteomyelitis in non-diabetic (plain films vs MR vs bone scan vs white cell scan)

5.2. Incorporating imaging findings into patient management including effects of pre-test probabilities

Management of the high suspicion hip fracture with negative plain filmsManagement of patients with low suspicion c-spine injuries and normal plain films (esp. whiplash injuries)Management of patients with persistant pain following injury, imaging negative (use of delayed films, bone scans, MR)

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Interventional Radiology



1.1. Techniques used in IR

ImagingFluoroscopy – risks of significant radiation dose, multianglesAngiographyCO2 studies in patients with renal failure

Image guided biopsy techniquesFluoroscopy-real time visualization of structures, radiation dose, (chest, bone biopsies, tube placements)CT (CT fluoro)-better visualization of small internal structures than fluoroscopy, radiation, time consuming, any area, can use stereotactic techniquesMR-limitations due to magnetic field, becoming resolved with new equipmentUS-real time visualization, limited depth, no radiation, limited by gas shadows, (renal, breast, liver, thoraco and paracentesis)

Image guided therapyDrainage tube placements (types)Central venous catheters (types)Stent placements, vascular and non-vascular Angioplasty RadioablationChemoablation


Pre-procedure labs required (coags, platelets, renal function)Peri- and post-procedure pain managementRisks and contraindications of sedative drugs

1.3. Studies that should be watched during elective period or during clinical rotations

Percutaneous biopsyAngiographic studyStent placement/angioplastyCentral venous access line placementPigtail catheter placement

1.4. Diagnostic situations/conditions unlikely to benefit from image guided procedures

Inaccessible lesionsLimitations due to volume of tissue required (biopsy)Very small lesionsLesions too hazardous to access (e.g. blood vessels)

2. Normal anatomy

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Refer to organ specific curriculae


3.1. Common pathological conditions/findings that the student should recognize or at least see examples of on diagnostic IR studies during radiology or clinical rotations

VascularPeripheral vascular stenosisAAARenal stenosisGI bleed or other site of hemorrhageCerebral aneurysmCarotid stenosis

Non-vascularUreteric/UPJ obstruction


IR is generally not used to make initial imaging diagnoses, but to obtain tissue or treat known conditions. Interpretation beyond the scope of medical student curriculum.



Diagnostic studiesStrokeCerebral hemorrhagePeripheral ischemia Bowel ischemiaVascular aneurysms (traumatic and non-traumatic)

Biopsy proceduresLung tumorsLiver massesPancreatic massOther mediastinal, abdominal and pelvic massesBone tumors

Drainage proceduresAbscesses – lung, abdomen, pelvicThoracocentesis and pleurodesis for pleural effusionsPneumothorax (pigtail, Heimlich valve)Paracentesis for ascitesUreteric obstruction (nephrostomy tube, internal/eternal drainage)Biliary obstruction

Angioplasty, direct intravascular thrombolysis and stent placementsPeripheral ischemia

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NMSCR 4/9/2023

Bowel ischemiaRenal hypertensionVenous stenosis/thrombosis (large central or pulmonary emboli)Biliary stricturesEndovascular AAA repairGreat vessel stenosis

Embolization proceduresCerebral and extracerebral aneurymsPersistent epistaxisPersistent hemoptysisGI hemorrhageCerebral AVMsPost-traumatic hemorrhage – aortic, spleen, liver, pelvic, limbFibroidsVaricocele

Access proceduresChemo/pharmacotherapy:

Central venous access – PICC, Dialysis catheters, subcutaneous portsFeeding

Gastrostomy tubesJejunostomy tubes (reflux rationale)

OthersPortal hypertension – TIPSPulmonary emboli/DVT – IVC filter placementInfertility - fallopian tube catheterizationOstopenic vertebral body collapse - vertebroplasty


5.1. Appropriate imaging management algorithms for common diagnostic/therapeutic situations including cost-effective imaging

Indications for placement of an IVC filter in DVT/PE Management of for small pneumothorax (pigtail vs chest tube)Management of recurrent pleural effusions (taps vs tubes vs pleurodesis)Management of lung mass (surgical vs percutaneous approach for biopsy)Management of inoperable tumors (chemo or RT vs chemoablation vs cryo vs RF)Management of obstructive jaundice (percutaneous vs endoscopic stent)Management of feeding tubes in patients with oropharyngeal tumors (gastrostomy vs jejunostomy vs surgical placement anagement)Management of patient with large embolus/thrombus (intravenous vs direct thrombolysis vs embolectomy)Management of fibroids (surgical vs embolism)Management of persistent epistaxis (surgical vs IR)Management of portal hypertension (surgical vs TIPS vs endoscopic sclerotherapy)Selection of type of venous access (Hickman vs CVL vs portacath vs PICC)Management of dialysis access (central vs peripheral)Management of pancreatic head tumors (percutaneous vs endoscopic biopsies)

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NMSCR 4/9/2023

Emergency Radiology

Note: While any condition may present to the emergency room, this curriculum focuses on those conditions that commonly present to the emergency room physician. Many overlap with the other organ-specific curricular.


