HO / MO guide to radiological investigations
Organisational chart of imaging departments - Important people in the department Pre-investigation preparation - Contraindications - Preparation - Consent Taking and Risks of procedure Radiological investigations - FAQ - Head And Neck / Neurology / Neurosurgery / ENT - Respiratory / Cardiology / Cardiothoracic Surgery (CTS) - Abdomen / Pelvis / Gastroenterology / HBS / Urology / Obstetrics / Gynaecology / Breast - Orthopaedics / Spine / Extermities / Trauma Disclaimer
Organisational chart of imaging departments (aka Which department do I arrange
this scan with?)
However, most of the hospitals don’t have all three departments. For some scans, they will be done by the radiology department; for others, the patient will have to travel to another hospital. In addition, the radiology departments in larger hospitals separate their inpatient and outpatient locations (E.g. SGH Inpatient is Blk 6, but outpatient is Blk 2)
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Important people in the department (aka Who do I look for?)
Who is he? Radiologist Medical doctor specialising in imaging His role Approve xray requests “Protocols” (gives technical instructions) on how to do the scan. Doesn’t actually do most scans! (except fluoro, U/S and angio) Covers medical emergencies. Interprets scans and issues report. X-ray conferences Radiographer Technologist who runs the xray machines(Diploma holder after ‘A’-level) Person who actually performs the xray, CT or MRI Prints the xray films Sonographer Clerk Specialised radiographer that does ultrasound Runs the front desk! Specialises in ultrasound Receives your request form Schedules appointments Issues instruction phamplets, oral contrast, etc. When you need to look for him! Urgent requests
Not sure which investigation (e.g. CT vs MRI), special circumstances (pregnancy, implants in MRI, post-op anastomotic leak)
Allergic reaction, collapse, resus Urgent report, second opinion Submit list of cases for round If you’ve brought the patient down and can’t find anyone! Need hardcopy film or CD Check if form has been received Check appointment date and ask for an earlier one (sometimes works!) Collect contrast/prep after urgent request is approved
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Plain Xrays i/v contrast: -CT -IVU Ultrasound MRI
Allergy: CT Contrast, Iodine, Fish
Pregnancy Renal disease (Raised Cr) Asthma DM on metformin Allergy: Multiple(> 3) -
Cochlear implant Pacemaker Intraocular foreign body Other mobile ferrous objects Suspected perforation / leak (use water-soluble contrast)
Depending on model/operation date Vascular clips Artificial heart valve Acute Intestinal obstruction Patient unable to stand/weight bear Patient unable to turn over
Barium swallow / meal / enema
Preparation (By modality)
Plain Xrays Mammogram Ultrasound Barium swallow / meal Barium enema IVU CT abdomen &/or pelvis MRI
Fasting (8 hours)*
No No For HBS and renal arteries Yes Yes, overnight Yes Yes For liver, MRCP
Ideally in first 14 days of menses (will be arranged by the appt desk)
Bowel preparation 1-2 days before Bowel preparation 1-2 days before May require oral contrast 1-2 hours before
*- Implication: Keep the patient nil-by-mouth if you think you need the scan urgently!
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Consent Taking and Risks of procedure
When is written consent required?
Varies between hospitals, but in general: 1. 2. 3. 4. Age < 21 Pregnant women Women who have missed their period, or are in 2nd half of cycle (for high dose Ix) All interventional procedures (including biopsy)
Risk from radiation is a slope, there is no one “cut-off” point below which it is “perfectly safe” even small radiation doses may have some risk. Therefore, statutory regulations require the dose to be “as low as reasonably achievable”. Having said that, there is no absolute “legal” limit to the dose a patient can receive - go ahead and order the scan if you think the investigation is medically indicated, and the benefits outweigh the risk. What then, is the risk, and how do you explain it to patients in layman terms?
