Susan Shamimi-Noori MD
Assistant Professor of Radiology
Thomas Jefferson University
August 7, 2016
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First Concept
Cura Personalis
Cura Personalis
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Cura Personalis
Care for the whole person
Attention to a specific organ/pathology but
also to the specific
personal/psychological/social needs of the
patient
Care for the mind and body
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Differential Diagnosis
List of diseases with similar signs and symptoms
Most probable diseases are listed first
Zebras are listed last (or not at all)
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22 y/o M non-smoker
Allergies
Asthma
Infection
Cancer
78 y/o M smoker
Chronic Bronchitis
Cancer
Infection
Allergies
* Radiology
Radiology
The branch of medical science using x-rays,
radioactive substances and other forms of
radiant and non-radiant energy in diagnosis
and treatment of disease
Turning things inside out
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Radiant Energy:
Electromagnetic Spectrum
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Radiant Energy:
Electromagnetic Spectrum
* Radiology
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Radiodensity
The relative inability of electromagnetic
energy to pass through a particular material
Air has LOW radiodensity
Attenuation
Radiodensity
X-Ray Source
Object
Detector
Image
Radiolucent
Air
Radiodense
Radiopaque
Metal
5 Basic Radiodensities
1. Air: Low density (black)
2. Fat: Low-Intermediate density
(gray-black)
3. Water/Soft Tissue: Intermediate
denisty (gray)
4. Bone: High density (white)
5. Metal/Contrast Agents: Very high
density (very white)
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5 Basic Radiodensities
Fat
Air
Bone
Metal
Soft Tissue
Radiograph Edges
An edge, or silhouette, is seen when objects
of different densities are adjacent to one
another
An edge is seen because two objects of
different radiodensities attenuate X-rays
differently
Radiograph Edges
Silhouette Sign
The lack of an interface between two objects
with similar radiodensities
Two objects with similar radiodensities
attenuate X-rays similarly and therefore
appear inseparable on a radiograph
Silhouette Sign
Silhouette Sign
Silhouette Sign
Computed Tomography
Computed Tomography= CT = Computerized
Axial Tomography = CAT scan
X-Rays are projected in many angles onto an
object and then detected on multiple angles
therefore resulting in a cross-sectional or
tomographic image
Computed Tomography
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Computed Tomography
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Image Planes
Axial
Coronal
Sagittal
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Laterality Convention
R
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Radiologic Modalities
Radiography
Computed Tomography (CT or CAT scan)
Nuclear Scintigraphy (Nuclear Medicine)
Magnetic Resonance Imaging (MR or MRI)
Ultrasound Imaging (US or Sonography)
Radiologic Modalities
Radiography
Density
Nuclear Scintigraphy
Radiopharmaceuticals are taken internally
(PO or IV)
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Nuclear Scintigraphy
External detectors capture radiation photons
emitted by the radiopharmaceutical resulting
in an image
Imaging contrast depends on biologic activity
(vs. radiography imaging contrast depends on structure
attenuation)
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Ultrasound Imaging
High frequency sound waves are emitted into
the body and bounce back as echoes
Different structures bounce back echoes of
the sound waves at varying times and
frequencies
Sound wave echoes are detected
resulting in an image
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Ultrasound Imaging
Image contrast depends on how a structure
echoes back a sound wave
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Radiologist
Physicians who diagnose and treat pathologic
processes using various imaging modalities
Radiologist Spectrum
Interpret images
Create and interpret images
Create images, interpret images and
perform image based procedures to aide
in diagnosis
Create images, interpret images and
perform image based procedures to
diagnose and treat
Interpretation
Differentiate normal and abnormal on an image
Combine the history/physical/other clinical
information with the Imaging findings and create
a differential diagnosis
Based on the differential diagnosis determine
what are the next tests to further narrow the
differential diagnosis
With small differential diagnoses, let the referrer
know what the treatment options are
Radiology Specialties
By Amount of Procedures
Performed
Diagnostic Radiology
Interventional Radiology
By Modality
MRI
Ultrasound
Nuclear Medicine
By Disease Groups
Womens Imaging
Oncologic Imaging
By Anatomy
Chest Radiology
Cardiovascular Radiology
Musculoskelatal Radiology
Neuroradiology
Mammography
Gastrointestinal Imaging
Genitourinary Imaging
Abdominal Imaging
Interventional Radiology
A specialty of radiology in
which minimally invasive
procedures are performed
using image guidance
A specialty that performs
diagnostic and
therapeutic interventions
for a variety of organ
systems/pathologic
entities
Interventional Radiology
Interventional Radiology
Consult service
Admitting service
Inpatient procedures
Outpatient procedures
Outpatient clinic
Interventional Radiology
Interest Group
Facebook group: Jefferson CVIR
JeffersonCVIR@gmail.com
Lindsay.Young@Jefferson.edu
(group president)
Sleep, 1937
Case
58 y/o male presents to his primary care
physician with 3 days of right leg swelling
Case
Vital Signs are Stable (VSS)
Temperature
Blood Pressure
Heart Rate
Respiratory Rate
Oxygen Saturation
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Case
Physical Exam (PE)
Alert & Oriented
Heart/Lungs/Abdomen Normal
Lower extremities Right leg swollen from
ankle to just above the knee
Case
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Case
Differential Diagnosis
VITAMIN C
(in no particular order)
Vascular
Infectious
Traumatic
Autoimmune
Metabolic
Idiopathic/Iatrogenic
Neoplastic/Neurologic
Congenital
Case
Differential Diagnosis
Trauma
Infection
Vascular
Arterial
Venous
Case
Differential Diagnosis
Trauma Ask more history
Infection Look for signs of infection
Vascular
Arterial Check pulses
Venous Radiology to the rescue!!!!
Our Patient
Treatment
Anticoagulation (blood thinners)
Case
5 days later, patient goes to the ER with acute
shortness of breath (SOB)
Case
Vital Signs
Elevated respiratory rate (Tachypnea)
Decreased oxygen saturation
Mild elevated heart rate (Tachycardia)
Physical Exam
Heart Tachycardic, but otherwise normal
Lungs Tachypnic, but otherwise normal
Remainder of exam, including lower
extremities, is normal
Case
Differential Diagnosis
Pulmonary Embolus (clot in lung artery)
Pneumonia
Asthma
Anxiety (panic attack)
Radiology to the rescue!!
Treat patient with oxygen in the meantime
(ABCs)
Chest Radiograph
Computed Tomography
Pulmonary Embolism
Treatment
Prevent more clot from going to the lungs
Radiology to the rescue!!
Case
Patients respiratory status normalizes and he
goes home
Case
9 days later, patient presents to primary care
physician with severe bilateral lower extremity
swelling and pain necessitating him to use a
wheel chair
Primary care physician sends patient to ER for
further evaluation
Case
Vital Signs
Stable
Physical Exam
Bilateral lower extremity swelling from the
ankles to the upper thighs
Bilateral medial thigh erythema (redness)
and tenderness
Remainder of the exam is normal
Case
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Ultrasound
Right Lower Extremity
Computed Tomography
Case
Treatment
Pharmacomechanical Thombectomy
Radiology to the rescue!!
Phamacomechanical Thombectomy
Case
Patient walks out of the hospital two days
later feeling great
Final Thoughts
Radiology is an invaluable specialty for the
diagnosis and treatment of disease
No matter what specialty you decide to enter,
you will use radiology
The field of radiology is diverse, fascinating
and rewarding!
GOOD
LUCK!!
Salvidor Dali
1904-1989