1.1. Techniques used to image this anatomical/physiological area Plain films (see core curriculum), include use of portable studies, trauma seriesCT: “trauma study”Ultrasound for intraperitoneal fluid

1.2. Patient preparation and education Short CT preps for traumaEducation about lack of need for imaging in certain conditions

1.3. Studies that ideally should be watched during elective period or during clinical rotations CT chest/abdomen/pelvisCT head/C-spinePlain film trauma seriesLimited abdominal ultrasound for fluid

2. Normal anatomy


1.1.1. Chest: See chest curriculum1.1.2. Abdomen: See Abdominal curriculum1.1.3. Head: See Neuro curriculum1.1.4. Musculoskeletal: See MS curriculum


3.1. Common pathological conditions/findings that the student should recognize or at least see examples of during radiology or clinical rotations:

TraumaMajor organ injury (CT/plain films)

Liver and splenic lacerationsAortic lacerationHemomediastium Diaphragmatic ruptureDuodenal/small bowel lacerationRenal lacerationBladder perforation (indications for cystography)Pneumothorax including signs of tension, supine and uprightHemothoraxRib fractures (significance of upper and lower rib fractures, posterior rib fractures in child abuse)

Common appendicular fractures/dislocations including:Metacarpal/phalangeal fractures Scaphoid fracture (importance of scaphoid view)

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Colles/Smith fractureRadial head (signs elbow effusion)Distal humeral fracture in a child (signs elbow effusion)Humeral head fractureAnterior shoulder dislocation and Hill Sachs fractureClavicle fractureFemoral neck and intertrochanteric fracturesFemoral shaft fractureMetaphyseal corner factures (bucket handle) in child abuseTibial plateau fractureToddler fracture tibia Medial and lateral malleolar fracturesLigamentous disruption of mortise joint ankleBase 5th metatarsal fractureLisfranc fracture/dislocationImportance of intra-articular extensionImportance of physeal plate involvementImportance of displacement and angulation

Common spinal injuries (Plain films and CT)Compression fractures thoracic and lumbar spinesBurst fractures (signs canal narrowing)Importance of identifying cervical lines and soft tissues on lateral filmC1 Jefferson fractureC2 fractures, dens and Hangman’sAnterior subluxation flexion injuryPosterior ligamentous injury (subtle signs of)Spinous process fractureBilateral jumped facets Spinal epidural hematoma (MRI)Cord contusion (MRI)

Neurological injuriesSubdural hematoma Epidural hematomaDiffuse axonal injury (MR)Parenchymal contusion/hemorrhage

Non-traumaticChest

Lobar pneumonia (see chest section)Atypical pneumonias such as mycoplasma, PCPCardiac failure (interstitial and pulmonary edema)Cardiomegaly (chamber enlargement)Aortic dissection (plain film, CT)Pulmonary embolus (plain film signs, CT)Pneumomediastinum

AbdomenAppendicitis (CT)Acute cholecystitis (U/S, hepatobiliary study)Diverticulitis (CT)Ruptured abdominal aortic aneurysm (CT, Ultrasound)Renal calculi (KUB, CT)Intraperitoneal free airSmall bowel obstruction

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Large bowel obstructionTesticular torsion

MusculoskeletalAcute osteomyelitisSeptic arthritis

Neurological Disorders Acute and subacute infarction (CT, MRI)Subarachnoid hemorrhage (CT)

Ob/Gyn DisordersEctopic pregnancy (u/s)Missed/completed abortionOvarian torsionOvarian cyst/cyst rupturePlacental abruption

Pediatric Disorders (specific)Aspirated foreign body in a child (CXR, fluoro)Intersusception (KUB, air vs barium enema)Bowel volvulusBronchiolitisEpiglottitisCroup

3.2. Iatrogenic pathology

Misplaced naso/oral gastric tubesCorrect position of chest tubesCorrect position of endotracheal tubesCorrect position of central linesIatrogenic pneumothorax and pneumomediastinum


Tension pneumothoraxAortic ruptureAortic dissectionDiaphragmatic ruptureChild abuse – posterior rib fractures, metaphyseal corner fractures, bilateral subdurals of different agesCerebral herniation (CT)Small or isodense subdural hematomasTesticular torsionAbnormalities of spinal-laminar lines/alignment of the c-spine e.g. posterior ligamentous injury


Use of CXR rather than rib films in suspected rib fracturesCoccygeal fractures (no imaging)Ankle injuries that do not fulfill Ottawa ankle criteriaAmbulating patients for r/o tibia/fibula fxs

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Ultrasound guided thoracocentesis and paracentesisPigtail catheter placement for pneumothorax

5. Imaging algorithms (appropriateness criteria) and cost effective imaging

5.1. Appropriate imaging algorithms for common diagnostic situations

Criteria for performing CT (C/A/P) in trauma patientCriteria for performing limited ultrasound for abdominal fluid in trauma patientCriteria for performing CT c-spine in neck injuriesIndications for performing CT prior to lumbar punctureCriteria for head CT for headacheAppropriate imaging for suspected acute cholecystitis (U/S vs CT vs hepatobiliary scan)Appropriate imaging for suspected appendicitis (child vs adult)Appropriate imaging for suspected CVA (CT vs MRI)Appropriate imaging for suspected PE (CT vs VQ vs angio)Appropriate imaging for suspected ectopic pregnancy (importance of HCG level)Appropriate imaging for suspected foreign body aspiration in child (fluoro vs exp vs decubitus views)Appropriate imaging for suspected renal stones (CT vs IVP vs ultrasound)Appropriate imaging for suspected aortic dissection (CT vs MRI vs transesophageal echo)Appropriate imaging for suspected occult hip fracture (bone scan vs MRI vs CT)Appropriate imaging for suspected skull and facial fractures (plain films vs CT)Appropriate imaging for suspected epiglottitisAppropriate imaging for suspected DVTAppropriate imaging for suspected ruptured aortic aneurym Appropriate imaging for suspected bladder rupture (CT vs fluoro vs both)Appropriate imaging for suspected pelvic inflammatory diseaseAppropriate imaging for the child with hip pain/limp (plain film vs U/S vs bone scan vs MRI vs CT)Appropriate imaging for the child with suspected child abuse (skeletal survey, bone scan)


