Download Student Curriculum - Association of University Radiologists

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NMSCR 6/22/2017
AMSER
National Medical Student Curriculum
in Radiology
Edited by:
Petra Lewis M.D.
Kitt Shaffer M.D.
Andrea Donovan M.D.
Updated 2/21/12
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NMSCR 6/22/2017
Table of Contents
Table of Contents........................................................................................................... 2
Key Concepts ................................................................................................................13
Aim ........................................................................................................................................ 13
Philosophy behind a student rather than resident based curriculum in Radiology. .................. 13
General concepts about the medical student curriculum in radiology ..................................... 13
Curricular Framework ...................................................................................................14
Core radiology topics ............................................................................................................. 14
Detailed organ-based curriculae ............................................................................................. 14
Curriculum resources ............................................................................................................. 15
Websites ........................................................................................................................................................................ 15
CDROM based programs ................................................................................................................................................ 15
Textbooks ....................................................................................................................................................................... 15
Diagnostic short-list ............................................................................................................... 15
Goals and Objectives .............................................................................................................. 16
AMSER Shared Resources ....................................................................................................... 16
Radiology ExamWeb .............................................................................................................. 16
Core Topics ...................................................................................................................17
1.
Physics concepts important to the clinician .........................................................17
What produces density differences on radiographs ................................................................ 17
Terminology used in radiology ............................................................................................... 17
Silhouette signs on CXR/KUB .................................................................................................. 17
Key modality differences ........................................................................................................ 17
2.
Limitations of modalities.....................................................................................17
3.
Contrast media ...................................................................................................18
Intracavitary: ......................................................................................................................... 18
IV: .......................................................................................................................................... 18
4.
Orientation to radiology department .................................................................18
Ordering urgent/routine studies ............................................................................................ 18
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Getting wet readings .............................................................................................................. 18
Accessing reports ................................................................................................................... 18
Use of PACS system (specific to individual programs) ............................................................. 18
5.
Radiation safety and risks ...................................................................................19
Risks associated with radiation exposure ............................................................................... 19
CXR equivalents of common examinations ............................................................................ 19
Methods to reduce radiation exposure ................................................................................... 19
Age dependance of radiation sensitivity ................................................................................. 19
6.
Imaging in pregnancy and breast feeding ...........................................................19
Preferred studies ................................................................................................................... 19
Studies that should be performed if absolutely necessary with shielding if possible ................ 20
Contraindicated studies ......................................................................................................... 20
7.
Other ‘risks’ of radiology .....................................................................................20
Contrast media ...................................................................................................................... 20
Risks of percutaneous biopsies and drainage procedures........................................................ 20
Claustrophobia ...................................................................................................................... 21
Complications specific to fluoroscopy ..................................................................................... 21
Complications specific to nuclear medicine ............................................................................ 21
Complications specific to MRI................................................................................................. 21
Complications specific to pulmonary angiography .................................................................. 21
False positive and negative studies......................................................................................... 21
8.
Financial costs.....................................................................................................21
Chest Imaging ...............................................................................................................23
1.
Technical aspects ................................................................................................23
Techniques used to image this anatomical/physiological area ................................................ 23
CXR: ................................................................................................................................................................................ 23
CT: .................................................................................................................................................................................. 23
MRI: ................................................................................................................................................................................ 23
Pulmonary angiography: ................................................................................................................................................ 23
Nuclear medicine: .......................................................................................................................................................... 23
Patient preparation and education ......................................................................................... 23
Studies that ideally should be watched during elective period or clinical rotations ................. 23
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Normal anatomy .................................................................................................23
Structures that should be identified on each modality ............................................................ 23
CXR (PA and lateral) and CT ........................................................................................................................................... 23
Pulmonary angiogram (CT and conventional) and MRI ................................................................................................. 24
3.
Pathological conditions .......................................................................................24
Common pathological conditions/findings that the student should recognize or at least see
examples of: .......................................................................................................................... 24
Atelectasis: ..................................................................................................................................................................... 24
Pneumonia: .................................................................................................................................................................... 24
Vascular abnormalities .................................................................................................................................................. 24
Pleural abnormalities ..................................................................................................................................................... 25
Cardiac abnormalities .................................................................................................................................................... 25
Masses ........................................................................................................................................................................... 25
Adenopathy.................................................................................................................................................................... 25
Interstitial abnormalities................................................................................................................................................ 25
Other .............................................................................................................................................................................. 25
Iatrogenic pathology .............................................................................................................. 25
Emergency “don’t miss” findings (CXR) ................................................................................... 25
Diagnostic situations/conditions that do NOT require imaging ............................................... 26
4.
Invasive procedures ............................................................................................26
Identify clinical scenarios where image-guided procedures are beneficial ............................... 26
5.
Imaging algorithms (appropriateness criteria) ....................................................26
Appropriate imaging management algorithms for common diagnostic situations ................... 26
Cost-effective imaging............................................................................................................ 26
Incorporating imaging findings into patient management ....................................................... 27
Effects of pre-test probabilities ..................................................................................................................................... 27
Abdominal Imaging ......................................................................................................28
1.
Technical aspects ................................................................................................28
Techniques used to image this anatomical/physiological area ................................................ 28
Patient preparation and education ......................................................................................... 28
Studies that should be watched during elective period ........................................................... 28
2.
Normal anatomy .................................................................................................28
Structures that should be identified on each modality ........................................................... 28
3.
Pathological conditions .......................................................................................29
Common pathological conditions/findings that the student should recognize or at least see
examples of: .......................................................................................................................... 29
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KUB: ............................................................................................................................................................................... 29
Fluoroscopic studies: ..................................................................................................................................................... 29
Ultrasound: .................................................................................................................................................................... 29
Emergency “don’t miss” findings ............................................................................................ 29
Diagnostic situations/conditions unlikely to benefit from imaging .......................................... 30
4.
Invasive procedures ............................................................................................30
Identify clinical scenarios where image-guided procedures are beneficial ............................... 30
5.
Imaging management (appropriateness criteria) ................................................30
Appropriate imaging algorithms for common diagnostic situations including cost-effective
imaging .................................................................................................................................. 30
Incorporating imaging findings into patient management including impact of pre-test
probabilities .......................................................................................................................... 30
Musculoskeletal Radiology ...........................................................................................31
1.
Technical aspects ................................................................................................31
Techniques used to image this anatomical/physiological area ................................................ 31
CT ................................................................................................................................................................................... 31
MR .................................................................................................................................................................................. 31
Fluoroscopy .................................................................................................................................................................... 31
Ultrasound ..................................................................................................................................................................... 31
Patient preparation and education ......................................................................................... 31
Studies that should be watched during elective period or clinical rotations ............................ 31
2.
Normal anatomy .................................................................................................31
Structures that should be identified on each modality) ........................................................... 31
3.
Pathological conditions .......................................................................................32
Common pathological conditions/findings that the student should recognize or at least see
examples of : ......................................................................................................................... 32
Trauma: .......................................................................................................................................................................... 32
Arthritis: ......................................................................................................................................................................... 33
Tumors: .......................................................................................................................................................................... 33
Metabolic bone disease: ................................................................................................................................................ 33
Infections: ...................................................................................................................................................................... 33
Emergency “don’t miss” findings ............................................................................................ 33
Diagnostic situations/conditions unlikely to benefit from imaging . Error! Bookmark not defined.
4.
Invasive procedures ............................................................................................33
Identify clinical scenarios where image-guided procedures may be beneficial ......................... 33
5.
Imaging algorithms (appropriateness criteria) ....................................................33
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Appropriate imaging management algorithms for common diagnostic situations including costeffective imaging ................................................................................................................... 33
Incorporating imaging findings into patient management including effects of pre-test
probabilities .......................................................................................................................... 34
Interventional Radiology ..............................................................................................35
1.
Technical aspects ................................................................................................35
Techniques used in IR............................................................................................................. 35
Imaging .......................................................................................................................................................................... 35
Image guided biopsy techniques ................................................................................................................................... 35
Patient preparation and education ......................................................................................... 36
Studies that should be watched during elective period or during clinical rotations .................. 36
Diagnostic situations/conditions unlikely to benefit from image guided procedures ............... 36
2.
Normal anatomy .................................................................................................36
Structures that should be identified on each modality ........................................................... 36
3.
Pathological conditions .......................................................................................37
Common pathological conditions/findings that the student should recognize or at least see
examples of on diagnostic IR studies during radiology or clinical rotations .............................. 37
Vascular.......................................................................................................................................................................... 37
Non-vascular .................................................................................................................................................................. 37
Emergency “don’t miss” findings ............................................................................................ 37
4.
Invasive procedures ............................................................................................37
Identify clinical scenarios where image-guided procedures may be beneficial ......................... 37
Diagnostic studies .......................................................................................................................................................... 37
Biopsy procedures ......................................................................................................................................................... 37
Drainage procedures...................................................................................................................................................... 37
Angioplasty, direct intravascular thrombolysis and stent placements .......................................................................... 38
Embolization procedures ............................................................................................................................................... 38
Access procedures ......................................................................................................................................................... 38
Others ............................................................................................................................................................................ 38
5.
Imaging algorithms (appropriateness criteria) ....................................................38
Appropriate imaging management algorithms for common diagnostic/therapeutic situations
including cost-effective imaging ............................................................................................. 38
Emergency Radiology ...................................................................................................41
1.
Technical aspects ................................................................................................41
Techniques used to image this anatomical/physiological area ................................................ 41
Patient preparation and education ......................................................................................... 41
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Studies that ideally should be watched during elective period or during clinical rotations ....... 41
2.
Normal anatomy .................................................................................................41
Structures that should be identified on each modality ............................................................ 41
3.
Pathological conditions .......................................................................................41
Common pathological conditions/findings that the student should recognize or at least see
examples of during radiology or clinical rotations: .................................................................. 41
Trauma ........................................................................................................................................................................... 41
Non-traumatic................................................................................................................................................................ 42
Iatrogenic pathology .............................................................................................................. 43
Emergency “don’t miss” findings ............................................................................................ 43
Diagnostic situations/conditions unlikely to benefit from imaging .......................................... 43
4.
Invasive procedures ............................................................................................44
Identify clinical scenarios where image-guided procedures may be beneficial ......................... 44
5.
Imaging algorithms (appropriateness criteria) and cost effective imaging ..........44
Appropriate imaging algorithms for common diagnostic situations Error! Bookmark not defined.
Incorporating imaging findings into patient management including effects of pre-test
probabilities .......................................................................................................................... 44
Women’s Imaging.........................................................................................................45
1.
Technical aspects ................................................................................................45
Techniques used to image this anatomical/physiological area ................................................ 45
Mammography (analogue, digital) ................................................................................................................................ 45
Ultrasound ..................................................................................................................................................................... 45
Hysterosalpingograms ................................................................................................................................................... 45
MRI ................................................................................................................................................................................. 45
Patient preparation and education ......................................................................................... 45
Breast imaging ............................................................................................................................................................... 45
Pelvic/fetal ultrasound ................................................................................................................................................... 45
Studies that should be watched during elective period or during clinical rotations .................. 46
Breast imaging ............................................................................................................................................................... 46
Pelvic/fetal ultrasound ................................................................................................................................................... 46
2.
Normal anatomy .................................................................................................46
Structures that should be identified on each modality ........................................................... 46
Breast imaging ............................................................................................................................................................... 46
Pelvic/fetal ultrasound ................................................................................................................................................... 46
3.
Pathological conditions .......................................................................................46
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Common pathological conditions/findings that the student should recognize or at least see
examples of: .......................................................................................................................... 46
Breast imaging ............................................................................................................................................................... 46
Pelvic/fetal ultrasound ................................................................................................................................................... 46
Emergency “don’t miss” findings ............................................................................................ 47
Diagnostic situations/conditions unlikely to benefit from imaging ......................................... 47
4.
Invasive procedures ............................................................................................47
Identify clinical scenarios where image-guided procedures are beneficial ............................... 47
Breast ............................................................................................................................................................................. 47
Pelvic/fetal ultrasound ................................................................................................................................................... 47
5.
Imaging algorithms (appropriateness criteria) ....................................................47
Appropriate imaging algorithms for common diagnostic situations including cost-effective
imaging .................................................................................................................................. 47
Breast Imaging ............................................................................................................................................................... 48
Pelvic/fetal ultrasound ................................................................................................................................................... 48
Indications for pelvic MR in non-pregnant woman ....................................................................................................... 48
Indications for MRI in pregnancy ................................................................................................................................... 48
Incorporating imaging findings into patient management including effects of pre-test
probabilities .......................................................................................................................... 49
Breast imaging ............................................................................................................................................................... 49
Pelvic and fetal ultrasound ............................................................................................................................................ 49
Neuroimaging...............................................................................................................50
1.
Technical aspects ................................................................................................50
Techniques used to image this anatomical/physiological area ................................................ 50
Patient preparation and education ......................................................................................... 50
Studies that should be watched during elective period or clinical rotations ............................ 50
2.
Normal anatomy .................................................................................................50
Structures that should be identified on each modality ............................................................ 50
3.
Pathological conditions .......................................................................................51
Common pathological conditions/findings that the student should recognize or at least see
examples of: .......................................................................................................................... 51
Tumors ........................................................................................................................................................................... 51
Infection ......................................................................................................................................................................... 51
Trauma ........................................................................................................................................................................... 51
Vascular disease ............................................................................................................................................................. 51
Miscellaneous: ............................................................................................................................................................... 51
Emergency “don’t miss” findings ............................................................................................ 51
Diagnostic situations/conditions unlikely to benefit from imaging .......................................... 51
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Invasive procedures ............................................................................................52
Identify clinical scenarios where image-guided procedures may be beneficial ......................... 52
5.
Imaging algoritms (appropriateness criteria) ......................................................52
Appropriate imaging algorithms for common diagnostic situations including cost-effective
imaging .................................................................................................................................. 52
Incorporating imaging findings into patient Management including effects of pre-test
probabilities .......................................................................................................................... 52
Nuclear Medicine ..........................................................................................................53
1.
Technical aspects ................................................................................................53
Techniques used to image this anatomical/physiological area ................................................ 53
Patient preparation and education ......................................................................................... 53
Studies that should be watched during elective period ........................................................... 53
2.
Normal anatomy .................................................................................................53
Structures that should be identified on each modality ........................................................... 53
3.
Pathological conditions .......................................................................................53
Common pathological conditions/findings that the student should recognize or at least see
examples of ........................................................................................................................... 53
Iatrogenic pathology .............................................................................................................. 54
Emergency “don’t miss” findings ............................................................................................ 54
Diagnostic situations/conditions unlikely to benefit from imaging .......................................... 54
4.
Invasive procedures ............................................................................................54
Identify clinical scenarios where image-guided procedures are beneficial ............................... 54
5.
Imaging algorithms (appropriateness criteria) ....................................................54
Appropriate imaging algorithms for common diagnostic situations ......................................... 54
Indications for common nuclear medicine exams: (Tracers used for these exams) ...................................................... 54
Incorporating imaging findings into patient Management including the effects of pre-test
probabilities .......................................................................................................................... 55
Pediatrics......................................................................................................................56
1.
Technical aspects ................................................................................................56
Techniques used to image this anatomical/physiological area ................................................ 56
Patient preparation and education ......................................................................................... 56
Studies that should be watched during elective period ........................................................... 56
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Normal anatomy .................................................................................................56
Structures that should be identified on each modality or at least seen during elective ............ 56
Abdomen: ...................................................................................................................................................................... 56
Skeletal plain films: ........................................................................................................................................................ 56
Brain ............................................................................................................................................................................... 57
3.
Pathological conditions .......................................................................................57
Common pathological conditions/findings that the student should recognize or at least see
examples of: .......................................................................................................................... 57
Infections: ...................................................................................................................................................................... 57
Tumors: .......................................................................................................................................................................... 57
Congenital abnormalities: .............................................................................................................................................. 57
Neonates: ....................................................................................................................................................................... 57
Emergency “don’t miss” findings ............................................................................................ 57
Diagnostic situations/conditions unlikely to benefit from imaging .......................................... 57
4.
Invasive procedures ............................................................................................57
Identify clinical scenarios where image-guided procedures may be beneficial ......................... 57
5.
Imaging algorithms (appropriateness criteria) ....................................................58
Appropriate imaging algorithms for common diagnostic situations including cost-effective
imaging .................................................................................................................................. 58
Contraindicated studies ................................................................................................................................................. 58
Incorporating imaging findings into patient management including effects of pre-test
probabilities .......................................................................................................................... 58
Curriculum Resources....................................................................................................59
1.
Teaching Methods ..............................................................................................59
Group based conferences ....................................................................................................... 59
Student presentations............................................................................................................ 59
One-on-one based teaching/shadowing ................................................................................. 59
Informal Quizzes .................................................................................................................... 60
Formal Exams ........................................................................................................................ 60
Games ................................................................................................................................... 60
Self-learning exercises............................................................................................................ 61
Hands-on-practical experiences.............................................................................................. 61
2.
Websites .............................................................................................................61
Casefiles ................................................................................................................................ 61
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Teaching programs................................................................................................................. 62
General information and Portals ............................................................................................ 63
3.
CDROM based programs .....................................................................................64
4.
Textbooks ...........................................................................................................64
Comprehensive radiology textbooks for medical students: ..................................................... 64
Problem or case-based format: .............................................................................................. 65
Pattern recognition format: ................................................................................................... 65
Pocket format: ....................................................................................................................... 65
Diagnostic Shortlist : The “Must See” Images................................................................67
Example of Goals and Objectives for a Student Elective ................................................69
Introduction ..................................................................................................................69
Reading room ...............................................................................................................69
Goals of rotation ............................................................................................................................................................ 69
Specific recommendations............................................................................................................................................. 69
Additional reading.......................................................................................................................................................... 70
CT/Body Imaging ..........................................................................................................70
Goals of rotation ............................................................................................................................................................ 70
Specific recommendations............................................................................................................................................. 70
Additional reading.......................................................................................................................................................... 71
Neuroimaging...............................................................................................................71
Goals of rotation ............................................................................................................................................................ 71
Specific recommendations............................................................................................................................................. 71
Additional reading.......................................................................................................................................................... 72
Fluoroscopy ..................................................................................................................72
Goals of rotation ............................................................................................................................................................ 72
Specific recommendations............................................................................................................................................. 72
Additional reading.......................................................................................................................................................... 72
Mammography.............................................................................................................73
Goals of rotation ............................................................................................................................................................ 73
Specific recommendations............................................................................................................................................. 73
Additional reading.......................................................................................................................................................... 74
Ultrasound....................................................................................................................74
Goals of rotation ............................................................................................................................................................ 74
Specific recommendations............................................................................................................................................. 74
Additional reading.......................................................................................................................................................... 74
Interventional radiology ...............................................................................................75
Goals of rotation ............................................................................................................................................................ 75
Specific recommendations............................................................................................................................................. 75
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Additional reading.......................................................................................................................................................... 75
Nuclear Medicine ..........................................................................................................76
Goals of rotation ............................................................................................................................................................ 76
Specific recommendations............................................................................................................................................. 76
Additional reading.......................................................................................................................................................... 76
Self study time ..............................................................................................................77
Goals of rotation ............................................................................................................................................................ 77
Suggestions for self study resources .............................................................................................................................. 77
Private practice day ......................................................................................................77
Goals of rotation ............................................................................................................................................................ 77
Specific recommendations............................................................................................................................................. 78
Diagnosis Please links ...................................................................................................78
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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 can be used as guidelines for those programs that wish to develop their own curriculum.
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
Consultations
Importance of providing clinical information
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Curricular Framework
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 signs
Terminology used in radiology
Key modality comparisons, advantages and limitations (modality and patient specific)
Use of contrast media, types, advantages
Orientation to radiology department
Ordering urgent/routine studies
Getting wet readings, accessing reports
Use of PACS system
Radiation safety
Risks associated with radiation exposure
CXR equivalents of common examinations
Pediatric exposure
Imaging in pregnancy
Other complications of radiology
Contrast media (complications, high risk groups, prophylaxis)
Interventional procedures
MRI
Societal and emotional impact
Comparative modality costs
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:
Chest
Musculoskeletal
Neuroimaging
Pediatrics
Woman’s imaging
Abdominal
Nuclear Medicine
Emergency Radiology
Interventional Radiology
Curricular topics:
Technical aspects
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Techniques used to image this anatomical/physiological area
Patient preparation and education
Studies that should be visualized during elective
Normal anatomy
Structures that should be identified on common modalities
Emphasis on cross-modality correlation
Pathological conditions
Common pathological conditions/findings that the student should recognize
Iatrogenic pathology
Emergency “don’t miss” findings
Diagnostic situations/conditions that do NOT require imaging
Invasive procedures
Identify clinical scenarios where image-guided procedures are beneficial
Imaging algorithms (appropriateness criteria)
Appropriate imaging management algorithms for common diagnostic situations
Cost-effective imaging
Incorporating pre-test probabilities
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 conferences
Student presentations
One-on-one teaching
Informal quizzes
Formal exams
Games
Self-learning exercises
Practical experience
Websites
Casefiles
Tutorials
General information and portals
CDROM based programs
Textbooks
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 are all available at AMSER-ID as a shared resource.
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Goals and Objectives
Aim:
To provide an example of goals and objectives that can be modified for specific programs.
Outline: Modality-specific goals and objectives, specific recommendations for students while on clinical rotations
and suggestions for further study with hyperlinked web-resources. These guidelines come from
Dartmouth-Hitchcock Medical Center.
AMSER Shared Resources
Are found at
http://www.dartmouth.edu/~amserimages/
Login: amserid
Password: roentgen
These include a 4000+ image dataset of commonly found conditions, lectures, curricula and other
shared resources donated by AMSER members.
Radiology ExamWeb
Is found at:
http://radiology.examweb.com