Modality / Procedure
Xray – Limbs * Eating 2 bananas a week for 1 year Xray – CXR Xray – Skull * Smoking 1 pack of cigarettes * Flight from Singapore to New York Mammogram Xray - Abdomen, Pelvis, Spine Tc-99m thyroid scan IVU Barium swallow, meal, follow-through CT Head Tc-99m dynamic cardiac scan CT Chest, abdomen or pelvis * Dying in a home accident each year
Equivalent of “normal” Risk of fatal cancer / death daily background radiation
1 day 1 day 3 days 9 days 1 month 2 months 4 months 6 months 1 year 1 – 1.5 years 10 months 2 years 3.5 years 0.03% 0.03% 0.03% 0.05% 0.1% (1 in 1,000) 0.1% (1 in 1,000) 0.35% 0.005% 0.01% (1 in 10,000) 0.0003% 0.001% (1 in 100,000) 0.001% 0.0001% (1 in a million)
* Smoking 1 pack of cigarettes a day x 1 year -
i/v contrast (IVU and CT scan)
(1) Allergic reaction / anaphylaxis - Idiosyncratic, just like all other drugs - Increased risk if (1)Multiple drug allergies (2)Recent asthma (<1 year ago) - Prevention: Prednisolone 10mg x 3 days before the scan (2) Extravasation - Definition: When the contrast is forced outside the vein - Background: About 50mls of contrast (which is as viscous as D50%) is injected as fast as 5mls/second under great pressure (If you don’t believe, get a 20ml syringe, some D50%, a blue plug, and see if you can inject everything out in 5 seconds!!). - Problem: Vein bursts (damn, got to reset the plug ;-) --> Contrast leaks out into tissue --> Draws water from surrounding tissues --> (1)Dehydration (& cell death)of surrounding tissues and (2)Compartment syndrome - Prevention: - i. Make sure plug works(They check, and you’ll just have to walk down to the
department to re-set it if it doesn’t work) - ii. Large bore (Pink/Green) plug for procedures requiring high-injection rates (generally anything vascular/arterial). - iii. If all else fails, blue plugs (but not in tiny finger veins!) may be acceptable for slowinjection rates (e.g. brain) - iv. PICCs are NEVER acceptable. (1) The tiny tip can blast off into the pulmonary arteries and (2) SVC rupture is not a pretty sight. - Treatment: - i. RICE (Rest, Ice-pack, Compress, Elevate extremity) - ii. Watch for compartment syndrome, especially if large volume (3) Contrast induced nephrotoxicity - Defined as a 25% increase in serum creatinine (does not always require dialysis though). - 1% in low risk patients - 10% in high risk patients (Diabetes, CCF, renal impairment, nephrotoxic drugs, age > 70yrs) - Prevention: - i. Any high risk factors: Pre-hydrate patient - ii. Renal impairment: Consider N-acetylcysteine (600mg bd x 2 day before and on day of scan) - iii. Space out contrast studies 72h apart, if possible (e.g. cancer staging) - iv. Consider non-contrast CT or alternate studies (e.g. US, MRI) - Paradoxically, patients whose kidneys have already failed and are on dialysis can ignore all the above. (4) Metformin-induced lactic acidosis - Metformin: Stop on the day, and 2 days after the scan. - Once again, do this proactively, if you think patient might be going for a contrast-CT soon! (Just don’t forget to convert to insulin/another OHGA, and to re-start it later!) (5) Breast feeding - Can scan as per normal, but no breast feeding x 24h after the scan Back to top
Radiological investigations FAQ Q: How do I know which scan to order? A: Specifying the modality(i.e. CT, MRI), organ of interest and including an
adequate history is usually enough. For example, “CT lung” for “Lung cancer” vs “PE” vs “Interstitial lung disease” will get you three different scans, but as long as you include the diagnosis/history, there is no need to specify the exact technical details. Even suspected clinical diagnosis or the clinical indication, no matter how silly (e.g. “Hemoptysis for Ix”, “right sided rib pain”, “TB x 40 years ago”).
