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INTERMEDIATE MODULEINDIAGNOSTIC RADIOLOGYREQUIREMENTS FOR TRAINING & EXAMINATION2010;GDD=?= G>H@QKA;A9FK 9F

THE COLLEGE OF PHYSICIANS AND SURGEONS PAKISTANwould appreciate any criticism, suggestions,advice from the readers and users of this document.Comments may be sent in writing or bye-mail to the CPSP at:National Directorate Residency Program (NDRP)College of Physicians and Surgeons Pakistan (CPSP)7th Central Street, Defence Housing Authority, Karachi-75500.ndrp@cpsp.edu.pkComposed by:Syed Faisal BabarDepartment of Medical EducationPublished: March, 2010;GDD=?= G> H@QKA;A9FK 9F< KMJ?=GFK H9CAKL9F*7th Central Street, Defence Housing Authority, Karachi-75500.Phone No. 99207100-10. UAN: 111-606-606. Fax No. 99266432

Contact Details:College of Physicians and Surgeons, Pakistan.7th Central Street, Phase II, D.H.A. Karachi - 75500.Phone: 99207100-10, UAN 111-606-606Facsimile: 99266450Website: www.cpsp.edu.pkCONTENTS1INTRODUCTION4TRAINING AND EXAMINATION7ASSESSMENT11COURSE FOR BASIC TRAINING IN DIAGNOSTICRADIOLOGY63USEFUL ADDRESSES AND TELEPHONE NUMBERS

INTRODUCTIONThe College was established in 1962 through an ordinance of theFederal Government. The objectives and functions of the Collegeinclude: promotion of specialist practice by securing improvementof teaching and training; arranging postgraduate medical, surgicaland other specialist training; holding and conducting examinationsfor awarding College diplomas and admission to the Fellowships ofthe College; and promotion of research.Since its inception the College has actively pursued improvementsin postgraduate medical education in Pakistan. Currently, theCollege offers Fellowships in fifty three disciplines compared to theinitial few in Medicine, Surgery, Paediatrics and Obstetrics andGynecology in 1963. Structured training programs have beendeveloped, criteria for recognition of training institutes have beenlaid down, and format of examinations has been improved withunbiased objective, reliable and candidate friendly methods ofassessment. Fellowship training can be undertaken in over 130accredited medical institutions throughout the country and 106accredited institutions abroad. Over 2000 supervisors are involvedin the CPSP training programs.The College has established 12 Regional Centers including fiveProvincial Headquarter Centres in the country to coordinate thetraining and examination, and facilitate the candidates of these areas.CPSP Intermediate Module in Diagnostic Radiology 20101

Constant efforts are made to improve the standards of examinationsand make them relevant, transparent, objective and fair to thecandidates. In its endeavor to decrease inter-rater variability, andincrease fairness and transparency, the College has introduced theuse of assessment forms for scoring of all the components of clinicaland oral examinations. Another step in this direction is theintroduction of Task Oriented Assessment of Clinical Skills (TOACS)in the FCPS II Clinical Examinations in a number of disciplines sinceSeptember 2001.CPSP Intermediate Module in Diagnostic Radiology 20102

INTERMEDIATE MODULETo ensure better training, the CPSP introduced an Intermediatemodule examination in several disciplines in 2001. This mid-trainingassessment strengthens the monitoring and in-training assessmentsystems by providing trainees with an estimate of mid-trainingcompetence. It also serves as a diagnostic tool for trainees andsupervisors, provides a curricular link between basic and advancedtraining, and an opportunity for sampling a wider domain ofknowledge and skills.Vide Notifications No. 6-1 / Exam-04 / CPS / 1438 S and R, dated July21, 2004, the Intermediate Module (IMM) examination is mandatoryeligibility requirement for all specified FCPS II examination as fromSeptember 2007. Trainees who passed FCPS I in 2001 and onwardsare required to complete two years training in Diagnostic Radiology,and take the Intermediate Module (IMM) examination.Even it they do not appear in the IMM examination, the trainees arepermitted to continue their training in the chosen discipline but mustpass the IMM examination prior to taking the final FCPS IIexamination.CPSP Intermediate Module in Diagnostic Radiology 20103

TRAINING ANDEXAMINATIONGENERAL REGULATIONSCandidate will be admitted to the examination in the name (surnameand other names) as given in the MBBS degree. CPSP will notentertain any application for change of name on the basis of marriage/divorce / deed.CPSP Intermediate Module in Diagnostic Radiology 2010REGISTRATION AND SUPERVISIONAll training must be supervised, and trainees are required to register withthe Research and Training Monitoring Cell (RTMC) within 30 days ofstarting their training for Intermediate Module. In case of delay inregistration, the start of training shall be considered from the date ofreceipt of application by the RTMC. Registration forms are available fromRTMC and at the Regional Centers. They can also be downloaded fromthe CPSP Website: www.cpsp.edu.pk. Training is compulsorilymonitored by an approved supervisor who is a CPSP fellow or aspecialist with relevant postgraduate qualifications and experienceregistered with the RTMC.APPROVED TRAINING CENTRESTraining must be undertaken in units, departments and institutionsapproved by the College. A current list of approved institutions isavailable from the College and its Regional Centres as well as on theCollege website: www.cpsp.edu.pkDURATIONThe duration of training for the Intermediate Module (IMM) is twoyears; the Intermediate Module examination is taken oncompletion of the two years training.4

ROTATIONSIn situations where all the training facilities forDiagnostic Radiology Intermediate Module are not availablewith in the institution, following rotations are mandatory for thetrainee to fulfill his/her training deficiencies:- MRI 8 weeks- Angiography 4 weeks- Nuclear Medicine 6 weeksIts is mandatory to inform RTMC prior to commencement ofrotation.COMPONENTS OF TRAININGMandatory WorkshopsIt is mandatory for all Intermediate Module trainees to attendthe following CPSP certified workshops in the two years ofIntermediate Module training:1. Introduction to Computer and Internet2. Research Methodology and Dissertation Writing3. Communication SkillsAny other workshop/s as may be Introduced (e.g. ACLS and ATLS)by CPSP.LogbookTrainees are required to maintain a logbook in which entries ofacademic/ professional work done during the period of trainingshould be made on a daily basis, and signed by the supervisor.Completed and duly certified logbook will form a part of theapplication for appearing in IMM examination.E-logbookThe CPSP council has decided to introduce E-logbook system forall trainees in FCPS from January 2009. Upon registration withRTMC each trainee is allotted a registration number and apassword to log on to the e-logbook on the CPSP website. Thetrainee is required to enter all work performed and the academicactivities undertaken in the logbook on daily basis. The concernedsupervisor is required to verify the entries made by the trainee.This system ensures timely entries by the trainee and promptverification by the supervisor. It also helps in monitoring theprogress of trainees and vigilance of supervisors.CPSP Intermediate Module in Diagnostic Radiology 20105

Research (Dissertation/Two Papers)One of the training requirements for fellowship trainees is adissertation or two research papers on a topic related to the fieldof specialization. For trainee in Diagnostic Radiology thedissertation synopsis or abstracts of the research papers must beapproved by the Research and Evaluation Unit (REU) in the firstyear of the Intermediate Module.General RequirementsTraining should incorporate the principle of gradually increasingresponsibility, and provide each trainee with a sufficient scope, volumeand variety of experience in a range of settings that include inpatients,outpatients, emergency and intensive care. The emphasis shall be onprinciples of surgery and essential concepts of trauma & critical care.Instructional MethodologyCPSP Intermediate Module in Diagnostic Radiology 2010Teaching occurs using several methods that range from formaldidactic lectures to planned clinical experiences. Aspectscovered will include knowledge, skills and practices relevant tothe discipline in order to achieve specific learning outcomes andcompetencies. The theoretical part of the curriculum representsthe current body of knowledge necessary for practice. This canbe imparted through lectures, grand teaching rounds, clinicopathologicalmeetings, morbidity/mortality review meetings,literature reviews and presentations, journal clubs, self directedlearning, conferences and seminars.Clinical learning is to be organized to provide appropriateexpertise and competence necessary to evaluate and managecommon clinical problems. Demonstration in outpatient andinpatient clinics, and procedural skills training on simulators,mannequins and patients are all practical training modalities.6

ASSESSMENTELIGIBILITY REQUIREMENTSFor appearing in Intermediate Module examination a candidateshould have:● Passed FCPS I in Diagnostic Radiology or granted exemption●●●●●Registered with the Research and Training Monitoring Cell.Completed two years of training under an approved supervisorin an institution recognized by the CPSP. A certificate ofcompletion of training must be submittedSubmitted a completed and attested logbookSubmitted certificates of attendance of mandatory workshopsApproval of the Synopsis for dissertation or abstracts for tworesearch articlesEXAMINATION SCHEDULE● The Intermediate Module theory examination will be heldtwice a year.● Theory examinations are held in various cities of the countryusually at Abbottabad, Bahawalpur, Faisalabad, Hyderabad,Islamabad, Karachi, Nawabshah, Larkana, Lahore, Multan,Peshawar and Quetta centers. The College shall decide whereto hold TOACS examination depending upon the number ofcandidates in a city and shall inform the candidates accordingly.● English is the medium of all examinations i.e. theory & TOACS.● The College will notify of any change in the centers, the datesand format of the examination.● A competent authority appointed by the College has the powerto debar any candidate from any examination if it is satisfiedthat such a candidate is not a suitable person to take theCollege examination because of using unfair means in theexamination, misconduct or other disciplinary reasons.EXAMINATION FEE● Fee deposited for a particular examination shall not be carriedover to the next examination in case of withdrawl, absence orexclusion.● Applications along with the prescribed examination fee andrequired documents must be submitted by the last date notifiedfor this purpose before each examination.● The details of examination fee and fee for change of centre,subject, etc shall be notified before each examination.CPSP Intermediate Module in Diagnostic Radiology 20107

