Procedural Skills and Office Technology (www.psot.com) Bulletin

 

Case-Based Learning and Competency-Based Testing

 

Chest X-Rays: When to Order and How to Interpret

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TO

SYLLABUS
 
Module I

Wm. MacMillan Rodney, M.D.

August 8, 2001

 

 

Presentations:

 

The University of Tennessee, Memphis, MS-3 Clerkship, 1994-2000

Meharry Medical College, Residency and Student Clerkship, 2000 to Present

 

Goals:

 

1.                  To produce relatively permanent changes in the physician’s behavior leading to high quality in health care for common problems.

2.                  Create and share enduring educational materials plus supplying a syllabus, clinical updates, and seminar experiences through case-based learning.  Link these materials to competency-based testing such that achievement and/or additional educational needs can be identified.

 

Background:

 

Attached you will find the three-page summary and some recommended readings.

This is part of a larger series on the reading of common office x-rays.  If you would like to be placed on the mailing list for an invitation to the presentations on common fractures of the foot, ankle, wrist, hand, and elbow; please leave your name, address, and phone number.  You will be notified.

Newly refined diagnostic and therapeutic techniques are constantly emerging, but medical education systems are slow to develop the necessary infrastructure for accountable instruction.  Additionally, physicians who have completed the formal part of training may not be in a position to leave a busy practice.  Therefore, organizations such as the American Academy of Family Physicians (AAFP), the National Procedures Institute (NPI), the Association for Rural Family and Emergency Medicine (ARFEM) and others have developed instructional modules for this purpose.  With over 20 years of experience in this area, it has been my observation that there is a difficult balance between the passive roles of student physician in lecture as opposed to the constantly active role of physicians in practice.

Adult learners seem to do best when presented with clinical material simulating the actual conditions of clinical practice.  However, there must be didactic materials, absorbed by the learner, before hands-on workshop experiences can be effective.  In the past, I have used terms “cognitive preloading,” “educational prescriptions,” “performance-based learning,” and “competency-based testing” as a quality improvement cycle.

 

Therefore, these materials are designed to augment the lecture format.  These materials are best used when the learner has received a syllabus and/or assigned readings, reviewed the readings, and clarified specific learning objectives.  This seminar will present syllabus material and briefly review it.  Learning objectives will be defined.

 

Books for the Interpretation of Chest X-Ray

1.         Burgener FA, Kormano M.  Differential diagnosis in chest x-rays.  1997 Thieme Verlag, ISBN#: 0-86577-677-6.

2.         Reed JC. Chest radiology: plain film patterns and differential diagnoses.  Mosby 1997, ISBN#: 0-8151-7122-6.

 

3.         Others by Request.

 

 

Attached Articles

 

1.                  Krone KD, Weiner SA. How to read chest x-rays, July 1992 , Hospital Medicine, 79-101.

2.                  Mongomery JL. Pneumonia: pearls for interpreting patients’ radiographs. Postgrad Med Oct 1991; 90(5):58-73.

3.                  Margolis P, Gadomski A. The Rational Clinical Examination. Does this infant have pneumonia. JAMA Jan 1998; 279(4):308-313.

4.                  Chen JTT. Radiographic diagnosis of heart failure. Heart Dis Stroke Mar/Apr 1992; 58-63.

 

The Appropriate Utilization of Chest Radiographs

 

Source:   Clinton JE.  Cost-Effective Diagnostic Testing.  Cantrill SV, Karas S (Eds), ACEP 1994 Dallas, Texas.  Edited and Abridged by Wm. Rodney, M.d., FACEP

 

Chest radiography is used for specific indications and as a screening mechanism for pulmonary disease in populations that are considered at risk.  The yield for positive findings varies widely by population.  Experience can be drawn upon to limit the unnecessary use of chest radiography in patients presenting to the emergency department.

 

Appropriate Use of Chest Radiography

 

--   Hemoptysis evaluation1

--   Acute, complicated asthmatic episode2

--   Symptoms of congestive heart failure3

--   The febrile and neutropenic patient4

--   Screening admission examinations, those with altered mental status, those who are HIV-positive, those with a history of cancer at any site, and those with congestive heart failure.5

--   Sickle cell patients with shortness of breath or chest pain who are in a pain crisis to diagnose occult infection.6

--   Cough and fever in patients over the age of 40.1

--   A strong clinical suspicion of pneumonia by a seasoned clinician in a patient who has at least one abnormal vital sign.5,7

--   Children who are admitted to a pediatric intensive care unit.8,9

 

Inappropriate Use of Chest Radiography

 

--   Initial evaluation of the uncomplicated asthmatic.2             

--   Routine hospital admission of a patient without chest symptomatology or risk factors.

