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139 Cards in this Set

  • Front
  • Back
How is a PA chest xray taken
Full inspiration at 72 inches and upright.
What is an apical lordotic view of the chest used to evaluate for and why is it done
Post primary TB adn pancoast tummor - it is done to move the clavicles out of the way.
Why is an expiration view of the chest done
To r/o acute obstructive emphysema or a possible pneumothorax
Why is a lateral decubitus view of the chest taken
to r/o pleural effusion - it must be taken with the person laying on the effected side so that you can see the fluid line
Why is an oblique view of the chest taken
It use to be used ro cardiomegaly, however U/S (echo cardiogram) is a better choice.
What are the studies used for chest xrays
Apical lordotic, expiration, lateral decubitus and oblique views.
What is the search pattern of a chest x-ray
levels of hemidiaphragms, costophrenic areas, subdiaphragmatic region, trachea, mediastinum, chest wall and pleura, hila and lung feilds, bones (spine, scapula, humeri)
Where should the hemidiaphragm levels be
btw T10-T11 (full inspiration). R & L should not vary > 1 rib interspace.
What does blunting of the hemidiaphram suggest and what view can show this earlier
indicates pleural effusion and can be seen earlier in the lateral view b/c the diaphragm and lungs come down further in the post angle.
What can give the illusion that a person's trachea is shifted to the side and how can you assess for this
Rotation in the upper body can cause this. To determine if the trachea is actually shifted to one side look to see if the clavicles are equal distance from midline.
What can cause tracheal deviation from midline
pt rotation, pneumothorax, collapsed lung, mass, atalectasis (shift will be towards an increased density)
Can the left ventricle be seen in xray?
No b/c it is sitting on the diaphragm.
What are causes of displacement of the pluera from the chest wall
internal bleeding (trauma), mass, pneumothorax
What changes can occur in the rib interspaces and what do they indicate
It is normal for space to vary from top to bottom, however should be the same from right to left. If ones side has less space first r/o is scoliosis, next is atalectisis
What should the hila look like
o Left hil should be about an inch higher than the right.
o Pulmonary vascularture should taper gradually moving peripherally – rapid tapering could suggest pulmonary hypertension.
o Inferior pulmonary vascular is more prominent on a upright films
Indications to order a chest film
• dyspnea with chest pain
• dyspnea with hx of occupational dust exposure
• cough with chest pain or other symptoms
• hemoptosis
• chest trauma
• questionable density seen on other x-rays
Search pattern for a lateral chest xray
1. Posterior costophrenic sulcus
o Shows earliest pleural effusion (blunting)
2. Retrosternal clear space
o Anterior mediastinal masses seen here
3. Posterior clear space (retrocardiac)
o R/O Lower lobe consolidation or masses
4. Bony thorax
o Sternum
o Spine
What is the acinus
parenchyma distal to terminal bronchiole
• respiratory bronchiole
• alveolar ducts
• alveolar sacs
• Alveoli
What is the airspace of the lungs
Bronchi and acinus
What type of pattern does airspace dz cause
A fluffy increased density or more homogenous pattern (except in emphysema - decreased density)
What makes up the Interstitium of the lungs (ie what is effected in interstial dz)
pulmonary vessels and lymphatics
What is one of the main findings on physical exam that suggests air space dz
consolidation (air spaces fill with fluid) Can't tell only by physical exam, must confirm w/xray.
