Department of Radiology
School of Medicine Queen's University
 

Chest Rotation Welcome Document

Chest Rotation

Welcome to your Chest Rotation. Dr. Dominique DaBreo, Dr. Rob Dhillon, and Dr. Justin Flood are your friendly Cardiothoracic Radiologists found in the Cardiothoracic Reporting Room 22.1.166.

Knowledge Objectives Block 1

  1. Develop knowledge of normal and abnormal chest anatomy as demonstrated on the chest radiograph and CT.
  2. Become knowledgeable about the different contrast agents available and begin to recognize abnormalities that are demonstrated on chest plain radiographs.
  3. Recognize the normal and abnormal position of supporting devices, lines and tubes on inpatient radiographs.
  4. Develop knowledge of the differential diagnoses of the more commonly encountered medical conditions such as pneumonia, congestive heart failure, pneumothorax, interstitial lung disease and thoracic trauma.
  5. Demonstrate the ability to recognize and describe common medical conditions depicted on chest imaging studies.
  6. Demonstrate an understanding of pathologic terminology related to the chest.
  7. Recognize cephalization of blood flow and pneumothorax both in upright and supine patients.
  8. Recognize pleural effusion on supine and upright radiographs and their different appearances.
  9. Recognize abnormal cardiac silhouette size and abnormal lung parenchymal opacities and formulate basic differential diagnosis.

 CANMED Goals block 1 

1. Develop an approach and be able to concisely dictate a chest radiograph report.

2. Develop an approach to acute CT chest pathologie

3. Communicate effectively with referring clinicians and supervisory staff

4. 
Obtain pertinent patient information relative to radiologic examinations and protocolling.

5. Demonstrate knowledge of the clinical indications for obtaining chest radiographs and when a chest CT or MR may be necessary.

Day work flow Block 1

1.     Be on time, please arrive by 800 AM to Cardiothoracic reporting room. Please look ahead to Radiologists schedule to see which work station will be available.

2.     Morning CT protocolling to be done by the resident, grey Chest folder in CT room. Please reference Chest CT protocols.

3.     Protocol CT Chest inpatients throughout the day as brought by CT technologists and booking. Please reference Chest CT protocols.

4.     Please leave Cardiac and Lung Biopsy protocolling to the Attending.

5.     Answer phone calls in Cardiothoracic Reporting room. Take consultation as far as you can and ask Attending as necessary.

6.     Provide consultation for Physicians who visit the Cardiothoracic Reporting room. Take consultation as far as you can and ask Attending as necessary.

7.     Dictate 20 xrays and any overnight STAT CTs in AM, then any outpatient CT cases.

8.     Dictate STAT CT first and outpatient CT cases in PM.

9.     Lung Biopsies are performed in the AM by Attending and Senior Residents.

10.  Thoracic Tumour Boards every Wednesday 12:30-1:30pm, attend if it does not conflict with noon rounds.

11.  Interstitial Lung Disease Rounds Friday 12-1pm (4 times a year), optional to attend if does not conflict with noon rounds.

Chest templates

Please ensure for Dr. Rob Dhillon and Dr. Dominique DaBreo to use our templates for Chest reporting. Please reference within Dr. Rob Dhillon’s macro in advance for list for CT Chest, CT Chest and Abdomen templates. Please clone templates into your macros in advance to rotation.

Chest xray reports must be concise 1- 3 lines. First report supportive lines/tubes, then any pertinent lung, cardiomedastinal, pleural or bony abnormality. Always answer clinical question provided on requisition. Also reference Dr. Dhillion’s macros in advance to the start of the rotation.

Example report

CHEST

FINDINGS: Support devices are unchanged. No focal consolidation, pleural effusion, pulmonary edema or pneumothorax. The cardiomediastinal borders are unchanged.

SUGGESTED READING/TUTORIALS PRIOR TO START OF ROTATION

Felson's Principles of Chest Roentgenology, a Programmed Text by Lawrence R. Goodman

http://eradiology.bidmc.harvard.edu/interactivetutorials/ Chest tutorials

https://www.med-ed.virginia.edu/courses/rad/cxr/index.html

Chest radiology in the ICU: Lines, Tubes, & Drains

Definition, Identification, and Significance of Signs and Finding Nomenclature in Thoracic Radiology. Knowledge should include diseases for which these signs are classic, potential alternative diagnoses, or pitfalls [Hansell et al. Fleischner Society: Glossary of Terms for Thoracic Imaging. Radiology 2008;246:697-722]


Cardiothoracic CT protocols

1. CHEST (with or without IV contrast). Majority of cases clinical question can be adequately assessed without contrast.

2. CHEST LOW-DOSE (LDT): noncontrast study for nodule follow up and lung cancer screening. DO NOT used for cancer follow up typically.