Management of suspected ectopic pregnancy when no gestational sac seenManagement of the high suspicion but imaging negative ?PE case

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Women’s Imaging

Items that are grayed may be considered too comprehensive for a general radiology elective but are suggested for students who are taking specialized woman’s imaging electives.



Mammography (analogue, digital)CC and MLO positioningRationale for compressionScreening versus diagnostic mammography Indications for diagnostic mammography

Palpable massCall back from screeningFocal painShort interval follow-up from prior ACR 3 mammogramBloody nipple discharge

UltrasoundBreastTransabdominalTransvaginalHysterosonograms

Hysterosalpingograms MRI

BreastPelvicFetal

Nuclear medicine (sestamibi, PET)


Breast imagingSensitivity and specificity of screening mammography Patient education regarding benefits and risks of screening mammographyIncreasing patient compliance with screening protocolsUnderstanding the screening call-back systemRadiation risk and cumulative exposure from screening mammography

Pelvic/fetal ultrasoundUse of transvaginal probesImportance of bladder filling on for some pelvic scansAppropriate timing of fetal ultrasound scans (dating, morphology)Medical test not family entertainmentSexing of fetuses not always possibleAccuracy of dating +/- 10%Use of tranvaginal ultrasound in early pregnancyImportance of understanding limitations of ultrasound

Sensitivity only about 80-85% in diagnosing anomaliesNormal scan normal babySmall fetuses (early scans)Obese patients

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1.3. Studies that should be watched during elective period or during clinical rotations

Breast imagingScreening mammogramBreast ultrasoundBreast biopsy (stereo and ultrasound)Needle localization

Pelvic/fetal ultrasoundTransvaginal and transabdominal ultrasoundEarly pregnancy (6-10 w) transvaginal scanMorphology (18-20) scan

2. Normal anatomy

2.1. Structures that should be identified on each modality with emphasis on cross-modality correlation

Breast imagingFat versus glandular tissueConcept of marked inter-patient variability

Pelvic/fetal ultrasoundUterusOvariesCervixCul-de-sacEarly fetal scan: yolk sac, gestational sac, fetal poleNormal early OB milestones (gest sac 5w, yolk sac 5.5w, heart beat 6w)Morphology scan: Head, abdomen, chest, limbs, cord, placentaMore detail not felt appropriate at medical student level



Breast imaging Recognition not required at general medical student level.Benign masses (cysts, fibroadenomas)Malignant masses (obvious cancer)Calcifications (benign, malignant)

Pelvic/fetal ultrasoundFibroidsThickened endometriumOvarian cyst/solid massEctopic pregnancy with ‘empty’ uterusKnowledge of the types of major anomalies that can be identified by ultrasound, and those that cannot:

Neuro (hydrocephalus, Chiari malforms, neural tube defects, anencephaly, etc)

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GI (omphalocele, gastroschisis, duodenal atresia)

Chest (thoracic masses, major cardiac anomalies)

MS (dwarfism, osteogenesis imperfecta, club foot)

Placental abnormalies (previa, abruption, molar)

Interpretation of pathological findings on OB ultrasound felt to be not appropriate at medical student level.


Recognition not required at general medical student level

3.3. Diagnostic situations/conditions unlikely to benefit from imaging (other than routine screening mammography if >40 yrs)

Diffuse breast painBilateral breast dischargeExpressible only, non-bloody dischargeLarge areas of breast “thickening” esp. if bilateralWaxing and waning massesUltrasound in the very early pregnancy (<5w or when serum HCG<1000 IU)



BreastRationale for performing core biopsies

Decreased scar/morbidityPre-operative planningReductions in repeat surgical ratesNeedle-wire localizations for non-palpable abnormalitiesIndications for stereotactic or ultrasound guided breast biopsies

Non-palpable masses, asymmetric densities, calcificationsPalpable masses

Pelvic/fetal ultrasoundUse of ultrasound in performing amniocentesis and fetal therapeutic proceduresUse of sonohystographyUse of uterine artery embolizationUse of fallopian tube catheterization


5.1. Appropriate imaging algorithms for common diagnostic situations including cost-effective imaging

Breast ImagingCurrently recommended screening protocols (ACR)Effect of screening mammography on breast cancer mortality ratesMammography screening in 40-50 age group controversies

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Mammography screening in high-risk groupsWhen to stop screeningEvaluation of palpable breast massesEvaluation of palpable masses in young patientsSurgical evaluation of questionable palpable findingsUse of ultrasound for cystic versus solid lesions

