Chest Radiology

Year one (1^st 4-week rotation)

Patient Care

Skills

• Gather clinical and radiological data on patients with thoracic disease
• Develop diagnostic plan based on the clinical presentation and prior imaging
• Demonstrate basic knowledge of IDX-RAD and UHIS computer systems
• Aid technologist in performing the correct x-ray/CT exam responsibly and safely, assuring that the correct exam is ordered and performed.
• Demonstrate the ability to use the Internet as an educational instrument

Education

• Active participation with faculty in exam interpretation/appropriately. Ask the attending questions.
• Participation in Journal Club
• Radiation safety lectures (T. Button, Ph.D.)
• Perform chest fluoroscopy

Assessment

• Global ratings by faculty
• 350 degree review from Core Supervising Technologists
• Place evidence of your accomplishments in your department portfolio

Medical Knowledge

Skills

• Demonstrate to recognize normal chest anatomy and appropriate positions for tubes, catheters and other medical devises on chest film
• Demonstrate ability to diagnose common conditions (e.g. collapsed lobes) and life threatening conditions (e.g. pneumothorax) on chest radiographs
• Demonstrate a clinically appropriate diagnostic treatment plan
• Demonstrate the proper use of radiological equipment such as fluoroscopy equipment and to obtain special radiographic views (e.g. decubitus views and lordotic views, and films in respiratory expiration
• Understand cardiac and aortic arch great vessel anatomy and the physiologic basis for common diseases (e.g. congestive heart failure and pulmonary hypertension, pericardial effusions with tamponade and coarctation of the aorta) and understand the plain film findings in common diseases of the heart and great vessels.

Education

• Required Reading:
  (FIRST ROTATION)
  

  Felson, A practical approach to chest radiology.
  Reed, W. Pattern recognition in chest radiology.

• Didactic lecture series (approximately 48 over two years)
• Participation in the clinical activities of the Thoracic Imaging Section
• Review a portion of the thoracic cases in the department teaching file

Assessment

• Global ratings by faculty
• Plan for future: Written examination based on required reading and curriculum
• ACR in-training examination
• Raphex physics exam
• Place evidence of your accomplishments in your department portfolio

Interpersonal and Communication

Skills

• Provide a clear report based
• Provide direct communication to referring physicians or their appropriate representative, and documenting communication in report for emergent or important unexpected findings
• Demonstrate the verbal and non-verbal skills necessary for face to face listening and speaking to physicians, families, and support personnel

Education

• Participation as an active member of the radiology team by communicating with clinicians face to face, providing consults, answering phones, problem solving and decision-making
• Act as contact person for technologists in managing patient and imaging issues
• Practical experience in dictating radiological reports
• Plan for future: Participation in weekly Pulmonary Multi-disciplinary conference

Assessment

• Global ratings by faculty
• 360 degree evaluation
• ACR In-service examination
• Place evidence of your accomplishments in your department portfolio

If needed, record review

Professionalism

Skills

• Demonstrate altruism
• Demonstrate compassion (be understanding and respectful of patient, their families, and medical colleagues)
• Demonstrate excellence: perform responsibilities at the highest level and continue active learning throughout one's career
• Demonstrate honesty with patients and staff
• Demonstrate honor and integrity: avoid conflict of interests when accepting gifts from patients and vendors
• Demonstrate sensitivity without prejudice on the basis of religious, ethnic, sexual or educational differences, and without employing sexual or other types of harassment
• Demonstrate knowledge of issues of impairment
• Demonstrate positive work habits, including punctuality and professional appearance
• Demonstrate the broad principles of biomedical ethics
• Demonstrate principles of confidentiality with all information transmitted during a patient encounter
• Teaching of medical students

Education

• Discussion of above issues during daily clinical work

Assessment

• Global ratings by faculty
• Attendance at the above conferences with logs as necessary
• Place evidence of your accomplishments in your department portfolio

Practice Based Learning and Improvement Skills

• Review all cases and dictate a preliminary report. Then review your interpretation with faculty and then correct report as needed before sending it to the faculty members report que
• Share good learning cases and missed diagnosis with others in the department

Education

• Participate in Journal club, clinical conferences, and independent learning
• Active participation in quality control and quality assurance activities.
• Submit form quality improvement to supervising technologist, residency review coordinator and department quality improvement secretary.
• Become aware of other quality improvement activities and cases in the department. The chief resident is present at most QA/QC meetings. All residents are involved with this during frequent residency meetings held by the residency program director.

