BPE & IMAGING: LE 2| TRANS 1

Introduction to Radiology & Normal Chest Radiograph

Dr. Marvin Ellis Uy Wee, MD, DPBR | 09/20/2022

OUTLINE ➔ uses imaging technology such as CT scans, MRI, and

ultrasounds to help guide medical procedures to eliminate the
I. Introduction to Radiology
need for surgery and scopes to diagnose and treat certain
A. Introduction
conditions
B. History
➔ therapies include embolization, angioplasty, stent placement,
C. Golden Rules for Ordering Imaging Tests
thrombus management, drainage, and ablation, among others
D. Types of Radiation
E. Effects of Radiation Radiation Oncology
F. Radiographic Densities
G. Diagnostic Modalities ➔ uses ionizing radiation and other modalities to treat malignant
H. Contrast Media and some benign diseases
I. Key Points ➔ may also use CT scans, MRI, ultrasound, and hyperthermia
II. Normal Chest Radiograph (heat) as additional interventions to aid in treatment planning
A. Chest Radiograph and delivery
B. Interpreting Chest Radiograph B. HISTORY
C. Normal Chest X-ray Anatomy
D. Tubes and Lines ➔ Wilhelm Conrad Rontgen
◆ German physicist
SUMMARY OF ABBREVIATIONS ◆ Accidentally discovered x-rays on November 8, 1985
CT scan Computed Tomography scan ◆ wrote the manuscript “On a New Kind of Ray” and
MRI Magnetic Resonance Imaging submitted it to the Wurzburg Physical Medical Institute
PET scan Positron Emission Tomography scan ◆ was studying what happened when he passed an
SPECT Single Photon Emission Computed Tomography electrical current through different gases at low pressure
HU Hounsfield Unit ◆ hooked electrodes to a glass cathode tube and applied
voltage to the gas
PA view Posterior to Anterior view
● causes a beam of electrons, known as a cathode
AP view Anterior to Posterior view
ray or a electron beam, to go from one end of the
AP window Aorto-pulmonary window tube to the other
CTR Cardiothoracic Ratio ● cathode rays: green when they strike the walls of the
LEGENDS glass tube
● ultimate goal for the experiment: to determine if the
❗
Must know
👩‍⚕️
Lecturer
📖
Book
🖥
Presentation
📝
Old Trans
rays could pass through glass so he covered the
glass tube with paper
● was surprised that the rays passed through both the
LEARNING OBJECTIVES
glass and paper
At the end of the lecture, the student should be able to: ● through continuous experimentation, he discovered
✔ Distinguish the 5 radiographic densities seen on conventional that the mysterious green light could pass through
most solid objects
radiographs
◆ Called the rays “X-rays,” with the “X” meaning
✔ Recognize the significance and effects of ionizing radiation “unknown,” because he didn’t know what they were
✔ Differentiate imaging modalities, their advantages, and ◆ Also found that he can create images of objects placed
disadvantages between the cathodes and a photographic plate
✔ Identify the types of contrast and their common side effects ● rays would create images of objects of different
✔ Understand and be able to interpret the normal chest thickness
radiograph ● at one point, his wife put her hand in between the
cathode and the plate → showed the bones of her
I. INTRODUCTION TO RADIOLOGY hand and her ring surrounded by a faint outline
surrounded by her flesh → first x-ray of a human
A. INTRODUCTION body part
➔ Radiologist
◆a physician that uses imaging modalities to diagnose and
manage patients and provide therapeutic options
Diagnostic Radiology
➔ refers to the field of medicine that uses non-invasive imaging
scans to create highly detailed images of an area to diagnose a
patient
➔ uses x-rays, radio nuclei, ultrasound, and electromagnetic
radiation to diagnose and treat disease
Interventional Radiology
➔ combines competence in imaging, image guided minimally
invasive procedures, and periprocedural patient care to
diagnose benign and malignant conditions of the thorax,
abdomen, pelvis, and extremities Figure 1. (L) Rontgen’s Experimental setup. (R) First x-ray of a human body part.

