Is it normal to order lung CT for people with cough, chest pain, bloody sputum but normal breath at first try? Some complain about late stage cancer detection without CT, On the other hand some believe that there is many false positives on CTs and does not worth radiation risk.How often x-ray fails on early stage cancer detection?
When Lung CT is ordered?
- Thread starter Pejmaan
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This is kind of being debated now, as there are studies that showed a mortality benefit in screening people at risk for lung cancer with CT scans. However, there's no set in stone recommendations now as to who should be screened, how often, how to screen them, etc. Anyone with bloody sputum, chest pain, and bloody sputum who had an infiltrate, nodule, mass, or pleural effusion on chest X ray would likely get a CT scan. Someone with nothing weird on CXR who had these symptoms? It's still very possible they'd get CT in case there was something small that couldn't be detected in the CXR. However, if you're talking about a lung cancer patient with those symptoms, chances are they have a large enough mass to be detected on CXR, and it's not going to be an early-stage tumor either. An early lung cancer is MOST LIKELY going to be asymptomatic.
I think you're kind of mixing up the concept of chest CT for screening of asymptomatic patients (not routinely done in the US at this time) with diagnostic chest CT in someone with symptoms of pulmonary malignancy.
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Rarely; in the ED most providers would get a cxr first, and certainly in the clinic they would, since they probably don't have a CT scanner there. One exception is if there's a high likelihood of PE, though.
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That's simply incorrect. Why are you asking this?
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We were simply talking about symptomatic patients dude!
I was not asking anything, that's my comment dude and there is two main reason for it:
1.infected people will most likely get CXR and if normal they will be treated on antibiotics first, then it will be bronchoscopy.
2.It's not just normal to order CT out of nowhere and tell your patient: "Uh, It's all clear dude but you just received some nice sharp 10 mSv radio-active rays from your fantastic spiral chest CT!
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It depends on what type of infection you are talking about. If you see a large pleural effusion on X ray, you might order a CT to see if it is loculated, exactly how big it is, etc even if it is due to pneumonia. You'd also order a CT if you suspected that the pneumonia was post-obstructive due to malignancy.
Yep dude, HRCT not spiral one.
Imagine this: symptoms are shortness of breath, cough and bloody sputum. Doctor orders antibiotics due to infection symptoms and a spiral CT. How the hell he has come to the spiral CT on the first shot?
I would say he is full of ****!
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Unfortunately, this is a true reflection of practice. It also shows how far off the tracks we've gotten with PE studies. A CXR is still indicated in these patients because it should be used to exclude other potential causes of the patient's symptoms prior to proceeding to CT.
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Yep, and the patient took it because he though something serious is wrong with him,How would you feel and what would you do if you were in the patient's shoes?
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Was it a CT angiography study or a CT non-contrast study.
BTW, the doctor doesn't get paid extra money for getting the test you know. The only way for him to earn money from it is if he also owns the radiology center or if he is also double boarded as a radiologist and interprets the study himself. (such a scenario is illegal under currently law)
non-contrast.
He can always advise you were to take it to be cheaper for you and that could be the place with friends and connections in. Who knows what's behind the curtains?
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deleted103644
You know pretty much all CT scans are spiral now, right? Short of CT-guided biopsies where you're just doing a single slice, or community hospitals with ancient scanners.
That refers to the scanning and reconstruction method, it doesn't really imply a higher radiation dose (or even higher quality per se).
That doesn't justify ordering non-contrast CT on the first shot I guess.From what I know CXR should be ordered first, then HRCT or spiral CT (angiography) may be ordered based on the CXR observations.
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deleted103644
Just say CT. Stop saying spiral.
Say CT Pulmonary Angiogram if you want to be specific (or just CTPA, or even CTA).
Sorry, the spiral thing just bugs me because everyone says it thanks to old board questions even though it's now silly.
Don't be buggy, try to concentrate on the question and forget about terms, Do you mean CT can be ordered right away without CXR being observed first? just because we call it CTA or non-contrast CT? Do you mean HRCT and spiral CT are merged into just one CTP test? Do you mean doctors do not still use spiral and "high resolution" terms on their prescriptions to distinguish between two?
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I've never seen an RX specify anything besides CT and then s or c contrast. Also, if clinical suspicion is high enough I've seen people order CT scans immediately and not xrays.
