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					Radiology Unit

       Understanding Radiology
•   PA
•   AP
•   Lateral
•   Oblique
•   Apical Lordotic View
•   Decubitus
•Ultrasound-sound waves-benign, no side effects (no
pregnancy risk of radiation exposure)
•CT-uses “circular” xray for images, computerized
imaging test=more detail & discrimination between soft
tissues & organs than reg. xray. (slices of bread)
•MRI-magnet,radio frequency, computer. Ability for an
infinite number of projections.
•Nuclear Medicine-documents organ, structure and
              Contrast Media
•   Barium
•   Iodine based dye for injection/drink
•   Gadolinium dye for injection
•   Air/ CO2 for bariums/ fluoroscopy
    Approach to reading Xrays
• Step by step
• Always start with the basics…name, ID,
  date, positioning is correct to what you
• Rotation, density, quality of film
• Correlate history with findings
T: Trachea
R: Rib
L: Lung
• Ascending Aorta
AK: Aortic Knob
H: Heart
LI: Liver
S: Spleen
P: Pulmonary Arteries
    Connecting the Pt & the CXR
•   Timing
•   Location
•   Gender
•   Age
•   Risk factors
•   Appearance
•   H&P
               Chest XRAY
•   Know the anatomy
•   Bony landmarks
•   Anatomy of lung tissue- ex. Lobes
•   Key findings on Xray
             Patterns on CXR
• Alveolar vs. interstitial
• Alveolar- airspace disease- some sort of fluid in
  the air spaces
• Usually caused by pus, water, blood, etc.
• Usually rapid onset
• Radiologic findings include increased density,
  fluffy appearance, air bronchograms through
  area of consolidation
• Can be seen in acute pulmonary edema, acute
  CHF, some pneumonias, tb, atelectasis
Alveolar Disease
            Pulmonary Edema
•   Kerley B Lines
•   Batwing Sign
•   Cephalization of Flow
•   Peribronchial cuffing
•   Know what they are and be able to
    recognize them on standard CXR
Kerley B Lines
       Peribronchial Cuffing


    Before treatment   After treatment
Batwing Sign

• Deflation of the alveoli causing a collapse of the
  lung (part or all of the lung)- volume loss
• Caused by blockage of the air passages or pressure
  on the lung
• One of the most common finding on CXR
• Always associated with a linear increase in
  density, decreased lung volume associated with
  opacities indicates atelectasis
• Most commonly seen in post op pts, esp
  abdominal surgery

              RUL- “Bronchial Wedge”
• Airspace disease and consolidation
• Airspaces filled with bacteria,
  microorganisms and pus
• Not associated with volume loss like
•   CXR findings: airspace opacity, lobar consolidation, or
    interstitial opacities, indistinct borders
RML Pneumonia
        Interstitial Lung Disease
• Linear strands or spherical densities, superimposed upon
  normal (add tissue)
• Distributed throughout the lung tissue that is otherwise
  well aerated
• Bilateral, little change over time, can be
  occupation related
• Some causes: edema, inflammatory cells, fibrosis,
  malignant cells, sarcoidosis, some pneumonias (atypical,
  PCP) etc.
• Honeycombing pattern
Interstitial lung disease
•   Air in the pleural space
•   Radiologic findings:
•   Pleural line- aka “Companion Line”
•   Area of lung without lung markings
•   May have mediastinal shift
L lung pneumothorax
           Pleural Effusion
• Fluid accumulation in the pleural space
• Loss of costophrenic angle
• Decreased breath sounds over area of
• Can be removed by thoracentesis, chest tube
• Common causes are malignancy, CHF,
  renal failure, infection, trauma, etc
Pleural Effusion
Pleural Effusion seen on CT
           Emphysema/ TB
• Increased AP diameter on lateral CXR
• Hyperinflated lung fields
• Bullae
• TB
• Cavitary lesion usually located in the apices
  of the lungs
• Get good history
• Upright CXR is the best view to identify
        Abdominal Radiology
• Abdominal Xray (KUB)
• Standard views: flat and upright (include a
  decubitus view for complete series)
• Ordered for pts with n/v/pain, to access for
  stones, intestinal blockages, foreign bodies,
  fluid in peritoneal space (ex. Ascites)
• Upright AXR is the best view for air fluid
     Small bowel Obrstruction
• Most common cause is #1: surgical
  adhesions #2 hernia #3 mass/ stone
• Key radiologic findings: air fluid levels on
  upright AXR, dilated loops of bowel
  proximal to the obstruction, collapsed
  bowel loops distal to obstruction (seen with
  barium- small bowel series)
 Ng tube


