RAD 5610: Clerkship in Diagnostic Radiology (VMS IV)

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Welcome to the Diagnostic Radiology Clerkship! I am delighted that you have chosen to take this elective and hope that you will find the course educational, intellectually stimulating, and enjoyable. Please take a few minutes to familiarize yourselves with the course curriculum. It outlines a number of important details about the course: goals, content, teaching activities, and attendance and assessment policies. It also contains a list of valuable educational resources (books and web pages) that you may find helpful throughout the month and even after the rotation is over.

Course Curriculum

  • The Clerkship in Diagnostic Radiology is designed to be relevant and suitable for all medical students, regardless of their ultimate career choice or interests; this course is not designed solely for students interested in pursuing a career in radiology.  The goals of the course are to acquaint medical students with the fundamentals of diagnostic imaging and to highlight optimal imaging pathways for various clinical conditions.  Other key topics such as ionizing radiation risks, contrast media, the strengths, limitations, and relative costs of the various imaging modalities, management of equivocal findings and negative examinations, the importance of open communication between clinicians and radiologists, and basic use of the PACS workstation will be covered as well.  Students will rotate through all diagnostic subspecialties in radiology and get a broad exposure to various pathologies and imaging modalities.  Besides getting daily instruction in the reading rooms by faculty, fellows, and residents, students will be engaged in a number of other educational activities.  Students will watch Radiology faculty lecture podcasts on various topics, complete reading assignments, attend live lectures presented by radiology residents, attend daily Radiology noon conferences, solve weekly unknown case challenges, and will prepare a 5 minute “interesting case” presentation to be given during the last week of the rotation.  The course has a pre-test and a final exam.

  • By the completion of the Diagnostic Radiology Clerkship, a student will

    • acquire a general understanding of the strengths, weaknesses, limitations, and relative costs of the various imaging modalities.
    • have a basic understanding of ionizing radiation risks and prevention strategies.
    • gain a general understanding of contrast media uses in medical imaging, recognize potential contrast media complications, and be able to recommend appropriate preventive and/or treatment strategies with at least 70% accuracy, as measured by the final exam and case discussions with the course director.
    • demonstrate proficiency in basic image interpretation (with emphasis on critical, "do not miss" and classic imaging diagnoses) with an accuracy of at least 70%, as measured by the final exam and unknown case discussions with the course director. 

  • Students are expected to be in the radiology department from 8 am to 5 pm Monday through Friday.  There is no call and there are no weekend duties.  It is the student’s responsibility to contact the course director and request permission to be absent from the rotation.   A few approved absences are considered acceptable.  The course director reserves the right to assign a grade of “Incomplete” if there are unaccounted/ unauthorized absences; this would be reversed when the student makes up for the missed days or completes a remediation assignment.

     

    The clerkship is 4 weeks long.  The final day may be used by the student to take the final exam.  This leaves 19 work days for observation, lectures, case presentations, discussion, etc.  To ensure that each student spends an adequate amount of time in each sub-section and gets adequate teaching in each subspecialty area of radiology, the following breakdown of attendance is recommended:

     

    Chest imaging: 3 days

    Body imaging: 4 days

    Musculoskeletal imaging: 3 days

    Neurological imaging: 3 days

    Pediatric radiology: 2 days

    Ultrasound: 2 days

    Nuclear medicine: 1 day

    Interventional radiology: 1 day

     

    It is best if students do not congregate in the same room but spread out throughout the Department.  This promotes one-on-one teaching by attendings and residents.

  • To receive a grade for the course, a student must:

    1. Take the pre-test

    2. Take the final exam

    3. Submit answers to the weekly unknown cases

    4. Present an interesting case during the last week of the course

    5. Turn in the provided textbook

    6. Complete the course evaluation survey

     

    Pre-test: a link to a web-based exam will be sent to the students a few days before the Clerkship starts.  The pre-test should be taken before the start of the rotation.  The goal of the pre-test is to allow the course directors to assess students’ preexisting knowledge base in radiology.  The chosen questions illustrate essential radiology knowledge taught in the course.


    Post-test: web-based multiple choice exam.  Students can take the exam on Thursday or Friday of the last week.  The student's performance on the final exam will account for 75% of the final grade for the course.