Q: What do I write in the “History” column? A: The keyword is “relevant”. Include whatever you think might be relevant
to the scan, such as Presenting complaint, Duration, Possible causes (e.g. TB, prostate cancer), Physical findings/relevant investigations (e.g. axillary LN, pyloric ulcer on OGD, Hep B carrier), Treatment so far (e.g. Subtotal gastrectomy on 21/4/06), and any previous scans (e.g. U/S Feb 06: 4cm liver mass). Also, include any questions your consultant had (e.g. ?increase in size since 2004, ?anastomotic leak) so that they can be specifically answered in the report (Which may well save you a trip down to bug an irritated, overworked radiologist!).
Q: That’s a lot to write! What can I leave out? A: More is better than less, especially if you’re unsure! (It’ll save you an
angry phone call from the radiologist, or even worse, having to explain to the patient why he needs another $350 CT scan of the same organ when he just had one yesterday, and to the consultant why the scan didn’t include the pelvic anastomosis…). But you can safely leave out irrelevant comorbidities (e.g. schizophrenia in a liver scan), and a summary of the history/physical exam is enough (e.g. “R breast lump x 2/12” vs “Admitted for # NOF. Incidental finding of R breast lump, 4.5cm, hard. L breast NAD. etc. etc.)
Q: Does the scan require i/v contrast (a.k.a Do I need to set a plug)? A: This is a tricky one. The full list is given below, but in general, the
following require contrast: Most CT scans, including those looking at/for: - Tumour - Inflammation - Blood vessels Some MRI scans, especially those looking at - Tumour All interventional studies (except PermCath and Hickman lines, but including PICC lines) Common scans that do NOT require i/v contrast include: CT head for stroke, trauma CT spine and extremities for trauma CT KUB for renal/ureteric stones
Q: How do I arrange for an “urgent” scan? A: This varies by hospital, but here is a suggested approach:
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HEAD AND NECK /NEUROLOGY / NEUROSURGERY / ENT
Indication Vault # Maxilla # Mandible # Orbit # Sinusitis (chronic) Investigation Skull (AP,Lateral, Towne’s) Skull (AP, Lateral, OM) Mandible X-xray Orbit X-ray X-ray Paransal sinuses
Orbital foreign body Orbit X-ray + Look up/down views
Indication FB Throat Cervical spine trauma Parotid stone Dental Investigation Neck xray,lateral (not C-spine) C-spine xray (not Neck) +/- Swimmer / Lat pull-down for C7/T1 Parotid xray (occlusal view) Occlusal / OPG
Indication Swallowing assessment / ?Aspiration FB throat / perforation / post-esophagect Nasolacrimal duct stenosis Salivary/Parotid duct stenosis Investigation (1)VFS if high % aspiration (2)Barium swallow (not gastrograffin) (1)Gastrograffin swallow (2)NB: CT neck better for FB Dacrocystogram* Sialogram*
* - Specialised, rarely performed investigation
Indication Young CVA Investigation U/S carotids Thyroid lump / goitre U/S thyroid
Indication Meningitis Fits, brain tumour, mets Chronic sinusitis Hearing loss, conductive Foreign body throat Investigation CT brain CT brain CT temporal bone CT neck Contrast? No Maybe Yes No Maybe Stroke, hemorrhagic Head injury (see NICE criteria) CT brain
CT paranasal sinuses No
Indication Stroke, hyperacute (< 12 hours) Investigation MRI brain (stroke protocol) NB: CT is better to exclude bleed Contrast? No
Stroke, brainstem Posterior fossa lesions MRI brain (more sensitive than CT) Maybe
Hearing loss, sensorineural Retrobulbar mass, orbital tumor Back to top
MRI IAM / MRI IAM screening MRI orbits
RESPIRATORY / CARDIOLOGY / CARDIOTHORACIC SURGERY (CTS)
Indication Basic CXR view Rib # Localise lung lesion Investigation CXR (Erect) CXR (Oblique) CXR (Lateral) Same side as suspected # i.e. R oblique for R # Same side as lesion Same side as effusion i.e. R LD for R effusion Opposite side of pneumothorax i.e. R LD for L pneumothorax Which side?