what are the 6 types of air space dz
alveolar (lobar) pneumonia, Bronchopneumonia (lobular pneumonia), primary atypical pneumonia, TB and aveolar edema
Describe alveolar pneumonia
• X-ray finding w/in 6-12 hrs after sx onset
• Sx of fever, chills, intense pleural pain, productive cough, very high WBCs (>20 k)
• Usually caused by strep pneumoniae (in previously healthy people) or klebsiella (in vagrants and alcoholics)
• Usually involves only 1 lobe
• Starts peripherally and spreads centripetally towards midline
What is a Silhouette sign
Two objects have the same radiolucancy and therefore can not be distinguished from each other. (silhouette is lost)
Describe Bronchopneumonia (lobular pneumonia)
Occurs in infants, elderly, hospital pts, in immune compromised or 2ary to viral pneumonia
• Sn/Sx of insidious onset, productive cough w/purulent expectoration, fever, chest pn (less sharp than alveolar usually)
How does bronchopneumonia present in an x-ray
o Unilateral or b/l segmental (lobular) densities
o Possible abscess formation w/capitation w/in the density – if there is a dark area that is called a cavitation. - Time is a really important aspect
o Possible empyema (pus w/in pleural space)
• Requires a chest tube for pus drainage
What are two concerns with bronchopneumonia
cavitations and empyema (pus in pleural space)
Describe Primary atypical pneumonia
Also called walking pneumonia
Usually mycoplasmic or viral
Sx of non-productive cough, myalgia, and fever
Usually self limiting
X-ray pattern is often patchy consolidation or interstitial pattern
In addition to primary atypical pneumonia, what else should be included in a DDX for a non-productive cough and low grade fever
PCP, Maybe the first signs of HIV.
Describe Pneumocystis pneumonia (PCP)
Caused by pneumocystis jirovecii (old name pneumocystic carini)
Fungal infection in immune compromised (eg AIDS)
Sx of non-productive cough, dyspnea, low grade fever (sometimes), possible wt loss and night sweats
X-Ray signs of patchy consolidation or interstitial w/no hilar lymph node enlargement
In addition to PCP what else could signs of patchy consolidation or interstitial w/no hilar lymph node enlargement indicate on xray
possible non-hodgkin’s lymphoma
Describe TB
•Primary TB often occurs in children and is self-limiting
•Usually occurs as focal consolidation in the middle or lower lobes
•Usually see lymphadenopathy and occasionally pleural effusion
•Hilar lymphadenopathy is most common
•More calcification of granulomas and lymph nodes than if post-primary TB
•Calcified granuloma called a Ghon lesion
•Ghon (Ranke) complex = Ghon lesion and calcified hilar lymph nodes
Describe postprimary TB
•Postprimary TB occurs more in adults and is debilitating
•Infiltrates in post segments of upper lobes and is superior segment of lower lobe
•Adenopathy is rare – unless there is spreading via the blood stream (hematologenous spreading)
•May see calcificatied granulomas after healing
•Miliary TB is hematogenous spread of postprimary and pts become very ill
oMultiple small nodules scattered throughout lungs
What else should be on a DDX with postprimary TB
Histoplasmosis (more eastern US) and thyroid metastasis
describe aveolar dz
•Fluffy increased density on x-ray (similar to alveolar pnemonea – difference are alveolar edema is not usually focal and begins centrally and moves periferal)
•Consolidation often begins centrally and extends peripherally
•Bat wing pattern
•Clearing of edema begins peripherally
•With clearing or moderate edema, density maybe patchy
•May be caused by congestive heart failure, head trauma, drug overdose, acute mountain sickness
What is Atelectasis
Incomplete expansion of a lung or a portion of it.
What are the 5 etiologies of atelectasis
Obstructive, compressive, Cicatricial, adhesive, and passive
Describe obstructive atelectasis
collapse of the lung due to an obstruction "up stream of it" such as a tumor, foreign body, mucous plugs. It is also called resorptive
Describe compressive atelectasis
Physical compression of the lung paranchyma. Such as from a tumor.
Describe cicatricial atelectasis
This is when excessive scar tissue causes the lung to collapse. It can be secondary to infection or radiation.
Describe adhesive atelectasis
Atelectasis due to a loss of serfactant. w/hyaline membrane dz (Respiratory distress syndrome of the newborn) or with pulmonary infarct 2ary to embolism
Describe passive atelectasis
In ability of lung to inflate even though airways are patent. Such as when the diaphragm can't move as much as it usually can or pneumothorax.