Pelvic/fetal ultrasoundAppropriate imaging for female pelvic pain (pregnant versus non-pregnant)Appropriate imaging for abnormal menstruation (when and who to scan)Appropriate imaging for pelvic masses (US vs MR vs CT)Appropriate imaging for infertility (US vs hysterosonography vs MR)Appropriate imaging for patients with suspected endometriosis (US vs MR vs laparoscopy)

Indications for scanning in the first trimester:Bleeding and or pelvic pain: (implantation bleed, subchorionic hematoma, molar pregnancy, incomplete abortion, ectopic pregnancy)Uncertainty of dates - LMP or size larger/smaller than dates (importance of early scans)Prior history of ectopic pregnancyPrior history of multiple pregnancyInfertility treatment (ectopic, multiples, reassurance)

Indications for scanning in the second trimester:Anomaly evaluation, especially in conjunction with abnormal maternal serologic screens (ie AFP, maternal triple screen, family or prior sibling with anomaly)Controversies of “screening scan” in low risk patientsSize/date discrepancyBleedingCervical incompetenceNo fetal heart by DopplerAmniocentesis

Indications for scanning in the third trimester:Size/date discrepancy (fetal biometry)Bleeding (previa/abruption),Cervical incompetenceMonitoring of known fetal or placental anomalyNo fetal heart by doppler PresentationCervical incompetence.Assessment of fetal well-being (biophysical profile) – eclampsia, hypertension, multiples, post dates, abnormal non-stress test etc

Indications for pelvic MR in non-pregnant womanStaging of cervical and uterine carcinomasEvaluation of ovarian massesEvaluation of congenital abnormalies of the uterus

Indications for MRI in pregnancyTraumaComplex neurological anomaliesComplex body wall anomaliesConcurrent maternal abdo-pelvic disease

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Breast imagingMeaning of ACR categories 0-5Significance and Management of ACR 3 findingsManagement of the image-negative palpable mass

Pelvic and fetal ultrasound

Importance of knowledge of serum HCG result when interpreting early OB scan results in patients with pelvic pain or bleedingImportance of incorporating certainty of dates by LMP with ultrasound dating for evaluation of fetal dating and growth restriction as well as first trimester loss.Sensitivity of ultrasound for diagnosis of Down’s syndrome approx. 80%Normal ultrasound approximately halves pre-scan (age + triple screen) risk of Down’s syndrome

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NMSCR 4/9/2023

Neuroimaging



1.1. Techniq u es used to image this anatomical/physiological area

NeuroCT and CT of the neck, sinuses and earNeuroMRCerebral angiographySpinal imaging-CTSpinal imaging-MRMyelographyCTA/MRA


Importance of holding still for long periods for MRINPO for several hours before IV contrastExternal halo devices for stereotactic procedures

1.3. Studies that should be watched during elective period or clinical rotations

Head or spine CTHead or spine MRMyelography Cerebral angiogramNeurointerventional procedure

2. Normal anatomy

2.1. Structures that should be identified on each modality (Emphasis on cross-modality correlation CT vs MR)

Lobes of brainMidbrainBrainstemSpinal cordVentriclesOptic nervesEpidural vs subdural vs subarachnoid spacesCarotids, MCA, ACASagittal sinus, jugularVertebral column and discs and nerve rootsAnterior vs posterior triangle of the neckParanasal sinusesPharynxLarynx


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TumorsIntraaxial tumorsMetastatic diseaseExtraaxial tumorsHead and neck tumors

InfectionCerebral abcessMeningitisDiscitisParaspinal abcessSinusitis

TraumaSubdural hematomaEpidural hematomaSubarachnoid hemorrhageIntracerebral hemorrhage (appearance of blood on MR vs CT, time dependancy)Diffuse axonal injuryCerebral herniationCervical spine traumaFacial trauma

Vascular diseaseCerebral aneurysmStroke: early vs late (atherosclerotic, thrombo/embolic)Vascular malformations

Miscellaneous:

Demyelinating diseasesDementia (atrophy)Normal age related changes


Hemorrhagic strokeTraumatic hemorrhage (subdural, epidural, subarachnoid, intraparenchymal)Signs of increased intracranial pressure, midline shift, Cerebral herniationHydrocephalusSpace occupying lesionsIsodense subduralsBilateral hematomas of different ages in child abuse


Skull films-NOT indicated in most cases of head traumaTiming for appearance of stroke findingsCT for migrainous/recurrent headache


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Treatment of berry aneurysmsBiopsy of tumorsTreatment of congenital vascular anomalies

5. Imaging algoritms (appropriateness criteria)


Appropriate imaging in the suspected stroke patient (CT vs MRI)Appropriate imaging in suspected SAH (CTvs MRI vs angio)Appropriate imaging in proven non-traumatic intracerebral hemorrhage (CTA vs MRA vs angio)When to order spine CT vs MR vs plain filmsAppropriate imaging sequence in spinal traumaAppropriate imaging sequence in facial trauma (plain films vs CT)Appropriate imaging for metastatic disease to CNS (CT vs MRI, contrast)Appropriate imaging for headache (CT vs MR vs none)Appropriate imaging for dizzinessAppropriate imaging for seizuresAppropriate imaging for dementiaAppropriate imaging for meningitisAppropriate imaging for AIDS in the CNS (MR vs PET vs thallium)Appropriate imaging for the suspect CNS tumor recurrence vs radiation necrosis (MR vs PET vs thallium)Imaging sinus disease (plain film vs CT vs MR vs none)When myelography is indicated vs MRWhen conventional neuroangiography is indicatedAppropriate imaging for stroke –early and late (CT vs MR vs angio)Appropriate imaging for TIAsCriteria for performing CT prior to lumbar puncture Vascular lesions that can be managed with interventional angiographyAppropriate imaging for encephalitisAppropriate imaging for multiple sclerosisAppropriate imaging for peripheral neuropathies