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BPE & IMAGING
➔ Within the first year of the first x-ray, a Glasgow hospital
opened its first radiology department
◆ produced the first image of a penny lodged in a child’s
throat and a kidney stone
➔ Soon, an american doctor used x-rays to trace food as it made
its way through the digestive tract
➔ 1896
◆ Antoine Henri Becquerel discovered radioactivity
◆ Thomas Alva Edison invented the first commercially
available fluoroscope, a movie-like x-ray, by passing an
x-ray beam through a body as it moves
● the fluoroscopy then transmits the images to a
TV-like monitor so doctors could see body parts and
movement in detail
➔ 1913
◆ Albert Salomon commences research leading to
mammography
➔ 1918
◆ George Eastman introduced film as an alternative to the
glass photographic plates that scientists previously used
➔ 1927
◆ Egas Moniz develops cerebral angiography
➔ 1958
◆ Ian Donald developed the first ultrasound for medical use
● used ultrasound to observe fetus development and
cysts
● also worked with engineerTom Brown to develop the
first portable ultrasound for patient use
➔ 1961
◆ James Robertson built the first PET scan
● uses a special dye containing radioactive tracers
that are swallowed, inhaled, or injected to the
patient’s vein
● PET scan detects radioactivity to create images
○ used to detect early signs of cancer, brain
disease, or heart disorders
➔ 1972 (TH note: 1971 in the audio recording)
◆ Godfrey Hounsfield introduces the CT scanner
● combines with computer software to create 3
dimensional cross sectional images
◆ first successful live CT scan was performed the same
year
➔ 1973
◆ Paul Lauterbur developed a way to generate 2D and 3D
MRI images
● use strong magnets to align atoms and water
molecules inside the body
○ when the radio technician turns the magnet off,
the protons resume their normal spin in the
energy
○ different tissues in the body emit different
energies and MRI detects this energy to
created images of the different body tissue
➔ 1977
◆ Raymond Vahan Damadian builds the first commercial
MRI scanner
C. GOLDEN RULES FOR ORDERING IMAGING TESTS
1. Avoid ordering tests when the results will not impact
patient care.
2. Review tests previously performed to answer current
questions.
3. Order the best test to maximize quality, efficiency, and
cost-effectiveness.
4. Prepare your patient to minimize delays in getting studies
done. In general, patients should be hemodynamically
stable and able to cooperate as active participants in
creating optimal images.
LE #2 TRANS #1 TG: Batulan, Martinez, Ong, Rabino
Introduction to Radiology & Normal Chest Radiograph
5. Provide the necessary clinical information to radiology
technicians to answer important questions/inquiries.
6. Consult your radiologist when unsure about next imaging
steps, the meaning of a radiology report, or the
significance of a negative or incidental finding.
7. Provide patient-centered care: inform, consent, and
educate.
D. TYPES OF RADIATION
➔ Radiation
◆ generally referred as energy emitted from a source
➔ Ionizing Radiation
◆ form of radiation that is of concern in medical imaging
◆ radiation that carries high enough energy to liberate
electrons from atoms or molecules, thereby ionizing them
◆ acts by removing electrons from atoms and molecules of
materials, including air, water, and living tissue
◆ can travel unseen and pass through materials
◆ on the right side of the electromagnetic spectrum in
figure 2 below
◆ Ionizing activity: can alter molecules within the cells of
our body
● may cause eventual harm (i.e., cancer)
● Intense exposure may produce skin and tissue
damage
◆ Medical exams that use ionizing radiation:
● CT/CAT scan
● X-rays
● PET scans
● Fluoroscopy
● Angiography
● Nuclear Medicine procedures
➔ Non-ionizing radiation
Figure 2. Visual chart of the electromagnetic spectrum.
1. Natural Background Radiation
➔ come from cosmic rays from our solar system and radioactive
elements normally present in the soil
➔ the major contributor to worldwide radiation exposure
➔ Radon: largest source of background radiation
2. Medical Radiation
➔ used for x-rays, CT scans, and other tests
➔ Radiation therapy
◆ used to treat some types of cancer
◆ involves dosages many thousand times higher than
those used in diagnostic x-rays
3. Non-medical, man-made radiation
➔ used in small amounts in food irradiation, airport security
scanners, and some consumer products
➔ exposure can happen in certain workplaces or in communities
as a result of above ground nuclear weapons testing and
nuclear accidents
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 BPE & IMAGING Introduction to Radiology & Normal Chest Radiograph