    Interesting case presentations: During the third week of the rotation, each student should prepare an interesting case to show to his classmates and the course director.  Each student’s presentation should last no more than 5 minutes.  The successful completion of this task shall account for 25% of the student's final grade for the course.

  • Attending Lectures

    Some of these are taught live.  Others are uploaded to the course website as podcasts/ lecture slides.  Please view the podcasts and review the lecture slides at your leisure during the rotation.  Any and all questions about the material are welcome and encouraged!

    Ionizing radiation

    Contrast Media
    Introduction to Arthritis

    MRI of the knee

    MRI of the shoulder

    Bone lesions

    Introduction to the Imaging Modalities

    Imaging of Trauma

    Introduction to Radiography
    Introduction to CT
    Introduction to MRI
    Introduction to Ultrasonography
    Introduction to Nuclear Medicine
    Introduction to Interventional Radiology
    Body Imaging
    Introduction to Pediatric Radiology

    Case presentations taught by residents

    Please preview each module on your own prior to the scheduled presentation.  In each preview module, a number of cases are presented as unknowns.  Try to figure out the correct answers by yourself.

    ICU Chest Films
    Pulmonary
    Chest Pain
    Orthopedics
    Body Trauma
    Neurosurgical Trauma
    Abdominal Pain
    Neurology
    Oncology

    Live cases teaching at the PACS workstation


    Daily noon conferences


    Weekly unknown cases

    Uploaded by the course director to the "unknown cases" blog on the course website.  You will receive notification from the course director that a new unknown has been posted.  Please respond to the course director's email with your answers (findings and diagnosis/ pertinent differential diagnoses) within 2-3 days of the post.  These cases will help you practice your diagnostic skills and prepare for the unknown case presentations.  The unknown cases are chosen to reinforce important topics covered in lecture/ in the reading room.

  • Please use this section as a guide.  Many of these topics will be covered in lectures and case presentations.  Some are covered in the uploaded lecture podcasts and slides.  Others will be discussed at readings stations in the reading rooms.   

    1. Core Radiology topics
      1. Strengths and weaknesses of the various imaging modalities
        1. Sensitivity and specificity of the various imaging modalities
        2. Advantages and disadvantages of the various imaging modalities
          1. For example, MRI and US do not use ionizing radiation
          2. Conventional radiographs use very little ionizing radiation
          3. CT provides amazing anatomic detail but uses a lot of ionizing radiation
      2. Relative cost of the various imaging modalities
      3. Limitations of the various modalities
        1. For example: what are the contraindications to MRI?  Artifacts in MRI.  Patient-related factors (obesity, claustrophobia, inability to remain still, etc.).
      4. Basic knowledge of how the various imaging modalities work
      5. Common terminology used by radiologists
        1. Density, opacity, silhouette sign.  What are we actually observing on a radiograph?
        2. What is the difference between radiography and computer tomography?
        3. Basic principles of MRI
        4. Basic principles of ultrasonography
        5. Hyperdensity, hyperintensity, hyperechogenicity: which term goes with which modality?
        6. Lucency, interstitial, alveolar, nodule, mass
        7. Attenuation, Hounsfield units
        8. Enhancement
        9. Hot spots, cold spots, radionuclide
      6. Ionizing radiation risks and prevention
        1. What is ionizing radiation?
        2. How do we know that ionizing radiation is harmful?
        3. Why is ionizing radiation harmful?
        4. Relative radiation doses of various modalities
        5. Putting the risk of ionizing radiation in medical imaging in perspective
      7. Contrast media (iodinated and Gadolinium chelates)
        1. Chemical structure and properties
        2. Allergic reactions and how to prevent them
        3. Chemotoxic reactions and how to prevent them
        4. When to use IV/ oral contrast?
        5. Guidelines for safe use of iodinated and Gadolinium-based contrast agents
        6. Nephrogenic systemic fibrosis
      8. Other risks of radiology
        1. Percutaneous biopsies and drains risks
          1. Bleeding, infection, pneumothorax, nerve injury, organ damage
        2. Complications of fluoroscopy
          1. Perforation, impaction, mediastinitis or peritonitis, aspiration
        3. Contraindications and risks related to MRI
          1. Bullets/ other metal in orbit, by spinal cord, by major vessel, etc.
          2. Newly placed stents and coils
          3. Pacemakers, deep brain stimulators
          4. Metal prostheses
          5. Tattoos
      9. PACS workstation
        1. Basic features
        2. The workflow of a contemporary Radiology Department