5.2. Incorporating imaging findings into patient Management including effects of pre-test probabilities

Management of MRA negative patient with subarachnoid hemorrhageManagement of the stroke patient with evidence of hemorrhageManagement of the stroke patient without evidence of hemorrhage (timing) with or without CT evidence of infarct

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Nuclear Medicine




Outline of gamma camera operationConcept of radiopharmaceuticals, in general99mTc as most commonly used isotopeConcept of 18F-FDG PET scanning and PET-CTConcept of physiological versus anatomical imaging


Caffeine withholding for cardiac pharmacologic stress testingFasting for PET scansIodine containing products for thyroid scanningRequirement for keeping still for 20-50 minutes

1.3. Studies that should be watched during elective period

Bone scan or other routine planar studySPECT scan of some typeCardiac stress test and perfusion scan

2. Normal anatomy 2.1. Structures that should be identified on each modality with emphasis on cross-modality

correlation

Recognize a bone scanRecognize a myocardial perfusion scan (left ventricular walls, right ventricle)Recognize a VQ scanRecognize a PET scanRecognize a hepatobiliary study (identify gallbladder, liver, bowel)Recognize a MUGA


3.1. Common pathological conditions/findings that the student should recognize or at least see examples of

Interpretation of nuclear medicine studies felt to be beyond the scope of student curriculum, however they should be shown examples of obvious common clinical entities including:

Large pulmonary emboli (VQ scan) Extensive bone metastases (bone scan)Acute fracture (bone scan)Obvious myocardial infarct/ischemia (myocardial perfusion study)Acute cholecystitis (hepatobiliary scan)

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NMSCR 4/9/2023

Toxic nodule (thyroid scan)Graves' diseaseUPJ obstruction (MAG3/DPTA scan)Metastastic tumor (PET FDG scan)

3.2. Iatrogenic pathology

Bile leaks s/p cholecystectomyUreteral obstruction


Emergency interpretation of nuclear medicine studies not expected by students or non-radiology interns/residents

3.4. Diagnostic situations/conditions unlikely to benefit from imaging Delayed imaging in GI bleeding scansBone scans in myeloma


4.1. Identify clinical scenarios where image-guided procedures are beneficial Shunt patency studies


5.1. Appropriate imaging algorithms for common diagnostic situations

Indications for common nuclear medicine exams: (Tracers used for these exams)

Bone scan (99mTc methylene diphosphonate (MDP))MetastasesFractureChild abuse (useful knowledge for future pediatricians)Osteomyelitis

Thyroid scan (99mTc pertechnetate, 123I NaI,131I NaI)ThyrotoxicosisThyroid nodules

Ventilation perfusion [VQ] scan (99mTc macro-aggregated albumin, 133Xe , 99mTc DPTA aerosol )Suspected pulmonary embolismDifferential lung perfusion

Myocardial perfusion imaging (99mTc Sestamibi, 201Tl)Suspected ischemiaEvaluation of infarct sizePost revascularization assessedPre-operative evaluation of high risk patients e.g AAA

MUGA (99mTc labeled RBC)Ejection fraction and wall motion prior to chemotherapyEvaluation of ischemic heart diease (+/- stress)

Hepatobiliary scan (99mTc DISIDA/mebrofenin)

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NMSCR 4/9/2023

Suspected acute cholecystitisSuspected chronic cholecystitis/biliary dyskinesis (CCK)

Renal scan (99mTcDPTA or MAG3 or DMSA) ObstructionRenovascular hypertensionRenal infarction

Gastrointestinal bleeding scan (99mTc labeled red blood cells)GI bleed with negative endoscopy

Gastric emptying study (99mTc sulfur colloid labeled egg sandwich)Suspected gastroparesis or gastric outlet obstruction

White blood cell [WBC] scan (99mTc HMPAO or 111In oxine labeled white blood cells)Osteomyelitis

PET scan (18F Fluorodeoxyglucose – FDG)Cancer diagnosis, staging and restagingMyocardial viabilitySeizure focus localization

Appropriate imaging for ?acute cholecystitis (hepatobiliary scan vs US vs CT)Appropriate imaging for ?pulmonary embolism (VQ vs CT angiogram)Appropriate imaging for GI bleeds (bleeding scan vs CT vs angiogram vs endoscopy)Appropriate imaging for suspected occult fractures (MRI vs delayed plain films vs bone scan)Diagnosis of osteomyelitis (x-ray v bone scan v MRI v WBC scan)

5.2. Incorporating imaging findings into patient Management including the effects of pre-test probabilities

Understanding the concept of PIOPED criteriaTumors that may produce false negative bone scans (renal, myeloma, lung, thyroid)Consideration for additional testing in high-risk patients with low or intermediate probability VQ scansCardiac stress test data effects interpretation of myocardial perfusion studies