Loculated effusion, or patient cannot sit CXR (Lateral up decubitus) Small pneumothorax, sit up Sternal # or patient cannot CXR (Lateral decubitus) Sternal Xray
General notes on CXR: The ‘standard’ CXR view is PA erect, but patient must be able to stand, and it cannot be done portable. AP Sitting is second best, followed by Supine. Lateral views are not routinely required. Ask yourself – “how will it affect management?”
Indication Investigation Diaphragmatic paralysis Fluoroscopic sniff test*
* - Specialised, rarely performed investigation
Indication Most lung conditions Interstitial lung disease Aortic aneurysm / dissection Investigation CT Thorax / CT Chest High resolution CT (HRCT) (NB: Slices are “skipped” – do not use for tumour No detection) CT Aortogram / CT Thoracic aorta Yes (High rate) Yes (High rate) Yes (High rate) Contrast
Pulmonary embolism (PE) CT PE / CT Chest (PE protocol) Coronary arteries CT Coronary Arteries / Cardiac CT
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ABDOMEN / PELVIS / GASTROENTEROLOGY / HBS / UROLOGY / OBSTETRICS / GYNAECOLOGY / BREAST
Indication Standard AXR view Air-fluid levels Ureteric/bladder calculi Investigation AXR (Supine) AXR (Erect) or (Lateral decubitus) KUB
Free air under diaphragm CXR (Erect) or (AP Sit) General notes on AXR: The ‘standard’ AXR does not always cover the pelvis. Order a KUB for pelvic pathology. Erect or decubitus views are not routinely required, even in IO. The supine view shows bowel distribution better, and free gas is better detected on the CXR.
Indication Kidneys Renal arteries Aorta Uterus/ovaries Testes Investigation U/S kidneys U/S renal artery U/S abdominal aorta U/S pelvis U/S testes Fast x 8 hours Fast x 8 hours Specialised investigation CT preferred, if possible Preparation Fast x 8 hours Notes Includes a quick look at kidneys Liver, gallbladder U/S liver / HBS
Kidneys & bladder U/S kidneys + bladder Needs to have a full bladder Not routinely ordered
Needs to have a full bladder May include endovaginal scan
General notes on ultrasound: Do NOT order "ultrasound abdomen" – only solid organs can be scanned, and the vast majority of the “abdomen” (including the bowel) is un-scannable. You will either get a rejected request, a call from an irate radiologist, or a vague scan of the region based on the clinical history in your form. They will never scan the entire “abdomen”, so you might as well be more specific.
Intravenous urogram (IVU)
Indication Investigation Preparation Fast overnight, bowel prep Hydronephrosis, ?stones IVU
General notes on IVU: IVU as an inpatient is usually suboptimal due to (1)poor bowel preparation or (2)infeasible to keep patient in hospital just for bowel prep. Alternatives include CT KUB (if looking for hydro and stones, or if renal function is poor) or CT urogram (if looking for renal function or pyelonephritis). Disadvantages of CT are higher cost and radiation dose.
Indication Esophagus / swallowing problem Investigation Barium swallow Requirements Be able to stand Notes
Stomach / PUD / Be able to stand and Barium meal reflux / hiatus roll over. Barium follow-through Small bowel pathology Enteroclysis Large bowel Barium enema Be able to stand and roll over. No fecal incontinence.