FORMAT OF EXAMINATIONTheory Examination:Theory Examination consists of:Paper I10 Short essay questions (SEQs) - to bereplaced in future by MCQs, after priornotification by CPSP.Paper II10 Short essay questions (SEQs)Clinical Examination:The examination is based on TOACS style and consists of:Static TOACS: 10 Stations(Film reporting and Basic Radiology)Interactive TOACS: 10 Stations (Clinical and Basic Radiology)Only those candidates who qualify in the theory will be eligible totake the TOACS examination.CPSP Intermediate Module in Diagnostic Radiology 2010TOACSTOACS will comprise of 20 stations with a change time of oneminute for the candidate to move from one station to the other.The stations may have an examiner, a patient or both.Structured clinical tasks will be set at each station. At stationswhere no examiner is present the candidates will have tosubmit written responses to short answer questions/ MCQs ona response sheet.There will be two types of stations: static and interactive. Onstatic stations the candidate will be presented with patientdata, a clinical problem or a research study and will be askedto give written responses about the questions asked. At theinteractive stations the candidate will have to demonstrate acompetency, for example, taking history, performing a clinicalexamination, counseling, assembling an instrument, etc. Oneexaminer will be present at each interactive station and willeither rate the performance of the candidate or ask questionstesting reasoning and problem-solving skills.8

TABLE OF SPECIFICATION FOR CLINICAL EXAMINATIONSTATIC GROUPA: Sire B: Basic RadCNS/H&NAnat; ProjectionalRESPAnat; ProjectionalCVSAnat: SectionalGITAnat: SectionalHBRadiation ProtectionGUTPhysicsPELVISPhysicsMSModalityMSPositioningBREAST/SPQualitativeINTERACTIVE GROUPA: Clin. Image B: Basic RadCNS/ H&NAnatomyRESPAnatomyCVSTechniquesGITTechniquesHBPositioningGUTPhysicsPELVISRadiation ProtectionMSModalityPAEDSContrast/ PharmacologyBREAST/SPTechniquesCPSP Intermediate Module in Diagnostic Radiology 20109

CPSP Intermediate Module in Diagnostic Radiology 2010KEY:SIRE:Structured Image Reporting ExaminationBasic Radiology:1. Anatomy- Projectional: conventional- Sectional: 3 D etc.- Physics2. Physics- Radiation protection/ PNRA regulations- Basic physics- Modality based: US, CT, MRI, Digital3. Positioning- Radiographic Positioning- Basic patient Handling in Modalities4. Techniques- Flouroscopic Techniques- Basic Interventional: Aspiration, Biopsy etc.- Basic Protocols in CT & MRI- Techniques in other modalities eg: US, Nuclear Medicine etc.5. Qualitative- Professionalism- Communication- Consenting- EthicsClinical Image:Radiological cases for short viva on basic concepts etc. as definedin IMM syllabus.Duration at each station:10 minutes (5 minutes each for component A & B respectively)10

COURSE FOR BASIC TRAINING INDIAGNOSTIC RADIOLOGYGENERAL GUIDELINESRegarding Structured Training Programme for IntermediateModule of Diagnostic Radiology:1. The difference between the Intermediate module and the postIMM FCPS will be on the basis of level of complexity of thecase/exam rather than on the basis of modalities.2. The listing is for the minimal levels of knowledge, skill andexperience.4. For the sake of brevity knowledge, skill and experience listedin the section for the first two years is not repeated for the lasttwo years; however this knowledge, skill and experience willalso be required and tested at the time of the final FCPS exams.5. The framework for core training will consist of rotations whichshould give appropriate experience in the areas identified below:System-based subspecialties:- Breast imaging- Cardiac imaging- Gastrointestinal (GI) imaging- Head and neck imaging including ear, nose and throat, & dental- Musculoskeletal and trauma imaging- Neuroradiology- Obstetric imaging and gynaecological imaging- Thoracic imaging- Uroradiology- Vascular imaging including interventionTechnique-based subspecialty:- Radionuclide radiologyAge-based subspecialty:- Paediatric imagingCPSP Intermediate Module in Diagnostic Radiology 201011

6. The core knowledge for each system-based module includesphysics, detailed radiological anatomy and techniques.The trainee will also be expected to have knowledge of howmultisystem disease manifests itself.7. Technique-based subspecialties (CT, MRI, US, interventionaland radionuclide radiology) are incorporated (for the purposesof defining structured training) within each system-basedmodule. Because training schemes deliver training centeredon technique-based rotations, the core competenciesnecessary to be acquired are listed on page 56-62.GENERAL OBJECTIVESOn Completion of the Intermediate Module training the trainee should:CPSP Intermediate Module in Diagnostic Radiology 20101. Have a detailed knowledge of anatomy and normal variantsrelevant to radiological examinations. In addition, the candidateshould have a clear knowledge of topographic anatomy asdisplayed by modern imaging techniques.2. Know the special "core of knowledge" of the current ionizingRadiation Protection Principles as per rules and regulation ofPakistan and it's other governing agencies e.g. PNRA.3. Have a knowledge of radiation protection sufficient to:- Understand current official radiation protection guidelinesand regulations, and to be able to explain those guidelinesand regulation to medical and radiographic staff as well asto patients, both for clinical practice and research purposes.- Comprehend those practical measures, which should bein place in department of Clinical Radiology.- Understand the relative risks of medical radiation.4. Have sufficient knowledge of X-radiation and diagnostic X-rayequipment to be able to understand the interaction of X-rays ontissues and the factors that affect image quality, in order to beable to discuss these subjects with radiographers, andclinicians, to recognize artifacts and to be able to useequipment correctly.12

5. Have sufficient knowledge of the basic principles of ultrasound,CT, MRI and radionuclide imaging to be able to understand thenature of the radiation/electromagnetic/ sounds waves used inthese techniques and to understand in outline the performanceof imaging equipment as well as the means by which therelevant images are created.6. Know sufficient basic radiography to demonstrate anunderstanding of the standard radiographic projections relatingto the regions outlined in the radiological anatomy syllabus, andto be able to give practical advice on improving the quality of theimage obtained.7. Have a knowledge of the techniques, including the materials(e.g. contrast agents, drugs) and equipment (e.g. catheters,needles) used in those techniques which a candidate isexpected to have carried out personally and on his/her ownduring the first 6 months of training in Radiology. Thesetechniques are listed in the syllabus under Section 1.2.8. Have a basic knowledge of and have observed the basicinterventional procedures e.g. angiographic procedure, basicpercutaneous techniques for urological and biliary interventionSYLLABUS OF INTERMEDIATE MODULE DIAGNOSTICRADIOLOGYCore competencies:By the end of two years of residency, the resident should be able to:Core knowledge1. show knowledge of current legislation regarding radiation protection2. offer advice as to the appropriate examination to perform inroutine clinical situationsCPSP Intermediate Module in Diagnostic Radiology 201013

Core skills1. participate in reporting plain radiographs which are takenduring the normal working day of a department of clinicalradiology2. perform any routine radiological procedures that might bebooked during a normal working day3. perform and report on-call investigations appropriate to thelevel of training with the appropriate level of supervision4. attend at and conduct clinico-radiological conferences andmultidisciplinary meetingsPHYSICSAlthough this will be tested formally in the Intermediate Module,understanding of the physical principles may be a requirement in finalFCPS examination.Radiological Physics1. Introduction:General properties of radiation and matter. Fundamentals ofnuclear physics and radioactivity. Structure of the atom.Definition of atomic number, mass number, nuclide, isotopeand electron volt.CPSP Intermediate Module in Diagnostic Radiology 20102. Electromagnetic radiation:Spectrum, general properties, wave and quantum theories.3. Radioactivity:Exponential decay, specific activity, physical, biological andeffective half-life, production of radioactive materials,radioactive decay schemes, units of activity, half life, propertiesof radiation - alpha, beta, gamma, basic knowledge of reactors.4. Production of X-raysPrinciples, essential components of X-ray tubes, continuousspectra, characteristic radiation. Factors controlling the natureof X-ray emission. Efficiency of X-ray production. Spatialdistribution of X-ray emission from target and factors on whichit depends, inverse square law.14

5. Tube rating:Stationary and rotating anodes, heat capacity, methods ofcooling, effect of focal spot size, exposure time, voltage waveform, multiple exposures, failing load operation, exposuretimers, automatic exposure control.6. Interaction of X-rays and Gamma raysInteraction of X-rays and gamma rays with matter and theireffects on the irradiated materials. Interaction processes andtheir relative importance for various materials and at differentradiation energies. Attenuation, absorption, scatter,exponential law, attenuation coefficients, half-value thickness.Homogeneous and heterogeneous radiation contrast.Effects: Heat, excitation, ionization, range of secondaryelectrons, chemical, photographic, fluorescent,phosphorescent, thermoluminescent.7. Measurement of X and gamma rays:Quantity: ionization, TLD and photographic dosimetry.Exposure: absorbed dose, and the relationship between themand radiation energy. Exposure and exposure rate meters.Geiger-Muller and scintillation detectors. Radionuclidedetection measurement. Counting statistics.Quality: radiation beam energy, mean, effective and peakenergy, half value thickness and filtration.8. Interaction of X-rays with the patient:Attenuation in various body tissues, high voltage radiography,mammography, enhancement by contrast media. Geometricfactors: magnification, distortion, positioning geometric andmovement unsharpness, obliteration, microradiography, beamlimitation, focal spot size.10. The radiological image:Image quality: description and meaning, resolution, noise,definition and contrast, film processing, developing equipment(manual & automatic), quality assessment.CPSP Intermediate Module in Diagnostic Radiology 201015

