We've reviewed many of the radiological studies anatomical and pathological checklists for studies interpretation.
We’ve formulated a simple,
handy yet bold and effective systematic approach that would make it much easier for residents as well as registrars to improve their workflow for each study interpretation.
That approach system includes checklists for study technique,
anatomy,
pathology,
and search pattern in context of the clinical question.
Thus fulfilling a comprehensive thinking manner seeking diagnosis and management.
As a beginning,
always keep in mind to confirm the basic details such as patient age,
history,
patient ID,
date of the study and whether there in any previous examinations.
QUATTRO METHOD
It’s -as the name suggests- comprised of 4 steps/ items that you should fulfill.[figure1]
I- TECHNIQUE:
How those images of the studies were technically obtained and how each modality work,
what is the name of this examination,
why it was done specifically this way,
what is the possibilities and capabilities of each modality,
is it technically adequate,
what is your judgement on the quality of study?
On Plain Radiography: basic knowledge of different tissues densities,
how they are projected on the film and how each medical device appears under x-ray is cardinal.
On CT, you have to know which window is this,
is it soft tissue,
lung,
or bone.
You should be aware of the best window and level of HU to get a certain lesion/ tissue.
What are the pitfalls of increasing or decreasing the contrast of certain window,
what lesions would be depicted best for each windowing.
On MRI, you should know the basic sequences used in all studies and some of the special sequences for specific studies,
get solid idea of how every tissue appears on each basic sequence.
Contrast or not? Consequences of that? How does contrast work in MRI?,
etc.
You should be aware of the best sequence or view for each part of the body .
Also some parts of the body are to be examined with specific protocols of CT or MRI depending on many factors or characteristic of these body parts.
There are some good books on techniques of different imaging modalities,
that you should get your hands on.
II- ANATOMY
Knowledge of detailed radiological anatomy is essential.
You should have a full awareness of each body system and exact relations of each organ by heart.
You should be able to correlate the different views/ cuts of each organ and part of the body,
formulating what's like a 3D map of body in your mind.
Anatomy is critical to make an accurate diagnosis.
When faced with a lesion,
always ask yourself where is the "epicentre" of the process is likely to be (i.e.,
where do you think the process started?).[2]
If you can’t decide where to begin,
just start asking yourself,
what are these specific structure in this slice,
where is it and it’s relations to the surroundings,
is it central or peripheral or upper,
lower,
follow this structure,
where it comes from,
is it artery,
vein,
muscle,
organ,
bowel.
What should be around it,
connected to it,
supplying it,
and how it should ideally be.
Also,
you have to be aware of normal variants which would count in the anatomy categories.
And always remember,when you get stuck or lost,
revert back to anatomy.
In some areas of body,
like brain and Neck,
knowledge of anatomy is the only key to start reporting their studies,
as their pathologies checklist is rather limited,
specific and is basically categorized depending on anatomical considerations.
[3],
[4],
[5]
III- SYSTEMATIC CHECK ‘CHECKLISTS’:
Check each organ/ space/ formation for each one of its pathologies.
Use the checklists provided in the attached tables [Tables 1- 22] as a guide or use your accustomed ones.
Correlating the clinical and laboratory,
and imaging findings with each other is cardinally essential in radiology.
IV- PATHOLOGY AND CLINICAL QUESTION:
According to the checklist of each organ's pathology.
Describe the lesion,
and then see what pathologies of it,
in this specific case,
age,
in context of history.
You have to be aware of the top differential diagnoses.
And you should Only provide differential diagnoses that are relevant to the patient's age group/ demographics.
You might consider the classic approach of classifying the lesions as:
Congenital,
traumatic,
inflammatory,
neoplastic,
vascular,
others,
which would work for many pathologies,
yet some parts of the body have their own special approach that you have to be fully aware of,
like many of MSK joints pathologies and checklists.
Another approach is searching for specific common pathology for each part/ organ of the study,
this methods becomes handy when doing x rays.
Or in other words,
you should develop what so called 'review areas' for each body part.
Correlate your findings with the clinical question considered.
In this exhibit,
we’ve presented many checklists for the common radiological studies,
including X Ray,
CT,
MRI.
Residents and radiologists can use these checklists in context of the Quattro Method,
they can accustom it to their preferences,
to make it fit for their practice and the current exam being addressed.
[Tables 1- 22]
These four steps are mostly done as a single combined shot by the experienced radiologist,
however it’s much useful for residents to build their search method systematically.
The Quattro method ought be applied for each examination included in these checklists.
The approach for each checklist may differ according to area of body being assessed,
pathology list,
anatomical consideration,
and modality type.
