MRPC Ordering Guide

This Ordering Guide is designed to provide our referring physicians with the most up-to-date information for ordering radiological imaging tests for their patients. This Guide is intended to assist you in determining the most appropriate test for your patient, but it is not intended to be a substitute for your independent medical judgment. This guide should be reviewed for technology and procedure changes. If you would like to consult with one of our Radiologists about what is the best test to order, please call 901-685-2696. We solicit your comments and observations and, if you would like to see changes and additions to the Guide, please call or contact Kim Asher at 901-685-2696 or asherk@memrad.net')
  • ABD/ PELVIC IMAGING
    • SYMPTOM/CONCERN
      EXAM TO CONSIDER
    • Abdominal distention
      CT ABD and Pelvis with oral and IV contrast
    • Abdominal pain or mass
      CT with oral and IV contrast. Include both abdomen and pelvis in most cases, unless very specific symptoms. Liver or pancreas mass (CT abd triple phase or MRI abd wo and w). Adrenal mass (CT ABD wo and w adrenal protocol or MRI wo)
    • Complex renal cyst
      MRI abdomen with and without contrast
    • Flank pain, suspect stone
      CT abd pelvis without contrast
    • GI Bleed
      NM GI Bleeding scan
    • IBD
      CT Enterography (requires IV contrast and a special oral contrast given at time of scan)
    • Painless hematuria
      CT Urography (without and with contrast)
    • Pancreatitis
      Initial episode or known disease without complicating factors, typically Abdominal US. If severe or complications suspected, CT abdomen with contrast.
    • Pyelonephritis
      None if uncomplicated. CT abdomen and pelvis with and without contrast if complications arise
    • Renal Mass
      MR kidneys with and without contrast. CT renal mass protocol if cannot do MR
    • Renal stone
      CT abd pelvis without contrast
    • Suspect cholelithiasis
      Gallbladder US
  • CHEST IMAGING
    • CHEST CONCERNS
      EXAM TO CONSIDER
    • Abnormal chest xray, lung finding
      CT chest without contrast (specify if for pulmonary nodule)
    • Abnormal chest xray, mediastinum or hilar finding
      CT chest with contrast
    • Chest pain with ECG uninterpretable OR unable to exercise with intermediate pre test probability
      Coronary CTA
    • Chest pain with no ECG changes and serial enzymes negative with intermediate pre test probability
      Coronary CTA
    • Chest pain with uninterpretable or equivocal stress test (exercise, perfusion, or stress echo) with intermediate pre test probability
      Coronary CTA
    • Chest pain with asymptomatic with high CHD risk
      Coronary CTA
    • Chest pain with evaluation of cardiac mass (suspected tumor or thrombus)
      Cardiac MRI
    • Chest pain with evaluation of pericardial conditions
      Cardiac MRI
    • Chest pain with evaluation of pulmonary vein anatomy prior to invasive radiofrequency ablation for atrial fibrillation
      CTA Chest
    • Chest pain with evaluation of suspected coronary anomalies and complex congenital heart disease
      Coronary CTA
    • Chest pain with Triple rule out – To exclude nonstructive CAD, aortic dissection, and pulmonary em-bolis with intermediate pre-test probability for one of the above with normal ECG and no ST-segment elevation and initial enzymes negative
      Gated CTA Chest
    • Chest pain with evaluation of bypass grafts and coronary anatomy
      Coronary CTA
    • Chest pain with history of percutaneous revascularization with stents
      MRA
    • Chest pain with aortic valve morphological evaluation
      MRA
    • Chest pain with evaluation and follow up of aortic aneurysm
      Cardiac MRI
    • Chest pain with evaluation of myocardial function
      Contrast en-hanced Cardi-ac
    • Chest pain with evaluation of myocardial viability
      MRI
    • Chest pain with evaluation of non ischemic cardiomyopathy
      Cardiac MRI