Assessment

• Global ratings by faculty
• 360 degree assessment by Core supervising technologist
• Place evidence of accomplishments in your department portfolio

Systems Based Practice Skills

• Demonstrate ability to design cost-effective care plans
• Demonstrate knowledge of the regulatory environment

Education

• Review of literature related to thoracic imaging, including ACR Appropriateness Criteria and ACR Practice Guidelines and Technical Standards
• Attendance and participation in multi-disciplinary conference
• Interaction with department administrators
• Discussions with faculty about cost-effective care plans and regulation
• Attend the NY State Radiological Society's Residency Career Workshop
• Journal Club articles on Issues related to Systems Based Practice
• Stony Brook University Hospital and Stony Brook Clinical Practice Management Lectures on issues such as JCAHO inspections, corporate compliance, medication ordering and errors, patient safety, etc.
• ACR/APDR Initiative for Residents in Diagnostic Radiology Modules

Assessment

• Global ratings by faculty
• Membership in professional radiology societies
• Place evidence of your accomplishments in your department portfolio

Year 2 (or 2^nd 4-week rotation)
Continue to improve all skills in the above Year one (1^st 4-week rotation)

Patient Care

Skills

• Correlate physical findings by other clinicians with radiographic findings
• Based on your radiographic findings and the clinical setting, guide clinicians in the use of more advanced thoracic imaging techniques such as high resolution CT, MR of cardiac and great vessel conditions and nuclear procedures such as PET-CT.

Education

• Understand the indications for radiographic interventional procedures and other specialized thoracic procedures

Assessment

• Global ratings by faculty
• 350 degree review with Core Supervising Technologists' input
• Place evidence of your accomplishments in your department portfolio

Medical Knowledge

Skills

• Demonstrate understanding of the principles of research project design and implementation and consider starting a scholarly project in thoracic radiology such as a case report or research project with the faculty and, if appropriate, interested medical student.
• Understand the proper use of radiological equipment such as chest sonography and demonstrate its use while on the ultrasound rotation
• Be able to monitor and interpret chest CT for pulmonary embolism
• Understand the anatomy and physiology of common congenital heart disease and begin learn the radiographic findings in these conditions.

Education

• Required Reading:
  (SECOND ROTATION)

  Naidich DP. CT and MR on the Thorax.

• Review current articles related to thoracic imaging in current issues of AJR, Radiology and Radiographics
• Didactic lecture series (approximately 48 over two years)
• Participation in case conferences (noon)
• Participation in the clinical activities of the Thoracic Imaging Section
• Core lectures and conferences

Assessment

• Global ratings by faculty
• Plan for future: Written examination based on required reading and curriculum
• ACR in-training examination
• Raphex physics exam
• Place evidence of your accomplishments in your department portfolio

Interpersonal and Communication Skills

• Present interesting cases after noon conference

Education

• Review the ACR Practice Guideline for Communication: Diagnostic Radiology

Assessment

• Global ratings by faculty
• 360 degree evaluation
• Place evidence of your accomplishments in your department portfolio

If needed, record review

Professionalism Skills

• Help teaching of Junior Residents and house staff from other departments

Education

• Participation in department and hospital based committees and educational activities
• Plan for Future: Training programs and/or videotapes on harassment and discrimination

Assessment

• Global ratings by faculty
• ABR written exam
• Attendance at the above conferences with logs as necessary
• Place evidence of your accomplishments in your department portfolio

Practice Based Learning and Improvement Skills

• Demonstrate knowledge of and apply the principles of evidence-based medicine in practice
• Demonstrate critical assessment of the scientific literature

Education

• Participate in Journal club, clinical conferences, and independent learning
• When on-call and when on thoracic service correlate and discuss your readings of chest x-plain radiographs with the residents and faculty who are interpreting the patient's CT or MR examinations.

