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Question

Difficulty: MediumOrdering Imaging Studies

Match each clinical presentation with the single most appropriate initial diagnostic imaging modality.

  • A 58-year-old man with painless gross hematuria and a 30-pack-year smoking history.Computed tomography (CT) urography
  • A 72-year-old woman with dysphagia to solids and liquids, regurgitation of undigested food, and severe halitosis.Barium esophagram (fluoroscopy)
  • A 45-year-old woman with a newly palpated solitary thyroid nodule and a normal serum thyroid-stimulating hormone (TSH) level.High-resolution ultrasound
  • A 68-year-old man with a history of treated prostate cancer presenting with progressive thoracic back pain that worsens at night.Magnetic resonance imaging (MRI) of the spine

Answer

The correct matches are: the hematuria patient requires CT urography; the dysphagia patient requires a barium esophagram; the thyroid nodule patient requires an ultrasound; and the back pain patient requires an MRI of the spine.
Each clinical scenario corresponds to a well-established, evidence-based imaging guideline. CT urography is standard for high-risk hematuria evaluation. A barium esophagram safely identifies Zenker diverticula. Ultrasound characterizes thyroid nodules when TSH is not suppressed. MRI sensitively detects spinal metastases in patients with cancer histories.

Step-by-Step Solution

1
Evaluate the hematuria presentation.
Identify risk factors for malignancy (age, smoking) and select CT urography.
Complete evaluation of painless macroscopic hematuria includes direct visualization of the bladder and cross-sectional imaging of the upper urinary tract.
2
Evaluate the dysphagia presentation.
Identify classic signs of a Zenker diverticulum and select barium esophagram.
A contrast study safely delineates the anatomical pouch, whereas an initial upper endoscopy poses an unacceptable risk of iatrogenic perforation.
3
Evaluate the thyroid nodule presentation.
Note the normal TSH level and select high-resolution ultrasound.
A normal TSH indicates the nodule is non-functioning, making ultrasound the standard next step to evaluate for malignant features.
4
Evaluate the back pain presentation.
Recognize red flag symptoms (history of cancer, nocturnal pain) and select MRI of the spine.
MRI is the most sensitive modality for detecting metastatic disease in the spine and assessing for epidural spinal cord compression.

Key Concept

Evidence-based selection of initial diagnostic imaging based on specific clinical presentations and associated risk factors.
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Ordering Imaging Studies

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