    • Chest pain with suspected ARVC
      Cardiac MRI
    • Dyspnea, suspect interstitial lung disease
      High Resolution CT chest without contrast
    • Dyspnea, suspect pulmonary embolism
      CT chest with contrast, PE Protocol
    • Follow up pneumonia/pleural effu-sion CT chest without contrast
      CT chest without contrast
  • LOWER EXT IMAGING
    • SYMPTOM/CONCERN
      EXAM TO CONSIDER
    • Ankle pain with concern for unstable osteochondral lesion
      MRI wo contrast
    • Bone metastasis
      Plain films followed by MRI or bone scan-PET/CT also consideration
    • Bone tumor/mass
      Plain films followed by whole body bone scan and CT and/or MRI
    • Elderly/osteoporotic patient with hip pain after fall
      Plain films followed by MRI or CT
    • Foot and ankle pain
      Plain films followed by MRI
    • Hip pain
      Plain films followed by MRI
    • Elderly/osteoporotic patient with hip pain after fall
      Plain films followed by MRI or CT
    • Foot and ankle pain
      Plain films followed by MRI
    • Hip pain
      Plain films followed by MRI
    • Hip pain with concern for AVN or occult fracture
      MRI
    • Knee pain after joint replacement
      Plain films followed by CT or bone scan
    • Knee pain with concern for unstable osteochondral lesion
      MRI wo contrast
    • Knee pain with negative radiographs
      MRI wo contrast
    • Knee pain with prior arthroscopy
      MRI wo contrast
    • Morton’s neuroma
      MRI with/ wo contrast
    • Multiple myeloma
      Bone survey or MRI-PET/CT also consideration
    • Osteomyelitis
      MRI with contrast – 3 phase bone scan or tagged WBC scan if MRI contraindicated
    • Osteomyelitis after joint replacement
      Plain films followed by CT if plain films neg-ative. Then tagged WBC scan with sulfur colloid scan
    • Pain with acute trauma
      Plain films to exclude fracture followed by CT or MRI if symptoms persist
    • Persistant joint pain with negative radiographs (shoulder, knee, elbow, etc.) and concern for occult bone
      MRI
    • Septic arthritis
      MRI with/ wo  contrast
    • SI joint pain or sacroilitis
      Plain films followed by MRI
    • Soft tissue infection
      MRI with/ wo  contrast
    • Soft tissue metastasis
      MRI with contrast
    • Soft tissue tumor/mass
      MRI with/ wo contrast
  • BREAST IMAGING
    • SYMPTOM/CONCERN
      EXAM TO CONSIDER
    • General
    • All asymptomatic women age > 39
      Annual Screening mammogram
    • Breast Cancer (Personal History)- Asymptomatic Women
      Annual bilateral diagnostic mammogram +/- US
    • Symptomatic patients age > 29
      Diagnostic Mammogram +/- US
    • Focal non-cyclical breast pain
      Bilateral DX MG +/- US
    • Hot, swollen red breast
      Bilateral DX MG and “US if needed” (on request form)
    • Nipple or skin retraction
      Add unilateral US to unilateral DX MG
    • Other Miscellaneous symptoms
      Unilateral or bilateral DX MG and “US if needed”
    • Palpable lump/mass age < 20
      Unilateral/Bilateral USG
    • Palpable lump/mass in males
      BIlateral DX MG and “US if needed”
    • Palpable lump/mass age > 29
      BIlateral DX MG with USG
    • Silicone Breast Rupture
      BIlateral Breast MRI wo contrast
    • Suspicious (unilateral, from one duct orifice and clear, watery, sanguinous or serosanguinous) discharge
      Bilateral DX MG and USG
    • High Risk Patients
    • BRCA 1 or 2 carrier
      Consider high-risk screening MRI in addition to (not as a replacement for annual screening mam-mography
    • History of chest radiation from ages 10-30
      Consider high-risk screening MRI in addition to (not as a replacement for annual screening mammography
    • Lifetime risk of breast cancer 20-25% or greater
      Consider high-risk screening MRI in addition to (not as a replacement for annual screening mammography
    • Untested patient with 1st degree relative positive for BRCA 1 or 2