     

    1. Chest
    1. Normal anatomy
      1. Normal appearance of the lungs, heart, aortic arch and descending thoracic aorta, main pulmonary artery and its major branches.
    2. Pulmonary diseases
      1. Parenchymal
        1. Lobar pneumonia
        2. Atelectasis
        3. Lung cancer
        4. Other (lung contusion, aspiration, parenchymal hemorrhage, alveolar edema, injury edema)
      2. Interstitial
        1. Interstitial pneumonia
          1. Viral/ mycoplasma
          2. Pneumocystis carinii pneumonia
        2. Interstitial edema
        3. Interstitial fibrosis
    3. Cardiovascular diseases
      1. Normal appearance of the heart and pulmonary vasculature
      2. Cardiomegaly
      3. Pericardial effusion
      4. Heart failure
    1. The vascular pedicle
    2. Increased central vascular volume
    3. Interstitial edema
    4. Alveolar edema
      1. Pulmonary arterial hypertension
      2. Pulmonary embolism
      3. Post-operative appearances: CABG, AO and Mitral replacements, stents
    1. Congenital variations/ anatomic variants
      1. Dextrocardia
      2. Right sided aortic arch
      3. Accessory pulmonary fissures
    2. Neoplasms
      1. Primary lung tumors
      2. Metastatic disease
      3. Mediastinal tumors
        1. Anterior
        2. Middle
        3. Posterior
    3. Pleural pathology
      1. Pleural effusion
      2. Pleural scarring, eventration
      3. Neoplastic (e.g., mesothelioma)
    4. Iatrogenic pathology
      1. Malpositioned lines and tubes
        1. NG/ Dobhoff tubes
        2. ET tube
        3. Central venous catheters
        4. PICC
        5. Pulmonary arterial catheter
    5. Do not miss findings
      1. Pneumothorax
        1. Apical
        2. Deep sulcus sign
        3. Tension pneumothorax
      2. Pneumomediastinum
      3. Pneumoperitoneum
      4. Traumatic aortic transection

     

    1. Abdomen and pelvis
      1. Cross-sectional anatomy
        1. Image modality and scan protocol
        2. Normal anatomy
          1. Normal appearance of the liver, spleen, pancreas, kidneys, renal collecting system, urinary bladder, adrenal glands, small bowel, large bowel, biliary system and gallbladder, mesentery, aorta and major arteries, IVC and major veins.
      2. GI disease
        1. Inflammatory bowel disease
        2. Acute appendicitis
        3. Diverticulitis
          1. Follow up imaging is required to make sure it’s not colon CA!
        4. Bowel obstruction
        5. Ileus
        6. Pneumoperitoneum
        7. Pneumatosis intestinalis
        8. Portal venous gas vs. pneumobilia
        9. Mesenteric ischemia
      3. Liver
        1. Cirrhosis
        2. Steatosis
      4. Gallbladder
        1. Cholelithiasis
        2. Acute cholecystitis
      5. Pancreas
        1. Acute pancreatitis
        2. Necrotizing pancreatitis
        3. Pseudocyst
      6. Trauma
        1. Solid organ lacerations
          1. Liver
          2. Spleen
          3. Kidneys
          4. Pancreas
        2. Viscous injuries
        3. Vascular injuries
        4. Mesenteric injury
        5. Shock bowel
        6. Fractures
      7. Neoplasms
        1. Examples of benign (liver hemangioma and cyst) and malignant (hepatocellular carcinoma, pancreatic adenocarcinoma, renal cell carcinoma, transitional cell carcinoma) conditions.
      8. Do not miss findings
        1. Pneumoperitoneum
        2. Portal venous gas
        3. Small bowel obstruction
        4. Pneumatosis intestinalis
        5. Liver, spleen, kidney, pancreas laceration
        6. Aortic dissection

     