11. The image receptor:Intensifying screens: construction, physical principles andapplications. X-ray film: structure and operation, characteristiccurve, density, speed, contrast, latitude, processing and thedark room, automatic X-ray film processor, functions,principles, construction, advantages and disadvantages,handling and storage, labeling and identification. Design andcare of cassettes. Display and perception of the radiographicimage, daylight imaging.Image intensifiers: construction, operation, brightness gain,optical couplings, TV systems. Recording analogue and digitalsystems.CPSP Intermediate Module in Diagnostic Radiology 201012. Scattered radiation:Effect and control of scatter: beam limitation, compression,grid construction and operation. Radiographic subtractiontechniques. Tomography (conventional): principles, layerthickness. Digital fluoroscopic systems: Data collection,storage and display including digital subtraction techniquesimplication of digital storage media.13. Radiation protection:Biological effects of radiation, risk of somatic and geneticeffects. Objectives of radiation protection. Recommendations ofI.C.R.P/PNRA. Concepts of dose equivalent quality factor,detriment, limitation, annual limits of intake, radiologicalprotection regulations. Relevant codes of practice. Dose controlby design and by operation in diagnostic X-ray procedures andnuclear medicine for both staff and patients. Doses received indiagnostic procedures, population somatic and genetic dose,risk estimates, benefits. personnel monitoring.16

14. Quality assurance:Methods of assessing image quality and their relationship tospecifications of system performance. Methods of monitoringequipment performance.15. Radionuclide imaging:Desirable properties of radiopharmaceuticals, production ofshort half life material, preparation of radiopharmaceuticals.The camera, role of the collimator, photomultiplier assembly,formation of the image of the radionuclide distribution, types ofdisplay and the role of the computer. Problems of radionuclideimages, resolution, examples of applications, static imaging,dynamic imaging. Special types of equipment scanningcameras (multiformat camera, principles), PET, SPECT. Safehandling of radioactive materials, clinical applications.16. Computed Tomography (C.T.):Basic principles: different types of scanning geometry,detectors, scan time slice thickness, field size, resolution, noisereduction, dose data collection, storage and display, pixel,image reconstruction and manipulation, window width, windowlevel, grey scale, enhancement, Multi detector CT, CT artifacts.17. Principles of diagnostic ultrasound:The nature of ultrasound waves and dependence of velocity onthe medium. The behaviour of ultrasound waves at a boundarybetween two media: diffraction. The hertz, decibel. Productionof ultrasound, the transducer. Pulse techniques andcontinuous wave techniques. Pulse echo methods,components of a system transmitter, receiver, swept gainamplifier, time base generator display, 3D, 4D, panoramic,tissue harmonics. A, B and M mode scanning, real timeimaging. Instruments utilizing the Doppler effect. Pulsed wave,velocity and amplitude mode Doppler, Artefacts. Displaymethods grey scale, scan converter. Possible hazards from theuse of ultrasound.CPSP Intermediate Module in Diagnostic Radiology 201017

18. Magnetic Resonance Imaging ( MRI):Basic principles and their application to imaging. Origin of thesignal, principles of parameters displayed, extraction ofimaging data. Comparison of different systems. Sequencesand artifacts.19. Other Imaging Techniques:Digital radiography, Computerised Radiography, interventionalprocedures, computer application to radiology including PACSconcepts.20. Contrast media:The contrast media to be studied are those which relate to thepractical procedures mentioned above for each contrastsubstance the following attributes are expected whererelevant: Official name, composition, modes of administrationand clinical uses. Routes of elimination. Relative advantagesof different types of media. Side effects and treatment ofreactions. Contraindications to use.CPSP Intermediate Module in Diagnostic Radiology 201021. Drugs:Some knowledge is expected of the drugs commonly used inradiological practice including their pharmacology and dosage.These can be considered under the following headings:- Preparation of the bowels: purgatives and colonic activators.- Sedation before radiological procedures.- Prophylaxis and treatment of reactions to contrast media.- Prophylaxis and treatment of reactions to radiologicalprocedures other than to contrast media e.g. inPheochromocytoma.- Drugs modifying the behaviour of the gastrointestinal tractduring investigation.Note: The drugs used for the purpose described in the section willvary widely and the candidate will therefore be required to outline thedrugs used in his own department and the reasons for their choice.18

NUCLEAR MEDICINE1. Introduction:- Production of Radionuclide- Commonly used Radionuclide- Radioactive decay and half life2. Detection Equipment- Gamma Camera- Well Counter- Principles of SPECT, PET3. Quantification:- Uptake function- GFR, ERPF, Indices4. Practical:- Imaging Protocols.- Accident and Incidental handling.- Clinical indication and Procedures of commonly useddiagnostic procedures.COMPUTERS IN RADIOLOGY1. Principles of Digital image manipulation.2. Health informatics including data management, storageand retrieval.3. Picture Archiving and Communication SystemsRadiological and cross-sectional anatomy as required inUltrasound, CT and MRI.RADIOLOGICAL & SECTIONAL ANATOMYTrainee must know the gross and sectional anatomy of thefollowing:1. Nervous system and head and neck2. Thorax- Its wall and contents- Respiratory system- Cardiovascular system- BreastCPSP Intermediate Module in Diagnostic Radiology 201019

3. Abdomen and pelvis- Its walls peritoneum and contents- Gastrointestinal system- Hepatobiliary system- Urinary system- Genital system both male and female4. Endocrine glands5. Musculo-skeletal system6. Peripheral vascular and Lymphatic systemPOSITIONING, RADIOGRAPHY AND PROCEDURES1. Radiographic Positioning2. For Procedures see competency ListCPSP Intermediate Module in Diagnostic Radiology 2010CLINICAL RADIOLOGY1. BreastAt the end of two years residency, the resident should be able to:Core knowledge:- understand breast pathology and clinical practicerelevant to clinical radiology- understand radiographic techniques employed indiagnostic mammography- understand the principles of current practice inbreast imaging and breast cancer screening- have awareness of the proper application of other imagingtechniques to this specialty (e.g. ultrasound,magnetic resonance imaging and radionuclideradiology)- identify normal vs. abnormal anatomic structures- discuss technical and physical factors unique to theproduction of a mammogram.- make a preliminary review of mammogram films andadvise the technologist on the need for additional views- able to establish a plan for follow-up protocol for probablybenign lesions.- select cases for appropriate ultrasound examination.- interpret ultrasound examinations.- be aware of Radiation Protection, International & PNRARegulations, etc.20

Core skills:- read and dictate mammograms of common breastdisease after review by the attending radiologist.Core experience:- participate in mammographic reporting sessions(screening and symptomatic)- observe breast biopsy and localizationDecision-Making and Value Judgment Skills:- recognize limitations in personal skills and knowledge,always making sure that decisions, dictations andconsultations are checked by the radiologist in charge.Intermediate Module Syllabus for breast diseases:● Breast anatomy, pathology relevant to imaging andcommon diseases:- breast development- normal breast anatomy and histology. Alterationwith age, pregnancy, menstrual cycle in hormonaleffects- Understanding of the term e.g. atypical ductalhyperplasia (ADH), lobar carcinoma in situ (LCIS),ductal carcinoma in situ (DCIS) etc.●Mammographic equipment and techniques:- features of dedicated mammography unit includingtarget, filtration, photo timing and grids- characteristics off mammographic film screensystems- mammography positioning techniques for CC andMLO views.- a view box criteria: Assessment of properpositioning, compression, exposure,contrast, sharpness, noise- breast compression: Rationale, selection oftechnical factors, including effects of mAs, kVp anddensity settings on image quality- factors affecting contrast, density, noise,sharpness- need for dedicated height intensity view box, viewbox masking and magnifying glassCPSP Intermediate Module in Diagnostic Radiology 201021

●Mammography quality control:- mammographic appearance of artifact such asgridlines, motion unsharpness, noise, dust, poorscreen film contact, pickoff and scratches●Mammographic interpretation:- normal mammographic anatomy and parenchymalpatterns- mammographic features of typically benigncalcifications- calcifications having a high probability formalignancy- significance of distribution of calcification- assessment of mass for criteria of benign versusmalignant nature- knowledge of ACR BI-RADS Lexicon●Breast ultrasound:- technique- indications- normal sonographic anatomy- differential features of cyst, benign and malignantsolid massesCPSP Intermediate Module in Diagnostic Radiology 2010●●Interventional procedures:- principles, indications and contraindications- equipment, techniqueMammographic reporting:- Understanding of ACR BI-RADS lexicon terms forbreast reporting.- Calcification: Significance of size, shape anddistribution to underlying pathology- State the appearances of:i. Cyst and giant cystii. Lipomaiii. Fibroadenomaiv. Cystosarcoma phylloides22

