CHEST



34290574675001670050-1248410DIAGNOSTIC RADIOLOGYGOALS & OBJECTIVESCHEST00DIAGNOSTIC RADIOLOGYGOALS & OBJECTIVESCHESTROTATION GOALS: To acquire the knowledge and experience towards competency in performing, interpreting and reporting thoracic radiology imaging studies and associated procedures. ROTATION OBJECTIVES:MEDICAL EXPERT:To demonstrate an understanding of normal and abnormal anatomy of the thorax, demonstrated on the CXR and CT.To develop an understanding of basic pulmonary physiology and pathology.To become knowledgeable about the different contrast agents.To demonstrate knowledge of how a chest radiograph is obtained, and the basic physics governing the acquisition of a satisfactory image.To develop an organized approach to interpretation of the chest radiography and to recognize the normal and abnormal position of supporting devices, lines and tubes on inpatient radiographs.To demonstrate an understanding of the common chest pathologies and their radiographic signs, including: cardiogenic and non-cardiogenic pulmonary edema, collapse and atelectasis, infection, neoplastic disease, interstitial lung disease, organic and inorganic lung diseases, mediastinal masses, diseases and abnormalities of the pleura and diaphragm, pneumothorax, pulmonary vascular patterns, cephalization of blood flow and pneumothorax both in upright and supine patients, pleural effusion on supine and upright radiographs and their different appearances.To develop skill in supervision, performance and patient management for: CT thorax, lung biopsies and/or chest tube MUNICATOR:To dictate well-organized reports, describing relevant findings, diagnosis and recommendations.To demonstrate effective communication skills when dealing with patients, during consent for procedures, as well as with consulting clinicians.COLLABORATOR:To demonstrate good consulting skills when interacting with other physicians & health team members.To interact appropriately with other radiology department staff, demonstrating a team approach to patient care.LEADER:To learn the indications for a CXR versus CT scan for thoracic pathology.To consider the advantages and disadvantages of available imaging modalities.To consider available imaging resources when planning and recommending patient care, using them effectively and efficiently.HEALTH ADVOCATE:To recognize and consider radiation doses when recommending, approving and protocoling cases.Understands and communicate the benefits and risks of fine needle aspiration biopsy, core biopsy and insertion of a pleural drainage catheter.Educate and advise others on the use and misuse of radiological diagnostic tests and intervention.SCHOLAR:To set personal learning goals and a reading plan during rotation.To contribute to the learning of others, with the teaching of elective students and off-service residents.Critical appraisal of medical literaturePROFESSIONAL:To demonstrate integrity, honesty and compassion.To practice understanding of ethical and medical-legal requirements of radiologists.To demonstrate awareness of own limitations.Exhibits appropriate personal and interpersonal professional behaviors.To be punctual and available for the assigned duties.METHODS:Please see the “Chest Welcome Document” see the “Chest – Lung Biopsy Guidelines for Residents” document. ExpectationsThe workday begins at 8:00 am or 8:30 am when there are resident rounds. Please look ahead to the Radiologist’s schedule to see which work station will be available.Morning CT protocolling to be done by the resident (grey Chest folder in CT room). Protocol CT Chest inpatients throughout the day, as brought by CT technologists, and bookings. Please reference Chest CT protocols.Please leave Cardiac and Lung Biopsy protocolling to the Attending.Answer phone calls in Cardiothoracic Reporting room. Take consultations as far as you can and ask Attending as necessary.Provide consultation for Physicians who visit the Cardiothoracic Reporting room. Take consultation as far as you can and ask Attending as necessary.Thoracic Tumour Boards - every Wednesday 