    1. Neurological conditions
      1. Normal anatomy
        1. Normal appearance of the brain parenchyma on unenhanced CT, T1 and T2 MRI (normal grey-white differentiation, sulci and gyri, ventricles, basal ganglia, brain stem, corpus callosum, major intracranial arteries, intracranial venous sinuses, major neck arteries.
        2. Normal appearance of the vertebral bone marrow signal on T1 and T2.
      2. Stroke
        1. Utility of CT, MRI, CT angiography, and CT perfusion studies in the evaluation of patients presenting with clinical findings of acute stroke
        2. Role of interventional radiology in the treatment of patients presenting with acute stroke
        3. Appearance of old stroke on CT and MRI
        4. Lacunar infarcts
      3. Trauma
        1. Intracranial hemorrhage
          1. Extra-axial
            1. Epidural
            2. Subdural
            3. Subarachnoid and intraventricular
          2. Intra-axial
            1. Cortical contusion
            2. White matter hemorrhagic shear
          3. Role of CT and MRI in the evaluation of intracranial hemorrhage
        2. Fractures
          1. Skull
          2. Face
          3. C spine
      4. Infections
        1. Brain abscess
        2. Epidural abscess
        3. Herpes encephalitis
        4. Meningitis
        5. Peritonsilar abscess
        6. Sinusitis
      5. Neoplastic conditions
        1. GBS
        2. Medulloblastoma
        3. Mets
        4. Peripheral nerve sheath tumor
      6. Other
        1. MS
        2. Hydrocephalus
      7. Do not miss findings
        1. Acute stroke on unenhanced CT
        2. Acute stroke on MRI.  Role of diffusion-weighted images
        3. Acute intracranial hemorrhage
          1. Epidural
          2. Subdural
          3. Subarachnoid
          4. Cortical contusion
          5. White matter shear
        4. Acute hydrocephalus

     

    1. Musculoskeletal conditions
      1. Fractures
        1. Nomenclature: location of fracture, simple vs. comminuted, intraarticular involvement, displacement and angulation
        2. Extremities
        3. Spine
        4. Pelvis
        5. Stress fractures
          1. Fragility
          2. Fatigue
        6. Fracture healing
          1. Incompletely united fracture vs. fracture non-union
        7. Complications of intraarticular fractures
      2. Arthritis
        1. Osteoarthritis
        2. Rheumatoid arthritis
        3. Pyrophosphate arthritis (calcium pyrophosphate dihydrate crystal deposition disease)
        4. Gout
        5. Psoriatic arthritis and reactive arthritis
        6. Ankylosing spondylitis
        7. Inflammatory bowel disease-associated sacroiliitis
      3. Infection
        1. Septic arthritis
          1. Role of MRI in the diagnosis of septic arthritis
          2. Role of arthrocentesis (joint aspiration) in the diagnosis of septic arthritis
        2. Osteomyelitis
          1. Role of MRI in the diagnosis of osteomyelitis, myositis, fasciitis, and soft tissue abscess
          2. Limitations of MRI in the diagnosis of osteomyelitis
          3. Role of IV Gadolinium in the diagnosis of osteomyelitis and soft tissue abscess
          4. Role of labeled WBC nuclear medicine scan
        3. Septic spondylitis and vertebral osteomyelitis
      4. Tumors and tumor-like conditions
        1. Major musculoskeletal neoplasms (Ewing’s sarcoma, osteosarcoma)
        2. Common benign lesions: fibrous dysplasia, non-ossifying fibroma, unicameral bone cyst, aneurysmal bone cyst
        3. Common metastatic lesions
          1. Sclerotic
            1. Prostate CA
            2. Breast CA
          2. Lytic
            1. Renal cell CA
            2. Lung CA
            3. Multiple myeloma
        4. Paget’s disease
        5. Renal osteodystrophy
        6. Sickle cell disease
        7. Osteopenia/osteoporosis/demineralization
      5. Sports injuries
        1. Injuries to the knee ligaments
        2. Meniscal injuries
        3. Other
          1. Lisfranc fracture-dislocation
          2. Ankle ligament injuries
          3. Rotator cuff tear
          4. Biceps tear at the elbow
          5. Biceps longhead tear/ dislocation at the shoulder
          6. Glenoid and acetabular labral tears
      6. Hardware issues
        1. Normal post-operative appearance
          1. Total hip prosthesis
          2. Total knee prosthesis
          3. Plate and screw device fixation of a fracture
          4. Intramedullary rod fixation of a fracture
        2. Role of the hardware in fracture repair
        3. Failed hardware
          1. Osteolysis
            1. Infection
            2. Particle disease
          2. Loosening and migration
          3. Periprosthetic fracture
          4. How do we image failed hardware
            1. Radiography
            2. CT
            3. MRI: MARS protocol
      7. Do not miss findings
        1. Lisfranc fracture dislocation
        2. Hip stress fracture on MRI/ radiographs
        3. Spine fractures
          1. Anterior wedge
          2. Burst
          3. Flexion teardrop
          4. Fracture-dislocation
          5. Hyperextension injuries in patients with AS and DISH
        4. Septic spondylitis and vertebral osteomyelitis
        5. Osteosarcoma
        6. Aggressive osteolytic processes (Ewing’s sarcoma, metastatic disease, osteomyelitis)
        7. Hardware failure, periprosthetic fracture

