Radiology Part 1: An Interview With Dr. Ty Vachon, MD

EBP Guidelines, Interview, Podcast, Radiology 6

The Nurse Practitioner Show Podcast Episode 20: Radiology Part 1 - An Interview with Dr. Ty Vachon

Meet The Host and Guest

Cynthia Jaffe DC, MSN, FNP-C, FIAMA Guest Host

Chiropractor and Family Nurse Practitioner
Dr. Jaffe’s Website

Ty Vachon, MD Guest

Radiologist and Imaging Informaticist
Dr. Vachon’s Website


Radiology Part 1

Click play above to hear this episode featuring Dr. Ty Vachon.

Patient engagement

Many healthcare providers are beginning to offer patient access to their medical records via an online portal. A major issue is the referring provider usually wants to control just how and when their patients get the results. There is a significant information gap between the public and their general providers. Ideally the medical record should be tailored to the patient so the patient can understand the content of the report. We need to address the wide divide over the years between the primary care providers, radiologists and the patients.

In order to pro-actively evaluate the report to address any patient concerns, many medical practices have implemented a 24 – 48 hour delay before upload to the patient’s portal.  In addition, the ordering healthcare provider hopes the radiology report is written in manner he or she can decipher what the next plan of care should be. The usual disclaimer on radiology reports is to correlate results with clinical symptoms. Can the radiologist add a little more, “what now and what next” value to their reports to provide a clear next step for the provider Yes, radiologists can have better reports. However, primary care colleagues need to give the radiologist more detailed requests to answer the question, “what are we looking for?”

Thyroid Nodules Found on Ultrasound
Benign Thyroid Nodule

  1. Typically found as an incidental finding on imaging studies.
  2. Majority are benign
  3. Additional costs and risks for further work-up
  4. Often indolent behavior of small malignancies
  5. Correlate small non-suspicious nodules with laboratory values
  6. Micro-calcification are visible on ultrasound
  7. Thyroid Nuclear Scan is helpful to see if a nodule indicates area of increased heat compared to the rest of the thyroid, maybe there is a hyper-functioning nodule. There should be another decision tree utilized to assess for a malignant nodule versus benign nodule. Do not perform in patients with renal disease or pregnancy.

If the TSH is low and the free T4 is high we suspect it is being made by thyroid tissue that is working too hard. Consider the size of nodule and imaging appropriateness. Report considerations: is it mostly cystic or does it have calcifications? If there is a nodule entirely cystic with no solid parts and less than 1.5 cm, no further action is needed. However, if there is solid nodule mixed with some cysts, and is 1.5cm or larger, the recommendation for further work-up presents itself due to the higher risk of malignancy.

Reference: Revised American Thyroid Association Management Guidelines for Patients with Thyroid Nodules and Differentiated Thyroid Cancer pages 6 and 7

Renal-Suspect Stone

Renal Calculi | Kidney StoneIn patients with acute renal colic, symptoms include hematuria and flank pain. Perform a CT Scan without contrast. This will allow visualization of small stones, an obstructed renal pelvis or ureter, and any possible inflammation.

Results

In absence of infectious etiology with stone less than 5-6 cm, an patient is hydrated, no further imaging is needed. The patient should be given the opportunity to pass the renal stone on their own. However, if the stone is lodged with increasing drainage behind the stone, a CT Scan with contrast would need to be ordered to rule out an abscess. In addition, an ultrasound may be helpful if needing to rule out hydronephrosis.

So when do you need to order a KUB? With calcific density 5-7mm range, we are able to visualize the stone as it is expelled with the KUB.

Would IV pyelography be needed? IV pyelography is not as useful as a CT scan.

Reference: American College of Radiology ACR Appropriateness Criteria® for Acute Onset Flank Pain — Suspicion of Stone Disease

CT Scan Radiation Versus X-Ray Radiation

Dr. Vachon points out that CT radiation dosage has significantly decreased over the past 3-4 years. The CT scan does have more radiation than an x-ray. However, it is important to consider the context of what is needed. Is it right for the patient at the time? What is the cost-benefit analysis? If there is a clinical question requiring an answer, ultimately, the benefit of discovering the answer to the question outweighs the CT radiation dosage. In addition, an adult is less sensitive to radiation than a child. Research indicates a greater radiation sensitivity for patients less than 30 years of age, and less radiation sensitivity for patients greater than 30 years of age.

The opinions expressed are solely that of Dr. Vachon and not of the US Navy, DOD, ABR, ACR or any other entity.

What type questions do you have? Share your questions in the comments below, and Dr. Vachon looks forward to bridging the gap of radiology knowledge between radiologists, healthcare providers, and patients.