      Consider high-risk screening MRI in addition to (not as a replacement for annual screening mammography
  • UPPER EXT IMAGING
    • SYMPTOM/CONCERN
      EXAM TO CONSIDER
    • Bone metastasis
      Plain films followed by MRI or bone scan-PET/CT
    • Bone tumor/mass
      Plain films followed by whole body bone scan and CT
    • Elbow pain with concern for ligament or in-tra articular injury including unstable oste-ochondral lesions
      MRI arthrogram
    • Elbow pain with negative radiographs
      MRI
    • Multiple myeloma
      Bone survey or MRI-PET/CT also consideration
    • Osteomyelitis
      MRI with contrast – 3 phase bone scan or tagged WBC scan if MRI contraindicated
    • Osteomyelitis after joint replacement
      Plain films followed by CT if plain films negative. Then tagged WBC scan with sulfur colloid
    • Pain with acute trauma
      Plain films to exclude fracture followed by CT or MRI if symptoms persist
    • Persistant joint pain with negative radiographs (shoulder, knee, elbow, etc.) and concern for occult bone or soft tissue injury
      MRI wo contrast
    • Septic arthritis
      MRI with/ wo contrast
    • Shoulder pain after dislocation or concern for labral tear
      MRI arthrogram
    • Shoulder pain after rotator cuff or labral repair
      MRI or CT arthrogram
    • Soft tissue infection
      MRI with/ wo contrast
    • Soft tissue metastasis
      MRI with contrast
    • Soft tissue tumor/mass
      MRI with/wo  contrast
    • Wrist pain with concern for ligament or intra articular injury
      MRI arthrogram
    • Wrist pain with negative radiograph
      MRI wo contrast
  • NM/PET CANCER IMAGING
    • SYMPTOM/CONCERN
      EXAM TO CONSIDER
    • Abdominal pain S/P cholecstectomy
      HIDA scan for bile leak
    • HIDA scan for bile leak
      Abdominal MSR without contrast. If neoplasm suspected, add MR with and without contrast.
    • Alzheimers disease diagnosis
      PET/CT Brain scan
    • Ataxia, Incontinence, Dementia
      NM Cisternogram
    • Back pain in cancer patient
      SPECT/CT NM bone scan
    • Bloating, abdominal pain
      Gastric emptying study
    • Bone pain r/o occult fracture
      3 phase bone scan
    • Breast Cancer
      PET/CT scan
    • Cancer evaluate for metastatic disease
      Bone scan
    • Carcinoid tumor, pancreatic islet cell tumor
      Octeotide scan
    • Diabetic joint pain, neuropathic joint vs infection
      SPECT/CT limited bone scan
    • Esophageal Cancer staging
      PET/CT scan
    • Fever of unknown origin
      Indium whole body scan
    • GI Bleed
      NM GI Bleeding scan
    • Head & Neck Cancer staging
      PET/CT scan
    • Hydronephrosis, renal obstruction
      Renal scan with lasix
    • Hyper/hypothyroidism
      NM I123 thyroid scan & uptake
    • Hypercalcemia, parathyroid adenoma
      NM Parathyroid scan/SPECT/CT Parathyroid scan
    • Hypertension, adrenal mass
      MIBG NM scan
    • Liver lesion (known)
      Abdominal MR (with +without contrast)
    • Joint pain, bone pain
      Bone scan
    • Lung cancer (follow-up)
      CT chest with contrast
    • Lung cancer staging
      PET/CT scan
    • Lymphoma staging
      PET/CT scan
    • Mass, unknown source
      CT with oral and IV contrast
    • Mass in liver, benign hemangioma
      NM hemangioma scan
    • Melanoma, drainage to lymph nodes
      Lymphoscyntigraphy & sentinel lymph node biopsy
    • Melanoma staging
      PET/CT scan
    • Metastatic disease to brain
      MRI of the Brain without and with IV contrast
    • Metastatic disease to bone/spine
      Bone Scan and/or MRI of the Cervical, Thoracic, and/or Lumbar Spine without and with IV contrast
    • Pain in a limb, infection or fracture
      3 phase bone scan
    • Pain in back no history of cancer
      SPECT/CT bone scan
    • Pain in bone/extremity, osteomyelitis
      Indium localized scan
    • Pain in the foot/hand, infection
      3 phase bone scan
    • Renal failure/insufficiency
      Renal scan
    • Right side abdominal pain; cholecystitis