2. HeartAt the end of two years residency, the resident should be able to:Core knowledge:● show knowledge of cardiac anatomy, and clinical practicerelevant to clinical radiology● know the manifestations of cardiac disease demonstratedby conventional radiographyCore skills:● report plain radiographs performed to show cardiacdiseaseThoracic Aorta and Great Vessels :● state normal dimensions of the thoracic aorta● describe classifications of aortic dissection(DeBakey I,II, III; Stanford A, B)● state and recognize the following on CT- aortic aneurysm- aortic dissection- ruptured aortic aneurysm- aortic coarctation● define the terms aneurysm and pseudoaneurysmIschemic Heart Disease:● describe common acute and late complications ofmyocardial infarction, including left ventricular failure● identify left heart failure on a chest radiographCardiac Valvular Disease:● state the findings that indicate each of the followingand identify each on chest radiographs:- enlarged right atrium- enlarged left atrium- enlarged right ventricle- enlarged left ventricle●●recognize an enlarged left atrium, vascular redistribution.State the most common etiologies of the following:- aortic stenosis- aortic regurgitation- mitral stenosis- mitral regurgitationCPSP Intermediate Module in Diagnostic Radiology 201023

Pericardial disease:● recognize pericardial calcification on a radiograph & chest CT● describe and identify most common chest radiographicsigns and causes of a pericardial effusionCongenital Heart Disease in the Adult:● recognize increased vascularity, decreased vascularityand shunt vascularity on a chest radiograph and statethe common causes of each● recognize the following on imaging examinations of the chest:- Left-to-right shunts and Eisenmenger physiology- Atrial septal defect- Ventricular septal defect- Patent ductus arteriosus- Coarctation of aortaCPSP Intermediate Module in Diagnostic Radiology 20103. ChestAt the end of the training, the resident should be able to:Core knowledge:● know respiratory anatomy and clinical practice relevantto clinical radiology● know the manifestations of thoracic disease as demonstratedby conventional radiography and CT● know the application of radionuclide investigations to chestpathology with particular reference to radionuclide lungscintigramsKnowledge Based Objectives:● identify normal anatomy of the chest as it is seen on theradiograph and CT.● identify and/or describe common variants of the normal.● demonstrate a basic knowledge of radiologic interpretation.● discuss various common diseases that give altered patterns oflung disorders.● describe the characteristics of common abnormal cardiacshadows.Core skills:● report plain radiographs performed to show chestdisease24

Technical Skills:● given a chest radiograph or CT, distinguish normal fromabnormal structures.● dictate a report that is brief and understandable undersupervision.● communicate verbally with referring physicians and house staffabout radiographic findings.● given an appropriate radiograph, recognize cardiacenlargement.● identify anatomy and significant pathology as seen on CT.Core experience:● observe image-guided biopsies of lesions within the thoraxDecision-Making and Value Judgment Skills:● make decisions about when to alert house staff to theimmediacy of a condition that is apparent on theradiograph.● determine when to request that a repeat examination isneeded because of technical inadequacy.● determine which cases can be interpreted and dictatedindependently and which cases require the assistance ofa faculty radiologist.General Objectives:After completion of the first two years, the resident will be able to:● demonstrate learning of the knowledge-based objectives● accurately and concisely prepare a chest radiograph report● communicate effectively with referring clinicians andsupervisory staff● understand standard patient positioning in chest radiology● obtain pertinent patient information relative to radiologicexaminations● demonstrate learning of the clinical indications forobtaining chest radiographs and when a chest CT orMRI may be necessary● demonstrate a responsible work ethicCPSP Intermediate Module in Diagnostic Radiology 201025

CPSP Intermediate Module in Diagnostic Radiology 2010Normal Anatomy:● name and define the three zones of the airways● define a secondary pulmonary lobule● define an acinus● list the lobar and segmental bronchi of both lungs● identify the following structures on the posteroanterior(PA) chest radiograph:- Lungs- Right, left, right upper, middle and lower lobes, leftupper and lower lobes, lingula- Fissures - minor, superior accessory, inferioraccessory, azygos- Airway - trachea, carina, main bronchi- Heart - right atrium, left atrial appendage, leftventricle, and location of the four cardiac valves- Pulmonary arteries - main, right, left, interlobar- Aorta - ascending, arch, descending- Veins - superior vena cava, azygos, left superiorintercostal- Bones - spine, ribs, clavicles, scapulae, humerus- Right paratracheal stripe- Junction lines - anterior, posterior- Aortopulmonary window- Azygoesophageal recess- Paraspinal lines- Left subclavian artery● identify the following structures on the lateral chest radiograph:- Lungs- Right, left, right upper, middle and lower lobes, leftupper and lower lobes, lingula- Fissures - major, minor, superior accessory- Airway - trachea, upper lobe bronchi, posterior wall ofbronchus intermedius- Heart - right ventricle, right ventricular outflow stripe, leftatrium, left ventricle, the location of the four cardiac valves- Pulmonary arteries - right, left- Aorta - ascending, arch, descending26

- Veins - SVC, IVC, left brachiocephalic (innominate),pulmonary vein confluence- Bones - spine, ribs, scapulae, humerus- Retrosternal line- Posterior tracheal stripe- Right and left hemidiaphragms- Raider's triangle- Brachiocephalic (innominate) arterySigns in Chest Radiology:By the end of two years residency, the resident should be abletodefine, identify and state the significance of the important signsfollowing on a radiograph:● Air bronchogram - indicates a parenchymal process,including non-obstructive atelectasis, as distinguished frompleural or mediastinal processes● Air crescent sign - indicates a lung cavity, often due tofungal infection● Deep sulcus sign on a supine radiograph - indicatespneumothorax● Continuous diaphragm sign - indicates pneumomediastinum● Flat waist sign- indicates left lower lobe collapse● Gloved finger sign - indicates bronchial impaction, whichcan be seen in allergic bronchopulmonary aspergillosis● Hampton's hump - indicates a pulmonary infarct● Silhouette sign - loss of the contour of the heart ordiaphragm used to localize a parenchymal process(e.g. a process involving the medial segment of the rightmiddle lobe obscures the right heart border; a lingularecess obscures the left heart border; a basilar segmentallower lobe process obscures the diaphragm)● Figure 3 sign - abnormal contour of the descending aorta,indicating coarctation of the aorta● Scimitar sign - an abnormal pulmonary vein in venolobarsyndrome● Double density sign - contour projecting over the right sideof the heart, indicating enlargement of the left atrium● Hilum overlay sign and hilum convergence sign - used todistinguish a hilar mass from a non-hilar massCPSP Intermediate Module in Diagnostic Radiology 201027

Interstitial lung disease:●●●●●●●list and identify on a chest radiograph and chest CT mostcommon patterns of interstitial lung disease (ILD)make a specific diagnosis of ILD when supportive findingsare present in the history or on radiologic imaging (e.g.dilated esophagus and ILD in scleroderma)identify Kerley A and B lines on a chest radiograph andexplain their etiologyrecognize the changes of congestive heart failure on achest radiograph - enlarged cardiac silhouette, pleuraleffusions, vascular redistribution, interstitial and/or alveolaredema, Kerley linesrecognize progressive massive fibrosis / conglomeratemasses secondary to silicosis or coal worker'spneumoconiosis on radiographyidentify and give appropriate differential diagnoses whenthe patterns of septal thickening, perilymphatic nodules,bronchiolar opacities (“tree-in-bud”), air trapping, cysts, andground glass opacities are seen on HRCTCPSP Intermediate Module in Diagnostic Radiology 2010Alveolar lung disease:●●●●list broad categories of acute & chronic alveolar lungdiseaselist most common causes of adult respiratory distresssyndromename most common predisposing causes of bronchiolitisobliterans organizing pneumoniasuggest a specific diagnosis of ALD when supportivefindings are present in the history or on the chestradiograph (e.g. broken femur and ALD in fat embolizationsyndrome, ALD and renal failure in a pulmonary-renalsyndrome, ALD treated with bronchoalveolar lavage inalveolar proteinosis)28

Atelectasis, Airways and Obstructive Lung Disease:●●●recognize partial or complete atelectasis of the followingon a chest radiograph:- right upper lobe- right middle lobe- right lower lobe- right upper and middle lobe- right middle and lower lobe- left upper lobe- left lower lobedistinguish lung collapse from massive pleural effusion ona frontal chest radiographname most common types and causes of bronchiectasisand identify each type on a chest CTMediastinal Masses and Mediastinal / Hilar Lymph NodeEnlargement:● state the anatomic boundaries of the anterior, middle,posterior and superior mediastinum● name most common causes of an anterior, middle andposterior mediastinal mass.● name most common etiologies of bilateral hilar lymph nodeenlargementSolitary and Multiple Pulmonary Nodules:● state the definition of a solitary pulmonary nodule andpulmonary mass● name most common causes and evaluation of solitary andmultiple pulmonary nodulesBenign and Malignant Neoplasm's of the Lung and Esophagus:● name the types of bronchogenic carcinoma that are usuallycentral● describe the TNM classification for staging esophagealcarcinoma.CPSP Intermediate Module in Diagnostic Radiology 201029