What are direct signs of atelectasis on xray
1. Increased density in area involved
2. Displaced pulmonary fissures – if it is bowed towards the density this signifies a collapse. If it bows away, it is a type of pneumonia
3. Croweded pulmonary vessels
What are indirect signs of atelectasis on xray
1. Hilar shift toward atelectasis
2. Medialstinal shift
3. Elevated hemidiaphragm
4. Narrowed rib interspaces (especially if it is chronic)
What is Focal (plate-like) atelectasis
Relatively thin line of increased density, often horizontal
• Usually in the basal lung fields
• Often due to postsurgical pulmonary secretions blocking segmental bronchus, restricted diaphragm, or elevated hemidiaphragm
What is pleural effusion
an excessive accumulation of fluid within the pleural space.
What can cause pleural effusion
a) Congestive Heart Failure
b) Trauma
c) Infection
d) Neoplasm
e) Embolism
What are the Radiographic Signs of pleural effusion
- Blunting of the costophrenic angle on upright film
-Fluid level along chest wall on lateral decubitus view
Describe Loculated pleural effusion
a) Located along a fissure
b) May mimic a tumor
c) Has tapered edges in plane of fissure
d) Due to fibrous adhesions
e) Seen in patients with congestive heart failure
f) Subpulmonic effusion occurs over the diaphragm and mimics elevation of the hemidiaphragm
What does a solitary nodule usually indicate in the lung
1. Usually due to a tumor or granuloma
2. Granuloma may be completely calcified
o Secondary to old TB, Histoplasmosis, or Coccidioidomycosis
3. Nodule may show cavitation
o Usually secondary to carcinoma, active TB or fungal infection, or metastasis
How is a solitary nodule in the lung evaluated
comparing previous chest films (>2 years old), CT for pulmonary, MRI for mediastinal, and biopsy if suspicious (percutaneous biopsy or transbronchially)
What does multiple nodules in the lung indicate
o Multiple granulomas (especially if calcified)
o Metastasis (especially if varying sizes)
Highlights of bronchogenic carcinoma
• Majority of lung tumors are malignant.
• Rare under the age of 40.
• Most common presenting symptom is hemoptysis.
• May be found coincidentally on spinal or rib x-rays.
• Chance of survival doubles (to 30%) if found before symptomatic.
• Suspect in patient that has recurring pneumonia in same location.
• Tumor may be masked by the atelectasis that it may cause.
What is a pancoast tumor
bronchogenic carcinoma in the superior pulmonary sulcus.
o May cause thoracic outlet type symptoms
o May cause Horner’s syndrome
o Ptosis, miosis, and anhidrosis
• Due to pressure on the cervical sympathetic ganglia
Highlights of Chronic Pulmonary Emphysema
• Hyperinflation of the lung due to decreased parenchymal elasticity
• The most severe type of Chronic Obstructive Pulmonary Disease
o Others are chronic bronchitis, and chronic asthma.
• Usually found in chronic smokers
• May be due to an enzyme deficiency
What are the radiographics signs of Chornic Pulmonary Emphysema
1. Decreased and irregular vascularity
2. Hyperlucent lung fields
3. Increased retrosternal clear space
4. Depression of the diaphragm - T12 – L1, not too concerned at T11
5. Vertical "teardrop" heart – heart wont have its typical shape and will look more like a tear drop.
6. Possible bullae formation
What is effected by interstitial dz of the lungs
• Primarily involves the interlobular connective tissue
What are conditions that can cause interstitial pulmonary dz
CHF, Pneumoconioses (benign (edema only) & malignant (w/fibrosis)), collagen dz, pnemonia (viral or mycoplasmic)
What are the radiological signs of interstitial pulmonary dz
Honey comb lung
Nodular pattern or reticular pattern
What is a Pneumothorax
abnormal air in the pleural space
What are causes of Pneumothorax
Trauma, iatrogenic, spontaneous (most common), histocytosis X
What type of imaging do you do to confirm a Pneumothorax
expiration AP - will have the airspace take up less space.