National database of multiple choice questions for students on radiology rotations

Open for all AMSER members/clerkship and elective directors

Exams developed, shared and taken on-line

For more information on using this resource contact [email protected]
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Core Topics
1. Physics concepts important to the clinician
What produces density differences on radiographs
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 units
Ultrasound:
Hyper and hypoechoic, attenuation
MRI:
Increased and decreased signal
Nuclear medicine
Hot spots, cold spots, radiotracer, radioisotope
Silhouette signs on CXR/KUB
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
2. 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
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3. Contrast media
Types of contrast media
Intracavitary:
Bowel
Rationale
Types (barium, water soluble, gastrograffin)
Double contrast versus single contrast
Use of water soluble agents versus barium GI studies
Benefits of oral contrast on CT
Tube placement/sinus studies
Intrathecal
Indications (myelography, CSF leak studies)
Low osmolar
Intraarticular
Indications
MR/CT
IV:
Iodine based (non-ionics, ionic agents)
Gadolinium
(Other MR agents)
Uses:
Improving soft tissue contrast
Solid organs
Vascular structures
Inflammation
Renal collecting systems
Bladder
4. Orientation to radiology department (specific to individual programs)
Ordering urgent/routine studies
Institutional methods of ordering routine studies
Institutional methods of ordering urgent studies
Importance of clinical information (protocoling, interpretation, billing)
Request legibility
Contact information
Getting wet readings
Office hours/on call
Accessing reports
Dictation system/written
Preliminary versus final reports
Use of PACS system (specific to individual programs)
Accessing images
Manipulating images
Downloading images for presentations
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Importance of reading reports
Confidentiality/legal issues
5. Radiation safety and risks
Risks associated with radiation exposure
Hematological malignancies
Solid organ malignancies
Local skin effects
Teratogenetic effects
ALARA principle
CXR equivalents of common examinations (or use period natural exposure)
Lumbar spine films
KUB
VQ scan
Bone scan
Myocardial perfusion
Chest CT
Abdo/Pelvic CT
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75
80
180
250
400 (approx. 20 yrs of 2 view mammograms)
750
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
Age dependance of radiation sensitivity
Cancer incidence with age exposure
Importance of reducing pediatric radiation exposure
6. Imaging in pregnancy and breast feeding
No proven risk to fetus of ultrasound
No proven risk to fetus of MRI, but avoid in first trimester if possible
Importance of performing examinations if medically necessary
Importance of re-evaluating “set protocols” e.g. trauma protocols in a pregnant patient
Dose reduction
Shielding
Tc99m tracers safe in pregnancy, other tracers avoided
Shielding unhelpful in nuclear medicine, hydration and bladder emptying
Breast feeding withheld for at least 4 half-lives of tracer
Use 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)
Preferred studies (limitations):
Dysnea – CXR (shielded)
Fetal scanning – ultrasound, MRI for evaluation complex fetal anomalies
Renal 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.
NMSCR 6/22/2017
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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
Studies that should be performed if absolutely necessary with shielding if possible
KUB
Limited IVP
CT, but limited dose
Contraindicated studies (except in very rare life threatening cases)
Angiography
CT pelvis (except rare cases)
GI Fluoroscopy (except in very rare cases)
131I therapeutic or diagnostic dose
201Tl scans
67Ga
111In white cell and other scans
7. Other ‘risks’ of radiology
Contrast media
Complications
Local pain and vomiting
Extravasations with tissue necrosis
Allergic reactions
Incidence (minor 3+%, severe: 0.2% for high osmolar, <0.04% for low osmolar, fatal
1:170,000)
Renal failure
Aspiration (barium vs ionic vs non-ionic)
Low risk of intra-luminal contrast
High risk groups
Allergy (asthma, previous reaction, not shellfish or iodine allergy)
Renal failure
Age > 65
Diabetic (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 complications
Low osmolar contrast media (cost implications)
Gadolium MRI
Steroid and antihistamine protocols
e.g. prednisone 50mg po 13 hours, 7 hours, and 1 hour prior to the exam +/- benadryl
50mg po one hour priory.
Pre and post hydration
N-acetyl cysteine
CO2 angiography
Risks of percutaneous biopsies and drainage procedures
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NMSCR 6/22/2017
Bleeding, infection, organ damage, pneumothorax
Claustrophobia
MRI>CT>nucs or fluoro
Complications specific to fluoroscopy
Bowel perforation
Barium impaction
Barium mediastinitis and peritonitis
Aspiration of contrast media (barium vs. ionic vs. non-ionic contrast media
Complications specific to nuclear medicine
Allergic reactions extremely rare except antibody studies
Persantine/adenosine reactions
Complications specific to MRI
Ferromagnetic displacement (eye debris, aneurysm clips, objects)
Electrical interference (pacemakers, defibrillators, neuro-stimulators)
Artifacts from metallic prostheses and debris
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
False positive and negative studies
Additional physical and financial risks of further imaging or biopsy
Emotional risks (e.g. screening mammography)
Risks of non-treatment in false negative cases
8. Financial costs
Patient and society
Comparative charges for common examinations at student’s institution
Example: (from DHMC)
Examination
CXR
Abdominal series
CT chest with contrast
Chest, abdomen, pelvic CT
CT abdomen with contrast
MRI abdomen with contrast
MRI of lumbar spine, no contrast
Abdominal US
UGI series with SBFT
$ charged as multiples of X (global fee)
1
2
10
17
9
12
12
4
4
22
NMSCR 6/22/2017
IVP
Barium enema
Colonoscopy
Bone scan
PET scan
VQ scan
4
3
16
5
16
6
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NMSCR 6/22/2017
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 (Year 1 and 2)
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:
Basic principles of imaging the heart, mediastinum and heart
Pulmonary angiography:
Basic principles, contraindications, riskts
Nuclear medicine:
(FDG lung cancer) – covered under nucs curriculum
VQ scans- covered under nucs curriculum
Patient preparation and education
Fasting 6hr for PET FDG scan
Need to hold breath for CT, respiratory gating MR
Studies that ideally should be observed during elective period or clinical rotations
PA and lateral CXR
Portable CXR
Chest CT
Chest tube insertion and/or thoracocentesis
2. Normal anatomy (Year 1 and 2)
Structures that should be identified on each modality (Emphasis on cross-modality
correlation)
CXR (PA and lateral) and CT
Lungs:
RUL, RLL, RML, LLL, LUL
Costophrenic and cardiophrenic angles
Minor and major fissures
Trachea and carina
Right and left main bronchi
Retrosternal clear space
Heart:
RV, RA, LV, LA
Aorta, pulmonary outflow track
Pericardium
Pulmonary veins
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NMSCR 6/22/2017
Position of heart valves
Mediastinum:
SVC
Carotid and subclavian vessels
Aortic knob, AP window
Right paratracheal line
Azygous vein
Carina
Right and left main pulmonary arteries
Azygo-esophageal line
Right paraspinal line
Left paraaortic line
Bone and soft tissues
Shoulders, C spine, thoracic spine
Scapulae
Clavicles
Sternum
Diaphragms
Liver
Stomach
Colon
Common normal variants
Azygous lobe
Cervical ribs
Mediastinal lipomatosis
Pericardial fat pads
Pulmonary angiogram (CT and conventional) and MRI
Right and left main pulmonary arteries
Ascending and descending aorta
Take off of great vessels
3. Pathological conditions (Year 3 and 4)
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.
Common pathological conditions/findings that the student should recognize or at
least see examples of:
Atelectasis:
Linear
Lobar: LLL, LUL, RLL, RML, RUL
Indirect signs (mediastinal, hilar, diaphragmatic and fissure shift)
Total lung atelectasis
Pneumonia:
Appearance of and DDX of consolidation (fluid, blood, malignancy, pus)
Silhouette and spine signs
Air bronchograms
Lobar patterns: LLL, LUL, RLL, RML, RUL
Viral/atypical patterns: mycoplasma, PCP
Vascular abnormalities
Recognition and differential of dilated aorta
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NMSCR 6/22/2017
Appearance of great vessel ectasia
Thoracic aortic aneurysm
Ruptured aorta
Aortic dissection
Pulmonary hypertension
PE (CXR, CT)
Pleural abnormalities
Pleural effusion (small, large, subpulmonic, decub films, supine and upright)
Pneumothorax (small, large, supine and upright, decub and expiratory films, tension)
Pneumomediastinum
Pleural thickening and calcifications (asbestos exposure)
Pseudotumor
Empyema
Cardiac abnormalities
Cardiomegaly (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 tumors
Non-small cell lung cancer (hilar mass, parenchymal tumor)
Anterior mediastinal mass (Hodgkins, goiter, thymoma etc)
Cavitating mass
Goitre
Granuloma
Distinguishing which mediastinal compartment masses are in
Adenopathy
Lymphoma
Sarcoidosis
Interstitial abnormalities
Interstitial edema
Emphysema
Extensive fibrosis (honeycombing, cystic fibrosis)
Other
Distinguishing causes of hemithorax opacification (effusion, vs atelectasis vs pneumonia vs
pneumonectomy).
Meaning of ‘ground glass opacity’ on CXR/CT
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
Emergency “don’t miss” findings (CXR)
Tension pneumothorax
Supine pneumothorax (deep sulcus sign)
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LUL collapse
Pulmonary edema (interstitial and alveolar)
Sub-diaphragmatic air
Pneumomediastinum
Signs of aortic dissection
Aortic rupture (supine CXR, CT)
Dobhoff in trachea/bronchus
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 (Year 3 and 4)
Identify clinical scenarios where image-guided procedures are beneficial
Pigtail chest tubes (when are they appropriate) for effusions and pneumothorax
Thoracocentesis (when is image guidance not needed), ultrasound, CT, Fluoro
Lung biopsy (CT, fluoro). Risk of pneumothorax
Lung abscess (when percutaneous drainage is required)
5. Imaging algorithms (appropriateness criteria) (Year 3 and 4)
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 patient
Appropriate 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)
Cost-effective imaging (Year 3 and 4)
Value of obtaining older studies
CXR vs CT for metastatic evaluation
CXR vs CT for lung cancer follow up
Daily ICU film indications
Lung cancer screening controversies
PET for lung cancer diagnosis and staging
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NMSCR 6/22/2017
Incorporating imaging findings into patient management
Effects of pre-test probabilities
Management of the low or intermediate probability VQ scan in high suspicion patient
Management of the negative CT pulmonary angiogram in the high suspicion patient, problems
with limited quality studies
Management of the benign appearing SPN in low risk patient
Management of the benign appearing SPN in high risk patient
Management of the normal supine CXR in high risk trauma patient
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NMSCR 6/22/2017
Abdominal 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 (Year 1 and 2)
Techniques used to image this anatomical/physiological area
KUB – upright, supine, use of decubitus views
Barium swallow (and modified)
Upper GI
Small bowel follow through
Double and single contrast enemas
Water soluble enema
IVP
Cystogram/VCUG
RUQ ultrasound
“Abdominal” ultrasound
Pelvic ultrasound
CT abdomen and pelvis
Hepatobiliary study (see nucs section)
Renal scintigraphy (see nucs section)
MRI abdomen and pelvis
Patient preparation and education (Year 3 and 4)
Bowel preparation for enemas (elderly patient risks)
Oral contrast for CT (diabetic contrast)
Hydration following barium studies
Hydration pre and post IV contrast
Rationale for bladder filling for pelvic ultrasound
Use of transvaginal/rectal ultrasound
Claustrophobia (MR>CT)
Studies that should be watched during elective period (Year 3 and 4)
UGI
Barium enema
CT scan
RUQ ultrasound
Pelvic ultrasound
VCUG
2. Normal anatomy (Year 1 and 2)
Structures that should be identified on each modality (where visible) with
emphasis on cross-modality correlation especially CT-Ultrasound-Fluoro-KUB
Esophagus
Stomach
Duodenum