Assessment

• Global ratings by faculty/360 degree assessment
• ACR in-service exam
• ABR written examination
• Place evidence of your accomplishments in your department portfolio

Practice Based Learning and Improvement Skills

Systems Based Practice Skills

• Demonstrate knowledge of funding sources
• Demonstrate knowledge of reimbursement methods

Education

• Interaction with department administrators
• Discussions with faculty about funding and reimbursement issues
• Attend the NY State Radiological Society's Residency Career Workshop
• Journal Club articles on Issues related to Systems Based Practice
• Stony Brook University Hospital and Stony Brook Clinical Practice Management Lectures on issues such as JCAHO inspections, corporate compliance, etc.
• ACR/APDR Initiative for Residents in Diagnostic Radiology Modules

Assessment

• Global ratings by faculty
• ACR in-training exam
• Documented membership in societies
• Place evidence of your accomplishments in your department portfolio

---

Year 3-4 (3rd 4-week rotation)
Continue to improve all skills in the above Year one (1^st 4-week rotation)

Patient Care

Skills

• Understand and be able to monitor, supervise and interpret specialized thoracic procedures such a high resolution CT.

Education

• Preparation of cases for Multi-disciplinary Conference

Assessment

• Global ratings by faculty
• 350 degree review with Core Supervising Technologists' input
• Place evidence of your accomplishments in your department portfolio

Medical Knowledge

Skills

• Understand the major radiographic findings in the major cardiac congenital anomalies and be able to offer a differential diagnosis based on the radiographic findings.
• Consider starting or continuing a scholarly project in thoracic radiology such as a case report or research project with the faculty and, if appropriate, interested medical student.
• Master the knowledge of congenital heart disease including the radiographic findings and physiology.

Education

• Required Reading:
  (THIRD ROTATION)

  Webb, Naidich, and Muller. High Resolution CT on the Chest.

• Didactic lecture series (approximately 48 over two years)
• Participation in case conferences (noon)
• Participation in the clinical activities of the Thoracic Imaging Section

Assessment

• Global ratings by faculty
• Written examination based on required reading and curriculum
• ACR in-training examination
• Written ABR exam
• Oral ABR examination
• Place evidence of your accomplishments in your department portfolio
• Core lectures and conferences

Interpersonal and Communication Skills

• Be able to present cases at conferences with other departments (e.g. the emergency department)

Education

• Participate in lectures and/or conferences for medical students during their radiology rotations

Assessment

• Global ratings by faculty
• 360 degree evaluation
• ACR In-service examination
• ABR Written and Oral exam
• Place evidence of your accomplishments in your department portfolio

If needed, record review

Professionalism Skills

• Discuss cases and teach faculty and fellows from other departments when the opportunity arises (such as when they are rounding in radiology)

Education

• Discussion of above issues during daily clinical work
• Plan for Future: Didactic presentations on "the impaired physician"
• Participation in department and hospital based committees and educational activities

Assessment

• Global ratings by faculty
• 360 degree evaluation
• Attendance at the above conferences with logs as necessary
• Place evidence of your accomplishments in your department portfolio

Practice Based Learning and Improvement Skills

• Analyze and develop improvement plans in the clinical practice, including knowledge, observation, and procedural skills

Education

• Participate in Journal club, clinical conferences, and independent learning
• Active participation in quality control and quality assurance activities. The chief resident is present at most QA/QC meetings. All residents are involved with this during frequent residency meetings held by the residency program director.
• ACR/APDR Initiative for Residents in Diagnostic Radiology Modules