--   Acute chest symptoms without physical findings in patients under the age of 40 unless hemoptysis is present.1

--   Chest pain in children without physical findings.10

--   Cancer screening in asymptomatic smokers. (WMR)

 

Risk Management Implications

 

Ample literature exists to support the decision of the physician who chooses not to order a chest radiograph in a young patient with acute symptoms who has no physical findings or risk factors but has complaints related to the chest.  Notable exceptions include the presence of hemoptysis or a strong clinical suspicion of pneumonia.  A reasonable approach to a patient with a persistent respiratory complaint would involve chest radiography as part of the work-up.  Overuse of chest radiography seems to occur during the initial evaluation of patients with self-limited or easily reversible complaints, such as viral syndromes or bronchospasm.  Appropriate follow-up must be provided to such patients so further evaluation can be done if their symptoms persist.

Case Examples

 

Case 1

A 12-year-old boy presents with acute wheezing and hyperinflation of the chest of one hour’s duration.  His vital signs are blood pressure 130/85mm Hg, pulse 110, respirations 24, and temperature 37oC (98.6o F).  Peak flow is 200 L/min.  Chest auscultation reveals diffuse wheezing with a prolonged expiratory phase.

 

Question:  Is a chest radiograph indicated in this patient?

Answer:  No.  Treatment should consist of bronchodilation and reevaluation.  Chest radiography is not indicated in this uncomplicated patient with asthma because its yield would be very low.

 

Case 2

A 35-year-old man, who has been previously healthy, presents with a picture of acute appendicitis and is being admitted for observation and possible surgery.

 

Question:  Is a chest radiography indicated in this patient?

Answer:  No.  Chest radiography is not indicated for admission of this patient, who has no chest-related symptoms.  The yield of such an examination would be exceedingly low.

 

Suggested Criteria for Monitoring the Use of Chest Radiographs

1.         Was admission screening performed in an adult patient less than 65 years of age who had no serious medical problems or symptoms?                                                             ____Yes    ____No

2.         Did the patient undergo initial evaluation of uncomplicated asthma?          ____Yes    ____No

3.         Was the patient a child with chest pain and no other physical findings?      ____Yes    ____No

 

A “yes” answer to any of these questions would indicate that chest radiography would have been of little benefit.
 
 

 

 

 

 

 

 

 

 

 

 


Summary:

 

-- Chest radiographs are inappropriate in the initial evaluation of uncomplicated asthmatics, for routine hospital admission, for acute chest symptoms without physical findings in patients under the age of 40 (except for hemoptysis), and for chest pain in children without physical findings.

-- Chest radiographs may be useful for evaluation of: hemoptysis; complicated asthma; symptoms of congestive heart failure; admission screening in certain high-risk patients, possibly including; those with altered mental status; HIV-positive patients; patients with a history of any type of cancer; sickle cell patients with respiratory symptoms; cough and fever in patients over the age of 40; clinical suspicion of pneumonitis in patients with one or more abnormal vital signs; and children who are admitted to a pediatric intensive care unit.

 

References:

 

1.         Benacerraf BR, et al.  An assessment of the contribution of chest radiography in outpatients with acute chest complaints: A prospective study.  Diagn Radiol 1981; 138-293.

2.         Aronson S, et al.  The value of routine admission chest radiographs in adult asthmatics.  Ann Emerg Med 1989; 18:1206-1208.

3.         Buenger RE.  Five thousand acute care/emergency department chest radiographs: comparison of requisitions with radiographic findings.  J Emerg Med 1988; 6:197-202.

4.         Donowitz GR, et al.  The role of the chest roentgenogram in febrile neutropenic patients.  Arch Intern Med 1991; 151:701-704.

5.         Pollack CV Jr., et al. Usefulness of empiric chest radiography and urinalysis testing in adults with acute sickle cell pain crisis.  Ann Emerg Med 1991; 20:1210-1214.

6.         White, et al.  The impact of routine chest radiography on the management of patients admitted from an emergency service.  Invest Radiol 1990; 25:720-723.

7.         Singal BM, et al.  Decision rules and clinical prediction of pneumonia: evaluation of low-yield criteria.  Ann Emerg Med 1989; 18:13-20.

8.         Hauser GJ, et al.  Routine chest radiographs in pediatric intensive care: a prospective study.  Pediatrics 1989;83:465-470.

9.         Sivit CJ, et al.  Efficacy of chest radiography in pediatric intensive care.  AJR 1989; 152:575-577.

10.       Rowe BH, et al. Characteristics of children presenting with chest pain to a pediatric emergency department.  Can Med Assoc J 1990; 143:388-394.