Small bowel
Colon
Liver
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Gallbladder
Spleen
Pancreas
Aorta
IVC
Kidneys
Ureters
Bladder
Uterus
Ovaries
3. Pathological conditions (Year 3 and 4)
Common pathological conditions/findings that the student should recognize or at
least see examples of:
KUB:
Free air (see below)
Small bowel obstruction
Colonic obstruction
Cecal and sigmoid volvulus
Illeus
Renal and ureteric calculi
Gallstones
Calcified aortic aneurysm
Benign calcifications (phleboliths, vascular etc)
Fluoroscopic studies:
Malignant colonic stricture (obvious)
Hiatal hernia
Esophageal tumor (obvious)
Gastric ulcer
Ultrasound:
Hydronephrosis
Biliary obstruction
Gallstones
Acute cholecystitis
CT:
Liver metastases
AAA (with and without rupture)
Hydronephrosis
Traumatic liver and splenic ruptures
Ascites
Emergency “don’t miss” findings
Free air – upright chest, supine, decubitus and upright KUB, CT
SBO
Cecal and sigmoid volvulus
Free fluid on CT
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30
Diagnostic situations/conditions unlikely to benefit from imaging
Ultrasound unhelpful for non-localizable abdominal pain
Renal failure in the setting of ICU patient (R/O hydronephrosis)
4. Invasive procedures (Year 3 and 4)
Identify clinical scenarios where image-guided procedures are beneficial
Advantages and disadvantages of CT vs US guided procedures
Hydronephrosis
Abscess drainage
When US required for paracentesis
Liver and renal biopsies
Biliary obstruction (ERCP guided stenting vs percutaneous)
TIPS procedures
AAA endovascular grafts
Renal stents
5. Imaging management (appropriateness criteria) (Year 3 and 4)
Appropriate imaging algorithms for common diagnostic situations including costeffective imaging
When to order the barium swallow versus upper GI
When to order the small bowel follow through
Double versus single contrast enemas – discuss with radiologist
Appropriate imaging for suspected renal calculi (KUB vs IVP vs non-contrast CT)
Appropriate imaging for painless hematuria
Appropriate 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 AAA
Appropriate imaging for SBO
Appropriate imaging for colonic obstruction/illeus
Appropriate imaging for suspected diverticulitis
Appropriate imaging for jaundice
Appropriate imaging for renal failure
Incorporating imaging findings into patient management including impact of pretest probabilities
Management of the image negative, high pretest probability suspected acute cholecystitis patient
Management of the image negative patient with suspected ectopic pregnancy
31
NMSCR 6/22/2017
Musculoskeletal Radiology
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 (Year 1 and 2)
Techniques used to image this anatomical/physiological area
Plain films
Importance 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)
CT
Good for bone detail, calcifications
Use of intravenous and intra-articular contrast
MR
Good for soft tissues, marrow, ligaments, multiple plains, marrow edema for occult fractures
Use of intravenous and intra-articular contrast
Fluoroscopy
Guidance for biopsy, analysis of motion
Ultrasound
Superficial tendons, ligaments, foreign bodies, superficial infections, joint effusions
DEXA for bone mineral density
Patient preparation and education
No driving after shoulder arthrogram
Post-procedure pain management
Importance of holding still during CT/MR
Studies that should be watched during elective period or clinical rotations
Extremity plain film
Arthrogram
Shoulder/hip/knee MR
Trauma series
Fluoroscopy for assessment of stability/motion
2. Normal anatomy (Year 1 and 2)
Structures that should be identified on each modality (Emphasis on cross-modality
correlation)
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:
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NMSCR 6/22/2017
Diaphysis, metaphysis, epiphysis
Common normal variants:
Cervical ribs, extra lumbar vertebra, bipartite patella
Soft tissues
Identification of and significance of normal soft-tissue fat interface, fat pads
Identification of major muscle groups felt to be beyond medical student level
3. Pathological conditions (Year 3 and 4)
Common pathological conditions/findings that the student should recognize or at
least see examples of:
Trauma:
Joint effusions
Knee
Elbow
Appendicular Fractures
Descriptive words for fracture orientation, displacement and angulation
Significance of intraarticular displacement
Significance of physeal plate involvement
Fracture ‘evolution’ on delayed films
Disuse osteopenia
Femoral neck, intertrocanteric fracture
Medial and lateral malleolar fractures
Base of 5th metatarsal fracture
Lisfranc fracture/dislocation
Spinal compression fractures
Spinal burst fracture
Metacarpal/phalangeal fractures
Scaphoid fracture (importance of scaphoid view)
Colles/Smith fracture
Radial head (signs elbow effusion)
Distal humeral fracture in a child (signs elbow effusion)
Humeral head fracture
Clavicle fracture
Metaphyseal corner factures (bucket handle) in child abuse
Tibial plateau fracture
Toddler fracture tibia
Common Spine Fractures
Compression fractures thoracic and lumbar spines
Burst fractures (significance of canal narrowing)
Importance of identifying cervical lines and soft tissues on lateral film
C1 Jefferson fracture
C2 fractures, dens and Hangman’s
Anterior subluxation flexion injury
Posterior ligamentous injury (subtle signs of)
Spinous process fracture
Bilateral jumped facets
Dislocations
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NMSCR 6/22/2017
Anterior shoulder dislocation and Hill Sachs fracture
Phalangeal dislocations
Hip dislocation
Soft tissue injuries
Rotator cuff injury
Knee ligament and meniscal injury
Arthritis:
Osteoarthritis
Inflammatory arthritis
Septic arthritis
Tumors:
Primary osteosarcoma
Bone metastasis - blastic vs lytic
Myeloma
Metabolic bone disease:
Osteoporosis
Infections:
Osteomyelitis
Cellulitis
Emergency “don’t miss” findings
Septic joint
Fracture with extension into joint
Elbow joint effusion, radial head fracture
Shoulder dislocation
Abnormalities of spinal-laminar lines/alignment of the c-spine e.g. posterior ligamentous injury
(Child abuse see pediatric section)
4. Invasive procedures (Year 3 and 4)
Identify clinical scenarios where image-guided procedures may be beneficial
Osteopenic vertebral collapse – vertebroplasty
Bone biopsy for suspected tumors
Joint aspiration for suspected septic joints
Arthrography (CT or not) for suspected rotator cuff disease
5. Imaging algorithms (appropriateness criteria) (Year 3 and 4)
Appropriate imaging management algorithms for common diagnostic situations
including cost-effective imaging
NMSCR 6/22/2017
34
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 imaging
Indications for plain films of the neck in trauma
Indications for CT of the neck in trauma
Indications for MR of the neck in trauma
Appropriate imaging for metastatic disease, plain film correlation with bone scan
Appropriate 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)
Appropriate imaging for suspected osteoporosis
Appropriate imaging after total knee arthroplasty
Appropriate imaging for primary and metastatic bone disease
Appropriate imaging for suspected avascular necrosis at the hip
Incorporating imaging findings into patient management including effects of pretest probabilities
Management of the high suspicion hip fracture with negative plain films
Management of patients with low suspicion c-spine injuries and normal plain films (esp. whiplash
injuries) including the Canadian Cervical Spine Rules and NEXUS criteria
Management of patients with persistant pain following injury, imaging negative (use of delayed
films, bone scans, MR)
Management of suspected avascular necrosis of the hip
Management of traumatic knee and ankle pain including the Ottawa and Pittsburg knee rules and
Ottawa Ankle Rules
35
NMSCR 6/22/2017
Interventional Radiology
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
Techniques used in IR (Year 1 and 2)
Imaging guidance for procedures
Fluoroscopy – real time visualization; multiangle orientation (R & L oblique, cranial-caudal, lateral);
risk of significant radiation dose (patient and operator)
Digital subtraction angiography – subtraction and patient motion artifacts
CT (CT fluoroscopy)-better visualization of small internal structures than fluoroscopy, risk of significant
radiation dose (patient and operator)
US-real time visualization, limited depth, no ionizing radiation, limited by air and bone
MR-limitations due to magnetic field; need for MR compatible equipment
C-arm Cone beam CT – advantages and disadvantages compared to conventional CT
3D rotational angiography
HIFU
Contrast Agents
Non-ionic contrast – intravenous and intra-arterial injections; injections into tubes/drains
CO2 - patients with renal failure or contrast allergy
Pre-procedure revjew of patient imaging
Plain films (eg. CXR, abdomen)
CT/CTA (eg. chest, abdomen, pelvis, brain, vascular runoff)
US (eg. abdomen, pelvis, carotid, thyroid, vascular)
MRI/MRA (eg. abdomen, pelvis, brain, spine, vascular runoff)
Nuclear Medicine (eg. PET/CT, bleeding scans)
CT/MR perfusion
Non-invasive vascular studies
Image guided procedures and therapy
Biopsy
Aspiration
Drainage tube placement
Central venous access
GI tube placement
Stent placements, vascular and non-vascular
Angioplasty
Embolization
Thrombolysis
Ablation (thermal, chemical, radiation)
Sclerotherapy
Devices/equipment (Year 3 and 4) – basic awareness of tools of the trade
Needles
Catheters (angiographic vs drainage)
Angioplasty balloons
Stents (covered, uncovered, endographs)
Embolization material (temporary vs. permanent agents)
NMSCR 6/22/2017
36
IVC filters (retrievable vs non-retrievable)
Patient preparation and education (Year 3 and 4)
NPO
Informed consent
Pre-procedure labs required (CBC, coagulation, renal function)
Correction of Coagulopathy
Pretreatment of contrast allergy
Hydration pre and post IV contrast
Antibiotics
Anticoagulation
Peri- and post-procedure pain management
Risks and contraindications of sedative drugs
Timeout (identification of correct side/site for procedure–right/left if applicable)
Tube and catheter care/management (in hospital and post discharge)
Radiation safety
Studies that should be watched during elective period or during clinical rotations
(Year 3 and 4)
Percutaneous biopsy
Angiographic study
Stent placement/angioplasty
Central venous access line placement
Pigtail catheter placement
Thoracentesis
Paracentesis
Percutaneous feeding tube (gastrostomy, gastrojejunostomy) placement
IVC filter placement/retrieval
Diagnostic situations/conditions unlikely to benefit from image guided procedures
Inaccessible lesions
Limitations due to volume of tissue required (biopsy)
Very small lesions
Lesions too hazardous to access (e.g. blood vessels)
2. Normal anatomy (Year 1 and 2)
Structures that should be identified on each modality (Emphasis on cross-modality
correlation)
Angiographic anatomy
Recognition of arterial vs venous structures
Major arteries (aorta-abdominal and thoracic, take off of great vessels, iliac, celiac, hepatic, splenic,
SMA, IMA, carotid)
Major veins (SVC, IVC, IVJ, subclavian, iliac)
Refer to organ specific curriculae for plain films, fluoroscopy, CT, US, MRI, Nuclear medicine
NMSCR 6/22/2017
37
3. Pathological conditions (Year 3 and 4)
Common pathological conditions/findings that the student should recognize or at
least see examples of on diagnostic/therapeutic IR studies during radiology or
clinical rotations
Vascular
Peripheral vascular disease (stenosis, obstruction)
AAA
Renal stenosis
GI bleed or other site of hemorrhage
Cerebral aneurysm
Carotid stenosis
DVT
Non-vascular
Ureteric/UPJ obstruction
Biliary obstruction
Pleural effusion
Empyema
Ascites
Abscess
Emergency “don’t miss” findings
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.
4. Invasive procedures (Year 3 and 4)
Identify clinical scenarios where image-guided procedures may be beneficial
Diagnostic studies
Stroke
Cerebral hemorrhage
Peripheral ischemia
Bowel ischemia
Vascular aneurysms (traumatic and non-traumatic)
Biopsy procedures
Lung tumors
Liver masses
Pancreatic mass
Other mediastinal, abdominal and pelvic masses
Bone tumors
Thyroid masses
Abnormal lymphadenopathy
Drainage procedures
Abscesses – lung, abdomen, pelvic
Thoracocentesis and pleurodesis for pleural effusions
Pneumothorax (pigtail, Heimlich valve)
Paracentesis for ascites
NMSCR 6/22/2017
Ureteric obstruction (nephrostomy tube, internal/external drainage)
Biliary obstruction
Angioplasty, direct intravascular thrombolysis and stent placements
Peripheral ischemia
Bowel ischemia
Renal hypertension
