Utility of radiology for investigation of abnormal physical findings 

Educational objectives

Know which imaging procedure to order to confirm a physical finding.
Know when to seek an imaging procedure to document a physical finding.

Ascites

• What is the best imaging procedure to confirm the presence of small ascites.
  • ultrasound
  • indication
    • imaging studies required only when paracentesis is contemplated for a small ascites or when one is not sure of findings
    • ultrasound will help localize the fluid and help in paracentesis
    • no need for imaging studies when ascites is obvious and paracentesis can be done without any imaging support
• What is the best imaging procedure to confirm the presence of loculated ascites.
  • CT or US
  • CT is also useful to tap loculated ascites and placement of catheter for drainage.
• What is the best imaging procedure to assist in the paracentesis of small ascites (free fluid).
  • US

Abnormal heart sounds

• What is the best imaging procedure to evaluate heart sounds and murmurs
  • phonocardiography
  • indication
    • for teaching and learning heart sounds
    • useful to record heart sounds and murmurs
    • timing and intensity can be studied easily

Prostate nodules

• You palpate a prostate nodule on rectal exam. Which imaging procedure will you order to confirm the presence of the nodule.
  • ultrasound
  • indication
    • when biopsy is contemplated
    • biopsy is done with ultrasound guidance

Bruits

• You hear a bruit on physical exam over the carotid artery. Which imaging procedure will you order to confirm and evaluate your finding?
  • Doppler US
  • indication
    • for quantitation of the extent of stenosis
    • for evaluation of carotid artery stenosis, abdominal aortic aneurysm and renal artery stenosis
    • It is difficult to distinguish bruit from AAA from renal artery.
  • Once the bruit is confirmed by doppler, CT or MR angiography will provide additional information.

Aneurysms

• You suspect abdominal aortic aneurysm on physical exam. Which imaging procedure will you order to confirm your finding?
  • imaging procedure
    • plain x-ray
    • ultrasound
    • CT
• indication
  • ultrasound
    • is the procedure of choice in all suspected cases
    • measurement of width, length and AP diameter
  • CT
    • provides the same information as ultrasound
    • useful in obese and gassy patients when ultrasound does not work
    • CT angiogram provides information about the extension of AAA to iliac arteries, to plan the extent of surgery
    • CT angiogram is useful to evaluate for dissection.
• sequence
  • thoracic
    • Plain x-ray
    • CT with contrast
  • abdominal
    • Ultrasound
    • CT with contrast
  • extremities
    • Ultrasound
    • CT with contrast or MR angiography

Testicular masses

• You suspect the presence of a painless mass in the right testis. Which imaging procedure will you order to confirm your finding.
  • ultrasound
    • in all cases suspected of having hydrocele 
    • to detect testicular mass
  • CT cannot be done for testicular evaluation for fear of radiation
• Patient presents with painful mass in right testis. You are concerned about testicular tort ion. Which imaging procedure will you order to evaluate your concern.
  • Doppler ultrasound is the procedure of choice.
  • Nuclear medicine scan

Thyroid nodules

• Which imaging procedure will you order when you suspect a thyroid nodule, to validate your physical exam finding.
  • imaging procedure
    • ultrasound
    • RAI uptake
  • indication
    • ultrasound
      • distinguish solid from cystic lesion
      • guidance for biopsy
    • RAI uptake
      • functional assessment
  • sequence
    • Ultrasound
    • RAI uptake
      
      

Hepato/splenomegaly

• You are not sure if the liver is enlarged, which imaging procedure will clarify your dilemma?
  
  

Breast lumps

You suspect that patient may have a breast lump but you are not sure. Which imaging procedure can assist you?

• imaging procedure
  • ultrasound
  • mammogram
• indication
  • mammogram
    • screening for early detection of cancer
    • detects non-palpable lesions
    • shows characteristics of the lesion and calcification
    • guidance for biopsy
  • ultrasound
    • distinguishes solid from cystic lesion
    • Ultrasound is best reserved for masses of breast in a young patient, where most likely it is benign
• sequence
  • for screening
    • mammogram
  • for palpable masses
    • ultrasound only if the clinical suspicion is, that it is benign
    • mammogram for all other masses