      HIDA scan; Gallbladder US
    • Short of breath
      NM lung scan
    • Thyroid cancer staging
      Whole body 1 131 scan
  • NEURORADIOLOGY
    • SYMPTOM/CONCERN
      EXAM TO CONSIDER
    • Arterial (carotid or vertebral) Dissection
      CTA of the neck
    • Ataxia
      CT or MRI Brain without IV contrast
    • Bell’s Palsy
      MRI Brain (IAC Protocol) with IV contrast
    • Brain Tumor
      MRI of the Brain with and without IV contrast
    • Carotid Stenosis
      Carotid ultrasound first, then CTA neck with contrast; or MRA neck without if patient can
    • CVA
      CT or MRI Brain without IV contrast
    • Dementia
      CT or MRI Brain without IV contrast
    • Diplopia
      MRI Brain and Orbits with IV contrast
    • Dizziness/Vertigo
      MRI Brain (IAC Protocol) with IV contrast
    • Dural venous sinus throm-bosis
      MRV head without IV contrast or CTV head with IV contrast
    • Dysphagia
      Barium swallow and/or CT Neck with IV con-trast
    • Head Trauma
      CT Head without IV contrast
    • Headaches
      CT or MRI Brain (without or with IV contrast – depends on associated clinical history)
    • Hearing Loss (sensorineural)
      MRI Brain (IAC Protocol) with IV contrast
    • Hearing Loss (Conductive )
      CT temporal bones without
    • Hoarseness
      CT Neck with IV contrast
    • Horner’s Syndrome/Suspected Carotid dissection
      CT angiogram neck
    • Intracranial Aneurysm
      CT Angiogram Head or MRA Head
    • Intracranial Hemorrhage
      CT Head without
    • Meningitis
      MRI Brain without and with IV contrast
    • Metastatic disease to brain
      MRI of the Brain without and with IV contrast
    • Multiple Sclerosis
      MRI Brain (MS Protocol) without and with IV contrast
    • Neck Mass – General
      CT Neck with IV contrast
    • Normal Pressure Hydro(NPH)
      MRI Brain without IV contrast
    • Optic Neuritis
      MRI Brain and Orbits without and with IV con-trast
    • Papilledema
      MRI Brain and Orbits without and with IV con-trast
    • Pituitary/Hormone Abnormal
      MRI Brain (Pituitary Protocol) without and with IV contrast
    • Seizures
      MRI Brain (Seizure Protocol) without and with IV contrast
    • Sinusitis
      CT Sinuses without IV contrast; If clinically suspect complicated sinusitis (i.e. facial swelling,
    • Swollen Salivary Gland/Sialoadenitis
      CT Neck with IV contrast
    • Thyroid Mass/Enlargement
      Ultrasound thyroid
    • TIA’s
      MRI Brain without IV contrast and consider MRA
    • Tinnitus
      MRI Brain (IAC protocol) with IV contrast
    • Tonsillitis/Tonsillar Abcess
      CT Neck with IV contrast
    • Traumatic Brain injury (Acute)
      CT Head without IV contrast
    • Traumatic Brain injury (Chronic)
      MRI of Brain without IV contrast
    • Trigeminal Neuralgia
      MRI Brain/Trigeminal Protocal without and with IV contrast
    • Visual Field Defect
      MRI Brain and Orbits with IV contrast
  • SPINAL IMAGING
    • SYMPTOM/CONCERN
      EXAM TO CONSIDER
    • Cervical neck pain/Degenerative Disc Disease/Disk Herniation/Radiculopaty
      MRI Cervical Spine without IV contrast
    • Compression Fracture Benign
      CT or MRI of the Cervical, Thoracic, and/or Lum-bar Spine without IV contrast
    • Compression Fracture Patho-logic
      MRI of the Cervical, Thoracic, and/or Lumbar Spine with and without IV contrast
    • Failed Back Syndrome
      MRI Lumbar Spine without and with IV contrast
    • Low back pain/Sciatica/Degenerative Disk disease/ Radiculopathy/Disk Herniation
      MRI of the Lumbar Spine without IV contrast. If prior Lumbar surgery then add IV contrast
    • Thoracic back pain/Degenerative disk disease/Disk Herniation
      MRI of the Thoracic Spine without IV contrast
    • Trauma C-spine/neck
      CT Cervical Spine without IV contrast
    • Trauma L-spine
      CT Cervical Spine without IV contrast
    • Trauma T-spine
      CT Cervical Spine without IV contrast