Venous stenosis/thrombosis (upper or lower extremity, IVC or pulmonary emboli)
Biliary strictures
Endovascular AAA/Thoracic aneurysm/dissection repair
Great vessel stenosis
Embolization procedures
Cerebral and extracerebral aneurysms/pseudoaneurysm
Persistent epistaxis
Persistent hemoptysis
GI hemorrhage
Cerebral and peripheral AVMs
Post-traumatic hemorrhage – aortic, spleen, liver, pelvic, limb
Fibroids
Post-partum hemorrhage
Varicocele
Pelvic congestion
Cancer therapy (Ablation, chemoembolization, radioembolization)
Lung cancer
Liver cancer
Renal cancer
Metastatic cancer
Access procedures
Chemo/pharmacotherapy:
Central venous access – PICC, Dialysis catheters, central lines, subcutaneous ports
Feeding
Gastrostomy tubes
Jejunostomy tubes (reflux rationale)
Others
Portal hypertension – TIPS
Pulmonary emboli/DVT – IVC filter placement
Infertility - fallopian tube catheterization
Ostopenic vertebral body collapse – vertebroplasty/kyphoplasty
Varicose veins
5. Imaging algorithms (appropriateness criteria) (Year 3 and 4)
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 pneumothorax
Management of pleural effusions (taps vs tubes vs pleurodesis)
Management of lung/liver/kidney mass (surgical/broncoscopic/endoscopic/laproscopic vs
percutaneous approach for biopsy/therapy)
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NMSCR 6/22/2017
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
gastrojejunostomy vs surgical placement or endoscopic placement)
Management of patient with large embolus/thrombus (intravenous vs direct thrombolysis vs
embolectomy)
Management of uterine fibroids (surgical vs IR)
Management of persistent epistaxis (surgical vs IR)
Management of portal hypertension (surgical vs TIPS vs endoscopic sclerotherapy)
Selection of type of venous access (non-tunneled vs tunneled central line vs port vs PICC)
Management of dialysis access (AV fistula vs AV graph, dialysis catheter, central vs peripheral
stenosis)
Management of abcesses (surgical vs IR)
Management of hydronephrosis/ureteral obstruction (retrograde stent vs IR)
Management of GI bleeding (surgery vs endoscopy vs IR)
Management of cholecystitis (surgery vs IR)
Management of peripheral vascular disease (surgery vs IR)
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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. Technical aspects (Year 1 and 2)
Techniques used to image this anatomical/physiological area
Plain films (see core curriculum), include use of portable studies, trauma series
CT: “trauma study”
Ultrasound for intraperitoneal fluid
Patient preparation and education
Short CT preps for trauma
Education about lack of need for imaging in certain conditions
Studies that ideally should be watched during elective period or during clinical
rotations
CT chest/abdomen/pelvis
CT head/C-spine
Plain film trauma series
Limited abdominal ultrasound for fluid
2. Normal anatomy (Year 1 and 2)
Structures that should be identified on each modality (Emphasis on cross-modality
correlation)
1.1.1.
1.1.2.
1.1.3.
1.1.4.
Chest: See chest curriculum
Abdomen: See Abdominal curriculum
Head: See Neuro curriculum
Musculoskeletal: See MS curriculum
3. Pathological conditions (Year 3 and 4)
Common pathological conditions/findings that the student should recognize or at
least see examples of during radiology or clinical rotations:
Trauma
Major organ injury (CT/plain films)
Liver and splenic lacerations
Aortic laceration
Hemomediastium
Diaphragmatic rupture
Duodenal/small bowel laceration
Renal laceration
Bladder perforation (indications for cystography)
Pneumothorax including signs of tension, supine and upright
Hemothorax
Rib fractures (significance of upper and lower rib fractures, posterior rib fractures in child abuse)
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Common appendicular fractures/dislocations including:
Metacarpal/phalangeal fractures
Scaphoid fracture (importance of scaphoid view)
Colles/Smith fracture
Radial head (signs elbow effusion)
Distal humeral fracture in a child (signs elbow effusion)
Humeral head fracture
Anterior shoulder dislocation and Hill Sachs fracture
Clavicle fracture
Femoral neck and intertrochanteric fractures
Femoral shaft fracture
Metaphyseal corner factures (bucket handle) in child abuse
Tibial plateau fracture
Toddler fracture tibia
Medial and lateral malleolar fractures
Ligamentous disruption of mortise joint ankle
Base 5th metatarsal fracture
Lisfranc fracture/dislocation
Importance of intra-articular extension
Importance of physeal plate involvement
Importance of displacement and angulation
Common spinal injuries (Plain films and CT)
Compression fractures thoracic and lumbar spines
Burst fractures (signs canal narrowing)
Importance of identifying cervical lines and soft tissues on lateral film
C1 Jefferson fracture
C2 fractures, dens and Hangman’s
Anterior subluxation flexion injury
Posterior ligamentous injury (subtle signs of)
Spinous process fracture
Bilateral jumped facets
Spinal epidural hematoma (MRI)
Cord contusion (MRI)
Neurological injuries
Subdural hematoma
Epidural hematoma
Diffuse axonal injury (MR)
Parenchymal contusion/hemorrhage
Non-traumatic
Chest
Lobar pneumonia (see chest section)
Atypical pneumonias such as mycoplasma, PCP
Cardiac failure (interstitial and pulmonary edema)
Cardiomegaly (chamber enlargement)
Aortic dissection (plain film, CT)
Pulmonary embolus (plain film signs, CT)
Pneumomediastinum
Abdomen
Appendicitis (CT)
Acute cholecystitis (U/S, hepatobiliary study)
Diverticulitis (CT)
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Ruptured abdominal aortic aneurysm (CT, Ultrasound)
Renal calculi (KUB, CT)
Intraperitoneal free air
Small bowel obstruction
Large bowel obstruction
Testicular torsion
Musculoskeletal
Acute osteomyelitis
Septic arthritis
Neurological Disorders
Acute and subacute infarction (CT, MRI)
Subarachnoid hemorrhage (CT)
Ob/Gyn Disorders
Ectopic pregnancy (u/s)
Missed/completed abortion
Ovarian torsion
Ovarian cyst/cyst rupture
Placental abruption
Pediatric Disorders (specific)
Aspirated foreign body in a child (CXR, fluoro)
Intersusception (KUB, air vs barium enema)
Bowel volvulus
Bronchiolitis
Epiglottitis
Croup
Iatrogenic pathology
Misplaced naso/oral gastric tubes
Correct position of chest tubes
Correct position of endotracheal tubes
Correct position of central lines
Iatrogenic pneumothorax and pneumomediastinum
Emergency “don’t miss” findings
Tension pneumothorax
Aortic rupture
Aortic dissection
Diaphragmatic rupture
Child abuse – posterior rib fractures, metaphyseal corner fractures, bilateral subdurals of different
ages
Cerebral herniation (CT)
Small or isodense subdural hematomas
Testicular torsion
Abnormalities of spinal-laminar lines/alignment of the c-spine e.g. posterior ligamentous injury
Diagnostic situations/conditions unlikely to benefit from imaging
Use of CXR rather than rib films in suspected rib fractures
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Coccygeal fractures (no imaging)
Ankle injuries that do not fulfill Ottawa ankle criteria
Ambulating patients for r/o tibia/fibula fxs
4. Invasive procedures (Year 3 and 4)
Identify clinical scenarios where image-guided procedures may be beneficial
Ultrasound guided thoracocentesis and paracentesis
Pigtail catheter placement for pneumothorax
5. Imaging algorithms (appropriateness criteria) and cost effective imaging (Year 3
and 4)
Criteria for performing CT (C/A/P) in trauma patient
Criteria for performing limited ultrasound for abdominal fluid in trauma patient
Criteria for performing CT c-spine in neck injuries
Indications for performing CT prior to lumbar puncture
Criteria for head CT for headache
Appropriate 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 epiglottitis
Appropriate imaging for suspected DVT
Appropriate imaging for suspected ruptured aortic aneurym
Appropriate imaging for suspected bladder rupture (CT vs fluoro vs both)
Appropriate imaging for suspected pelvic inflammatory disease
Appropriate 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)
Incorporating imaging findings into patient management including effects of pretest probabilities
Management of suspected ectopic pregnancy when no gestational sac seen
Management 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.
1. Technical aspects (Year 1 and 2)
Techniques used to image this anatomical/physiological area
Mammography (analogue, digital)
CC and MLO positioning
Rationale for compression
Screening versus diagnostic mammography
Indications for diagnostic mammography
Palpable mass
Call back from screening
Focal pain
Short interval follow-up from prior ACR 3 mammogram
Bloody nipple discharge
Ultrasound
Breast
Transabdominal
Transvaginal
Hysterosonograms
Hysterosalpingograms
MRI
Breast
Pelvic
Fetal
Nuclear medicine (sestamibi, PET)
Patient preparation and education (Year 1 and 2 in epidemiology and ethics
sessions and also Year 3 and 4 during clinical rotations)
Breast imaging
Sensitivity and specificity of screening mammography
Patient education regarding benefits and risks of screening mammography
Increasing patient compliance with screening protocols
Understanding the screening call-back system
Radiation risk and cumulative exposure from screening mammography
Pelvic/fetal ultrasound
Use of transvaginal probes
Importance of bladder filling on for some pelvic scans
Appropriate timing of fetal ultrasound scans (dating, morphology)
Medical test not family entertainment
Sexing of fetuses not always possible
Accuracy of dating +/- 10%
Use of tranvaginal ultrasound in early pregnancy
Importance of understanding limitations of ultrasound
Sensitivity only about 80-85% in diagnosing anomalies
Normal scan  normal baby
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Small fetuses (early scans)
Obese patients
Studies that should be watched during elective period or during clinical rotations
(Year 3 and 4)
Breast imaging
Screening mammogram
Breast ultrasound
Breast biopsy (stereo and ultrasound)
Needle localization
Pelvic/fetal ultrasound
Transvaginal and transabdominal ultrasound
Early pregnancy (6-10 w) transvaginal scan
Morphology (18-20) scan
2. Normal anatomy (Year 1 and 2)
Structures that should be identified on each modality
Breast imaging
Fat versus glandular tissue
Pelvic/fetal ultrasound
Uterus
Ovaries
Cervix
Cul-de-sac
Early fetal scan: yolk sac, gestational sac, fetal pole
Normal early OB milestones (gest sac 5w, yolk sac 5.5w, heart beat 6w)
Morphology scan: Head, abdomen, chest, limbs, cord, placenta
More detail not felt appropriate at medical student level
3. Pathological conditions (Year 3 and 4)
Common pathological conditions/findings that the student should recognize or at
least see examples of:
Breast imaging
Recognition not required at general medical student level.
Benign masses (cysts, fibroadenomas)
Malignant masses (obvious cancer)
Calcifications (benign, malignant)
Pelvic/fetal ultrasound
Fibroids
Thickened endometrium
Ovarian cyst/solid mass
Ectopic pregnancy with ‘empty’ uterus
Knowledge of the types of major anomalies that can be identified by ultrasound, and those that
cannot:
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Neuro (hydrocephalus, Chiari malforms, neural tube defects, anencephaly, etc)
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.
Emergency “don’t miss” findings
Recognition not required at general medical student level
Diagnostic situations/conditions unlikely to benefit from imaging (other than
routine screening mammography if >40 yrs)
Diffuse breast pain
Bilateral breast discharge
Expressible only, non-bloody discharge
Large areas of breast “thickening” esp. if bilateral
Waxing and waning masses
Ultrasound in the very early pregnancy (<5w or when serum HCG<1000 IU)
4. Invasive procedures (Year 3 and 4)
Identify clinical scenarios where image-guided procedures are beneficial
Breast
Rationale for performing core biopsies
Decreased scar/morbidity
Pre-operative planning
Reductions in repeat surgical rates
Needle-wire localizations for non-palpable abnormalities
Indications for stereotactic or ultrasound guided breast biopsies
Non-palpable masses, asymmetric densities, calcifications
Palpable masses
Pelvic/fetal ultrasound
Use of ultrasound in performing amniocentesis and fetal therapeutic procedures
Use of sonohystography
Use of uterine artery embolization
Use of fallopian tube catheterization
5. Imaging algorithms (appropriateness criteria) (Year 3 and 4)
Appropriate imaging algorithms for common diagnostic situations including costeffective imaging
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Breast Imaging
Currently recommended screening protocols (ACR)
Effect of screening mammography on breast cancer mortality rates
