The lights go down as the radiologist in front of the classroom prepares the computer for a case presentation. A switch is flicked on. Suddenly, a black and white PowerPoint case begins to shine brightly on the screen in front of you. The radiologist glances about the room looking to see who would be the best fit for this next case. You begin to sweat and fidget with your hands, praying your faculty will not call on you next. The attending’s glance remains fixed upon you. He says, “Tell me about this patient with a 2-year history of a cough!”. You become flustered and unsure what to say.
The scenario above occurs commonly in radiology residencies across the country. However, since the oral exam has disappeared, I have noticed an overall decrease in proficiency in how residents present each radiological case. The art has been lost. You can blame some of it on poor teaching. Decreased time allotted to education may cause some of it. Some of it can relate to the emphasis on the new board examination system. And, perhaps the new radiology residency culture may be responsible for some of the changes.
In whatever case, it is a shame. Taking oral cases is a crucial step to becoming a well-rounded radiologist. You need to relate to your colleagues’ images in a timely, logical manner, no matter what you are looking at. If you want to look like a star, you need to have this process down cold. To enable you to have the tools to get through a radiological case, I will go through the basics, including determining the kind of study, presenting descriptive findings, coming up with a differential diagnosis, and ultimately determining proper management.
What The Bleep Am I Looking At?
Whenever your attending introduces you to a new oral case, the first thing you need to do is determine what you are looking at. Take your time and think about what kind of images you see. You often lose the case discussion even before you have begun because you never identify the correct study. Is it an ultrasound, CT scan, MRI, x-ray, or nuclear medicine study? Is the examination performed with or without contrast? During what phase?
For nuclear medicine studies in particular, if you can identify the study before going through the case, you have already completed 80 percent of the heavy lifting. You have already isolated the differential diagnosis if you can identify the radiopharmaceutical. If you are not sure, you should start describing the physiological distribution of activity to determine the type of study. Often the act of defining the distribution helps the resident to understand the kind of study.
Also, scan the images for any identifying information. If it is an ultrasound, it will often tell you which organ you are looking at. I have found it can become difficult to tell the testes, ovaries, and kidneys apart on a single image. Usually, the ultrasound technologist labels these studies so you can differentiate among the options.
Finally, make sure to look at the top of the film to see if you can find the patient’s age and sex. This information can also further help you to hone in upon the correct differential diagnosis.
Describing The Findings
This part of the oral case is when the newer residents fall short compared to residents studying to take the oral boards. Residents tend to stop very quickly at the description part of the puzzle and then enter rapidly into a differential diagnosis. Often, a poor quick description leads to a poor differential diagnosis. Again, you need to take your time to describe all the salient points.
So, what should you include in this part of the case? Always describe the location, the size, the intensity (if nuclear medicine), the shape, the density, and borders. Describe its effect upon adjacent structures. Make sure to use buzzwords if available. If you see an angry-looking mass on a CT scan that looks like a star, you may want to use the words spiculated or stellate. If a lesion enhances with rim nodularity and fills in from the edge to the center, use peripheral nodular enhancement with centripetal filling. These buzzwords connote certain types of differentials in the minds of the radiologist listeners. They provide information on the kind of disease entity even before going through a differential diagnosis.
Finally, don’t get happy eye syndrome. Look for other findings that may support or refute your differential diagnosis. I can’t tell you how many times a resident will stare at one section of the film to forget to look at the rest of the images or film. He loses the forest for the trees.
Concise Relevant Differential Diagnoses
A novice and more seasoned resident starkly differ when they give a concise and relevant differential diagnosis. The beginner will have no idea what to say. Or, she will continue to drone on about multiple different possibilities for the final diagnosis. She does not even differentiate between the zebra and the most common diagnosis.
Again, take your time before speaking. Before even starting this process, you should go through broad categories of differential diagnosis in your mind. Is it neoplasm, infection, inflammation, iatrogenic, congenital, etc.? When you have come up mentally with some reasonable possibilities, make sure to talk about no more than three etiologies of the most likely diagnoses. And start with the most feasible and then go down to the least likely. This process will allow you to speak logically. Also, it will enable you to show that you have thought about the differential analytically.
What Next For The Patient?
Three options exist for the further management of the case after you have completed the basics of determining the findings and differential diagnosis. The first possibility: the patient needs no further workup, and you have made a final diagnosis. One example would be an adrenal nodule with a Hounsfield unit of 2. This finding is consistent with an adrenal adenoma—end of story. No further workup is needed.
Alternatively, it may be imperative that you need another step to work up the case. For instance, if you need to determine the matrix of an aggressive osseous lesion on a musculoskeletal MRI without a final diagnosis, make sure to recommend a plain film. Otherwise, you may never determine the final disposition of the patient.
And lastly, you may find a lesion with low clinical significance but needs to be followed over time. This category includes the small lung nodule or the nonaggressive indeterminate liver lesion.
You can almost always categorize your case into one of these three groups. And, it will show that you thought about the ramifications of the imaging upon the clinical picture of the patient.
Final Thoughts: Taking Oral Cases Should Be Fun!!
Taking oral imaging cases should not be a difficult or embarrassing process. It should become something that you should look forward to, building your confidence and becoming a better radiologist. It sums up the essential ingredients needed to make an excellent radiologist: the ability to make the findings, synthesize the data, develop an outcome, and communicate the clinician’s results.
Unfortunately, in many programs, the radiologist just expects you to know how to take an oral case despite not having been taught the process. If so, now you have a framework of the fundamentals of how to take a case outlined above. Like anything else, being adept at taking oral cases is simply a matter of practice and knowing the process. Once you have the process down and the base knowledge, you can more easily build upon your abilities and become better and better over time. You, too, can become a star at taking cases!!!
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