3. CHEST & ABDOMEN: usually give IV contrast (unless poor renal function), no oral contrast for majority cases.

4. ILD new pt (includes expiratory study).

5. ILD follow up (no expiratory study).

6. ASCENDING AORTA (can be done with or without IV contrast and gated or non-gated).

7. PULMONARY VEIN (done as with and without IV contrast).

8. DISSECTION: LDT and contrast enhanced chest arterial phase.  If positive study for Type B should extend study to include abdomen +/- pelvis. If high pretest probability for Type A, perform study gated.

9. CT PULMONARY ANGIOGRAM (CTPA).

10. DOUBLE RULE OUT: Specific protocol designed for optimal enhancement of both the pulmonary arteries and thoracic aorta. Rule out PE and aortic dissection. We DO NOT perform triple rule protocols.


Reading General Chest Books

  • Imaging of Diseases of the Chest
    David M. Hansell , Peter Armstrong , David A., MD Lynch , Page H., MD. McAdams
    Hardcover: 1272 pages
    Publisher: C.V. Mosby; 4th Rev edition (March 30, 2005)
  • Thoracic Imaging
    Richard Webb, Charles Higgins
    Hardcover: 834 pages
    Publisher: Lippincott Williams & Wilkins (September 20, 2004)
  • Radiologic Diagnosis of Diseases of the Chest
    Nestor Luiz Muller (Editor), Richard S. Fraser , Neil C. Colman , P. D. Pare
    Hardcover: 790 pages
    Publisher: W B Saunders Co; 1st edition (July 6, 2001)
  • Chest Radiology: The Essentials : Hardbound
    Jannette Collins MD, MEd, Eric J Stern MD
    Hardcover: 304 pages, 723 illustrations
    Publisher: Lippincott (September 1999)
  • Fundamentals of Diagnostic Radiology (Chest Chapters)
    William E. B r ant (Editor), Clyde A. Helms (Editor)
    Hardcover: 1460 pages
    Publisher: Lippincott, Williams & Wilkins; 2nd edition (January 15, 1999)
  • Thoracic Radiology: the Requisites
    Theresa C. McLoud, M.D.
    Hardcover: 541 pages
    Publisher: Mosby; Illustrated edition (August 15, 1998)
  • Radiologic Approach to Diseases of the Chest
    Irwin M. Freundlich (Editor), David G. Bragg (Editor)
    Hardcover: 866 pages
    Publisher: Lippincott, Williams & Wilkins; 2nd edition (January 15, 1997)

CT Reading

  • High-Resolution CT of the Lung: Hardbound
    W. R Webb MD, Nestor L Müller MD, PhD, David P Naidich MD
    Hardcover: 688 pages, 426 illustrations
    Publisher: Lippincott; 3 rd edition (November 2000)
  • Computed Tomography and Magnetic Resonance of the Thorax: Hardbound
    David P Naidich MD, W. R Webb MD, Nestor L Müller MD, PhD, Glenn A Krinsky MD, Elias A Zerhouni MD, Stanley S Siegelman MD, Georgeann McGuinness MD
    Hardcover: 784 pages, 1399 illustrations
    Publisher: Lippincott Williams & Wilkins Publishers , 3 rd edition (November 1998)
  • High Resolution Lung CT-- CDROM
    W. Richard Webb
    Publisher: Lippincott Williams & Wilkins Publishers (December 1999)

Pathology

  • Diseases of the Lung: Radiologic and Pathologic Correlations
    Nestor L. Mller , Richard S. Fraser, Kyung Soo Lee, Takeshi Johkoh, Nestor L. Muller
    Hardcover: 440 pages
    Publisher: Lippincott Williams & Wilkins Publishers (March 2003)

Case Review

  • Thoracic Imaging- Case Review Phillip Boiselle and Theresa McLoud Softcover: 181 pages, 276 illustrations Publisher: Mosby (2001)

Reference

  • Diagnosis of Diseases of the ChestFraser, Muller, Colman, ParéHardcover: Four volumes Publisher:W.B. Saunders Company (1999)
  • Chest Radiology -- Plain Film Patterns and Differential Diagnoses James C. Reed Hardcover: 480 pages
    Publisher: C.V. Mosby; 5th edition (August 7, 2003)

Manuscripts:

Please see Cardiothoracic Teaching Folder on the V drive for reference articles. We encourage you to use online resources including StatDx, Radiopaedia, or online Radiographics articles for chest nomenclature, staging, and help guide your differential diagnosis.

Reference ABR core study guide articles for Thoracic Imaging http://pubs.rsna.org/page/radiographics/abr-core-exam-study-guide.