Practice Based Learning and Improvement Skills

Assessment

• Global ratings by faculty
• 360 degree assessment
• Place evidence of your accomplishments in your department portfolio
• Systems Based Practice Skills
• Demonstrate knowledge of basic management principles such as budgeting, record keeping, medical records, and the recruitment, hiring, supervision and management of staff

Education

• Interaction with department administrators
• Membership and participation in local and national radiological societies
• Discussions with faculty about practice patterns and reimbursement issues
• Attend the NY State Radiological Society's Residency Career Workshop
• Journal Club articles on Issues related to Systems Based Practice
• Stony Brook University Hospital and Stony Brook Clinical Practice Management Lectures on issues such as JCAHO inspections, corporate compliance, medication ordering and errors, patient safety, etc.

Assessment

• Global ratings by faculty
• ABR written exam
• ACR in-training exam
• Documented membership in societies
• Place evidence of your accomplishments in your department portfolio

Year one (1^st 4-week rotation)

I.Goals
After completion of the first chest rotation, the resident will have learned:

1. Demonstrate learning of the knowledge-based objectives
2. Accurately and concisely dictate a chest radiograph report
3. Communicate effectively with referring clinicians and supervisory staff
4. Understand standard patient positioning in chest radiology
5. Obtain pertinent patient information relative to radiologic examinations
6. Demonstrate learning of the clinical indications for obtaining chest radiographs and when a chest CT or MR may be necessary
7. Demonstrate a responsible work ethic

II. Objectives
Part A. Knowledge-based: At the end of the first chest rotation, the resident will demonstrate learning of at least one-third of the following knowledge-based objectives:

Normal Anatomy

1. Name and define the three zones of the airways
2. Define a secondary pulmonary lobule
3. Define an acinus
4. List the lobar and segmental bronchi of both lungs
5. Identify the following structures on the posteroanterior (PA) chest radiograph:
   • Lungs - right, left, right upper, middle and lower lobes, left upper and lower lobes, lingula
   • Fissures - minor, superior accessory, inferior accessory, azygous
   • Airway - trachea, carina, main bronchi
   • Heart - right atrium, left atrial appendage, left ventricle location of the cardiac valves
   • Pulmonary arteries - main, right, left, interlobar
   • Aorta - ascending, arch, descending
   • Veins - superior vena cava, azygous, left superior intercostal ("aortic nipple")
   • Bones - spine, ribs, clavicles, scapulae, humerus
   • Right paratracheal stripe
   • Junction lines - anterior, posterior
   • Aortopulmonary window
   • Azygoesophageal recess
   • Paraspinal lines
   • Left subclavian artery
6. Identify the following structures on the lateral chest radiograph:
   • Lungs - right, left, right upper, middle and lower lobes, left upper and lower lobes, lingual
   • Fissures - major, minor, superior accessory
   • Airway - trachea, upper lobe bronchi, posterior wall of bronchus intermedius
   • Heart - right ventricle, right ventricular outflow stripe, left atrium, left ventricle, the location of the four cardiac valves
   • Pulmonary arteries - right, left
   • Aorta - ascending, arch, descending
   • Veins - SVC, IVC, left brachiocephalic (innominate), pulmonary vein confluences
   • Bones - spine, ribs, scapulae, humerus
   • Retrosternal line
   • Posterior tracheal stripe
   • Right and left hemidiaphragms
   • Raider's triangle
   • Brachiocephalic (innominate) artery

