Abstract
Introduction: Soft tissue concerns are common, yet most primary care physicians must refer patients to radiology for further imaging, leading to potential delays in diagnosis and management. Point-of-care ultrasound (POCUS) is increasingly available in primary care and has been shown to improve clinical decision making. However, current Family Medicine POCUS curricula focus primarily on cellulitis and abscess, overlooking other common soft tissue pathologies. This study aims to evaluate the frequency of soft tissue pathologies and associated follow-up recommendations on comprehensive radiology ultrasound exams ordered by Family Medicine physicians.
Methods: A retrospective study of radiology-performed comprehensive ultrasound exams ordered by an academic urban Family Medicine practice over the course of the 2019 was performed. Data collected included patient demographics, ultrasound findings, anatomic location, and follow-up recommendations. Diagnoses were categorized, and time from order to completion was calculated.
Results: Soft tissue ultrasounds comprised 10% (n = 168) of all ultrasound studies ordered. The most common diagnosis were lymph nodes, n = 44 (25%), lipomas n = 32 (18%), and no lesion/normal n = 23 (13%). Only 2 studies diagnosed abscess (1%). The median time from order date to completion was 6 days (IQR 2 to 22 days), with 48% waiting over a week. Half (51%) of studies required no further follow up, while 26% required additional imaging or biopsy.
Discussion: These findings highlight the need for expanded Family Medicine POCUS training to include high-yield diagnoses such as lipomas, lymph nodes, and cysts. POCUS could reduce unnecessary referrals, expedite care, and improve diagnostic confidence. Future research should explore primary care-specific POCUS protocols and their impact on patient outcomes.
- Family Medicine
- Medical Education
- POCUS
- Point-of-Care Systems
- Primary Health Care
- Radiology
- Soft Tissue Neoplasms
- Technology
- Ultrasonography
Introduction
Ultrasound examination is often the first-line imaging modality for evaluating soft tissue masses, as recommended by the American College of Radiology.1 Soft tissue concerns are common in primary care, yet most primary care physicians (PCPs) must refer patients to radiology to obtain further imaging, introducing challenges such as scheduling, transportation and limited access that can lead to diagnostic delay. The increasing availability of point-of-care ultrasound (POCUS) in primary care presents an opportunity to address these challenges. Family Medicine physicians have found that POCUS can improve triage and clinical decision making.2
POCUS is considered a core competency in Emergency Medicine residency training, including its use for diagnosing and managing skin and soft tissue pathology.3 The American Academy of Family Physicians has developed POCUS curriculum guidelines for Family Medicine residents, emphasizing pathology such as cellulitis and abscess.4 However, additional soft tissue pathologies commonly encountered in primary care were not included in that curricular outline.5 Studies have demonstrated that ultrasound can reliably identify a range of masses including lipomas, fat necrosis, epidermal inclusion cysts, peripheral nerve sheath tumors, vascular malformations, and hematomas.6 There is also a role for the ultrasound evaluation in lymphadenopathy and nonspecific masses.7 Despite its value, there is limited published research on soft tissue POCUS within Family Medicine, with most studies originating from Emergency Medicine settings, which may not be directly applicable to primary care.8–10
The aim of this study was to identify the frequency of various soft tissue pathologies and follow up recommendations identified through radiology-performed ultrasounds. The findings may help refine Family Medicine soft tissue POCUS education by highlighting high-yield diagnoses.11
Methods
A retrospective study of radiology-performed comprehensive ultrasound exams ordered by an academic urban Family Medicine practice over the course of the 2019 calendar year was performed. The data were pulled from the electronic medical record. Initial analysis included all ultrasound exams ordered to determine the study type. All ultrasounds with the words “soft tissue” in the order name were isolated for further analysis. Patients under the age of 18 were excluded as well as 1 patient with a postoperative follow up ultrasound.
Data collection included: patient demographics, date ordered, date performed, diagnosis codes and an impression. The sonographic impressions were coded by final diagnosis, anatomic location and follow up recommendation. Final impressions that were found to contain more than one diagnosis (n = 9) were separated into individual data points for the purpose of this study. Coding was performed by a Family Medicine-trained ultrasound fellow and reviewed by the POCUS Fellowship Director for quality assurance. There were no discrepancies in the coding of the impressions and the data were not blinded. Days between date ordered and date performed were considered the ‘time to study’. All studies contained a final impression some which included the words “no lesion” or “normal tissue.” Studies that included multiple possible diagnoses or recommended further imaging for diagnosis were classified as nondiagnostic. Anatomic locations were classified as head/neck, chest, back, upper extremities and lower extremities. Follow up recommendations were classified into the following: Magnetic Resonance Imaging (MRI), Computed Tomography (CT), tissue sampling, interval ultrasound, or follow-up clinically. The studies listing a diagnosis without further recommendations were coded as “no further follow-up.”
The data were recorded and analyzed using Excel (Microsoft Corporation, 2018). The study was approved by the institutional review board as exempt.