Mammography screening in 40-50 age group controversies
Mammography screening in high-risk groups
When to stop screening
Evaluation of palpable breast masses
Evaluation of palpable masses in young patients
Surgical evaluation of questionable palpable findings
Use of ultrasound for cystic versus solid lesions
Pelvic/fetal ultrasound
Appropriate 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 pregnancy
Prior history of multiple pregnancy
Infertility 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 patients
Size/date discrepancy
Bleeding
Cervical incompetence
No fetal heart by Doppler
Amniocentesis
Indications for scanning in the third trimester:
Size/date discrepancy (fetal biometry)
Bleeding (previa/abruption),
Cervical incompetence
Monitoring of known fetal or placental anomaly
No fetal heart by doppler
Presentation
Cervical 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 woman
Staging of cervical and uterine carcinomas
Evaluation of ovarian masses
Evaluation of congenital abnormalies of the uterus
Indications for MRI in pregnancy
Trauma
Complex neurological anomalies
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Complex body wall anomalies
Concurrent maternal abdo-pelvic disease
Incorporating imaging findings into patient management including effects of pretest probabilities
Breast imaging
Meaning of ACR categories 0-5
Significance and Management of ACR 3 findings
Management 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 bleeding
Importance 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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Neuroimaging
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 (Year 1 and 2)
Techniques used to image this anatomical/physiological area
NeuroCT and CT of the neck, sinuses and ear
NeuroMR
Cerebral angiography
Spinal imaging-CT
Spinal imaging-MR
Myelography
CTA/MRA
Patient preparation and education
Importance of holding still for long periods for MRI
NPO for several hours before IV contrast
External halo devices for stereotactic procedures
Studies that should be watched during elective period or clinical rotations
Head or spine CT
Head or spine MR
Myelography
Cerebral angiogram
Neurointerventional procedure
2. Normal anatomy (Year 1 and 2)
Structures that should be identified on each modality (Emphasis on cross-modality
correlation CT vs MR)
Lobes of brain
Midbrain
Brainstem
Spinal cord
Ventricles
Optic nerves
Epidural vs subdural vs subarachnoid spaces
Carotids, MCA, ACA
Sagittal sinus, jugular
Vertebral column and discs and nerve roots
Anterior vs posterior triangle of the neck
Paranasal sinuses
Pharynx
Larynx
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3. Pathological conditions (Year 3 and 4)
Common pathological conditions/findings that the student should recognize or at
least see examples of:
Tumors
Intraaxial tumors
Metastatic disease
Extraaxial tumors
Head and neck tumors
Infection
Cerebral abcess
Meningitis
Discitis
Paraspinal abcess
Sinusitis
Trauma
Subdural hematoma
Epidural hematoma
Subarachnoid hemorrhage
Intracerebral hemorrhage (appearance of blood on MR vs CT, time dependancy)
Diffuse axonal injury
Cerebral herniation
Cervical spine trauma
Facial trauma
Vascular disease
Cerebral aneurysm
Stroke: early vs late (atherosclerotic, thrombo/embolic)
Vascular malformations
Miscellaneous:
Demyelinating diseases
Dementia (atrophy)
Normal age related changes
Emergency “don’t miss” findings
Hemorrhagic stroke
Traumatic hemorrhage (subdural, epidural, subarachnoid, intraparenchymal)
Signs of increased intracranial pressure, midline shift,
Cerebral herniation
Hydrocephalus
Space occupying lesions
Isodense subdurals
Bilateral hematomas of different ages in child abuse
Diagnostic situations/conditions unlikely to benefit from imaging
Skull films-NOT indicated in most cases of head trauma
Timing for appearance of stroke findings
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CT for migrainous/recurrent headache
4. Invasive procedures (Year 3 and 4)
Identify clinical scenarios where image-guided procedures may be beneficial
Treatment of berry aneurysms
Biopsy of tumors
Treatment of congenital vascular anomalies
5. Imaging algoritms (appropriateness criteria) (Year 3 and 4)
Appropriate imaging algorithms for common diagnostic situations including costeffective imaging
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 films
Appropriate imaging sequence in spinal trauma
Appropriate 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 dizziness
Appropriate imaging for seizures
Appropriate imaging for dementia
Appropriate imaging for meningitis
Appropriate 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 MR
When conventional neuroangiography is indicated
Appropriate imaging for stroke –early and late (CT vs MR vs angio)
Appropriate imaging for TIAs
Criteria for performing CT prior to lumbar puncture
Vascular lesions that can be managed with interventional angiography
Appropriate imaging for encephalitis
Appropriate imaging for multiple sclerosis
Appropriate imaging for peripheral neuropathies
Incorporating imaging findings into patient Management including effects of pretest probabilities
Management of MRA negative patient with subarachnoid hemorrhage
Management of the stroke patient with evidence of hemorrhage
Management of the stroke patient without evidence of hemorrhage (timing) with or without CT evidence
of infarct
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Nuclear Medicine
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 (Year 1 and 2)
Techniques used to image this anatomical/physiological area
Outline of gamma camera operation
Concept of radiopharmaceuticals, in general
99mTc as most commonly used isotope
Concept of 18F-FDG PET scanning and PET-CT
Concept of physiological versus anatomical imaging
Patient preparation and education
Caffeine withholding for cardiac pharmacologic stress testing
Fasting for PET scans
Iodine containing products for thyroid scanning
Requirement for keeping still for 20-50 minutes
Studies that should be watched during elective period
Bone scan or other routine planar study
SPECT scan of some type
Cardiac stress test and perfusion scan
2. Normal anatomy (Year 1 and 2)
Structures that should be identified on each modality with emphasis on crossmodality correlation
Recognize a bone scan
Recognize a myocardial perfusion scan (left ventricular walls, right ventricle)
Recognize a VQ scan
Recognize a PET scan
Recognize a hepatobiliary study (identify gallbladder, liver, bowel)
Recognize a MUGA
3. Pathological conditions (Year 3 and 4)
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)
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Acute fracture (bone scan)
Obvious myocardial infarct/ischemia (myocardial perfusion study)
Acute cholecystitis (hepatobiliary scan)
Toxic nodule (thyroid scan)
Graves' disease
UPJ obstruction (MAG3/DPTA scan)
Metastastic tumor (PET FDG scan)
Iatrogenic pathology
Bile leaks s/p cholecystectomy
Ureteral obstruction
Emergency “don’t miss” findings
Emergency interpretation of nuclear medicine studies not expected by students or non-radiology
interns/residents
Diagnostic situations/conditions unlikely to benefit from imaging
Delayed imaging in GI bleeding scans
Bone scans in myeloma
4. Invasive procedures (Year 3 and 4)
Identify clinical scenarios where image-guided procedures are beneficial
Shunt patency studies
5. Imaging algorithms (appropriateness criteria) (Year 3 and 4)
Appropriate imaging algorithms for common diagnostic situations
Indications for common nuclear medicine exams: (Tracers used for these exams)
Bone scan (99mTc methylene diphosphonate (MDP))
Metastases
Fracture
Child abuse (useful knowledge for future pediatricians)
Osteomyelitis
Thyroid scan (99mTc pertechnetate, 123I NaI,131I NaI)
Thyrotoxicosis
Thyroid nodules
Ventilation perfusion [VQ] scan (99mTc macro-aggregated albumin, 133Xe , 99mTc DPTA aerosol )
Suspected pulmonary embolism
Differential lung perfusion
Myocardial perfusion imaging (99mTc Sestamibi, 201Tl)
Suspected ischemia
Evaluation of infarct size
Post revascularization assessed
Pre-operative evaluation of high risk patients e.g AAA
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MUGA (99mTc labeled RBC)
Ejection fraction and wall motion prior to chemotherapy
Evaluation of ischemic heart diease (+/- stress)
Hepatobiliary scan (99mTc DISIDA/mebrofenin)
Suspected acute cholecystitis
Suspected chronic cholecystitis/biliary dyskinesis (CCK)
Renal scan (99mTcDPTA or MAG3 or DMSA)
Obstruction
Renovascular hypertension
Renal 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 restaging
Myocardial viability
Seizure 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)
Incorporating imaging findings into patient Management including the effects of
pre-test probabilities
Understanding the concept of PIOPED criteria
Tumors 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
scans
Cardiac stress test data effects interpretation of myocardial perfusion studies
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Pediatrics
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 (Year 1 and 2)
Techniques used to image this anatomical/physiological area
Fluoroscopy-with low dose pulsed fluoroscopy, shielding where possible
Plain films-with restraints if necessary
CT-with sedation
MR-with sedation
Ultrasound-no sedation, no radiation, used overall more than in adults
including neuroimaging prior to closure of fontanelles
Nuclear medicine – may or may not need sedation
Patient preparation and education
Use of ‘pain-free’ child anesthesia services
Experienced i.v. teams, use of ‘Emla’ cream before i.v. lines
Parents sometimes are in room during procedures
Decide whether it is better to have parents in or out
Pre-procedure information & preparation for children can be very helpful
Studies that should be watched during elective period
VCUG
Barium swallow/UGI
Abdominal ultrasound
Chest radiograph
KUB
Cranial ultrasound
2. Normal anatomy (Year 1 and 2)
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 baby
Normal pulmonary vascularity
Heart (noting different ratio heart:thorax in neonate)
Thymus
Abdomen:
Liver
Spleen
Kidneys
Skeletal plain films:
Normal appearance of growth plates, identification of metaphysis, physis and epiphysis
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Order 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
Brain
Normal neonatal brain appearance (US, CT)
3. Pathological conditions (Year 3 and 4)
Common pathological conditions/findings that the student should recognize or at
least see examples of:
Trauma:
Growth plate injuries
Elbow effusion (significance of)
Greenstick fractures, esp distal radial torus fracture, toddler fracture
Infections:
Pneumonia and round pneumonia
Bronchiolitis (hyperinflation)
Tumors:
Wilm's tumor
Neuroblastoma
Congenital abnormalities:
Example of congenital cyanotic heart disease e.g. Tetralogy of Fallot
Pyloric stenosis
Vesicouretic reflux (VCUG)
Neonates:
Neonatal radiology felt beyond general medical student level, for dedicated electives consider:
TTN/ hyaline membrane disease
Meconium aspiration
Pneumonia
Bronchopulmonary dysplasia
Emergency “don’t miss” findings
Child abuse – posterior rib fractures, metaphyseal corner fractures, unusual spiral fractures of long
bones, signs of old multiple fractures, bilateral subdural hematomas of different ages
Pneumoperitoneum
Pneumothorax in a neonate
Diagnostic situations/conditions unlikely to benefit from imaging
Chronic abdominal pain
Recurrent, uncomplicated asthma
4. Invasive procedures (Year 3 and 4)
Identify clinical scenarios where image-guided procedures may be beneficial
Biopsy
Abscess drainage
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PICC line placement
Prenatal therapy
Sclerotherapy (lymphatic malformations)
5. Imaging algorithms (appropriateness criteria) (Year 3 and 4)
Appropriate imaging algorithms for common diagnostic situations including costeffective imaging
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 studies
Intussusception reduction attempt in child with surgical abdomen
Abdominal CT in unstable trauma patient
Incorporating imaging findings into patient management including effects of pretest probabilities
Management of borderline pyloric measurements in projectile vomiting
Management of negative plain films in high suspicion bony injuries (e.g. distal humerus)
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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
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
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