Signs in Chest Radiology

1. Be able to define, identify and state the significance of the following on a radiograph:
   • air bronchogram - indicates a parenchymal process, including non- obstructive atelectasis, as distinguished from pleural or mediastinal processes
   • air crescent sign - indicates a lung cavity, often due to fungal infection
   • deep sulcus sign on a supine radiograph - indicates pneumothorax
   • continuous diaphragm sign -indicates pneumomediastinum
   • ring around the artery sign (around pulmonary artery on lateral chest radiograph) - indicates pneumomediastinum
   • fallen lung sign - indicates a fractured bronchus
   • flat waist sign - indicates left lower lobe collapse
   • gloved finger sign - indicates bronchial impaction
   • Golden S sign - indicates lobar collapse with a central mass, suggesting an obstructing bronchogenic carcinoma in an adult
   • luftsichel sign - indicates upper lobe collapse, potentially due to an obstructing bronchogenic carcinoma in an adult
   • Hampton's hump - indicates a pulmonary infarct
   • silhouette sign - loss of the contour of the heart or diaphragm used to localize a parenchymal process (e.g. a process involving the medial segment of the right middle lobe obscures the right heart border; a lingula process obscures the left heart border; a basilar segmental lower lobe process obscures the diaphragm)
   • cervicothoracic sign - a mediastinal opacity that projects above the clavicles is retrotracheal and posteriorly situated while an opacity effaced along its superior aspect and projecting at or below the clavicles is situated anteriorly
   • tapered margins sign - a lesion in the chest wall, mediastinum or pleura will have smooth tapered borders and obtuse angles with the chest wall or mediastinum while parenchymal lesions usually form acute angles
   • figure 3 sign - abnormal contour of the descending aorta, indicating coarctation of the aorta
   • fat pad sign or sandwich sign - indicates pericardial effusion on lateral chest radiograph
   • hilum overlay sign and hilum convergence sign - used to distinguish a hilar mass from a non-hilar mass
2. In addition these additional CT finds will be expected to be learned by the resident during there first rotation including identificatuion and state the significance of the following on a chest CT:
   • CT angiogram sign - enhancing pulmonary vessels against a background of low attenuation material in the lung
   • halo sign - suggesting invasive pulmonary aspergillosis in a leukemic patients
   • split pleura sign - a sign of empyema

Chest Trauma

1. Identify a widened mediastinum on a trauma radiograph and state the differential diagnosis (including aortic-arterial injury, venous injury, fracture of sternum or spine)
2. Identify the indirect and direct signs of aortic injury on contrast-enhanced chest CT scan
3. Identify and state the significance of chronic traumatic pseudoaneurysm on a chest radiograph, CT or MRI
4. Identify fractured ribs, clavicle, spine and scapula on a chest radiograph or chest CT
5. Name five common causes of abnormal lung opacity on a trauma radiograph or CT
6. Identify an abnormally positioned diaphragm or loss of definition of a diaphragm on a trauma chest radiograph and suggest the diagnosis of a ruptured diaphragm
7. Identify a pneumothorax and pneumomediastinum on a trauma chest radiograph
8. Identify the fallen lung sign on a radiograph or chest CT scan and suggest the diagnosis of tracheobronchial tear
9. Identify a cavitary lesion on a post-trauma radiograph or chest CT and suggest the diagnosis of laceration with pneumatocele formation, hematoma or abscess secondary to aspiration
10. Name the three most common causes of pneumomediastinum in the setting of trauma
11. Recognize and distinguish between pulmonary contusion, laceration and aspiration

Infection (Immunocompetent, Immunocompromised and Post-transplant Patients)

1. Name the radiographic manifestations of primary pulmonary tuberculosis
2. Name the three most common segmental sites of involvement for reactivation tuberculosis in the lung
3. Define Ranke complex and Ghon lesion; recognize both on a radiograph and CT
4. Name and describe the four types of pulmonary Aspergillus disease
5. Identify an intracavitary fungus ball on chest radiography and chest CT
6. State the radiographic appearances of Cytomegalovirus pneumonia
7. Name the major categories of disease causing chest radiograph or chest CT abnormalities in the immunocompromised patient
8. Other than bacterial infection, name 2 important infections and 2 important neoplasms to consider in patients with AIDS and chest radiograph or chest CT abnormalities
9. Describe the chest radiograph and chest CT appearances of Pneumocystis carinii pneumonia
10. Name the 4 most important etiologies of hilar and mediastinal adenopathy in patients with AIDS
11. Describe the time course and chest radiographic appearance of a blood transfusion reaction
12. State the radiographic appearances of mycoplasma pneumonia
13. Describe the radiographic and CT appearance of a miliary pattern and provide a differential diagnosis
14. Name the diagnostic considerations in a patient who presents with recurrent or persistent pneumonias
15. Name the endemic mycoses, the specific geographic regions where they are found, and their radiographic manifestations
16. State the most common pulmonary infections seen after solid-organ (i.e. liver, renal, cardiac) transplantation
17. Describe the radiographic and CT findings of post-transplant Iymphoproliferative disorders