How do you evaluate for cardiomegally
PA chest view -
Measure internal diameter of the chest, heart should be < 1/2 of this width
What events during x-ray can cause a false positive for cardio megally
expiration view or a poor inspiration study can cause a false positive
What is a typical cardiac series in x-ray
1. PA, left lateral, RAO and LAO chest views
2. RAO view may use barium swallow to look for displacement of the esophagus
What are etiologies for cardiac enlargement
Valvular dz, Cardiomyopathies, congenital heart dz, masses, pericardial effusion (not true enlargement, but can look the same)
How can true cardiac enlargement and pericardial effusion be differentiated
U/S of the heart
What two etiologies of cardiac enlargement lead to overall enlargement and not specific chamber enlargement
Cardiomyopathies and pericardial effusion
How does pulmonary hypertension present in xrays
Enlargements of the great vessels.
What is Echocardiography
- Used to rule out pericardial effusion.
- Can evaluate cardiac chamber size and contour. – this a way to look for regurgitation.
- Doppler used to evaluate direction and velocity of blood flow through heart.
- Real time Ultrasound is used to evaluate:
- Dynamic activity of the heart walls
- Evaluate valve functioning.
What is Radioisotope imaging of the heart used to evaluate
• Used to evaluate myocardial perfusion.
What are clinical indications for radioisotope imaging of the heart
o Abnormal resting ECG
o Non-diagnostic Treadmill stress test
• Patient unable to reach 85% Max Heart Rate
• Patient on digoxin – this changes the test.
o Intermediate risk for coronary artery disease determined on treadmill test
What evaluation is indicated for a pt with high risk for coronary artery dz
• High risk patients often get coronary angiography to evaluate surgical indicators
What radioisotopes are used in imaging of the heart
• One of two radioisotopes are commonly used.
o Thallium (Tl 201) or Tc-sestamibi
How is maximum flow evaluated in radioisotope imaging of the heart?
• Maximum flow can be evaluated by a stress test using exercise, beta adrenergic agonist, or direct vasodilators
What does decreased perfusion on resting and stress test (fixed defect) indicate
an area of infarct.
What does a “defect” (area of decreased perfusion) during stress but normal or improved during rest (reversible defect) indicate?
ischemia with risk for an infarct
Describe MRI of the heart
gating technique used to compensate for cardiac motion.
o ECG information fed to computer to determine when heart is contracting.
What is an MRI of the heart useful for? Give examples
o Chronic diffuse ischemia
o Infection of heart muscle
o From prescribed or recreational drugs – cocaine and other recreational drugs.
o Granulomatous diseases
• Sarcoidosis, Wegener’s granulomatosis
o Metabolic or connective tissue disorders
What are the common plain film views used for abdominal imaging
KUB & Upright abdomen
What does KUB stand for
Kidney, Ureters, Bladder
What is a KUB view and what is the benefit of it
o AP supine view of the abdomen
o shows outline of kidneys better due to perirenal fat being more posterior
What is the benefit of doing an upright abdomen
- It shows fluid levels which are not seen in KUB view. (usually seen on the R side)
- shows pneumoperitoneum
- shows ascities
What pathologies are seen on plain film of the abdomen
Abnormal gas patterns, pneumoperitoneum, organomegaly, calcifications,
What are possible etiologies of abnormal gas patterns
Adynamic Ileus and mechanical obstruction
What is adynamic ileus
It is when peristalsis is decreased due to inflammation, postop pts, drugs, and bedridden. It is also called reflux ileus. It is basically a shock rxn of the digestive system.