Chest Trauma:● identify a widened mediastinum on a trauma radiograph andstate the differential diagnosis (including aortic / arterial injury,venous injury, fracture of sternum or spine)● identify the indirect and direct signs of aortic injury on contrastenhancedchest CT scan● identify fractured ribs, clavicle, spine and scapula on a chestradiograph● identify a pneumothorax and pneumomediastinum on atrauma chest radiograph● name most common causes of pneumomediastinum in thesetting of trauma.● recognize and distinguish between pulmonary contusion,laceration and aspirationCPSP Intermediate Module in Diagnostic Radiology 2010Chest Wall, Pleura and Diaphragm:● recognize and state most common causes of a largeunilateral pleural effusion on a radiograph.● recognize the typical chest radiographic appearances ofpleural effusion, given differences in patient positioning● recognize a pneumothorax on an upright and supine chestradiograph● recognize pleural calcification on a radiograph and suggestthe diagnosis of asbestos exposure (bilateral involvement ) orold TB or trauma (unilateral involvement)● recognize apparent unilateral elevation of the diaphragm on achest radiograph and suggest a specific etiology withsupportive history and associated chest radiograph findings(e.g. subdiaphragmatic abscess after abdominal surgery,diaphragm rupture after trauma, and phrenic nerveinvolvement with lung cancer)● recognize a tension pneumothorax and understand the acuteclinical implications● recognize diffuse pleural thickening, as seen in fibrothorax,malignant mesothelioma and pleural metastases30

Infection (Immunocompetent, Immunocompromised andPost-transplant Patients):●●●name the radiographic manifestations of primary pulmonarytuberculosisname and describe the types of pulmonary Aspergillus diseaseIdentify an intracavitary fungus ball on chest radiography andchest CTUnilateral Hyperlucent Lung (or hemithorax):●●●recognize a unilateral hyperlucent lung on a radiographIdentify the common causes for unilateral hyperlucent lung ona chest radiographgive an appropriate differential diagnosis when a hyperlucentlung is seen on a chest radiograph, and suggest a specificdiagnosis when certain associated findings are seen(i.e absence of a breast after mastectomy, absence of apectoralis muscle, unilateral bullous disease / emphysema, orair trapping on expiration in a patient with Swyer-Jamessyndrome or an endobronchial foreign body)Congenital Lung Disease:●recognize a mass in the posterior segment of a lower lobe ona chest radiograph and chest CT, and suggest the possiblediagnosis of pulmonary sequestrationPulmonary Vascular:●●●recognize enlarged pulmonary arteries on a chest radiographand distinguish them from enlarged hilar lymph nodesname most common causes of pulmonary artery hypertension.define the role of ventilation-perfusion scintigraphy in theevaluation of a patient with suspected venous thromboembolicdisease, including the advantages and limitationsCPSP Intermediate Module in Diagnostic Radiology 201031

Monitoring and support devices - “tubes and lines” :● be able to identify, state the preferred placement of,complications associated with malposition and identify thelocation on chest radiography for each of the following:- Endotracheal tube- Central venous catheter- Feeding tube- Nasogastric tube- Chest tube- Pacemaker and pacemaker leads- Automatic implantable cardiac defibrillator- Pericardial drain- Intra esophageal manometer, temperature probe orpH probe- Tracheal or bronchial stentCPSP Intermediate Module in Diagnostic Radiology 2010Technical, Communication and Decision-Making Skills:At the end of the first two years rotation, the resident willdemonstrate the following technical, communication, and decisionmakingskills:● dictate understandable chest radiograph reports that includepatient name, patient medical record number, date of exam,date of comparison exam, type of exam, indication for exam,brief and concise description of the findings and shortimpression● call ordering physicians about all significant or unexpectedradiologic findings and document who was called and the dateand time of the call in the dictated report● obtain relevant patient history from computer records, dictatedreports, or by calling referring clinicians● describe patient positioning and indications for a PA, lateral,decubitus, and lordotic chest radiograph● decide when it is appropriate to obtain help from supervisoryfaculty in interpreting radiographs when answering questionsfor referring clinicians● arrive for the rotation assignment on time and prepared, afterreviewing recommended study materials32

GASTROINTESTINAL (INCLUDING LIVER, PANCREASAND SPLEEN)Resident at the end of two years of training should be able to:Core knowledge:● know gastrointestinal anatomy and clinical practice relevant toclinical radiology● know the radiological manifestations of disease within theabdomen on conventional radiography, contrast studies,ultrasound● know the applications, contraindications and complications ofrelevant interventional procedures● discuss the proper clinical and radiologic indications for thefollowing studies:- barium swallow- upper GI series- barium enema, single contrast and double contrast- small bowel follow-through- Enteroclysis- ERCP- Fistulograms● state the physiologic properties, proper concentrations andproper indications for the use of the following contrast material- barium- water soluble contrast media used in GI radiology● discuss the following information about glucagon/Buscopan- proper indications and dosage used in GI radiology- physiologic effects- side effects- contraindications● discuss the following information about glucagon/ buscopan● recognize the normal radiographic appearance of thestructures of the GI tract● given in an appropriate radiograph, demonstrate abasic knowledge of radiographic abnormalities of theGI tract● described and/or discuss gastrointestinal tract pathology inspecific detailCPSP Intermediate Module in Diagnostic Radiology 201033

CPSP Intermediate Module in Diagnostic Radiology 2010Core skills:● report plain radiographs performed to show gastrointestinaldisease● perform and report the following contrast examinations:- Swallow and meal examinations- Small bowel studies- Enema examinations● perform and report transabdominal ultrasound of thegastrointestinal system and abdominal viscera performing:- ultrasound-guided biopsy and drainage(Competency level 1 & 2)- computed tomography-guided biopsy and drainage(Competency level 1 & 2)● demonstrate basic knowledge of the equipment to beused during fluoroscopy, including proper KVtechniques for the various procedures, radiation safetyfeatures of the machines, and proper radiation safetytechniques● demonstrate fluoroscopy techniques for performing thefollowing procedures- barium swallow- barium meal and upper GI studies- barium enema, single contrast and double contrast- small bowel follow-through enteroclysis- ERCP- Fistulograms● demonstrate knowledge of proper KV technique,positioning and type of films that should be taken forthe procedure listed above● demonstrate initial development of fluoroscopic skillsby identifying the more common abnormalities duringthe performance of the studies.● demonstrate the ability to identify the abnormality atfluoroscopy and modify the technique or change thepatient's position to take more diagnostic fluoroscopicspot films● demonstrate the ability to perform efficiently throughdecreasing fluoroscopic time, needed to perform astudy without compromising diagnostic acumen.34

Core experience:● perform and report the following contrast medium studies:- GI Fluoroscopic studies- Cholangiography- SinogramIntermediate Module Syllabus for Gastrointestinal Radiology :1. Physics● Composition of standard contrast agents● KVp setting for standard studies2. Pharynx● Technique of examination● Normal anatomy● Benign diseases● Identification and definition of the following abnormalities- Webs- Diverticula- Foreign bodies- Trauma● Malignant tumors● Differentiation of malignant from benign lesions● Motility disorders- Normal pharyngeal motion- The modified barium swallow3. Esophagus● Technique of examination● Normal anatomy● Esophageal lesions● Identification and description of the lesions and most commoncomplications of the following esophageal conditions:- Trauma and foreign body esophagus- Diverticula and intra-mural pseudo diverticulae- Gastro-esophageal reflux and reflux esophagitis- Hiatal hernias- Stricture caused by ingestion of caustics and drug-induced- Malignant lesionsCPSP Intermediate Module in Diagnostic Radiology 201035

3. Stomach● Normal anatomy and variations● Technique of examination● Identification of the lesion and complications of the followinggastric conditions:- Gastritis- Peptic ulcer disease- Post operative stomach5. Duodenum● Identification and description of the lesion of the followingduodenal conditions:- Duodenitis and duodenal ulcers6. Small Intestine● Technique of examination● Normal anatomy and variants● Identification of the lesion and the most common complicationsof the following intestinal conditions:- Vascular disease: intestinal ischemia and infarction- Crohn's disease- IntusussceptionCPSP Intermediate Module in Diagnostic Radiology 20107. Colon and Appendix● Technique of examination● Normal anatomy● Identification and description of the lesions of the following colonconditions:- Diverticular disease and diverticulitis of colon- Colitis including ulcerative colitis- Crohn's disease.- Adeno carcinoma and other malignant lesions8. Pancreas● Normal anatomy● Imaging methods● Pancreatitis + Calcifications on plain film abdomen anddifferential diagnosis36

9. Liver● Normal anatomy- Classical gross anatomy and segmentation● Imaging methods including Ultrasound and CT● Identification and description of the lesions on US of thefollowing liver conditions:- Cirrhosis- Fatty infiltration- Liver abscess- Portal Hypertension- Hepatocellular carcinoma10. Bile Ducts and Gallbladder● Normal anatomy and variants● Techniques of examination● Identification of the lesion and description of the most commonconditions of the following Bile duct and Gallbladderconditions:- Acute and Chronic Cholecystitis- Cholelithiasis- Caroli's disease- Primary sclerosing cholangitis11. Multisystem Disorders● Acute abdomen● Trauma to the abdomenCPSP Intermediate Module in Diagnostic Radiology 201037

MUSCULOSKELETAL INCLUDING TRAUMAAt the end of the two years training the resident should be able to:Core knowledge:● know musculoskeletal anatomy and clinical practicerelevant to clinical radiology● know normal variants of normal anatomy, which maymimic trauma● know the manifestations of musculoskeletal disease andtrauma as demonstrated by conventional radiography andCT scanKnowledge Based Objectives:● discuss basic bone physiology● describe the stages different types of fractures go through inthe process of healing● list and describe the basic principles of examination ofmusculoskeletal studies.● state the indications for computed tomography, plaintomography, MRI and bone scans.CPSP Intermediate Module in Diagnostic Radiology 2010Core skills:● report plain radiographs relevant to the diagnosis ofdisorders of the musculoskeletal system including trauma● Identify with a high level of accuracy, most types of bonefractures.● recognize the commonly used radiographic projectionsin musculoskeletal radiology.● arrange musculoskeletal radiographs in an orderlyfashion for review and interpretation.● identifiy normal musculoskeletal structures and some ofthe normal variants.Decision-Making and Value Judgment Skills:● given musculoskeletal radiographs that are not diagnosticwithout further study, state whether the patient should haveadditional exams in CT, MRI, plain tomography or nuclear imaging.● given a radiograph of a healing bone fracture, determine thestage of bone healing.38

