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When to Order Contrast-Enhanced CT - Article
ABSTRACT: Family physicians often must determine the most appropriate diagnostic tests to order for their patients. It is essential to know the types of contrast agents, their risks, contraindications, and common clinical scenarios in which contrast-enhanced computed tomography is appropriate. Many types of contrast agents can be used in computed tomography: oral, intravenous, rectal, and intrathecal. The choice of contrast agent depends on route of administration, desired tissue differentiation, and suspected diagnosis. Possible contraindications for using intravenous contrast agents during computed tomography include a history of reactions to contrast agents, pregnancy, radioactive iodine treatment for thyroid disease, metformin use, and chronic or acutely worsening renal disease. The American College of Radiology Appropriateness Criteria is a useful online resource. Clear communication between the physician and radiologist is essential for obtaining the most appropriate study at the lowest cost and risk to the patient.
ABSTRACT: Approximately 1 percent of primary care office visits are for chest pain, and 1.5 percent of these patients will have unstable angina or acute myocardial infarction. The initial goal in patients presenting with chest pain is to determine if the patient needs to be referred for further testing to rule in or out acute coronary syndrome and myocardial infarction. The physician should consider patient characteristics and risk factors to help determine initial risk. Twelve-lead electrocardiography is typically the test of choice when looking for ST segment changes, new-onset left bundle branch block, presence of Q waves, and new-onset T wave inversions. For persons in whom the suspicion for ischemia is lower, other diagnoses to consider include chest wall pain/costochondritis (localized pain reproducible by palpation), gastroesophageal reflux disease (burning retrosternal pain, acid regurgitation, and a sour or bitter taste in the mouth), and panic disorder/anxiety state. Other less common but important diagnostic considerations include pneumonia (fever, egophony, and dullness to percussion), heart failure, pulmonary embolism (consider using the Wells criteria), acute pericarditis, and acute thoracic aortic dissection (acute chest or back pain with a pulse differential in the upper extremities). Persons with a higher likelihood of acute coronary syndrome should be referred to the emergency department or hospital.