     

    1. Pediatric Imaging
      1. Chest
        1. Neonate with respiratory distress
          1. Surfactant deficiency / Respiratory distress syndrome of the newborn
            1. Ddx: Group B strep pneumonia
          2. Meconium aspiration syndrome
            1. Ddx neonatal pneumonia
          3. Transient tachypnea of the newborn
        2. Congenital chest masses
          1. Congenital diaphragmatic hernia
          2. CPAM
          3. Congenital lobar emphysema
          4. Sequestration
          5. Bronchogenic cyst
        3. Congenital heart disease
          1. Cardiomegaly
          2. Shunt vascularity
          3. Cardiac situs
          4. Vascular rings
        4. Normal thymic shadow
      2. GI
        1. Neonatal abdomen
          1. Necrotizing enterocolitis
            1. Xray findings
          2. Esophageal atresia and tracheoesophageal fistula
            1. Xray findings
          3. Proximal bowel obstruction
            1. Xray findings
            2. Upper GI series evaluation
            3. Causes
              1. Duodenal atresia/stenosis/web
              2. Annular pancreas
              3. Malrotation with midgut volvulus
              4. Jejunal atresia
          4. Distal bowel obstruction
            1. Xray findings
            2. Contrast enema evaluation
            3. Causes:
              1. Ileal atresia
              2. Meconium ileus
              3. Colonic atresia
              4. Hirshprung disease
              5. Meconium plug syndrome
              6. Imperforate anus
          5. Meconium peritonitis
            1. Xray findings
        2. Hypertrophic pyloric stenosis
          1. Diagnosis by ultrasound
        3. Intussusception
          1. Diagnosis by ultrasound
          2. Air enema reduction
      3. GU
        1. Congenital urinary tract anomalies
          1. Duplication of the collecting system – partial or complete
          2. Causes of hydronephrosis
            1. Vesicoureteral reflux
            2. UPJ obstruction
            3. Posterior urethral valves
        2. Congenital renal anomalies
          1. Renal ectopia (i.e. pelvic kidney)
          2. Cross-fused renal ectopia
          3. Horseshoe kidney
          4. Renal agenesis
      4. Common extracranial pediatric tumors
        1. Neuroblastoma
        2. Wilms tumor
      5. Brain
        1. Neonatal head ultrasound
          1. Germinal matrix hemorrhage
            1. Grading system
            2. US findings
          2. Periventricular leukomalacia
            1. US findings
        2. Developmental abnormalities
          1. Chiari malformation type 1 and 2
          2. Dandy-Walker malformation / variant
          3. Holoprosencephaly
      6. Bones
        1. Pediatric fractures
          1. Bowing
          2. Greenstick
          3. Buckle
          4. Toddler’s fracture
          5. Salter-Harris classification
        2. The limping child
          1. DDH
          2. Toxic synovitis
          3. Legg-Calve-Perthes disease
          4. Slipped Capital Femoral Epiphysis (SCFE)
      7. Child abuse
        1. High specificity fractures
          1. Posterior rib fractures
          2. Metaphyseal corner fracture (a.k.a. classic metaphyseal lesion)
          3. Multiple fractures in different stages of healing
        2. Abdominal injuries
          1. Duodenal hematoma
          2. Pancreatitis, pancreatic pseudocyst
          3. Liver/splenic laceration
        3. Brain injuries
          1. Acute and/or chronic subdural hematomas
          2. Cerebral edema
      8. Radiation exposure concerns in pediatric imaging
        1. Image Gently Campaign
        2. The A.L.A.R.A. Principle
      9. Which imaging modalities utilize ionizing radiation and which do not?