Unilateral Hyperlucent Lung (or hemithorax)

1. Recognize a unilateral hyperlucent lung on a radiograph or chest CT
2. Identify the common causes for unilateral hyperlucent lung on a chest radiograph
3. Give an appropriate differential diagnosis when a hyperlucent lung is seen on a chest radiograph, and suggest a specific diagnosis when certain associated findings are seen (i.e. absence of a breast in a patient after mastectomy for breast cancer, absence of a pectoralis muscle in a patient with Poland's syndrome, unilateral bulbous disease/emphysema, or air trapping on expiration in a patient with Sawyer-James syndrome or an end bronchial foreign body)

Congenital Lung Disease

1. Name the components of the pulmonary venolobar syndrome
2. Recognize venolobar syndrome on a frontal chest radiograph, chest CT and chest MRI, and explain the etiology of the retrostemal band of opacity seen on the lateral view
3. Recognize a mass in the posterior segment of a lower lobe on a chest radiograph and chest, and suggest the possible diagnosis of pulmonary sequestration
4. Explain the differences between intralobar and extralobar sequestration
5. Recognize bronchial atresia on a radiograph and chest CT, and state the most common lobes of the lungs in which it occurs

Pulmonary Vascular

1. Recognize enlarged pulmonary arteries on a chest radiograph and distinguish them from enlarged hilar lymph nodes
2. Recognize enlargement of the central pulmonary arteries with diminution of the peripheral pulmonary arteries as pulmonary arterial hypertension and suggest the possible diagnosis of primary pulmonary artery hypertension
3. Name five of the most common causes of pulmonary artery hypertension
4. Recognize lobar and segmental pulmonary emboli on chest CT and chest MRI (including MR angiography)
5. Define the role of ventilation-perfusion scintigraphy, chest CT, chest MRI/MRA and lower extremity venous studies in the evaluation of a patient with suspected venous thromboembolic disease, including the advantages and limitations of each modality depending on patient presentation

Thoracic Aorta and Great Vessels

1. State the normal dimensions of the thoracic aorta
2. Describe the classifications of aortic dissection (DeBakey 1,11, III; Stanford A, B), and implications for classification on medical versus surgical management
3. State and recognize the findings of, and distinguish between each of the following on CT and MR:
   • aortic aneurysm
   • aortic dissection
   • aortic intramural hematoma
   • penetrating atherosclerotic ulcer
   • ulcerated plaque
   • ruptured aortic aneurysm
   • sinus of valsalva aneurysm
   • subclavian or brachiocephalic artery aneurysm
   • aortic coarctation
   • aortic pseudocoarctation
4. Recognize a right aortic arch and a double aortic arch on a radiograph, chest CT and chest MR
5. State the significance of a right aortic arch with mirror image branching versus with an aberrant subclavian artery
6. Recognize a cervical aortic arch on a radiograph and chest CT
7. Recognize an aberrant subclavian artery on chest CT
8. Recognize normal variants of aortic arch branching, including common origin of brachiocephalic and left common carotid arteries ("bovine arch"), separate origin of vertebral artery from arch
9. Define the terms aneurysm and pseudoaneurysm
10. State the common cardiac anomalies associated with aortic coarctation
11. State and identify the findings seen in Takayasu's arteritis on chest CT and chest MR
12. State the advantages and disadvantages of CT, MRI/MRA and transesophageal echocardiography in the evaluation of the thoracic aorta