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NMSCR 4/9/2023

Pediatrics




Fluoroscopy-with low dose pulsed fluoroscopy, shielding where possiblePlain films-with restraints if necessaryCT-with sedationMR-with sedationUltrasound-no sedation, no radiation, used overall more than in adultsincluding neuroimaging prior to closure of fontanellesNuclear medicine – may or may not need sedation


Use of ‘pain-free’ child anesthesia servicesExperienced i.v. teams, use of ‘Emla’ cream before i.v. linesParents sometimes are in room during proceduresDecide whether it is better to have parents in or outPre-procedure information & preparation for children can be very helpful

1.3. Studies that should be watched during elective period

VCUGBarium swallow/UGIAbdominal ultrasoundChest radiographKUBCranial ultrasound

2. Normal anatomy

2.1. Structures that should be identified on each modality or at least seen during elective (Emphasis on cross-modality correlation)

Chest:Assessment of CXR rotation in babyNormal pulmonary vascularityHeart (noting different ratio heart:thorax in neonate)Thymus

Abdomen:LiverSpleenKidneys

Skeletal plain films:Normal appearance of growth plates, identification of metaphysis, physis and epiphysisOrder of appearance of ossification centers felt to be beyond student level, but some concept of sequential ossification, e.g. femoral heads not ossified at birth

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NMSCR 4/9/2023

BrainNormal neonatal brain appearance (US, CT)



Trauma:Growth plate injuriesElbow effusion (significance of)Greenstick fractures, esp distal radial torus fracture, toddler fracture

Infections:Pneumonia and round pneumoniaBronchiolitis (hyperinflation)

Tumors:Wilm's tumorNeuroblastoma

Congenital abnormalities:Example of congenital cyanotic heart disease e.g. Tetralogy of FallotPyloric stenosisVesicouretic reflux (VCUG)

Neonates:Neonatal radiology felt beyond general medical student level, for dedicated electives consider:TTN/ hyaline membrane diseaseMeconium aspirationPneumonia

Bronchopulmonary dysplasia


Child abuse – posterior rib fractures, metaphyseal corner fractures, unusual spiral fractures of long bones, signs of old multiple fractures, bilateral subdural hematomas of different agesPneumoperitoneumPneumothorax in a neonate


Chronic abdominal painRecurrent, uncomplicated asthma



BiopsyAbscess drainagePICC line placement Prenatal therapySclerotherapy (lymphatic malformations)

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NMSCR 4/9/2023



Appropriate imaging for suspected appendicitis (US vs CT vs KUB)Appropriate imaging for blunt abdominal trauma (US vs CT) Appropriate imaging for cervical spine injury (when to do CT/MR)Appropriate imaging for the clicky hip (US vs plain films, age dependence)Appropriate imaging for the child with a limp (plain films vs US vs aspiration vs bone scan, joints to image)Appropriate imaging for acute and chronic back pain in children (plain films vs CT vs bone sca with SPECT)Appropriate imaging for suspected child abuse (plain films vs bone scan vs head MR)Appropriate imaging for suspected intussusception (KUB vs air/barium/water enema vs US)Appropriate imaging for a neonate or young infant with bilious vs non-bilious vomiting (UGI vs US vs enema)Appropriate imaging for one or more UTIs in girl/boy (when to image, US vs VCUG vs nuclear cystogram vs IVP) Appropriate imaging for failure to pass meconium (water soluble vs ba enema)

Contraindicated studiesIntussusception reduction attempt in child with surgical abdomenAbdominal CT in unstable trauma patient


Management of borderline pyloric measurements in projectile vomitingManagement of negative plain films in high suspicion bony injuries (e.g. distal humerus)

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NMSCR 4/9/2023

Curriculum Resources

The following are lists of potential teaching resources and methods for a student elective or required course in Radiology. These are collated from multiple programs with different resources, program formats and needs, and obviously not all could be applied in any one program.

1. Teaching Methods

1.1. Group based conferences

Didactic slideshow digital/non-digital

Film based/digital “hot seat” case conference

Digital interactive teaching using graphical pad and image manipulation software (e.g. Photoshop or Paintshop Pro)

Case conferences with preview of cases (film, digital, web-based)

Case-based image Management conferences with or without preview of clinical scenarios

1.2. Student presentations

Case based or topic based

Film or digital

To department or just to other students

Posting past presentations as teaching files or examples on websites or CDROMs

Examples of good and bad presentations

Giving them clear guidelines for effective presentation

Assigning staff or residents to assist in case presentation, preview and critique

Image digitization and download workshop

Videotaping presentations for feedback and critique

Development into published case reports

Evaluation by staff/residents/students as part of the elective evaluation

Practical feedback/group discussion following presentations

1.3. One-on-one based teaching/shadowing

Viewbox observation

Passports or lists of procedures and scans to observe during rotation

Observation of patient experiences

Longitudinal shadowing of specific resident or staff mentor

On-call with resident

“Sub-intern” experience – assigned cases for interpretation

Individual OSCE with structured questions and immediate feedback

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NMSCR 4/9/2023

1.4. Informal Quizzes

Film or digital slide quiz

Web-based multiple choice quizzes with feedback (with or without cumulative student responses for self-comparison)

CDROM based quizzes

Group or individual effort

1.5. Formal Exams

Film based or digital

Paper or computer based

Multiple choice or textural

Fact based or image based

Timed or open

Powerpoint or web-based

Self-scoring or not

Oral case discussions

Provide immediate immediate/delayed/no feedback and explanatory answers

Multiple or single attempts

Pre-course and post-course examinations

Supervised or honor system

Individual OSCE with structured question

1.6. Games

Team film conference (previewed or not)

Image Jeopardy (blank downloadable from AMSER website)

Image “Who wants to be a Millionaire”

“Radiology Charades” conference (contestant has to describe the findings of a projected film using the correct radiology terminology and the audience who have their backs to the film have to guess what it is).