   Note dilated small bowel centrally placed
    with air/fluid levels on upright exam.
      Large bowel Obstruction
• Most common cause is carcinoma,
• Types of tests used for the large bowel
  obstruction/ carcinoma
• Key radiologic findings: dilated loops of
  bowel, “apple-core” lesion on BE study.
• Be able to identify on Xray
         Diverticular Disease
• Outpounchings that occur in the inner lining
  of the large bowel
• Most frequently found in the sigmoid colon
• Can be seen on CT or BE- no BE during
  acute phase of diverticulitis
• Can cause wall thickening, spasm,
  inflammation, fistulas, abscess formation
           Chrohn’s Disease
• Inflammatory disease- know effects on the
• Classic Radiologic findings: “Skip lesions”
  and string sign, fistulas
• Small bowel involvement (differs from
  colitis) can be anywhere in bowel but does
  not involve anus or rectum
• Loss of mucosal pattern
           Ulcerative Colitis
• Inflammatory bowel disease
• only occurs in large bowel, mucosal
  ulcerations/ irritations
• Narrowing of lumen from fibrosis
• Radiologic findings: “cobblestoning”, loss
  of haustra
         Esophageal Disease
• Know the various diseases associated with
  the esophagus.
• Be able to identify specific key radiologic
  findings for each disease process (hiatal
  hernia, varices, Mallory-Weiss tear, cancer)
     Interventional Radiology
• Minimally invasive procedures using
  radiologic guidance
• Procedures include angiogram, fistulagram,
  drainage procedures, catheter placements,
  thrombolysis, filter placements, etc
• Know indications for interventional
Common Iliac Artery Stenosis-
angioplasy/ stent
IVC Filter (aka Greenfield Filter)
metallic filters placed in the inferior vena cavae to prevent
propagation of deep venous thrombus, both temporary and
•Used primarily for pts who require long term IV
antibiotics, parenteral nutrition, no IV access, blood
draws, chemo if port fails
•Allows pt to be discharged from hospital and
receive treatments from home
•Inserted peripherally into the deep veins in upper
arm, tip sits in SVC
•Be able to recognize venous access lines on CXR
           Subcutaneous Ports
•Inserted similarly to Tunnelled dialysis catheters
except the port in inserted into a pocket in the snterior
chest wall.
•Primary use is for chemotherapy
•But are also put in for pt who have no venous access
and who require multiple hospital admissions.
•Can stay in longer than PICC
Biliary Drainages/ Nephrostomy
         Tube Insertions
• Know indications for each
• Be able to recall modalities used for each
  and the basic steps at which each are done
• Be able to recognize a pt experiencing a
  stroke and know the appropriate radiologic
  exam to order
• Initial sign of stroke to TPA within 3 hours
• CT asap on arrival to hospital (door to Ct
  scan within 30 minutes)
• Be able to determine ischemic stroke vs.
  hemmorhagic stroke based on CT findings
Ishemic stroke- loss of grey-
     white disctinction
• Be able to recognize each on CT exam
• Know presentations of each and basic mechanisms
  of injury
• Subarachnoid- sudden onset/ mostly caused by
• Epidural- mostly caused by head trauma with a
  skull fracture
• Subdural-traumatic brain injury, increased ICP,
  bamage to brain tissue from pressure
Epidural Hematoma
Subdural Hemmhorage
             Brain Tumors
• Best seen on MRI
• Do with and without contrast to see if mass
  highlights---indicates positive tumor
  (priamry or malignant)
• Be able to recognize a brain mass vs. other
  pathologic brain findings
• Identify normal anatomy of the spine on
  plain films
• Recognize spine injuries on radiologic
  images such as fractures, herniated disc,
  compression fracture
• Identify the appropriate radiologic tests that
  is appropriate for each injury discussed.
• Know the normal anatomy of the bones and
  be able to identify them on a plain film.
• Be able to identify common bone tumors
  based on pt history, clinical findings and
  radiologic images.
• Identify fractures/dislocation on plain films
  and be able to describe fracture qualities
• Be able to identify on plain film:
• Salter Harris Fractures, common childhood
  fractures, Bennett’s fracture, Scaphoid fracture,
  Colles fracture, Monteggia’s fracture, stress
  fractures, avulsions, pathologic, etc
• Be familiar with classical signs and symptoms of
  certain fractures and mechanism of injury
Salter II
            Stress fractures
• Commonly sports related injury
• Repetative force of foot striking hard
• Occurs in weight bearing bones (lower leg,
  ankle, foot)
• Initial xrays may be negative. Follow-up
  xrays may show evidence of bone healing
              Bone Tumors
• Know characteristics of each bone tumor,
  benign vs. malignant
• Including presentation, key clinical history,
  age appropriate tumors
• Key xray findings in each
• Most common location of tumor
• Most common benign bone tumor
• Made up of cartilage and bone
• Can be found anywhere
• Pedunculated lesion arising off smooth
  cortex of bone
• Usually painless
• Most common in 10-20 yr olds
             Osteoid Osteoma
•   Benign, bone forming tumor
•   Most common in femur
•   Teenagers/young adults
•   Localized pain > @ night, relieved by
• Made up of cartilage
• Most commonly seen in the hand
• Common to see pathologic fractures
  associated due to weakening of surrounding
         Malignant Bone Tumors
•Metastatic Bone Tumors:
•Most common malignant bone tumor
•Usually osteolytic (radiolucent) when from lung,
kidney, thyroid
•Osteoblastic (radiopaque) when mets from
breast or prostate CA
•Most common sites are spine,pelvis, ribs, skull,
and proximal humerus and femur
          Multiple Myeloma
• Most common primary malignant bone
• Older adults >60yrs old
• Spine, ribs, pelvis, skull, and proximal ends
  of the humerus and femur
• May need bone scan to differentiate
• “Punched out” lytic lesions, moth-eaten, no
  new surrounding bone formation
•   Malignant bone tumor
•   Bone forming cancer
•   Sunburst patern
•   Codman’s Triangle
•   Most common between 10-25yrs
•   Bony destruction, ragged, poorly defined
•   Cortical destruction
             Ewing’s Tumor
• 5-25 yrs old
• Xray- “Moth Eaten” pattern, poorly defined
  margins, large, destructive
• Layered periosteal reaction- “onion skin”
• Most common complaint is pain, pain @ night and
  @ rest
• Not responsive to pain meds
• Get Nuc study if suspicious- initial xray can be
             Child Abuse
• Be aware of common fractures seen in child
  abuse cases
• Inconsistant history from parents
• Get skeletal survey if suspicious