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
NMSCR 6/22/2017

“Sub-intern” experience – assigned cases for interpretation

Individual OSCE with structured questions and immediate feedback
Informal Quizzes

Film or digital slide quiz

Web-based multiple choice quizzes with feedback (with or without cumulative student responses for selfcomparison)

CDROM based quizzes

Group or individual effort
Formal Exams

http://radiology.examweb.com
o
National database of multiple choice questions for students on radiology rotations.
o
Exams developed, shared and taken
o
For more information contact [email protected]

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
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).
60
NMSCR 6/22/2017

Use of audience response pads

Use of team/individual response buzzers
61
Self-learning exercises

Student specific teaching files (film or digital)

CDROMS (see below)

Websites (see below)

Web-based tutorials

Imaging algorithms with clinical scenarios

Anatomy identification on images (film or digital) with or without immediate answers

Slide-tape sets

Past student presentations
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
Casefiles
AMSER Shared Resources are found at
http://www.dartmouth.edu/~amserimages/
Login: amserid
Password: roentgen
These include a 4000+ image dataset of commonly found conditions, lectures, curricula and other shared
resources donated by AMSER members

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.

Washington University, Musculoskeletal Teaching file
(http://www.rad.washington.edu/academics/academic-sections/msk/teaching-materials/teaching-files)
Excellent MS teaching file as well as other info
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
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.