Use of audience response pads

Use of team/individual reponse buzzers

1.7. Self-learning exercises

Student specific teaching files (film or digital)

CDROMS (see below)

Websites (see below)

Web-based tutorials

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NMSCR 4/9/2023

Imaging algorithms with clinical scenarios

Anatomy identification on images (film or digital) with or without immediate answers

Slide-tape sets

Past student presentations

1.8. Hands-on-practical experiences

Supervised ultrasound practice on other students (with or without atlas reference)

PACS access and image download practice exercise

“Sub-intern” experience – assigned cases for interpretation from regular worklist

2. Websites

2.1. Casefiles

University hospitals of Cleveland and Rainbow Childrens Pedi files (http://www.uhrad.com/pedsarc.htm) Pediatric cases

Pediatricradiology.com (http://www.pediatricradiology.com/) Extensive links to collections of pediatric cases, and additional links to tutorials on pediatric imaging

procedures, congenital heart disease, pediatric measurements and fractures amongst others.

Society of Skeletal Radiology (http://www.skeletalrad.org/teachingfiles.htm) From The Society of Skeletal Radiology site with peer reviewed musculo-skeletal teaching file sites nicely linked

Washington University, Musculoskeletal Teaching file (http://www.rad.washington.edu/mskbook/index.html)

Excellent MS teaching file as well as other info

Compare Radiology (http://www.evaluation.idr.med.uni-erlangen.de/Ecomparetitlepage.htm) This site was developed by students and staff at Univ. Erlangen, Germany. It is quite a nice if not "glossy" interactive student teaching tool for general radiology.

Case Western Reserve Radiology Teaching Files (http://www.uhrad.com) There are a lot of teaching files available on this site, which is maintained by University Hospital's Department of Radiology, Cleveland, Ohio

XRay files from the Scottish Radiological Society (http://www.radiology.co.uk/xrayfile/xray/index.htm) The Scottish Radiological Society hosts this site, and there are links as well as tutorials and case presentations

Collaborative Hypertext of Radiology (http://chorus.rad.mcw.edu) CHORUS - Collaborative Hypertext of Radiology. Indexed by disease rather than unknown cases. One of the oldest on-line. University of Wisconsin

Brigham Rad (http://brighamrad.harvard.edu/education.html) Casefiles and “Find the Path” – interactive imaging algorithms for common ER presentations. Several cardiac and nuclear medicine tutorials.

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http://brighamrad.harvard.edu/education.html

http://chorus.rad.mcw.edu/

http://www.radiology.co.uk/srs-x/cases.htm

http://www.uhrad.com/

http://www.evaluation.idr.med.uni-erlangen.de/Ecomparetitlepage.htm

http://www.rad.washington.edu/mskbook/index.html

http://www.skeletalrad.org/teachingfiles.htm

http://www.pediatricradiology.com/

http://www.uhrad.com/pedsarc.htm

NMSCR 4/9/2023

2.2. Teaching programs

Chest X-ray.com (http://www.chestx-ray.com) Site devoted to thoracic imaging with many links. Also has a more public section describing all of the modalities and their protocols. One link is designed for medical students

University of Virgina Radiology Teaching (http://www.med-ed.virginia.edu/courses/rad/radmain.jpg)Excellent radiology tutorial series.

Breast Cancer Detective (http://www.med.umich.edu/lrc/breastcancerdetective) Interactive game teaching basic mammography to medical students from Marilyn Roubidoux at the University of Michigan

Washington University, Musculoskeletal Teaching file (http://www.rad.washington.edu/mskbook/index.html)

Excellent MS teaching file as well as other info

Washington University Skeletal Anatomy (http://www.rad.washington.edu/RadAnatomy.html) Review of basic skeletal anatomy on plain films. This site also has more complex MRI-based MS anatomy tutorials

3-D anatomy teaching modules from University of Iowa (http://www.vh.org/adult/provider/radiology/3DReconstruction/index.html)These are some nice 3D anatomy modules developed by Brian Mullen

LUMEN crossectional anatomy project (http://www.lumen.luc.edu/lumen/meded/grossanatomy/x_sec/mainx_sec.htm) using CT and the Visible Human Project from Loyola University

Brigham Rad (http://brighamrad.harvard.edu/education.html) Casefiles and “Find the Path” – interactive imaging algorithms for common ER presentations. Several cardiac and nuclear medicine tutorials.