General Objectives:1. Aspects of Basic Science related to bone:● Histogenesis of developing bone- Intramembranous ossification- Endochondral ossification- Remodeling●●Bone anatomy- Cellular constituentsi Osteoblastsii OsteoclastsNon cellular constituents- Organic matrix- Inorganic matrix2. Techniques Relevant to Musculoskeletal Radiology:● Radiography- Routine and specialized views● Computed tomography● Magnetic resonance imaging● Conventional tomography● Ultrasonography● Densitometry● Bone age determination3. General considerations:Normal Features and Variants● Sequence of ossification at joints (e.g., elbow)● Physiologic radiolucencies● Bone island (enostosis)● Vascular channels● Periosteal reaction of infancy● Spinal dysraphism, meningomyelocele● Diastematomyelia● Scheuermann disease● Congenital Anomalies and Dysplasias (Basic)CPSP Intermediate Module in Diagnostic Radiology 201039

CPSP Intermediate Module in Diagnostic Radiology 2010●Identify the lesion and describe the most common causes,differential diagnosis and complications of the followingmusculo-skeletal conditions:- Talipes equinovarus (clubfoot)- Pes planus- Pes cavus- Achondroplasia- Osteogenesis imperfecta- Osteopetrosis- Osteopoikiloisis- Melorheostosis- Osteopathia striata- Diaphyseal dysplasia- Metaphyseal dysplasia (Pyle)- Neurofibromatosis- Bacterial & Tuberculous acute + chronic infections- Brodie's Abscess- Sclerosing osteomyelitis- Fibrous dysplasia- Enchondroma- Osteochondroma- Chondrosarcoma- Osteosarcoma- Simple cyst and Aneurysmal bone cyst- Giant cell tumor- Ewing Sarcoma- Bennett’s fracture- Greenstick fracture- Monteggia fracture/dislocation- Lisfranc fracture/dislocation- Galeazzi fracture/dislocation- Osteomalacia- Renal osteodystrophy- Primary hyperparathyroidism- Secondary hyperparathyroidism- Acromegaly- Thalassaemia or variant- Paget's disease- Osteoarthritis- Rheumatoid arthritis- Psoriatic arthritis- Ankylosing spondylitis- Gout40

NEURO-RADIOLOGY / HEAD AND NECK IMAGINGINCLUDING ENT/ EYE & DENTALAt the end of two years of residency the resident should be able to:Core knowledge:● know neuro-anatomy of head and neck and clinical practicerelevant to neuro-radiology● know the manifestations of CNS, ENT/eye and dental diseaseas demonstrated on conventional radiography, relevantcontrast examinations, ultrasound, CT, myelography, and MR.● have awareness of the applications, contraindications andcomplications of invasive neuro-radiological procedures● have awareness of the application of ultrasound with particularreference to the thyroid and salivary glands and other neckstructures● have awareness of the application of radionuclide investigationswith particular reference to the thyroid and parathyroid glands● given normal neuro images, demonstrate a proficientknowledge off the anatomy of the head and neck, spineand central nervous system● given an appropriate film, demonstrate a thoroughknowledge of the vascular anatomy of the central nervoussystem● given an appropriate neuroradiology plain film, make anaccurate interpretation of the information on the film● discuss the basic principles of CT and MRI physics● describe in considerable detail, CT and MR imaging protocolsCore skills:● report plain radiographs in the investigation of neurologicaldisorders● report plain radiographs performed to show ENT / EYEand dental disease performing and reporting relevant contrastexaminations (e.g. including video barium swallows,sialography and dacrocystography)● perform and reporting ultrasound of the neck (including thethyroid, parathyroid and salivary glands (competency level 2 & 3)CPSP Intermediate Module in Diagnostic Radiology 201041

●supervise and reporting of cranial and spinal CT and MRessentially related to acute emergencies- screen, prescribe, and supervise routine neuro-imagingprocedures- supervise in the screen imaging patient- demonstrate proficiency in performance andinterpretation of myelogramsCore experience:●●●observe of carotid ultrasound including Dopplerreport brain CT under supervisionrelated fluoroscopy proceduresOptional experience:● observe or experience in performing ultrasound of the eyeDecision making and value judgment skills:●Interactive primary care physicians and neurologist inconsultation when more common pathologies are at questionCPSP Intermediate Module in Diagnostic Radiology 2010Intermediate Module Syllabus for CNS:●Understand the fundamental concepts for the Imagingapproach of CNS disease especially in CT & MRI e.g.:- Imaging features of the mass lesion- Imaging features suggestive of differentiatingbetween benign versus malignant nature of themass- Understanding of the brain edema- Classification of different types of hemorrhage isan understanding of their aging estimationsaccording to CT and MRI criteria including itspatho-physiological rationale42

●Intracranial- CNS infectionsi. Meningitisii. Abscessiii. Subdural and epidural empyema- Traumai. Imaging strategies: CT / MR / skull filmsii. Focal lesions e.g. cortical contusions,different types of hemorrhage in accordingto compartment etc.iii. Diffuse cerebral swelling and edema- Neoplasm's and other massesi. Names of sella / parasellar massesii. Names of cerebello-pontine angle tumoriii. Names of intraventricular tumors- Cerebrovascular diseasesi. Infarction●Head and Neck- Eyei. Retinoblastomaii. Hemangioma- Necki. Multinodular Goiter- ENTi. Sialographyii. DacrocystographyCPSP Intermediate Module in Diagnostic Radiology 201043

OBSTETRICS AND GYNAECOLOGYAt the end of two years residency the resident should be able toCore knowledge:● know obstetric and gynaecological anatomy and clinicalpractice relevant to clinical radiology● know the physiological changes affecting imaging of thefemale reproductive organs.● know the changes in fetal anatomy during gestation and theimaging appearances of fetal abnormalityCore skills:● report plain radiographs performed to show obstetric andgynaecological disorders● perform and report transabdominal and endovaginalultrasound in gynaecological disordersCore experience:● perform and report hysterosalpingography● perform and report transabdominal and endovaginalultrasound in obstetricsCPSP Intermediate Module in Diagnostic Radiology 2010URO-RADIOLOGYCore knowledge:● know urinary tract anatomy and clinical practice relevant toclinical radiology● know the manifestations of urological diseases asdemonstrated on conventional radiography, ultrasoundfamiliarity with the current application of radionuclideinvestigations for imaging the following:- Kidney- Renal function- Vesico-ureteric reflux● discuss the proper clinical and radiologic indications forthe following studies- IVU- cystogram- voiding cystourethrogram- Hysterosalpingogram- Ultrasonography44

●●●●●●state the physiologic properties, proper concentrations andproper indications for the use of the following contrast material- ionic intravenous contrast media- non-ionic intravenous contrast medialist the high risk factors for the allergic reactions tointravenous contrast mediastate the proper assessment and treatment for allergicreactions to contrast mediarecognize the normal radiographic appearance of thestructures or the GU tractgiven an appropriate radiographs, demonstrate a basicknowledge of radiographic abnormalities of the GU tractdescribe and / or discuss GU tract pathology in specific detailCore skills:●●●●●report plain radiographs performed to show urinary tract diseaseperform and report the following contrast studies:- Intravenous urogram- Nephrostogram- Ascending urethrogram- Micturating cysto-urethrogramperform and report transabdominal ultrasound to image theurinary tractdemonstrate basic knowledge of the equipment to beused during fluoroscopy and IVU, including proper kVtechniques for the various procedures, accessories used,radiation safety features of the machines, and properradiation safety techniquesdemonstrate fluoroscopy techniques for the followingprocedures- IVU- cystogram- voiding cystourethrogram- HysterosalpingogramCPSP Intermediate Module in Diagnostic Radiology 201045

●●●●demonstrate knowledge of proper kV technique, patientpositioning and type of, since that should be taken for theprocedures listed abovedemonstrate initial development of fluoroscopic skills byidentifying the more common abnormalities during theperformance of the studiesgiven a fluoroscopic examination, demonstrate the ability toidentify the abnormality at fluoroscopy and modify thetechnique or change the patient's position to take morediagnostic fluoroscopic spot filmsdemonstrate the inability to perform and efficiently throughdecreasing fluoroscopic time needed to perform a studywithout compromising diagnostic acumenCPSP Intermediate Module in Diagnostic Radiology 2010Decision-making and value judgmental skills:● review history of the patient for whom a procedure has beenrequested and determine the appropriateness of the requestedstudy● communicate with the referring physician about anyrecommendations for change in the type of procedure to beperformed● communicate with the technologist about any special oradditional views that should be obtained to demonstrate thepathology identified● read and dictate the studies performed under the supervisionof the faculty radiologist● communicate to the referring physician any significantabnormalities identified on the examination● evaluate an integrated data from other studies (CT, MRI,ultrasound and nuclear medicine) of the GU tract to makerecommendations to the referring physician about moreappropriate or additional diagnostic studies needed forevaluation of the patient's abnormality● read and dictate studies under supervision of the facultyradiologist46