Mallinkrodt teaching files (http://gamma.wustl.edu/home.html)
Excellent nuclear medicine teaching cases
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. Nice chest CT anatomy section.

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 Skeletal Anatomy (http://uwmsk.org/RadAnatomy.html) Review of basic skeletal
anatomy on plain films. This site also has more complex MRI-based MS anatomy tutorials

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
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
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

Yale Cardiothoracic Imaging (http://www.med.yale.edu/intmed/cardio/imaging/).
Comprehensive audio and visual modules covering plain film, ct, mri and angiography of the
cardiothoracic system. Normal and abnormal. Primarily for residents, but also of interest to
students.

Beth Israel (Gillian Lieberman) web-tutorials
(http://www.bidmc.org/MedicalEducation/Departments/Radiology/MedicalStudents.aspx) .
This is an extensive series of sites, containing modules for students as well as primary care
practitioners. It includes flash and ppt modules, some with voice. Excellent and
comprehensive site, esp for chest and abdomen. Some files very large.

Dartmouth anatomy (Nancy McNulty) (http://www.dartmouth.edu/~anatomy)
Basic anatomy and radiological anatomy modules, most suitable for first year students or
refresher for clinical years.

CT/MRI/cadaver anatomy from Univ Aukland
(http://www.fmhs.auckland.ac.nz/sms/anatomy/atlas/intro.aspx)
Sectional anatomy with CT and MRI correlation of entire body

Anatomy modules from West Virginia University
(http://anatomy.hsc.wvu.edu/eStudyGuide/SecondLevel/Radiologic/P2index.swf)
Various radiological anatomy modules, both plain film and cross sectional

SUNY Downstate brain MRI anatomy
(http://ect.downstate.edu/courseware/neuro_atlas/mri_horizontal.html)

OB Ultrasound.net (Joseph Woo) (http://www.ob-ultrasound.net/). Nice introductory site for students
interested in learning the rudiments of obstetrical ultrasound.

Beth Israel nuclear medicine tutorial
(http://mycourses.med.harvard.edu/vp_view.asp?frame=Y&case_id=%7BA05B20FA-F648-468F-BB4CF6FE9ED09438%7D) Course designed for primary care physicians covering the indications and
descriptions of the common nuclear medicine studies. Nice review for students.
General information and Portals

AMSER (http://www.aur.org/Affiliated_Societies/amser/index.cfm)
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

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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
Association of Program Directors in Radiology (http://www.apdr.org/)
Includes information for medical students, teaching resources and program information

RSNA (http://www.rsna.org/residency.cfm)
Links for medical students interested in a career in Radiology.

Radiology Education (http://www.radiologyeducation.com/)
Multiple links to a huge number of websites, lists textbooks and case files.

Medicalstudent.com (http://www.medicalstudent.com
This is an extensive site with current links to all areas of medicine including radiology. This site has won
several awards

ACR appropriateness criteria
(ttp://www.acr.org/secondarymainmenucategories/quality_safety/app_criteria.aspx) A must for every
medical student to know about. Useful resource for image algorithm sessions.
64
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)
4. Textbooks
Comprehensive radiology textbooks for medical students:
Essential Radiology: Clinical Presentation, Pathophysiology, Imaging 2nd Edition by Richard Gunderman
Publisher: Thieme Medical Publishers, Incorporated
Pub. Date: January 2006
ISBN-13: 9781588900821
Squire's Fundamentals of Radiology: Sixth Edition by Robert A. Novelline
Publisher: Harvard University Press
Pub. Date: February 2004
ISBN-13: 9780674012790
Medical Imaging by Peter Scally
Publisher: Oxford University Press, USA (February 17, 2000)
Language: English
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ISBN-10: 0192630563
ISBN-13: 978-0192630568
Blueprints Radiology (2nd Edition) by Alina Uzelac, Ryan W. Davis, Ryan Davis
Publisher: Lippincott Williams & Wilkins
Pub. Date: October 2005
ISBN-13: 9781405104609
Essentials of Radiology by Fred A. Mettler Jr.
Publisher: Elsevier Science
Pub. Date: September 2004
ISBN-13: 9780721605272
Clinical Radiology: The Essentials 3rd edition by Daffner, Richard H Daffner, Richard H
Publisher: Lippincott Williams & Wilkins
Pub. Date: February 2007
ISBN-13: 9780781799683
The Hands-On Guide to Imaging by David C. Howlett, Brian Ayers
Publisher: Wiley, John & Sons, Incorporated
Pub. Date: September 2004
ISBN-13: 9781405115513
Imaging for Students by David Lisle
Publisher: Hodder Arnold
Pub. Date: March 2007
ISBN-13: 9780340925911
Problem or case-based format:
Case Studies in Medical Imaging: Radiology for Students and Trainees by Anil T. Ahuja (Editor),
Gregory E. Antonio (Editor), K. T. Wong (Editor)
Publisher: Cambridge University Press
Pub. Date: August 2006
ISBN-13: 9780521682947
Pattern recognition format:
Learning Radiology: Recognizing the Basics: by William Herring
Publisher: Elsevier Science
Pub. Date: May 2007
ISBN-13: 9780323043175
Pocket format:
The Radiology Handbook: A Pocket Guide to Medical Imaging by J. S. Benseler
Publisher: Ohio Univ Pr
Pub. Date: September 2006
ISBN-13: 9780821417089
Radiology Recall 2nd Edition by Spencer B. Gay, Richard J. Woodcock Jr., Richard J. Woodcock (Editor)
Publisher: Lippincott Williams & Wilkins
Pub. Date: November 2007
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ISBN-13: 9780781765596
66
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Diagnostic Shortlist : The “Must See” Images
Images all students should see
This is a limited list of diagnoses and their respective imaging modalities that all students should be shown and
be able to recognize classic examples of, regardless of their planned speciality. Images that can be used for
teaching this list are available at AMSER-ID (see websites above).
Condition
Details
Modalities
Pneumothorax
Upright, supine, signs of tension,
adult and child
CXR, CT
Pneumonia
Lobar, sublobar, viral, spine sign
CXT, CT
Pneumomediastinum
CXR, CT
Pneumoperitoneum
Upright, supine
CXR, KUB, CT
Pleural effusion
Upright, supine
CXR, CT
Pulmonary edema
P.venous hypertension, interstitial,
alveolar
CXR
Aortic dissection
CXR, CT
Aortic rupture
CXR, CT
Diaphragmatic rupture
KUB, CT
SBO
Upright, supine
Cecal and sigmoid volvulus
Distal large bowel obstruction
KUB
KUB, enema
Upright, supine
Ascites
US, CT
Missed placed lines/tubes
Dobhoff/NG tubes, central venous
catheters, endotracheal tubes
CXR, KUB
Child abuse
Metaphyseal and rib fractures,
bilateral subdurals (inc. isodense)
CXR, extremity films, CT/MR
Stroke
Edema, hemorrhage, mass effect
CT
Intracranial traumatic hemorrhage
Epidural, subdural, subarachnoid,
intraparenchymal
CT
Increased intracranial pressure
Inc. shift and cerebral herniation,
hydrocephalus
CT
Space occupying lesions
Mass effect, +/- contrast
CT, MR
Cervical spine injury
Abnormalities of spinal-laminar
lines/alignment of the c-spine e.g.
posterior ligamentous injury
Plain films
Fracture with extension into joint
Knees, ankles, wrist, elbow
Plain films
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Elbow joint effusion
Radial head fracture, distal
humneral fracture
Plain films, child and adult
Shoulder dislocation
Anterior and posterior
Plain films
Buckle fractures
Radius, child
Plain films
Scaphoid fracture
Proximal femoral fracture
Plain films
Obvious and more subtle
Plain films
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NMSCR 6/22/2017
Example of Goals and Objectives for a Student
Elective
This is an example of modality specific goals and objectives for 4th year medical students on a 4-week rotation
in radiology (from Dartmouth-Hitchcock Medical Center). It includes web resource links for the students.
(current version available at http://docs.google.com/View?id=dc544pq3_2ds3ks2dg )
Goals and Objectives for Medical Students on Radiology Elective at DHMC
Introduction
This document is intended to focus student educational efforts on the elective and also to provide guidance to staff
within specific areas. These goals and objectives include material covered during letures and workshops and self
study time as well as clinical rotations.
Reading room
Goals of rotation

Learn normal CXR anatomy and become familiar with the range of normal appearances through seeing
multiple examples of normal films

Gain a familiarity with the interpretation of portable CXRs

Identify the different CXR views and when they are helpful, as well as the limitations of each (PA, AP,
lateral, supine, upright, decubitus, expiratory, lordotic)

Learn to recognize common conditions on CXRs: Pneumonia, pneumothorax, pleural effusions, pulmonary
edema, ARDS atelectasis, cardiomegaly, pulmonary masses, granulomas, hilar enlargement,
COPD/emphysema, aortic rupture

Learn to identify correct and incorrect tube placements: Central lines, ETT, PICC, NG, Dobhoff

Learn the common indications for performing CXRs and when additional imaging with CT, MRI or nuclear
medicine studies may be helpful

Be able to recognize some of the common plain film MSK abnormalities: Hip fracture, ankle fractures,
scaphoid fracture, wrist fractures inc. buckle fractures, osteoarthritis, rheumatoid arthritis, knee and elbow
effusions, spinal compression fracture, shoulder dislocation

Understanding how we describe fractures

Understand the importance of obtaining the appropriate views (scaphoid, radial head, shoulder internal and
external rotation)

Know some of the indications for and benefits of obtaining further imaging with MRI, CT or arthrography
Specific recommendations

Read Felson CXR workbook (provided)

Review CXR anatomy
NMSCR 6/22/2017

If in the RR in the morning, you should ensure that you sit in on the on-call resident readout

Aim to spend your time in the reading room predominately split between the chest and float staff

Those with an interest in pediatric imaging should spend time with Drs. Vaccaro and Sargent on M, T, Th
pms

Those with an interest in MSK imaging, should spend some time with Drs. Goodwin and Cheung in the
MSK room - note, MSK plain films are also read by float radiologists

Pre-read films (6-8 at a time) then review with radiologist who will dictate
70
Additional reading
Learningradiology.com (various modules)
How to see abnormalities on CXRs from www.cxr.com
University Virginia CXR module
University Virginia ICU chest film module
CT/Body Imaging
Goals of rotation

Develop a method, or approach to evaluate CT scans of the chest, abdomen and pelvis

Review normal CT anatomy of the chest, abdomen and pelvis

Learn about the different scanning techniques and understand why they are performed. Be familiar with
some general protocol categories: CT angiography, multiphase imaging protocols, CT enterography

Learn about contrast allergies, the contraindications to iv contrast, and prevention of contrast reactions with
steroids

See CTs and CT guided procedures performed so that you can explain them to patients

Learn the radiation risks of CT, understand how those risks differ in different patient populations, and
understand methods which can be used to reduce the risk: Dose reduction techniques, Limiting the region
scanned, limiting repeat CTs

Learn the CT findings of commonly encountered acute conditions: Diverticulitis, colitis, appendicitis,
pancreatitis, renal stone disease,pulmonary embolism, aortic dissection,
pneumoperitoneum,hemoperitoneum, aortic rupture and dissection,

Learn the CT findings of commonly encountered chronic conditions: Solid organ tumors, metastases,
ascites, lymphoma, aortic aneurysms
Specific recommendations

Read out the on-call CTs with on-call resident (if you are in the reading room this may occur during that
rotation)

If a workstation is available, pre-read appropriate CT scans (one at a time) before reviewing with staff
radiologist
NMSCR 6/22/2017
71

Towards the end of the rotation, sit down with the resident who is doing the protocols and learn about how
we choose which protocol to use.

Spend time in the CT core area observing the technologists performing at least 2 scans; one of these
should include an iv contrast injection.