     

    1. Female and male urogenital pathology
      1. Normal anatomy
        1. Normal appearance of the uterus and ovaries; testis and epididymis; kidneys, renal collecting systems and urinary bladder.
      2. Uterus
        1. Fibroids
        2. Adenomyosis
        3. Polyps
        4. Cancer
      3. Ovaries
        1. Ovarian torsion
        2. Normal follicles
        3. Ovarian cysts and neoplasms.  Criteria for further assessment.
      4. Pregnancy
        1. Focus on early pregnancy
          1. Normal early pregnancy
          2. Multiple gestation
          3. Fetal demise
        2. Ectopic pregnancy
      5. Tubo-ovarian abscess
      6. Testicles
        1. Torsion
        2. Neoplasms
      7. Acute epididymitis
      8. Hydrocele
      9. Kidneys
        1. Normal anatomy
        2. Nephrolithiasis
        3. Ureteral obstruction
        4. Acute pyelonephritis
        5. Hydroureteronephrosis
        6. Renal cell carcinoma
      10. Bladder
        1. Diverticula
        2. Transitional cell carcinoma
      11. Do not miss findings
        1. Ovarian torsion
        2. Testicular torsion
        3. Hydroureteronephrosis

     

    1. Nuclear medicine
      1. Understand the concept of physiological imaging
      2. See examples of common nuclear medicine examinations:
        1. Pet CT scan
        2. Cardiac perfusion studies
        3. Bone scan
        4. Renal scan
        5. Hepatobiliary scintigraphy (HIDA scan)
        6. VQ scan
        7. Thyroid scan
      3. Know the appearance of common conditions on this examinations:
        1. Pet CT scan: lung cancer, metastatic disease
        2. Cardiac perfusion studies: ischemia and infarction
        3. Bone scan: metastasis, trauma
        4. Renal scan: obstruction
        5. Hepatobiliary scintigraphy (HIDA scan): acute cholecystitis
        6. VQ scan: pulmonary emboli
        7. Thyroid scan: Graves’ disease
      4. Understand the difference between SPECT and PET
      5. Know patient preparations for nuclear medicine studies such as FDG pet CT, cardiac perfusion study, HIDA scan etc.

     

     

    1. Vascular and Interventional radiology
      1. Background
      2. Basic techniques
        1. Seldinger technique for access
        2. Digital subtraction angiography
    2. Tools of the trade
    1. Catheters
    2. Balloons
    3. Stents
    4. Embolic agents
    5. Drains
      1. Embolization
        1. Arterial
        2. Acute arterial injury
        3. Traumatic
        4. Iatrogenic 
        5. Pseudoaneurysm
        6. Uterine artery embolization
        7. Hepatic artery embolization
        8. Chemoembolization
        9. Radioembolization
        10. Bronchial artery embolization
        11. Renal artery embolization
        12. Visceral artery embolization
        13. Venous
        14. Gonadal vein embolization
    6. Thrombolysis
      1. Arterial
      2. Cold leg/foot
      3. Mesenteric ischemia
      4. Stroke
      5. Venous
      6. Deep venous thrombosis
    7. Vascular Access
      1. Central venous catheters
      2. Dialysis access
      3. Shuntogram
      4. Fistulagram
    8. Percutaneous Drainage/Biopsy
      1. Abscesses
      2. Paracentesis/thoracentesis
      3. Malignant pleural effusions/malignant ascites
      4. Decompression of an obstructed system
      5. Nephrostomy
      6. Biliary drainage/cholecystostomy
      7. Tumor biopsy/ablation
    9. Miscellaneous Procedures
      1. IVC filters
      2. Transjugular intrahepatic portosystemic shunt (TIPS)
      3. Gastrostomy/GJ tubes
      4. Foreign body retrieval