Intermediate Module Syllabus of Gastrourinary System:1. Embryology of the Gastrourinary tractCongenital Anomalies:●●●●●●Renal- agenesis- horseshoe kidney- crossed fused ectopia- malrotationUreteral- blind ureter- duplication- a topic ureteroceleBladder- exstrophyUrethra- epispadias and hypospadias- posterior valvesMale genital- cryptorchidismFemale- unicornuate uterus, septate uterus, bicornuate uterus,uterus didelphys2. Normal Anatomy●●●●●●●●renalureterbladderurethramale genitalfemale genitaladrenalretroperitonealCPSP Intermediate Module in Diagnostic Radiology 201047

3. ProceduresDiagnostic Procedures:●●●Radiography of upper urinary tract- plain radiography- intravenous urography- retrograde pyelography- antegrade pyelographyRadiography-lower urinary tract- plain radiography- cystography- voiding cystourethrography- retrograde urethrogram feeRadiography-genital- HysterosalpingographyCPSP Intermediate Module in Diagnostic Radiology 2010Ultrasonography:●●●Radiography of upper urinary tract- real-time grayscale imaging- doppler waveform and color Doppler principles, resistiveindices- renal, ureteral-ureteral jets- bladder- scrotum and contents- female genitali. obstetricii. transvaginal- adrenal- transrectal prostatic- penile grayscale, Doppler (importance)Computed TomographyNuclear Medicine Diagnostic Procedures48

Kidney:●●Identify the lesion and describe the most common causes,differential diagnosis and complications of the followingconditions:- Medullary sponge kidney- Wilms tumor- Renal cell carcinoma- Transitional cell carcinoma- Pyelonephritis- Renal abscess- Nephrocalcinosis, types and causes- Nephrolithiasis- Ureterocele- Vesicoureteral reflux- Stress incontinence- Neurogenic bladder- Bladder outlet obstruction- Prostate- Testes- Scrotum- Hydrosalpinx- Renal traumaImaging features on IVU, ultrasound and emergency CTCPSP Intermediate Module in Diagnostic Radiology 201049

PAEDIATRIC RADIOLOGYAfter completion of two years residency, the resident should be able to:Core knowledge:● know pediatric anatomy and clinical practice relevant to clinicalradiology● know disease entities specific to the pediatric age group andtheir clinical manifestations relevant to clinical radiology● know disease entities specific to the pediatric age group andtheir manifestations as demonstrated on conventional radiography,ultrasound, contrast studies and also in CT scan, MRI andradionuclide investigations for the most common pathologies- identify normal/abnormal airways on chest x-ray of theinfant or old child● identify abnormalities associated with congenital heartdisease on the chest radiograph of the infant/older child● identify normal versus abnormal skeletal structures(especially extremities on a bone survey)● describe the proper procedure for fluoroscopy often infant/older child● establish bone age on the basis of radiographic findings● describe positioning techniques in technical factors leading tooptimum chest, GU radiographs of the infant and older childrenCPSP Intermediate Module in Diagnostic Radiology 2010Core skills:● report plain radiographs performed in the investigation ofpediatric disorders including trauma● perform and reporting ultrasound in the pediatric age group● supervise and report cranial CT studies, particularly in thesetting of acute trauma● perform and report routine fluoroscopic procedures in thepediatric age group, particularly:- contrast studies of the urinary tract- contrast studies of the GI systemCore experience:● experience of supervising and reporting conventional studiesand ultrasound.● experience of CT, MRI and radionuclide investigations of thepediatric age group may be considered additional but desirable50

Decision making and value judgment of skills:●●●●make preliminary review of outpatient and pediatric ICU films,discuss findings with the radiologist, and dictate as directedassess the technologist and preparation of the patient forfluoroscopic examination (e.g. enemas, etc.)review of neonatal intensive care unit films for completeness ofstudy and four (4) significant findings that require promptattention and make decision in regard to notification of theresident physician if the radiologist is not immediately availablefor consultationRecognize limitations and personal knowledge and skills beingcareful to not make decisions beyond the level of personalcompetence. Make sure medications andconsultations are checked by the radiologist In charge.VASCULAR INTERVENTIONCore knowledge:● know vascular anatomy and clinical practice relevant to clinicalradiology● have familiarity with the indications, contraindications,pre-procedure preparation (including informed consent),sedation and anesthetic regimes, patient monitoring duringprocedures and post-procedure patient care● have familiarity with procedure and post-procedurecomplications and their managementCore skills:● report plain radiographs relevant to cardiovascular disease● perform and reporting the following procedures:- Lower limb venography (contrast or ultrasound) atcompetence level 2 / 3● perform the following techniques:- Ultrasound (including Doppler), venous and arterial atcompetence level 2 / 3CPSP Intermediate Module in Diagnostic Radiology 201051

RADIONUCLIDE RADIOLOGYCore knowledge:●●●●●have secure knowledge of the relevant aspects of currentlegislation regarding the administration of radiopharmaceuticalsknow the technical aspects of radionuclide radiology relevantto optimising image qualityknow the radiopharmaceuticals currently available for thepurposes of imaging organs and locating inflammatorycollections, tumors and sites of hemorrhageknow the relevant patient preparation, precautions (includingdrug effects), and complications of the more commonlyperformed radionuclide investigationsknow the strengths and weaknesses of radionuclideinvestigations compared to other imaging modalitiesCPSP Intermediate Module in Diagnostic Radiology 2010ULTRASOUNDCore knowledge:●●●●●know the technical aspects of ultrasound relevant to optimizingimage qualityknow the cross-sectional anatomy as visualized on ultrasoundhave experience in performing and reporting transabdominalultrasound examination, and should be able to discussedthoroughly the ultrasound Procedures and Findings ofstructures in the following anatomical areas:- General abdomen (including vessels)- Obstetric- Pelvis (non-obstetric)- Small parts (scrotum, thyroid, neck structures)- Upper abdomen (including lower chest)have experience of performing Doppler ultrasound imaging(e.g. leg veins, portal vein, carotid artery)perform transcranial pediatric ultrasound52

●●●discuss the Basics ultrasound physics and instrumentation,especially related to equipment operation and thespecifications for various probesdescribe from observation, the technique used to perform eachof the routinely performed proceduresshould identify and discuss significant characteristics of thepathologies mentioned in the above list of ultrasoundsCore skills:●●●●●●demonstrate familiarity with the equipment and techniquesused in vascular, biliary, and renal interventional techniquesdemonstrate familiarity with the indications, contraindications,pre-procedure preparation including informed consent, patientmonitoring during the procedure and post-procedure patient caredemonstrate familiarity with procedure and post-procedurecomplications and their managementreview history of patient to be examined each day todetermine the relevance of this study to clinical symptomsrecord pertinent history of the patientacquire special views of the specific parameters of thestudy that require special attentionDecision making and value judgment of skills:●●●in the given ultrasound case, based on the preliminary imagingshould be able to get additional views or repeat views asneededshould be able to make decisions in regard to notification of thereferring physician based on the urgent findings on ultrasoundexaminationshould be able to report ultrasound examination under thesupervision of the faculty radiologistCPSP Intermediate Module in Diagnostic Radiology 201053

GENERAL PROFESSIONAL DEVELOPMENT:In addition to the above radiological knowledge the trainee will alsobe expected to attain an appropriate level of knowledge in:● clinical conditions in which radiology has a role indiagnosis and/or treatment● applied pathology and physiology where it contributes to abetter understanding of radiological signs and methods ofinvestigation● those aspects of clinical medicine and pathology whichare essential to the safe and effective conduct ofinterventional procedures● current trends and recent advances in clinical radiology● medical ethics● statistics and research methods● communication (breaking bad news, consent,communication with colleagues, etc.)CPSP Intermediate Module in Diagnostic Radiology 2010The trainee will develop skills as part of his/her generalprofessional development in:● teaching● clinical audit- clinical effectiveness- clinical risk management including discrepancyreview- quality standards● researchHEALTH INFORMATICSThe trainee should:● develop core skills in information technology, especially the abilityto perform basic word-processing, and to access computerizedmedical databases, electronic mail systems and the internet● keep abreast of developments in information managementrelevant to radiology departments54

COMPETENCE LEVEL EXPECTED OF ATRAINEE IN DIAGNOSTIC RADIOLOGYFOR INTERMEDIATE MODULEA candidate is expected to attain the laid down level of competenceby the end of each specified period as given below:1. Observer status2. Assistant status3. Performed under supervision4. Performed under indirect supervision5. Performed independentlyNote:Levels 4 and 5 for practical purposes are almostsynonymousCPSP Intermediate Module in Diagnostic Radiology 201055

CPSP Intermediate Module in Diagnostic Radiology 2010COMPETENCIES3 Months 6 MonthsLevel Cases Level CasesFirst Year9 Months 12 MonthsLevel Cases Level CasesTotal Cases1st YearProceduresBarium Swallow 1,2 5 2,3 10 3,4 5 3,4 10 30Barium Meal 1,2 5 2,3 10 3,4 5 3,4 10 30Barium Enema 1,2 2 2,3 3 3,4 5 3,4 5 15I.V.U 1,2 10 2,3 10 3,4 10 3,4 20 50Nephrostogram 1,2 2 2,3 3 3,4 3 3,4 4 12T-Tube Cholangiogram 1,2 2 2,3 2 3,4 3 3,4 3 10Sinogram 1,2 3 2,3 4 3,4 4 3,4 4 15Fistulogram 1,2 3 2,3 4 3,4 4 3,4 4 15Radiograph reporting bone trauma, chest etc 1,2 100 2,3 100 2,3 150 3,4 150 500Retrograde Urethrogram 1,2 2 2,3 4 2,3,4 4 3,4 5 15Micturating Cystourethrogram / Cystography 1,2 2 2,3 4 2,3,4 4 3,4 5 15Hysterosalpingography 1,2 2 2 5 2,3,4 8 3,4 10 25Myelography 1,2 3 1,2 3 2,3,4 4 2,3,4 5 15Sialography 1,2 2 1,2 2 1,2,3 4 2,3,4 4 12Cont-256

