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    The Value of Patient History in Medical Imaging: Glen Stancil M.Ed., RT (R) (CT) (ARRT) Director of Service GE Healthcare IT

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    Vijay Rangarajan
    The document discusses the importance of patient history in medical imaging. It provides a case study of a patient, Joe, who presented with right flank pain and was initially misdiagnosed without a complete history provided to the radiologist. The summary emphasizes that a systematic approach including subjective history, objective findings, laboratory tests, and any deviations can help provide crucial context to ensure the correct diagnosis. Failing to obtain Joe's full history led to a missed appendicitis diagnosis and subsequent complications.

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    The Value of Patient History in Medical Imaging: Glen Stancil M.Ed., RT (R) (CT) (ARRT) Director of Service GE Healthcare IT

    Uploaded by

    Vijay Rangarajan
    40 views19 pages
    The document discusses the importance of patient history in medical imaging. It provides a case study of a patient, Joe, who presented with right flank pain and was initially misdiagnosed without a complete history provided to the radiologist. The summary emphasizes that a systematic approach including subjective history, objective findings, laboratory tests, and any deviations can help provide crucial context to ensure the correct diagnosis. Failing to obtain Joe's full history led to a missed appendicitis diagnosis and subsequent complications.

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    The document discusses the importance of patient history in medical imaging. It provides a case study of a patient, Joe, who presented with right flank pain and was initially misdiagnosed without a complete history provided to the radiologist. The summary emphasizes that a systematic approach including subjective history, objective findings, laboratory tests, and any deviations can help provide crucial context to ensure the correct diagnosis. Failing to obtain Joe's full history led to a missed appendicitis diagnosis and subsequent complications.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    40 views19 pages

    The Value of Patient History in Medical Imaging: Glen Stancil M.Ed., RT (R) (CT) (ARRT) Director of Service GE Healthcare IT

    Uploaded by

    Vijay Rangarajan
    The document discusses the importance of patient history in medical imaging. It provides a case study of a patient, Joe, who presented with right flank pain and was initially misdiagnosed without a complete history provided to the radiologist. The summary emphasizes that a systematic approach including subjective history, objective findings, laboratory tests, and any deviations can help provide crucial context to ensure the correct diagnosis. Failing to obtain Joe's full history led to a missed appendicitis diagnosis and subsequent complications.

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    The Value of Patient History in Medical Imaging

    Glen Stancil M.Ed., RT(R)(CT)(ARRT) Director of Service GE Healthcare IT

    LEGAL DISCLAIMER
    The opinions expressed in this continuing medical education activities are those of the author and do not represent those of AboutImaging.com or its affiliates and subsidiaries. The information provided is for general education purposes only. The information is not warranted to be inclusive of all approaches to a medical issue or exclusive of other methods for obtaining the same result. The material is not meant to substitute for the independent professional judgment of a physician or other health care professional relative to diagnostic and treatment options for a specific patient's medical condition. The author does not warrant the completeness, accuracy, or usefulness of any opinions, options, advice, services, or other information provided through this educational activity. In no event will AboutImaging.com or its affiliates and subsidiaries be liable for any decision made or action taken in reliance upon the information provided through this activity. The participant acknowledges that case studies may be modified or changed from the actual case to protect the identity of patients.

    Case Study: Joe


    Age: 37 Years Gender: Male Chief Complaint: Right Flank Pain Scheduled Exam: CT Abdomen / Pelvis Provided History: R/O Renal Stone Exam was scheduled on the same day as Outpatient

    Technologist History: None Additional Exam Performed: CT Abdomen / Pelvis W/O Only

    Case Study: Joe


    Radiologist Interpretation: No evidence of hydronephrosis No renal calculi identified in the renal pelvis or ureters Heavy stool in colon No abnormalities detected

    Treatment: Antibiotics to treat Kidney Infection while awaiting C&S from Urinalysis Pain Meds
    Patient outcome: Emergency surgery 4 hours later Initial hospital stay of 8 days Several follow up visits to hospital required

    What Happened?
    Can the primary blame for case mismanagement be placed on the technologist?
    Was there anything that the technologist could do to prevent this situation?

    Objectives
    At the end of this lesson, the student will be able to:
    Discuss the benefits and risks of providing patient history to the radiologist Describe the elements of a complete patient history

    Why Obtain Patient History?


    ASRT (2003) Code of Ethics states that Patient Diagnosis is outside the scope of practice
    However, it further states:

    The radiologic technologist acts as an agent through observation and communication to obtain pertinent information for the physician

    Arguments For Obtaining Patient History


    Technologists are physician extenders and often the only person to see the patient in the medical imaging setting Referring physician provided history may be incomplete or inaccurate May assist the radiologist in providing differential diagnoses to referring physician Critical for high risk exams, such as biopsies and MRI

    Arguments Against Obtaining Patient History


    Knowing patient history may skew the radiologists interpretation Technologists are not trained to examine patients and therefore it is out of scope for the profession Technologists dont have time to elicit a full patient history from all patients

    Systematic Approach to Patient History


    Radiologists must be SOLD on your patients medical history
    Subjective History Objective History Laboratory Tests Deviations from Norm

    Subjective History
    What history is the patient providing that is unobserved by the technologist?
    Last menstrual period Mechanism of injury Progression of symptoms What makes the pain worse (or better)? Personal medical history Family medical history

    Objective History
    What history can be gained from direct observation by the technologist
    Cuts / Bleeding Discoloration Deformity Physical exam techniques
    Palpation Range of Motion

    Laboratory Tests
    What pertinent lab tests were performed and what were the results?
    Complete Blood Count Hemoglobin / Hematocrit BUN / Creatinine Urinalysis HCG D-Dimer Thyroid Panel (mainly NM and US) Pathology Results

    Deviations from Norm


    What is different from this exam compared with routine exam?
    Patient Motion Unusual Positioning or Projections Patient Refusal to Continue Technical Issues

    Case Study Follow-Up: Joe


    Subjective: Pain started slowly 2 days ago Very dull when at referring physician mostly in the right flank Now sharp and in the Right Lower Quadrant (RLQ) of abdomen

    Objective: RLQ Guarding Vomiting


    Laboratory Tests: UA Clear / No RBCs present; Elevated WBC Deviations From Norm: None

    Joes Diagnosis
    APPENDICITIS
    Without contrast, appendix was not visualized due to heavy stool Joes appendix ruptured due to delay in treatment Subsequent abscesses required several draining procedures

    Review
    Technologist has the duty to report all pertinent information to the physician Radiologist may review history before or after their initial interpretation due to their personal philosophy Radiologist must be SOLD on the patients history

    Systematic Approach to Patient History


    Radiologists must be SOLD on your patients medical history
    Subjective History Objective History Laboratory Tests Deviations from Norm

    References
    American Society of Radiologic Technologists. (2003). Code of ethics. Retrieved from: https://www.asrt.org/media/pdf/rt/codeofethics.pdf

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