Observe or participate in a CT guided biopsy. Review the patient history, learn the indication for the
procedure, understand the technique used, follow up on the pathology results.

Observe or participate in a CT guided drainage. Review the patient history, learn the indication for the
procedure, understand the technique used. If applicable, follow up on the microbiology results.
Additional reading
CT/MRI/cadaver anatomy from Univ Aukland
CT abdomen and pelvis from WVU
CT chest anatomy from chestxray.com
Neuroimaging
Goals of rotation

Understand the strengths, weaknesses and limitations of CT vs. MRI in the evaluation of patient’s with
central neurologic symptoms and diseases

Understand the strengths, weaknesses and indications of spine CT, MRI, and myelography in the
evaluation of the spine and spinal cord

Understand the indications for conventional carotid and cerebral angiography, its risks and benefits in
comparison with CTA and MRA

Understand the role of imaging (including MRI vs. CT) in the evaluation of common clinical complaints,
including stroke, headache, trauma, mass lesions, back pain, radiculopathy and demyelinating disease

See how different MR sequences are used to identify different pathophysiological processes.

Understand the usual appearances of gray matter, white matter, fluid, edema, masses, blood, and fat on
common MR sequences (T1, T2, FLAIR, STIR )

Know some of the uses of contrast in MRI and CT

Review basic neuroanatomy on head CT and MRI

Develop a basic but comprehensive standard method to evaluate routine non-contrast head CTs

Get an overview of common procedures done in neuroradiology, including the use of nerve root blocks for
management of back pain and vertebroplasty for compression fractures

Be able to recognize the appearance of common pathological processes such as stroke, edema,
herniation, subdural, epidural and subarachnoid hemorrhage on CT
Specific recommendations

Be involved in the morning readout of the call resident (usually around 8am)

Accompany the neuroradiology fellow/resident during the workup and performance of nerve root blocks and
vertebroplasties
NMSCR 6/22/2017

72
Become an active participant in the daily MR and CT reading including pre-reading studies when a
workstation is available
Additional reading
University Virginia Intro to Head CT module
University Virginia Evaluation of the Cervical Spine
SUNY Downstate brain MRI anatomy
Fluoroscopy
Goals of rotation

Understand how fluoroscopy is used to image cavities and lumen

Learn the difference between the different fluoroscopic tests and what structures they image: Modified
swallow, single and double contrast swallow, UGI, small bowel follow through, single, air and double
contrast enemas, IVP, VCUG

Learn the common indications for fluoroscopic tests

See studies performed so that you can explain them to patients: Ba swallow, UGI, enema, VCUG,
arthrogram, IVP

Understand the advantages and limitations of fluoroscopy

Understand some of the risks of fluoroscopy - radiation, contrast extravasation/aspiration, perforation

Understand the differences between the various contrast medias used in fluoroscopy

Learn normal KUB anatomy and become more comfortable with the range of normal appearances

Become familiar with interpretation of common conditions on plain abdominal radiographs: Obstruction,
free air, illeus, abnormal calcifications (vascular, gallbladder, renal, bladder), large masses
Specific recommendations

Pre-read KUB studies and then review with radiologist

Follow at least one patient through a study with the technologist,

preferably one of the more complex studies such as an enema. You should have worked up this patient
beforehand on CIS.
Be present at the 8am case discussion each morning. Watch the studies being performed with the
resident/attending (in room with lead unless pregnant) and the interpretation afterwards Try to see as wide
a variety of studies being performed as possible including pediatric studies
Additional reading
University Virginia GI site (this may be more detailed than you need but good sections)
Learningradiology.com plain abdominal film intrepretation
Learningradiology.com (various student modules)
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Mammography
Goals of rotation

See how mammograms and breast ultrasound are performed

Be able to briefly describe mammographic procedures to patients

See how we use different mammographic views and ultrasound for problem solving in diagnostic
mammography

Understand the differences between screening and diagnostic mammography

Know the effect of screening mammography on survival rates Know the current recommendations for
screening mammography and MRI

Understand the management of screening 'call back' patients

Understand the meaning of BIRADS 0-6 categories

Know the indications for referral for diagnostic mammography and how to indicate the abnormality
appropriately.

Know the current indications for breast MRI.

Understand some of the limitations of breast imaging techniques including the effect of breast density.

See how ultrasound is used in the diagnostic setting and some of its limitations

Know what the options are for image guided procedures in the breast.

Understand how clinical examination and imaging are inter-related and how they affect management
especially of palpable breast masses.

Understand what a radiologist is looking for on a mammogram and what those terms mean:
o

Calcifications, Asymmetric densities, Architectural distortion, Masses.
See some examples of benign and malignant processes in the breast on mammography and ultrasound
Specific recommendations

Spend a minimum of one diagnostic session in mammography

See at least one full mammographic series (CC, MLO) being obtained by a technologist

Follow at least one patient through her diagnostic evaluation including additional mammo views and
ultrasound, watching the tech performing the views as well the radiologist interpreting them.

Perform a clinical breast examination on consenting women with palpable masses prior to the ultrasound

Look up the BIRADS categories

Go through CORE Women's Imaging Case 2 again

Review Dr. Poplacks lecture and/or this lecture from U.Washington on screening or this one on diagnostic
mammography/breast MRI

For students spending > 1 session in mammography should also aim to:
o
See image guided breast procedures performed, assist in basic patient care procedures where
possible
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o
74
See some examples of breast MR studies
Additional reading
ACS 2003 review and guidlelines for screening mammography
Breast Cancer Detective
Beth Israel (Lieberman) breast imaging module
Ultrasound
Goals of rotation

Gain hands-on practice in using ultrasound imaging:

Be able to find and recognize major intra-abdominal organs

Gain basic familiarity with how moving the transducer changes the imaging plane

See how altering scanning parameters such as gain, depth and focal zone affect our images

See how different transducers are used for different purposes

Learn the basic ultrasound imaging characteristics of tissues –
o
simple fluid, complex fluid, soft tissue, bone, air, fat

See how the different types of Doppler ultrasound (m mode, pulsed, color and power) image motion

Learn the appropriate indications for the common ultrasound examinations

See some of the limitations of ultrasound –
o

obesity, bowel gas etc
Learn classic appearance of common conditions:
o
RUQ: gallstones, acute cholecystitis, biliary obstruction
o
Abdominal aortic aneurysm
o
Renal: renal stones, hydronephosis
o
Pelvic: Fibroids, endometrial thickening, ovarian cysts, early pregnancy, normal 2nd trimester
pregnancy
o
Other: pleural fluid and ascites
Specific recommendations

Students should spend at least 50% of time with technologists watching scans

Scan patients themselves (not transvaginally), with patient permission after tech leaves room.

Remainder of time with attending/residents in reading room, helping with clinical workflow where possible.

After they see an abnormal study: look up brief background on condition/additional images (e.g.
http://www.mypacs.net (search under ultrasound), www.ultrasoundcases.info or the Brigham teaching
database.
Additional reading
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75
University of Virginia Emergency Ultrasound
Introduction to obstetrical ultrasound
Interventional radiology
Goals of rotation

Learn how different imaging modalities are used to guide procedures and begin to understand when each
is used: ultrasonography, fluoroscopy, CT, MRI

Be familiar with the indications and techniques of the following common IR procedures:
o

Be able to describe to a patient the following procedures (observe any of these which occur the day you
are on angio):
o

central vascular access, fluid aspiration and drain placement, angiography, percutaneous
nephrostomy, percutaneous transhepatic cholangiography, gastrostomy tube placement,
percutaneous angioplasty and stent placement
Vascular access, angiography, fluid aspiration and drainage, tube placement in stomach
(gastrostomy), kidney (nephrostomy)
Learn how we work up requests for IR procedures and the factors that go into determining if a procedure is
necessary and indicated, safe, and able to be performed.
Specific recommendations

Introduce yourself to the staff of the day

Attend the morning conference to discuss the days cases. This begins at 7:15 am in the small reading
room near angio; anyone in the angio suite can direct you

If you are spending more than one day in angio, in the afternoon before an IR day:
o
Pick one case that you would like to be involved with from the board (check with the resident, fellow
or NP/PA on the service) and participate in/do the patient work-up. Review the relevant patient
history, allergies, medications, PMH, Labs and pertinent imaging studies. Understand the
indications for the requested procedure and how it is performed. Write the pre-procedure note and
have an attending review it and sign it

Put your initials on the angio board next to the cases you wish to participate in

Observe and/or participate in several additional IR cases from start to finish: Review the patient history,
labs and relevant imaging, learn the indication for the procedure, learn the pre-procedure work up and
patient preparation.

Follow the technologist and nurses as they set up the room, bring the patient in, position them and prep
and drape the field. Understand the techniques used to perform the procedure.
Additional reading
Vascular anatomy- see "vasculature" section in each learning module
DHMC angio survival manual
NMSCR 6/22/2017
Nuclear Medicine
Goals of rotation

Understand the concept of physiological imaging

Radioisotopes vs. radiotracers

Learn some of the common indications for nuclear medicine studies

See examples of common examinations:

o
PET-CT scans
o
Bone scans
o
Renal scans
o
Hepatobiliary studies
o
Cardiac perfusion scans
o
VQ scan
o
Thyroid scan
Know the appearance of common conditions on these studies
o
PET-CT scans: lung cancer, metastatic disease
o
Bone scans: metastases, trauma, degenerative changes
o
Renal scans: obstruction
o
Hepatobiliary studies: acute cholecystitis, CBD obstruction
o
Cardiac perfusion scans (ischemia, infarction)
o
VQ scan: pulmonary emboli
o
Thyroid scan: Grave disease, hot and cold nodules

Understand some of the limitations of nuclear medicine examinations

Understand the difference between SPECT vs. PET

Know some of the important patient preparations for nuclear medicine studies (PET studies, thyroid,
cardiac etc)

Know how common studies are performed to explain them to patients
Know some of the therapeutic uses of nuclear medicine (I-131 therapy)
Specific recommendations

Minimum 1/2 day in nuclear medicine

Spend 30+ minutes watching techs performing exams in department

The remainder of the time alternating between the attending reading PET-CT and conventional nuclear
medicine studies

Many PET-CT scans are shown in CTOP conference Tues 8 am.
Additional reading
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NMSCR 6/22/2017
77
University Virginia Intro to PET-CT module
Intro to nuclear medicine ppt
Harvard teaching files
Mallinkrodt teaching files
Beth Israel nuclear medicine tutorial
Self study time
Goals of rotation

A variable amount of self study time is provided in the schedule depending on student learning style and
requests, as well as the amount of time taken for interviews or other days out of the schedule. A maximum
of 3 days is allowed, but time away is taken from this.

It is expected that this time ibe used to utilize text, web and CD/ROM learning resources and prepare for
workshops and presentations.

Note: the self study room is NOT available M, Tu, W mornings
Suggestions for self study resources
CORE cases
Provided text books
CDROMS available through the student co'ordinator
Student teaching file in student room
Disc with Powerpoint presentations of lecture series
www.learningradiology.com (note, use the ppt links, some of the flash links go to adverts for his book)
University Virginia radiology tutorials
BrighamRad teaching cases
Beth Israel (Lieberman) web-tutorials (see list at bottom page)
Harvard guide to imaging in pregnant patients
Dartmouth Anatomy web-course
Yale cardiothoracic imaging module
ACR appropriateness criteria
AMSER National Curriculum in Radiology for Medical Students
Private practice day
Goals of rotation

Generally intended for students considering radiology as a career
NMSCR 6/22/2017

See how a general private practice radiologist functions in a community hospital

One-on-one teaching with the radiologist
Specific recommendations

Most students go to Speare Hospital Plymouth (staffed by DHMC rads), but I have contacts with
radiologists at St.Johnsbury also.

Shadowing with radiologist for a day, aid radiologist where possible
Diagnosis Please links
Diagnosis Please 1
Diagnosis Please 2
Diagnosis Please 3
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