12:30-1:30pm, attend if it does not conflict with noon rounds.Interstitial Lung Disease Rounds - Friday 12-1pm (4 times a year), optional to attend if they do not conflict with noon rounds.REPORTING TEMPLATESPlease ensure for Dr. Rob Dhillon and Dr. Dominique DaBreo to use our templates for Chest reporting. Please reference within Dr. Rob Dhillon’s macro in advance for a list for CT Chest, CT Chest and Abdomen templates. Please clone templates into your macros in advance of the rotation.Chest X-ray reports must be concise and 1- 3 lines. First report supportive lines/tubes, then any pertinent lung, cardiomedastinal, pleural or bony abnormality. Always answer clinical question provided on the requisition. Reference Dr. Dhillion’s CXR macros in advance to the start of the rotation.PGY - 2 – Block 1 (see suggested reading prior to rotation below)The resident is expected to review and report 20-30 inpatient (including ICU films which are located in the KGH inpatient folder) and emergency chest x-rays and any STAT CTs in AM (expected 5 CTs of the thorax per day). Dictate STAT CTs first and then outpatient CT cases in PM. Lung Biopsies are performed in the AM by the Attending and Senior Residents.PGY - 3 – Block 2The resident is expected to review and report 20-30 inpatient (including ICU films which are located in the KGH inpatient folder) and emergency chest x-rays plus 5-10 CTs of the thorax per day, with some involvement in lung biopsies/procedures, at the discretion of the attending staff. The resident will be expected to follow the cardiothoracic radiologist to HDH and to monitor, post process and report the Cardiac CT cases. PGY – 4 – Block 3 The resident is expected to review and report 30-40 inpatient (including ICU films which are located in the KGH inpatient folder) and emergency chest x-rays plus 10 CTs of the thorax per day, and some involvement in lung biopsies, procedures and the management of complications (chest tube insertions) at the discretion of the attending staff. The resident will be expected to follow the cardiothoracic radiologist to HDH and to monitor, post process and report the Cardiac CT cases. PGY - 5 – Block 4 (during Cardiac block)The resident will primarily be expected to review and report all the cardiac MRI studies (4-6 per week), and any Cardiac CT cases not assigned to other residents. In addition, the resident will review for all inpatient (including ICU films which are located in the KGH inpatient folder) and emergency chest x-rays plus 10 CTs of the thorax every day and increasing responsibility for lung biopsies, at the discretion of the attending staff. At the discretion of the attending staff, the resident may be expected to review and report non-cardiac MRI scans of the thorax.RECOMMENDED TEXTBOOKS/READING:Suggested PRIOR to the start of PGY1 Block rotation Felson's Principles of Chest Roentgenology, a Programmed Text by Lawrence R. Goodman Chest tutorials radiology in the ICU: Lines, Tubes, & DrainsDefinition, Identification, and Significance of Signs and Finding Nomenclature in Thoracic Radiology. Knowledge should include diseases for which these signs are classic, potential alternative diagnoses, or pitfalls [Hansell et al. Fleischner Society: Glossary of Terms for Thoracic Imaging. Radiology 2008;246:697-722]RECOMMENDED TEXTBOOKS/READINGGENERALImaging of Diseases of the Chest - David M. Hansell , Peter Armstrong , David A., MD Lynch , Page H., MD. McAdams, Hardcover: 1272 pages, Publisher: C.V. Mosby; 4th Rev edition (March 30, 2005)Thoracic Imaging- Richard Webb, Charles Higgins, Hardcover: 834 pages, Publisher: Lippincott Williams & Wilkins (September 20, 2004)Radiologic Diagnosis of Diseases of the Chest - Nestor Luiz Muller (Editor), Richard S. Fraser , Neil C. Colman , P. D. Pare, Hardcover: 790 pages, Publisher: W B Saunders Co; 1st edition (July 6, 2001)Chest Radiology: The Essentials, Jannette Collins MD, MEd, Eric J Stern MD,Hardcover: 304 pages, 723 illustrations, Publisher: Lippincott (September 1999)Fundamentals of Diagnostic Radiology (Chest Chapters), William