COMPETENCIES3 Months 6 MonthsLevel Cases Level CasesFirst Year9 Months 12 MonthsLevel Cases Level CasesTotal Cases1st YearProceduresDacrocystography - - - - 1,2 1 1,2 1 2Antegrade Urography 1 1 1 1 1 1 1,2 2 5Venography 1 1 1,2 2 1,2 3 2,3 4 10Ultrasound of abdomen, Obstetrics, Pelvis,Non-Obstetrics 1,2 50 1,2,3 50 2,3 75 2,3,4 75 250Doppler ultrasound / small parts 1 1 1,2 1 1,2,3 4 2,3 4 10PTC / ERCP (flurocoverage) - - 1,2 1 1,2 1 1,2 1 3Interventional and guided biopsies with the helpof fluoro, CT or Ultrasound Aspirations,drainage procedures 1 2 1,2 3 1,2 5 1,2 5 15CT 1 2 1,2 5 1,2 8 1,2 10 25MRI 1 2 1,2 2 1,2 2 1,2 4 10Angiography/DSA 1 1 1 1 1,2 1 1,2 2 5Mamography 1 2 1 3 1,2 5 1,2 5 15CPSP Intermediate Module in Diagnostic Radiology 201057

CPSP Intermediate Module in Diagnostic Radiology 2010COMPETENCIESSecond Year15 Months 19.5 MonthsLevel Cases Level CasesTotal Cases2nd YearProceduresBarium Swallow 4 10 4 10 20Barium Meal 4 10 4 10 20Barium Enema 4 5 4 5 10I.V.U 4 25 4 25 50Nephrostogram 4 3 4 5 8T-Tube Cholangiogram 4 5 4 5 10Sinogram 3,4 5 4 5 10Fistulogram 3,4 5 4 5 10Radiograph reporting bone trauma, chest etc 3,4 250 3,4 250 500Retrograde Urethrogram 3,4 7 4 8 15Micturating Cystourethrogram / Cystography 3,4 7 4 8 15Hysterosalpingography 3,4 10 4 15 25Myelography 3,4 5 4 10 15Sialography 3,4 4 3,4 4 8Cont-258

COMPETENCIESSecond Year15 Months 19.5 MonthsLevel Cases Level CasesTotal Cases2nd YearProceduresDacrocystography 2,3 1 - - 1Antegrade Urography 1,2 2 2 3 5Venography 2,3 - 2,3 - -Ultrasound of abdomen, Obstetrics, Pelvis, Non-Obstetrics 3,4 100 3,4 150 250Doppler ultrasound / small parts 2,3 5 2,3 5 10PTC / ERCP (flurocoverage) 2,3 1 2,3,4 1 2Interventional and guided biopsies with the help of fluoro, CT orUltrasound Aspirations, drainage procedures 1,2 10 2,3 5 15CT 2,3 10 2,3 15 25MR 1,2 5 2,3 5 10Angiography/DSA 1,2 3 2,3 2 5Mamography 1,2 5 2,3 10 15CPSP Intermediate Module in Diagnostic Radiology 201059

ROTATIONAL TRAININGCPSP Intermediate Module in Diagnostic Radiology 2010ROTATIONSLevel CasesMRI (Eight Weeks Rotation)Principles of application, indication, contraindications - -CNS-Head and Spine - technique, sequence and anatomy review 1,2 20Thorax - pulmonary, vascular, cardiac - technique and sequence 1,2 10Hepatobiliamy - techniques, sequences, contrast medium pharmacoknetics 1,2 10Gastroinfestmal MR - techniques, sequences, contrast medium pharmacoknetics 1,2 10Muscloskektal MR - techniques, sequences, contrast medium pharmacoknetics, arthrograms 1,2 20MR - Angiography - techniques, sequences, contrast medium pharmacoknetics 1,2 10MR Safety; contrast medium regulatory rules in adults and Pediatrics 1,2,3 10MR Urology, Breast, Spectroscopy 1,2 1060

ROTATIONSLevel CasesNUCLEAR MEDICINE (Six Weeks Rotation)Regulatory aspects of radiopharmcentreal use, dose, QA, Storage,Waste handling, radiation protection 1,2 10Physics of equipment, Cameras, Spect, PET, CT, QA, Optimum techniques, adult/pediatrics 1,2 20Chest : V/Q scans, pulmonary embolism, Cardiac and Coronary scans 1,2,3 10Hepatobiliaum and Spleen / Pancreas and GI tract study 1,2 10Renal tract : Morphologic and functional studies 1,2,3 10Bone and marrow, WBC,RBC scans 1,2,3 10Endocrine : Thyroad, parathyroad, Adrenals, carcinoids/istet cell lesions etc 1,2,3 10Vascular and Lymphatic studies 1,2 10CNS-morphologics and functional studies 1,2 10CPSP Intermediate Module in Diagnostic Radiology 201061

CPSP Intermediate Module in Diagnostic Radiology 2010ROTATIONSLevel CasesANGIOGRAPHY (Four Weeks Rotation)Vascular anatomy and Variants (total body) - Total BodyIndications, Contraindications of Angiography 1,2,3 20Informed written consenting 1,2,3 20Premedication, patient monitoring, post procedure care 1,2,3 10Complication of Angiography, Angioplasty, Stenting etc 1,2 10Pattern of reporting, decision algorithums for management 1,2,3 20Equipment used for DSA, CTA, MRA & CEUS - 20Techniques, Catheters, Guidewires, Baloons & Stents types & handling 1,2 20Contrastmedia 1,2 -62

USEFUL ADDRESSESAND TELEPHONENUMBERS1. Regional Offices of the CPSPMUZAFFARABADCMH MuzaffarabadAzad KashmirTEL: 058810 - 43307FAX: 058810 - 43902Email: ssgr-brehman@cpsp.edu.pkABBOTTABADAyub Hospital ComplexAbbottabadTEL: 0992-383330Email: rc_abbottabad@cpsp.edu.pkPESHAWARHayatabad Medical ComplexPhase IV, Hayatabad,PeshawarUAN: 091-111-666-666TEL: 091-9217011, 091-9217320-1FAX: 091-9217062Email: rc_peshawar@cpsp.edu.pkISLAMABADP.I.M.S, Ravi Road, Sector G- 8/ 3Islamabad.UAN: 051-111-666-666TEL: 051-9262590-1,FAX: 051-9262592Email: rc_islamabad@cpsp.edu.pkFAISALABADPunjab Medical CollegeFaisalabadUAN: 041-111-666-666TEL: 041-9210131, 9210366-8FAX: 041-9210224il:rc_faisalabad@cpsp.edu.pkLAHORENext to INMOL, HospitalNew Muslim Town, Block-DLahore.UAN: 042-111-666-666TEL: 042- 9231320-8FAX: 042- 9231327Email: rc_lahore@cpsp.edu.pkMULTANNishtar Medical College,Distt. Jail Road, Opp Circuit House,Multan.UAN: 061-111-666-666TEL: 061-9200946, 9200952Email: rc_multan@cpsp.edu.pkBAHAWALPURQuaid-e-Azam Medical CollegeBahawalpurTEL: 062- 9250461Email: rc_bahawalpur@cpsp.edu.pkNAWABSHAHPeoples Medical College for GirlsNawabshahTEL: 0244-9370271, 9370479FAX: 0244-9370478Email: rc_nawabshah@cpsp.edu.pkLARKANAChandka Medical CollegeLarkanaTEL: 074 – 9410726Email: rc_larkana@cpsp.edu.pkCPSP Intermediate Module in Diagnostic Radiology 201063

HYDERABADLiaquat University Hospital, JamshoroHyderabadTEL: 022-3877393Email: rc_hyderabad@cpsp.edu.pkQUETTACPSP Bolan Medical CollegeSandeman Civil HospitalTEL: 081- 9202424Email: rc_quetta@cpsp.edu.pk2.KARACHIDepartments of CPSP KarachiOVERSEAS CPSP CENTRESUAN – 021-111-606-606● Examination (FCPS Part I)9207100 -10 Ext: 311●●Examination (FCPS Part II)9207100 -10 Ext: 215Department of MedicalEducation9207100 -10 Ext: 305● Registration, Training &Monitoring Cell9207100 -10 Ext: 320For further Information visit theCollege website at:www.cpsp.edu.pk3. Saudi ArabiaRIYADHSaudi Commission for HealthSpecialities,Diplomatic Quarter, P.O. Box 94656Riyadh -11614, KSA.TEL: 966-1-4822415 Ext: 156/141966-2-6401000 Ext: 25843Email: medexam5@scfhs.org4. NepalKATHMANDUT.U. Institute of MedicineMaharajganj, Kathmandu, NepalTEL: 977-1- 416224Email: cpsp@iomdit.org.npCPSP Intermediate Module in Diagnostic Radiology 201064