How does images of adynamic iliues differ from mechanical obstruction
 if air-fluid levels present, smaller and fewer than with mechanical obstruction
 sentinel loop is the term for a localized
adynamic ileus due to visceral inflammation. e.g. cholecystitis
How does mechanical obstruction present in imaging
There are larger gas filled areas than in adynamic ilium. There will be large air/fluid levels and there will be many of them.
What are possible causes of mechanical obstruction
Adult - neoplasm, adhesions (post-op), hernia, & volvulus.

Child - intussusception
What are the normal sizes of the different areas of bowels?
 small bowel shouldn’t be >3cm diameter,
 most of colon shouldn’t be >6cm
 cecum shouldn’t be >8cm
What imaging is used for intussusception
Usually a barium study b/c it will undo the telescoping
What is Pneumoperitoneum
Air in the peritoneum, that is outside of the GI tract
What are possible causes of pneumoperitoneum
• On upright film, goes to highest area, subdiaphragmatic.
• Often due to perforated duodenal ulcer, surgical procedure, perforation of a diverticulm.
How does hepatomegaly present in x-ray imaging
o Inferior pole of liver extending below iliac crest
o Liver displacing hepatic flexure inferomedially
How does splenomegaly present in x-ray
o Spleen measurement too large
o Spleen displacing stomach across midline
Do most gallstones show up on xray? How do they present
No- most are cholesterol, and therefore must be evaluated w/U/S. There will most likely be multi faceted if they are visualized -this is from rubbing against one another.
How do Renal calculi present in x-ray
o Often solitary and posteriorly located in body
oUsually within renal pelvis
oWalls of collecting system may calcify
What are staghorn calculus
When walls of collecting system calcify.
Name is d/t the branching pattern.
Usually secondary to infections or stasi
Do not use lithotripsy on these!!!
What is nephrolithiasis
Punctate calcification within renal cortex or medulla
How does nephrolithiasis present in xray
It is a poke-a-dot pattern rather than large round stones. Name is just d/t location.
What causes nephrolithiasis
Often secondary to hypercalcemia
(e.g. hyperparathyroidism), papillary necrosis (could be d/t drug abuse such as NSAIDs) or chronic glomerulonephritis (more peripheral calcification)
What is porcalin gallbladder and how should it be handled
This is when the walls of the gallbladder calcify. A clear outline of the walls will be seen on xray. Refer out as it is pre-cancerous.
How is adrenal calcification dx
It will be seen in a plain film. It is just superior and posterior to the kidneys and will be a modeled look rather than punctinate. Must do a lateral view to distinguish from pancreatic calcification.
What causes adrenal calcification
o Usually due to hemorrhage within adrenal gland, or secondary to TB, or idiopathic (common, when seen at birth usually resolves)
What is the typical cause of calcifications in the lymph nodes
o Usually secondary to previous chronic granulomatous infection; e.g. TB, Histo, Cocci
What are the most common nodes to calcify
Most common are those in the mesenteric chain. Especially those within midline or right lower quadrant. Hilar lymph nodes can also calcify.
How do calcified uterine fibroids present?
o Popcorn type calcification and sometimes multiple
How does prostatic calculi present
o Punctate calcification over the pubic symphysis. Not very common.
How do pancreatic calculi present
o Punctate or modeled calculi often extending across midline at L1-2 level
Can be located only in the head and therefore must also do a lateral view to differentiate from adrenal calcifications.
What are the most common causes of pancreatic calculi
o Due to chronic pancreatitis (2ary to alcoholism is very common) or pancreatic carcinoma
What percentage of abdominal aneurysms are seen in plain film and at what point they considered a concern (ie a possible aneurysm)
50% are seen on plain film and we are concerned when they are >3.5 (at 3.8 they are considered an aneurysm)
What is commonly mistaken as a vertebral artery calcification
Calcification of the thyroid cartilage.
When should a cleansing enema not be given?
Mega colon, UC and colon obstruction - don't want to cause perforation.