Results
A total of 1,631 comprehensive radiology-performed ultrasound exams were ordered in 2019. Pelvic ultrasounds accounted for 46% of scans (n = 750), followed by Deep Vein Thrombosis (DVT) 11% (n = 179). Soft tissue ultrasounds were the third most common ultrasound at 10% (n = 168, Table 1) that met study criteria.
Breakdown of the Comprehensive Radiology-Performed Ultrasounds Ordered by Family Medicine Physicians Between January 1, 2019, and December 31, 2019, by Examination Type
Of the 168 patients with soft tissue ultrasounds, 71% were identified as female; the average age was 44 years (range: 18 to 83 years). The majority of these patients were reported as Black/African-American (59%), followed by White (24%), Hispanic/Latino (7%), and Asian/East Indian at (4%). Nine scans had multiple diagnoses, for a total number of n = 178 diagnoses. Most ultrasounds were performed in the head/neck region n = 79 (47%), followed by lower extremities n = 33 (20%), upper extremity n = 27 (16%), back n = 19 (11%), and chest n = 10 (6%). The most common sonographic diagnosis was lymph nodes accounting for 25% (n = 44), the majority 57% (n = 25) of which were considered normal, followed by lipoma 18% (n = 32), and no lesion/normal was the third most common diagnosis 13% (n = 23) (Figure 1). Only 2 studies diagnosed abscess.
The number (N) and percentage (%) of each final diagnosis as listed in the radiology impression of the soft tissue ultrasounds ordered by Family Medicine physicians. There were a total of 178 diagnoses. Each arrow represents a further analysis of each category, including the different type of lymph nodes and cysts. Other diagnoses that were identified once or twice are listed out individually.
The median time from order date to performance date was 6 days (IQR 2 to 22 days). There were 15 patients (9%) who had their ultrasounds performed by radiology on the same day it was ordered, 67 patients (48%) patients waited beyond 1 week, 32 patients (19%) waited beyond 1 month and 2 patients waited a year (Figure 2).
Days from the date an ultrasound was ordered by Family Medicine physicians to the date it was performed by radiology. Each dot represents 1 study. The black bar represents the median (6 days). Shaded box represents interquartile range (2 to 22.5 days).
Roughly half (51%) of the soft tissue studies had no further recommendation for follow-up from radiology, while (23%) recommended follow-up based on a change in clinical signs or symptoms. The remainder had additional recommendations including CT, MRI, interval ultrasound and biopsy (Figure 3).
Follow up plan as indicated by the radiology impression for soft tissue ultrasounds ordered by Family Medicine physicians.
Discussion
This retrospective analysis found that lymph nodes, lipomas, and normal tissue were the most common findings on soft tissue ultrasounds ordered by Family Medicine physicians. These sonographic findings are not commonly addressed in current Family Medicine POCUS curriculum.4 While yet undiscovered, the ideal Family Medicine curriculum may be deficient, noting limited data on primary care soft tissue POCUS.
As ultrasound machines become ubiquitous in primary care, there will be more opportunities for clinicians to use this modality, aiding in timely diagnosis and management of common soft tissue pathology. This study presents a unique opportunity to develop curriculum targeted to the range of conditions seen within the primary care setting. The results show the importance of including and focusing on the features of lipomas, lymph nodes, and cysts. Creating soft-tissue scanning protocols will be important to give clinicians a strong foundation to assess pathology while bedside with the patient.10 The variety of pathologies identified in this study highlights the great potential of POCUS to aid in PCPs when faced with diagnostic uncertainty.
There are many limitations of this retrospective study including selection bias excluding pathology that physicians felt confident diagnosing without the aid of ultrasound or may have opted for other imaging modalities (MRI, CT, Radiograph) for certain soft tissue pathologies. This study did not analyze delays in result communication or patients that never completed their ordered ultrasound. We did not analysis the effect of wait times on outcomes. This study is limited to a single-center thus may not be representative of the broader population including racial and gender mix, although future studies can expand to other institutions and/or consider its impact on patient outcomes.
Although clinicians might not be able to diagnose sonographic findings, a POCUS evaluation could still prove valuable to improving time from presentation to diagnosis and treatment, including advocating for sooner follow up, stronger referrals and/or biopsies when suspicious features are indentified.12,13 Any diagnosis that can be confidently made with POCUS in a primary care setting allows the opportunity to increase access in radiology for patients with more urgent concerns and allows Family Medicine physicians to reduce fragmentation of care.2 POCUS has the potential to reduce additional imaging requests when no lesion is identified.
By refining POCUS education to include high-yield soft tissue diagnoses, Family Medicine physicians can improve efficiency, unnecessary referrals, and optimize patient care. Future research should explore POCUS protocols tailored to primary care and assess its impact on patient outcomes.
Notes
This article was externally peer reviewed.
Conflict of interest: The authors report no conflicts of interest.
Funding: None.
- Received for publication December 30, 2024.
- Revision received March 21, 2025.
- Accepted for publication March 31, 2025.
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