Ischemic Heart Disease

1. Describe the anatomy of the coronary arteries and identify the following on a coronary arteriogram and CT scan
   • right coronary artery
   • left main coronary artery
   • left anterior descending coronary artery left circumflex coronary artery
2. State the clinical significance of coronary arterial calcification on a chest radiograph
3. Recognize coronary arterial calcification on CT and state the current role of coronary artery calcium scoring with helical or electron beam CT
4. State which coronary artery is usually diseased when there is papillary muscle dysfunction
5. Describe the common acute complications of myocardial infarction, including left ventricular failure, myocardial rupture and papillary muscle rupture, and recognize radiologic findings that may indicate these
6. Describe the common late complications of myocardial infarction, including ischemic cardiomyopathy, left ventricular aneurysm, left ventricular pseudoaneurysm,coronary-cameral fistula, dyskinesis and akinesis and recognize radiologic findings that may indicate these
7. Identify left heart failure on a radiograph and chest CT 8. Recognize acute myocardial infarction on MR imaging
8. Define ejection fraction and state the normal left ventricular ejection fraction
9. ldentify myocardial calcification on CT and state the etiology and significance of this finding
10. State the difference between a left ventricular aneurysm and pseudoaneurysm
11. Define and identify myocardial bridging on MR
12. Define the role of angiography, echocardiography, stress perfusion scintigraphy, chest CT, and chest MRI in the evaluation of a patient with suspected ischemic heart disease, including the advantages and limitations of each modality

Myocardial Disease

1. Define the types of cardiomyopathy (dilated, hypertrophic, restrictive) and list the common causes of each
2. Define right ventricular dysplasia and identify on MRI
3. State the most common benign primary cardiac tumors, including myxoma, lipoma, fibroma and rhabdomyoma
4. State the most common malignant primary cardiac tumors, including angiosarcoma, rhabdomyosarcoma, lymphoma
5. Distinguish cardiac tumor from thrombus on CT and MRI
6. State the most common malignancies to metastasize to the heart, and the appearance on a radiograph, chest CT and chest MR
7. State the advantages and disadvantages of echocardiography, CT, and MRI for evaluation of cardiomyopathy and cardiac tumors

Cardiac Valvular Disease

1. State the findings that indicate each of the following and identify each on chest radiographs:
   • enlarged right atrium
   • enlarged left atrium
   • enlarged right ventricle
   • enlarged left ventricle
2. Recognize an enlarged left atrium, vascular redistribution, and mitral valve calcification on a chest radiograph and suggest the diagnosis of mitral stenosis
3. Recognize an enlarged ascending aorta and aortic valve calcification on a chest radiograph and suggest the diagnosis of aortic stenosis
4. State the most common etiologies of the following:
   • aortic stenosis
   • aortic regurgitation
   • mitral stenosis
   • mitral regurgitation
   • tricuspid regurgitation
   • pulmonary stenosis
5. State the cardiac diseases associated with mitral annulus calcification
6. Identify endocarditis and/or complications of endocarditis on radiographs, chest CT and chest MR
7. State the advantages and disadvantages of echocardiography and MRI for evaluation of valvular heart disease

Pericardial disease

1. Recognize pericardial calcification on a radiograph and chest CT and list the most common causes
2. Describe and identify two chest radiographic signs of a pericardial effusion
3. State five causes of a pericardial effusion
4. State and recognize the findings of each of the following on radiography, CT and MR:
   • pericardial cyst
   • constrictive pericarditis
   • pericardial hematoma
   • pericardial metastases
   • partial absence of the pericardium
   • pneumopericardium