More invasive than followthrough, but better results
Water-soluble / As for similar barium ?anastomotic leak gastrograffin swallow/ study. meal/ enema. Urethral stricture Ascending urethrogram Vesico-ureteric reflux Post PCN MCU Check nephrostogram
Include op details (incl anastomosis type), and exact date study is required on form. Include op details if any Include op details if any
Indication Upper abdominal pathology Pelvic / gynae pathology Investigation CT abdomen CT pelvis Contrast Yes Yes
Entire abdominal cavity required CT abdomen + pelvis (abdo/pelvis) Yes Liver (Routine e.g. abscess) CT liver Yes Liver lesion ?HCC Liver HCC post-TACE Pancreas Renal /ureteric stone Kidneys Kidneys, ureter, bladder CT liver (triphasic) CT liver (plain + triphasic) CT pancreas (fine cuts) CT KUB (may differ by hospital) Yes (High rate) Yes Yes No
CT kidneys Yes (High rate) CT urogram(may differ by hospital) Yes (High rate) and Lasix
Abdominal aorta CT abdominal aorta Yes (High rate) Colon< td> CT colongraphy Yes and rectal gas General notes on CT: There are many, many different CT protocols for the abdomen (e.g. see CT liver above!). If unsure, it is best to state the organ of interest, and provide sufficient history, rather than guess blindly. Abdomen and Pelvis (in radiological protocol terminology) are completely different!! Your consultant may casually order a “CT abdomen” for “?sigmoid CA” or “abd pain for ix”, when what he really means is “CT Abdomen + Pelvis”. The radiographers protocoling the scan are not medically qualified, and may or may not catch your meaning, so make sure you fill the form in correctly! (As an aside, the main reason why the pelvis is not automatically included in a “CT abdomen” is due to the high radiation dose to the gonads and bowel.) Almost all abdo scans require fasting. If you’re clerking a patient and think he might need an urgent scan, keep him NBM!
Indication Liver Investigation Contrast MRI liver Yes Bile duct stones MRCP Maybe Pancreas MRI pancreas Yes Kidneys MRI kidneys Yes
General notes on MRI: There are many, many, many MRI protocols for the abdomen, even more than for CT. MRI liver for HCC alone has 12 sequences. Don’t bother trying to specify them, just state the organ of interest, and provide sufficient history.
Indication Screening Evaluation of breast lump Investigation Mammogram Ultrasound + Mammogram Note
Biopsy of lump Ultrasound guided bx Specialised investigation Biopsy of lesion on mammogram Mammotome / Stereotactic biopsy Specialised investigation Implant rupture MRI breast Specialised investigation
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ORTHOPAEDICS / SPINE / EXTERMITIES / TRAUMA
General notes on orthopaedic xrays: Othopaedic xrays are really easy to order – if you can name the bone that is likely to be fractured, then that's the xray you ask for! So go ahead, and order xrays according to where you think the problem is. Using radio-opaque markers, especially for foreign bodies, is highly recommended. If you can’t personally accompany the patient and put the marker – just write a “with marker” on the xray form, and make sure the patient can point out the site of the problem!
Plain x-rays Skull Spine
See head and neck
Cervical spine Cervical spine (Swimmers view) or (Lateral pulldown) Open-mouth / Odontoid views Thoracic spine Lumbar spine Oblique views of above Coccyx
Clavicle Scapula Shoulder Humerus Elbow Forearm or radius/ulna Wrist Scaphoid Hand x finger
Pelvis (AP) Pelvis (Inlet / Outlet) Judet views (for acetabulum)
Hip Femur Knee Skyline (Patella) Tib/Fib Ankle Calcaneum Foot
CT / MRI for tumour or trauma
Specify region as above. 3D-reconstructions are not performed by default at most hospitals, so specify if your consultant needs them.
Indication Rotator cuff pathology DDH / CDH (< 4-6 mths) Investigation U/S shoulder U/S hip
Carpal tunnel, cysts, neuroma U/S wrist
Spine (specify region, level, and side of symptoms) Shoulder* Wrist* Hip Knee Ankle General notes on MRI: While MRI is highly detailed, it is not cheap, and before ordering one, ask yourself if it will affect subsequent management. * - These procedures may involve use of intra-articular contrast injection (arthrogram), which depends on indication for the scan, and varies between hospitals. Once again, include all relevant details on the request form (esp. suspicion of tears and any previous operation) and advise patient he may require an injection. Back to top
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