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deleted103644
Almost all CT scans are now "spiral" CTs.
It refers to a technique where the gantry keeps spinning as the patient moves through the tube (ie the source and the detectors move in a spiral relative to the pt).
High resolution vs low resolution is a separate issue.
And yes, for a PE you order a CTPA as soon as you become suspicious.
A CXR rarely helps the diagnosis, so there is no reason to order one first (although it often happens prior to suspicion for PE).
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if you are suspicious for a PE and they are hemodynamically stable. do cxr first, then vq scan if ckd, otherwise go to cta after cxr.
If unstable call intensivist, start lovenox 1mg/kg and get consent for tpa. I don't think imaging is needed as it is a clinical diagnosis if you have the clinical supicion and EKG changes. though they may be having an MI. So get stat troponin and ekg. But even that isn't as helpful because they could be having NSTEMI and troponin elevation is common in right heart strain due to PE also. So would a CTA be appropriate? Start lovenox, rush to scanner, call intensivist. treat with tpa.
PE's are tricky diagnosis.
If unstable call intensivist, start lovenox 1mg/kg and get consent for tpa. I don't think imaging is needed as it is a clinical diagnosis if you have the clinical supicion and EKG changes. though they may be having an MI. So get stat troponin and ekg. But even that isn't as helpful because they could be having NSTEMI and troponin elevation is common in right heart strain due to PE also. So would a CTA be appropriate? Start lovenox, rush to scanner, call intensivist. treat with tpa.
PE's are tricky diagnosis.
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high enough clinical suspicion?! don't mix things up. we have had the scenario a few lines above
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Wrong dude,You are mixing things up without answering straight. the case we were studying included infection symptoms where CXR is needed first to avoid unnecessary radiation to those with normal CXR and to detect the kind of CT we gonna use for abnormal CXRs.
also sometimes they use spiral CT for low resolution spiral CT and HRCT for high resolution spiral CT.(spiral CT vs HRCT although they are both spiral)
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deleted103644
I was never answering your primary question.
I was just trying to get you to stop using the phrase "spiral CT".
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I always get a chuckle out of the people requesting a "spiral" CT, as if they're asking for something special. Quit calling it that. Besides, helical is the more common term.
The high resolution CT cracks me up almost as much as the spiral thing. It's like people think "well, if normal resolution is good, then high resolution must be even better." Nope. HRCT and normal chest CTs are reconstructed from the same raw data; it's just that HRCTs are formatted and filtered differently in order to evaluate for interstitial lung disease. Often times, prone imaging is done for HRCT as well. Eighty-five % of the time when someone asks for a HRCT, they just need a regular chest CT.
Disagree, although I admit this is common practice. Very few patients, even ones with acute PEs, are so unstable that they can't at least get a portable. Besides, if they're so unstable that you can't get a CXR, then they've got no business in the CT scanner.
Also - as I posted earlier - the CXR isn't to make the diagnosis, but to exclude other problems. That should be relevant because the presentation of PE is so nonspecific that a lobar pneumonia, pneumothorax, or other explanation for their symptoms found on CXR should put a halt to the CT.
Relatively new guidelines say that perfusion imaging is now first-line (well, after CXR) in young females with few-to-zero risk factors. It's significantly less dose to the breasts. This only works if you use DTPA for ventilation. If you use xenon, then dose and turn-around time go up, in which case you're better off getting the CT. Of course, nobody pays attention to the guidelines, so everyone gets a CT anyway.
Solve this:
Imagine this: symptoms are shortness of breath, cough and bloody sputum. Doctor orders antibiotics due to infection symptoms and a non-contrast CT. How the hell he has come to the non-contrast CT on the first shot?
I would say he is full of ****!
Imagine this: symptoms are shortness of breath, cough and bloody sputum. Doctor orders antibiotics due to infection symptoms and a non-contrast CT. How the hell he has come to the non-contrast CT on the first shot?
I would say he is full of ****!
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Why are you so angry?
I do not like unnecessary radiation. I do not like greedy bastards too.
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deleted103644
Communist.
I do like kings without cancer.