Congenital Heart Disease in the Adult

1. Recognize increased vascularity, decreased vascularity and shunt vascularity on a chest radiograph and state the common causes of each
2. Recognize the following on imaging examinations of the chest, including radiographs, CT and/or MRI:
   Heart disease presenting during adulthood
   • Left-to-right shunts and Eisenmenger physiology
   • Atrial septal defect
   • Ventricular septal defect
   • Partial anomalous pulmonary venous connection
   • Patent ductus arteriosus
   • Coarctation of aorta
   • Tetralogy of Fallot and pulmonary atresia with ventricular septal defect
   • Congenitally corrected transposition of the great arteries
   • Persistent left superior vena cava
   • Truncus arteriosus
   • Ebstein anomaly
   • Cardiac malposition, including abnormal situs
   Heart disease originally treated in childhood
   • Coarctation of the aorta
   • Tetralogy of Fallot and Pulmonary atresia with ventricular septal defect
   • Complete transposition of the great arteries
   • Congenitally corrected transposition of the great arteries
   • Truncus arteriosus
   • Commonly performed surgical corrections for congenital heart disease
3. Define the role of angiography, echocardiography, chest CT, and chest MRI in the evaluation of an adult patient with congenital heart disease, including the advantages and limitations of each modality depending on patient presentation

Monitoring and support devices -"tubes and lines"

1. Be able to identify, state the preferred placement of, complications associated with malposition and identify the location on chest radiography for each of the following:
   • endotracheal tube
   • central venous catheter
   • Swan-Ganz catheter
   • feeding tube
   • nasogastric tube
   • chest tube
   • intra-aortic balloon pump
   • pacemaker and pacemaker leads
   • automatic implantable cardiac defibrillator
   • left ventricular assist device
   • atrial septal defect closure device ("clamshell device")
   • pericardial drain
   • extracorporeal life support cannulae
   • intraesophageal manometer, temperature probe or pH probe
   • tracheal or bronchial stent
2. Explain how an intra-aortic balloon pump works

Post-operative chest

1. Identify normal post-operative findings and complications of the following procedures, on chest radiography, CT and MRI:
   • wedge resection, lobectomy, pneumonectomy
   • coronary artery bypass graft surgery
   • cardiac valve replacement
   • aortic graft
   • aortic stent
   • transhiatal esophagectomy
   • lung transplant
   • heart transplant
   • lung volume reduction surgery

At the end of the first chest rotation, the resident will demonstrate the following technical, communication, and decision-making skilIs:

1. Dictate understandable chest radiograph reports that include patient name, patient medical record number, date of exam, date of comparison exam, type of exam, indication for exam, brief and concise description of the findings and short impression
2. Call ordering physicians about all significant or unexpected radiologic findings and document who was called and the date and time of the call in the dictated report
3. Obtain relevant patient history from computer records, dictated reports, or by calling referring clinicians
4. Describe patient positioning and indications for a PA, lateral, decubitus, and lordotic chest radiograph
5. Decide when it is appropriate to obtain help from supervisory faculty in interpreting radiographs when answering questions for referring clinicians
6. Arrive for the rotation assignment on time and prepared, after reviewing recommended study materials

Year 2 (or 2^nd 4-week rotation)

I.Goals
After completion of the first chest rotation, the resident will:

1. Demonstrate learning of the knowledge-based objectives
2. Continue to build on chest radiograph interpretive skills
3. Develop skills in protocolling, monitoring, and interpreting chest CT scans
4. Demonstrate an understanding of ACR appropriateness criteria for chest radiology

Year 3-4 (or 3^rd 4-week rotation)

I. Goals
After completion of the third chest rotation, the resident will:

1. Demonstrate learning of the knowledge-based objectives
2. Refine skills in interpretation of radiographs and chest CT scans
3. Develop skills in protocolling, monitoring, and interpreting HRCT scans
4. Develop skills in protocolling, monitoring and interpreting chest MR studies, including cardiovascular MRI
5. Become a more autonomous consultant and teacher
6. Correlate pathologic and clinical data with radiographic and chest CT findings