Radiological anatomy from McGill University (http://sprojects.mmi.mcgill.ca/radiology/). Basic plain film and cross-sectional anatomy for students

Radlabs from Harvard Medical School (http://mycourses.med.harvard.edu/ocw_rbview.asp?course=RD501M%2E23). Interactive review of basic radiological anatomy for medical students (Kitt Shaffer

Albert Einstein radiology education site (www.learningradiology.com)- Albert Einstein Medical Center Radiology teaching resources and tutorials, cases aimed at medical students and radiology residents-in-training with a very good section for students

2.3. General information and Portals

AMSER (http://www.aur.org/amser/) Alliance of Medical Student Educators in Radiology is a affiliate of the Association of University Radiologists and a excellent resource for medical student program directors in radiology

AMSER discussion board (http://groups.yahoo.com/group/AMSER)

Aunt Minnie.com (http://www.auntminnie.com) General radiology news, cases, well used med student discussion board. Good if you hear about some new radiology test/news and want the inside story on it before your patients ask you....

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http://www.auntminnie.com/

http://groups.yahoo.com/group/AMSER

http://www.aur.org/amser/

http://www.learningradiology.com/

http://mycourses.med.harvard.edu/ocw_rbview.asp?course=RD501M.23

http://sprojects.mmi.mcgill.ca/radiology/

http://brighamrad.harvard.edu/education.html

http://www.lumen.luc.edu/lumen/meded/grossanatomy/x_sec/mainx_sec.htm

http://www.vh.org/adult/provider/radiology/3DReconstruction/index.html

http://www.rad.washington.edu/RadAnatomy.html

http://www.rad.washington.edu/mskbook/index.html

http://www.med.umich.edu/lrc/breastcancerdetective

http://www.med-ed.virginia.edu/courses/rad/radmain.jpg

http://www.chestx-ray.com/

NMSCR 4/9/2023

Association of Program Directors in Radiology (http://www.apdr.org/edu_portal.htm) Includes information for medical students, teaching resources and program information

RSNA (http://www.rsna.org) Portal for all of radiology, including links for medical students interested in a career in Radiology. Includes a Medical Student Resources Link and an Educational Resources Link

Radiology Education (http://www.radiologyeducation.com/) Multiple links to a huge number of websites, lists textbooks and case files.

Medicalstudent.com (http://www.medicalstudent.comThis is an extensive site with current links to all areas of medicine including radiology. This site has won several awards

Medical Education Resources (http://www.meduniv.lviv.ua/inform/studlinks.html) This is another very large collection of links for medical students with many international sites included

Americal College of Radiology (http://www.acr.org/frames/f-residents.html) This is a helpful list of links for radiology residency programs

3. CDROM based programs

Interactive Atlas of Clinical Anatomy (Frank H. Netter, MD)

Introduction to Clinical Imaging (Henry I. Goldberg MD)

Radiologic Anatomy (Linda Lanier, MD)

Skeletal Radiology (Felix S. Chew, MD)

ACR Chest Teaching File

ARCOG Interactive OB U/S

CD Roentgen (Michael P. McDermott, MD)

Essentials of Radiology (Judith Korek Amorosa, MD)Textbooks

Squire’s Fundamentals of Radiology ( Novelline 2004)

Essential Radiology (Gunderman 1997)

Felson’s Principles of Roentgeology, A programmed text (Goodman 1999)

Basic Radiology (Chen 2004)

Practical Pediatric Imaging (Kirks 1998)

Fundamentals of Pediatric Radiology (Donnelly 2001)

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http://www.acr.org/frames/f-residents.html

http://www.meduniv.lviv.ua/inform/studlinks.html

http://www.medicalstudent.com/

http://www.radiologyeducation.com/

http://www.rsna.org/

http://www.apdr.org/edu_portal.htm

NMSCR 4/9/2023

Diagnostic Shortlist : The “Must See” ImagesImages all students should recognize

This is a limited list of diagnoses and their respective imaging modalities that all students should be able to recognize, regardless of their planned speciality. An image set based on this list could be developed by AMSER as a shared resource.

Condition Details ModalitiesPneumothorax Upright, supine, signs of tension,

adult and childCXR, CT

Pneumomediastinum CXR, CTPneumoperitoneum Upright, supine CXR, KUB, CTPleural effusion Upright, supine CXR, CTPulmonary edema P.venous hypertension, interstitial,

alveolarCXR

Aortic dissection CXR, CTAortic rupture CXR, CTDiaphragmatic rupture KUB, CTSBO Upright, supine KUBCecal and sigmoid volvulus KUB, enemaDistal large bowel obstruction Upright, supineAscites US, CTMissed placed lines/tubes Dobhoff/NG tubes, central venous

catheters, endotracheal tubesCXR, KUB

Child abuse Metaphyseal and rib fractures, bilateral subdurals (inc. isodense)

CXR, extremity films, CT/MR

Stroke Edema, hemorrhage, mass effect CTIntracranial traumatic hemorrhage Epidural, subdural, subarachnoid,

intraparenchymalCT

Increased intracranial pressure Inc. shift and cerebral herniation, hydrocephalus

CT

Space occupying lesions Mass effect, +/- contrast CT, MRCervical spine injury Abnormalities of spinal-laminar

lines/alignment of the c-spine e.g. posterior ligamentous injury

Plain films

Fracture with extension into joint Plain filmsElbow joint effusion Radial head fracture, distal

humneral fracturePlain films

Shoulder dislocation Plain films

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amser.doc

Health & Medicine

risks of radiology

chest imaging

abdominal imaging

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radiology department

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