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If the patient is that unstable and you are considering tpa (or emergent thrombectomies), low molecular weight heparin should NOT be started ... heparin drip should be started instead (which can be turned off should the decision to give tpa or pulm artery thrombectomy be done)
/the decision to order CT Scan is based on clinical judgement, scenerio, differentials, as well as "community standards"
Again, why are you so angry? This sound like a personal issue, not a professional one. Especially since you keep harping on the "greed" thing, despite the fact that he doesn't earn money from getting a CT.
And I'm actually surprised that you're stuck on the CT thing, I'm more concerned by the fact that antibiotics are ordered without an established diagnosis. The CT issue is hard for any of us to comment on because all we see is a chief complaint, we don't see a history, physical exam, and you haven't told us the clinical reasoning used to order a non-con Chest CT.
Deal with it as a professional,don't think about money.infection symptoms were found in sputum, physical exam and history reveals generally healthy person (except for the infection), there is no complaint, symptoms were discussed many times, seems CT was ordered instead of CXR (ridiculous!)
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Sorry, absolutely heparin drip over lovenox if you are even thinking about possibly needing to use tPA.
1. You provided a set of chief complaints, you still have not provided a physical exam (as in the lung sounds, vital signs, etc.), a proper history, or the medical reasoning used by the doctor. We have no way to judge whether the noncon CT was appropriate or not. For all I know this could be someone with an 80pack year smoking history and a family history of lung Ca, someone with a nodule on a CT 9 months ago, someone with diffuse rales on exam suggesting an infiltrative disease, or what not. Or maybe it was an anxious 20 year old person with URI symptoms and bronchitis who didn't even warrant an Xray or antibiotics in the first place.
2. The only one concerned about money here is you, despite the fact that you're going on and on about a greedy doctor who generated 0 profit from ordering the test.
3. Why are you so pissed off? Were you taking care of the patient and over-ridden by the doctor? Or maybe you were the patient or it was a relative or something?
1.It was an anxious 28 year old person with URI symptoms and bronchitis who were not told by the doctor to provide Xray in the first place with no history of lung cancer in family but previous light smoker (7 years ago)
2. You don't know that, but you try to defend you career and that's ok because you are a good person.
3.That's non of your business. You should provide a solution for the scenario as a pro.
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How bloody are we talking?
What do you mean pal?
Well, since this is "none of my business" and you're not giving me a full H&P with vitals., nor can you explain the medical decision making behind the CT (If you order a radiology test, you are supposed to provide the history and purpose of the test)
I have a feeling then that the patient is either you or a loved one, and you don't yet have enough medical knowledge to provide us with the type of information in a standardized way that would allow us to make a sound judgment on whether or not this was appropriate care for the patient.
I also think that whatever I or anyone else says, you've already made up your mind that this doctor was "greedy" despite the fact that it's a completely illegal practice to obtain any profit from referring someone for a CT that is carefully monitored by medicaid. I'm guessing greedy is simply the adjective used since the patient probably had to pay money for an expensive test that he retrospectively is sore about, whether appropriately or not.
I have a feeling then that the patient is either you or a loved one, and you don't yet have enough medical knowledge to provide us with the type of information in a standardized way that would allow us to make a sound judgment on whether or not this was appropriate care for the patient.
I also think that whatever I or anyone else says, you've already made up your mind that this doctor was "greedy" despite the fact that it's a completely illegal practice to obtain any profit from referring someone for a CT that is carefully monitored by medicaid. I'm guessing greedy is simply the adjective used since the patient probably had to pay money for an expensive test that he retrospectively is sore about, whether appropriately or not.
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He means was this scant hemoptysis/blood-tinged sputum, mild hemoptysis, or significant hemoptysis.
scant, it was later detected as cute bronchitis
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deleted103644
CT was ordered because as the doctor said: "It is more accurate than CXR!" and this is simply ridiculous for the person with no cancer factor.
I have the feeling you can not defend or justify the orders of the greedy doctor nor you can face the truth.
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You obviously don't know how this stuff works, friend. 60-something percent of ED care goes uncompensated thanks to EMTALA. If you're this mad about someone getting an expensive test, it makes me think this is someone close to you who is paying out of pocket. Do you think ED physicians order extraneous testing for uninsured patients to make more money?
You haven't given a full history. You haven't provided PE findings. You can't make this call based on what you've provided. And you don't seem to understand how ED reimbursement works.
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45408
Exactly my thought by about the third post.
Since you are the smartest of all. I guess you had it by the first post
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