What are spot films used for
To examine any of the areas of common problems in the GI tract - (usually junctions) E-G junction, duodenal bulb, colon flexures, ileocecal junction, and rectosigmoid colon
How are air-contrast studies conducted
Utilize thick barium and some source of air - gas releasing tablets in upper GI study and rectal tube in a barium enema
What is an esophogram
Used to evaluate the esophagus, oral barium, fluoroscopy and static xrays
What is an esophoram usually used to visualize
diverticulum (Zenker's), peristalsis (carcinoma can cause rigidity) and varicies
How is an upper GI study conducted
Barium swallow orally, fluoroscopy and static x-rays.
What is an upper GI study used to evaluate
stomach and proximal duodenum
What is the concern in a pt > 50 y/o w/ a peptic ulcer
Concern is carcinoma, especially in recurrent ulcers. Should tx all as if they are carcinoma as prognosis is very bad.
Where will the air bubble be in a prone pt? Where will it be in a supine pt?
Prone - top of stomach
Supine - bottom of stomach
What is a small bowel study
This is a study beginning at the highest point after the duodenal bulb and ending at the ileocecal valve.
How does a hiatal hernia typically present on contrast
Large air bubble superimposing over the heart.
What is a barium enema used for
Contrast evaluation of the colon

air is often also introduced to the colon to produce an air-contrast study

easier to see polyps and other masses projecting into the lumen
What does barium in the iluem suggest when conducting a barium enema
Incompetent ileocecal valve or a tech that put the barium bag too high.
When is a U/S study conducted of the GI tract
• used with suspected biliary or pancreatic disease
• have largely replaced oral cholecytography
When is CT of the abdomen indicated
• used to study jaundice (worse prognoses is going to be a mass, especially pancreatic cancer), pancreatic disease, spleen and possible hepatic metastasis (changing liver fnx)
• intravenous contrast may also be used
When is nuclear medicine used to evaluate the abdomen
hepatobiliary scans are used in cases of acute cholecytitis
g. Perfusion studies used to evaluate slow bleeding lesions (as low as 0.5 ml/min) vs angiogram (4 ml/min).
What are the pros of a virtual colonoscopy
Not as invasive as a regular
What are cons of the virtual colonoscopy
Shows 10 mm polyps very well, however then can't biopsy them. Also have to do the same "cleaning" procedure to prepare.
What are important aspects of intestinal polyps
May be pedunculated or on a sessile.
May be malignant or not (great increase in malignancy when >2cm)
well seen with air contrast
How does a Mucosal Masses typically present on imaging.
- may begin as a small polyp – most malignancy are by the colon sigmoid jnx.
- may circumscribe the intestine producing an "apple core"or "napkin ring" appearance - sign of malignancy
Where do ulcers occur, is there a specific place more common for specific ages
Stomach or duodenal bulb most common locations.
Stomach - older individuals
Duodenal bulb - younger individuals
How does a duodenal ulcer present on imaging
it will show an out-pouching
How does a gastric ulcer present
there will be a ring around the ulcer, unless it is in the center of a carcinoma
In the case of the carcinoma there will be a filling defect
Specific details of UC
-Involves mucosa and submucosa only
- Ulcerations are shallow and coalescent
- Fluoroscopy may show acute stage spasm and irritability
- Usually involves the entire colon contiguously – spares the rectum, often will begin in the colon and move up.
- Eventually result in loss of haustral markings and lumen narrowing – this is many years into dz progression.
i. Lead pipe colon
ii. May lead to carcinoma.
Specific details of crohn's dz
- involves all layers.
- leads to strictures, obstruction, fistula
- shows "skip areas "
- Cobblestone appearance due to longitudinal ulcers with transverse fissure
- usually spares the rectum – can involve the anus, but then spares the rectum.
- almost always involves the terminal ileum – usually near iliosecal valve.
- right side of colon is more involved than left
- may see fistulas on barium study
What is the string sign
it when small strings of barium are seen in contrast studies, it is a sign of crohn's dz d/t the decreased lumen from inflammation