The Importance of In‐Person Review of Imaging Test Results

1Yale School of Medicine, New Haven, CT

Meeting: Hospital Medicine 2013, May 16-19, National Harbor, Md.

Abstract number: 497

Case Presentation:

A 47‐year‐old Hispanic man with active intravenous heroin abuse presented with 2‐3 weeks of severe (“11”/10) chest discomfort. The pain was described as constant, though the severity waxed and waned, and located substernally with intermittent radiation to the left arm. The patient's symptoms were exacerbated by movement, and there was no relationship to oral intake. His intravenous heroin use was intermittent, with last use reported three days prior to presentation. On admission to observation status, the patient was febrile to 101.7°F, and physical examination was remarkable for point tenderness of the xiphoid process but otherwise without cardiac murmur or peripheral stigmata of infective endocarditis. Laboratory testing revealed normal chemistries, a mild leukocytosis of 16,000/μL, and negative troponin T. Electrocardiogram and chest radiograph were unremarkable. CT of the chest was officially read as without pulmonary embolism and or any additional abnormality. Transesophageal echocardiogram (TEE) was officially read as positive for a vegetation on the aortic valve, consistent with infective endocarditis. On transfer from the observation to the inpatient unit, the diagnosis of infective endocarditis was questioned given that Duke's criteria were not met. The TEE was reviewed in person with the interpreting cardiologist, who revised the read to reflect that the aortic valve abnormality was most likely a noninfectious Lambl's excrescence. The previously obtained chest CT was then reviewed in person with the attending chest radiologist, who noted that the study demonstrated significant mediastinitis. The remainder of the patient's medical course was complicated by two separate against medical advice discharges. Ultimately, the patient returned with a fatal acute upper gastrointestinal hemorrhage that was due to an autopsy‐confirmed aortoesophageal fistula.

Discussion:

There is little or no research available on the difference between the interpretation of imaging studies in report form versus in person review with a clinician. Recently published clinical practice guidelines from the American College of Radiology state “effective communication is a critical component of diagnostic imaging,” though there is no proscription as to how communication is to occur. Clinicians not infrequently witness alterations and revisions in study findings when images are reviewed in person with the attending radiologist. In this case, the direct review of two separate imaging studies (TEE and chest CT) between clinician and interpreting attending yielded results antithetical to those dictated in the original reports. In this case, a “slam dunk” diagnosis of infective endocarditis was changed to mediastinitis of uncertain etiology.

Conclusions:

Though the patient ultimately died from a very rare clinical entity, the case underscores the essential nature of direct communication and image review between ordering and interpreting physicians.

To cite this abstract:

Sankey C. The Importance of In‐Person Review of Imaging Test Results. Abstract published at Hospital Medicine 2013, May 16-19, National Harbor, Md. Abstract 497. Journal of Hospital Medicine. 2013; 8 (suppl 2). https://www.shmabstracts.com/abstract/the-importance-of-inperson-review-of-imaging-test-results/. Accessed May 24, 2019.

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