E. Brant (Editor), Clyde A. Helms (Editor), Hardcover: 1460 pages, Publisher: Lippincott, Williams & Wilkins; 2nd edition (January 15, 1999)Thoracic Radiology: the Requisites - Theresa C. McLoud, M.D., Hardcover: 541 pages,Publisher: Mosby; Illustrated edition (August 15, 1998)Radiologic Approach to Diseases of the Chest, Irwin M. Freundlich (Editor), David G. Bragg (Editor), Hardcover: 866 pages, Publisher: Lippincott, Williams & Wilkins; 2nd edition (January 15, 1997)CT High-Resolution CT of the Lung - W. R Webb MD, Nestor L Müller MD, PhD, David P Naidich MD, Hardcover: 688 pages, 426 illustrations, Publisher: Lippincott; 3 rd edition (November 2000)Computed Tomography and Magnetic Resonance of the Thorax, David P Naidich MD, W. R Webb MD, Nestor L Müller MD, PhD, Glenn A Krinsky MD, Elias A Zerhouni MD, Stanley S Siegelman MD, Georgeann McGuinness MD,Hardcover: 784 pages, 1399 illustrations, Publisher: Lippincott Williams & Wilkins Publishers , 3 rd edition (November 1998)High Resolution Lung CT—CDROM, W. Richard Webb, Publisher: Lippincott Williams & Wilkins Publishers (December 1999)PATHOLOGYDiseases of the Lung: Radiologic and Pathologic Correlations, Nestor L. Mller , Richard S. Fraser, Kyung Soo Lee, Takeshi Johkoh, Nestor L. Muller, Hardcover: 440 pages, Publisher: Lippincott Williams & Wilkins Publishers (March 2003)CASE REVIEWThoracic Imaging- Case Review - Phillip Boiselle and Theresa McLoud Softcover: 181 pages, 276 illustrations Publisher: Mosby (2001)REFERENCEDiagnosis of Diseases of the Chest - Fraser, Muller, Colman, ParéHardcover: Four volumes Publisher:W.B. Saunders Company (1999)Chest Radiology -- Plain Film Patterns and Differential Diagnoses James C. Reed Hardcover: 480 pages, Publisher: C.V. Mosby; 5th edition (August 7, 2003)MANUSCIPTS:Please see Cardiothoracic Teaching Folder on the V drive for reference articles. We encourage you to use online resources including StatDx, Radiopaedia, or online Radiographics articles for chest nomenclature, staging, and help guide your differential diagnosis.Reference ABR core study guide articles for Thoracic Imaging of Thoracic Imaging: Resident and Fellows Corner: Resident responsible for reviewing all learning resources provided which are overall excellent.Thoracic Radiology Articles: a folder of articles created and maintained by Dr. Dhillon, which review essential and important radiology topics in thoracic imaging. Cardiothoracic CT protocols1. CHEST: (with or without IV contrast). Majority of cases clinical question can be adequately assessed without contrast.2. CHEST LOW-DOSE (LDT): Noncontrast study for nodule follow up and lung cancer screening. DO NOT used for cancer follow up typically.3. CHEST & ABDOMEN: usually give IV contrast (unless high risk for contrast nephropathy), no oral contrast for majority cases.4. ILD NP: (includes expiratory study and prone position inspiration study).5. ILD FU: (excludes expiratory study and prone position inspiration study).6. PULMONARY VEIN: ECG-gated heart study with IV contrast.7. DISSECTION: Noncontrast thorax and contrast enhanced thorax arterial phase. If positive study for Type B, should extend study to include abdomen +/- pelvis. If high pre-test probability for Type A, option to perform study ECG-gated as clinically indicated.8. CT PULMONARY ANGIOGRAM (CTPA) WITH OR WITHOUT DELAYED STUDY: Pulmonary embolism assessment. If there is high probability of significant underlying non-pulmonary embolism thoracic disease, then consider a delayed acquisition at 55 secs post-injection to optimize overall thoracic assessment.9. DOUBLE RULE OUT: Specific protocol designed for optimal enhancement of both the pulmonary arteries and thoracic aorta. We DO NOT perform triple rule protocols.10. CTEPH: Work up for chronic thromboembolic disease. This study is reserved for specific patients most likely followed in the Pulmonary Hypertension Clinic.11. CORONARY CTA (CCTA): ECG-gated prospective or retrospective study of the coronary arteries and heart. ................
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