Reporting considerations:
While radiology report is the final product of the radiologist,
this exhibit is not mainly focused on reporting techniques and skills.
It's mainly concerned with the many steps that precede the actual reporting process.
So,
before proceeding with your report,
there are four cardinal questions to be answered in:
1.
What can be seen on the study?
This assesses your observational skills.
This can include both normal features that are relevant to the case and abnormalities.
2.
Why does it look like that?
Once you have recognized an abnormality,
you must be able to describe it so that when someone reads just the report they will be able to imagine it.
3.
What has caused it?
This question is asking about the diagnosis or possible diagnoses.
It is assessing your analytical skills and whether you are able to understand what you have seen is significant or not.
4.
What needs to be done next?
The radiologist’s role is essential in directing the clinician for the appropriate management,
especially when an urgency arises and there is a need for urgent clinical input.[6]
It’s essential to be aware of different tiers of Structured Reporting,
with benefits like decreased ambiguity and enhanced opportunities for research,
clinical decision support,
and quality improvement.[7]The systematic approach in reading and interpreting is the first basic step that radiologist should be aware of towards making a meaningful,
thoughtful report,
addressing the clinical question,
and making a better change in the patient’s life.
Hints when faced with a radiological study:
Don't get your attention withdraw by the significant lesion,
examine the rest of the film,
as you would find the cause of this lesion,
then search for the cause and result of the abnormality.
Examine the non-indicated areas of the study,
it may contain the finding rather than a normal indicated study.
Have a quick look at the film or a quick scroll across the images stack to see if an obvious abnormality is apparent.
Use the clinical information that is available to direct this.
If you can’t appreciate an overt abnormality on the initial survey,
concentrate on a single organ before moving to another organ.
This will allow you to build up a picture and exclude abnormalities as you progress.
If you try to look at every organ on one image before moving to another one,
you will spend overall more time and may miss Details.[2]
Reporting Environment Considerations
It’s worth mentioning that different factors surrounding the reporting radiologist will definitely affect his performance.
Light/ ambient light: Incorrect ambient light can obscure good contrast on the screen,
leading to missing some minute findings.
Personal factors such as fatigue and eye strain,
sitting position,
etc would definitely affect radiologists performance,
and it’s worth knowing that these effects differs from the senior consultant to the junior resident.
Types of errors:
Radiologist should be aware of different types of errors,
pitfalls and how to avoid each one of them.
Perceptual/ Cognitive errors common examples:
Search: failure of perception of a certain finding.
Recognition and Decision: notice of the finding but didn’t record or consider it as a finding.
Classification:Found,
record,
but called benign instead of malignant.
The Quattro Method is mainly concerned with search and recognition errors,
though you have to build a solid foundation of diagnostic radiologic pathologies knowledge to avoid other errors.
Satisfaction of search and other pitfalls
One of the benefits of this Quattro method is it would avoid many pitfalls and falling in the trap of (SOS),
it happens when the radiologist fails to continue to search for subsequent abnormalities (other lesions remain undetected) after identifying an initial one.
Generally,
we recommend before calling a study/ radiograph a normal study,
revising your list of pitfalls for each study,
e.g” before dictating a chest x-ray (CXR) normal,
check the anterior ribs if it’s slopped vertically and check the right border of the heart "obliterated",
if yes,
you’re dealing with a Pectus excavatum”,
ect.
Subtle pneumothoraces are sometimes missed on the CXR,
hidden lytic lesions of clavicles due to Pancoast’s tumor are easily missed on a day to day cervical spine radiography.
The cause of shoulder pain after trauma,
with a normal looking glenohumeral joint and no dislocation,
might be in fact due to a metastatic lesion in the bones of shoulder.
All these pitfalls and errors would have been avoided if the reporting radiologist stick to a systematic approach,
and needless to say,
these all can directly steer the clinical decision and thus affect patient’s life.
These Figures show some of (SOS) examples from our practice.[Figures 2-5]
In lateral CXR -for example- (Feigin DS)[8] recommends optimal systematic analysis.
First is a general look and overview,
followed by analysis of the airway and major hilar structures.
Next is attention to the three areas where the image darkens in the absence of visible structure edges.
Last is attention to the periphery and the upper abdomen.
All these approaches and others would help lessens any missed pathologies.
It’s worth mentioning that residents' reporting scores showed significant improvement over the course of their residency training.
This indicates that there may be a benefit in using an organized reporting curriculum to track resident progress in producing reports that may improve patient care,
as shown by (Collard MD,
et al.)[9]