➔ Famous example: atomic bomb dropped in Nagasaki and 5. the most appropriate modality
Hiroshima
E. EFFECTS OF IONIZING RADIATION F. X-RAY PHOTONS AND HUMAN TISSUE INTERACTION
➔ Ionizing radiation is harmful and potentially lethal but it can ➔ determines how anatomic images are produced and the
have health benefits in radiation therapy for the treatment of patient’s radiation dose
certain cancers Three things that can happen upon exposure
➔ Health effects are classified into two categories:
◆ Deterministic Effect (direct effect) 1. Pass all the way through the body
◆ Stochastic Effect (occurs by chance) ○ renders the film dark, radiolucent, air has a low atomic
1. Deterministic Effect number → x-rays get through → image is dark
2. Be deflected or scattered
➔ usually predictable and reproducible ○ renders the film light (white), radio-opaque, bone has a high
➔ short-term adverse tissue reactions resulting from a dose that atomic number → x-rays are blocked → image is light
is significantly high enough to cause damage to living tissues 3. Be absorbed
➔ For example, localized doses to certain parts of the body in ○ no image information rendered
increasing levels will result in well-understood biological effects ○ wearing lead apron → completely absorbs x-ray → prevents
◆ the severity of a deterministic effect increases with passing → no image
radiation doses above a threshold, below which the
detectable tissue reactions are not observed
➔ Common examples
◆ radiation-induced skin burns
◆ acute radiation syndrome
◆ radiation sickness
◆ cataracts
◆ sterility
◆ tumor necrosis
◆ fetal demise
2. Stochastic Effects
➔ probabilistic effects that occur by chance
➔ occur many years later
➔ severity is independent of the dose received
➔ Examples
◆ cancer development
● rare
● probability of occurrence is typically proportional to Figure 3. Three fates of radio waves upon contact with the human body
the dose received
● since many agents in the environment are known Five Radiographic Densities
carcinogens and because cancers occur 1. Air Density
spontaneously, it is not possible in most cases to ● density of least absorption
directly link radiation exposure to an observed ● no resistance in radiation → radiation is reflected in the
cancer radiographic plate
◆ Gene mutation ● colored black
➔ Risk of developing cancer from medical imaging radiation ● e.g., lungs and air-filled structures
◆ generally very small and depends on 2. Fat density
1. Radiation dose: lifetime risk of cancer increases ● absorb a minimum density that is somewhat higher than
the larger the dose and the more x-ray exams a air → faint whitish-grey color
patient undergoes ● e.g., fat or muscle; can be seen surrounding the intra
2. Patient’s age: lifetime risk of cancer is larger for a abdominal structures
patient who receives x-rays at a younger age than 3. Soft tissue or fluid density
for one who receives them at an older age ● tissues that exhibit this density have a high aqueous
3. Patient’s sex: women are at somewhat higher content
lifetime risk than men for developing ● amount of x-rays absorbed is greater → appears brighter
radiation-associated cancer after receiving the same or whiter than the previous two densities
exposures at the same age ● e.g., heart, liver, spleen, kidneys, etc.
4. Body region: some organs are more radiosensitive 4. Bone density
than others ● absorbs more x-rays
○ actively differentiating cells (e.g., hematopoietic ● a few are scattered → appear white with a tinge of grey
cells and GI tract epithelium) tend to show ● e.g., calcified cartilages, vascular calcifications
higher radiosensitivity 5. Metal
Balancing Benefits and Risks ● does not naturally exist in the body
● absorbs the most radiation in all densities → intense
➔ Benefits outweigh risks when it is white color
1. needed for diagnosis ● e.g., pacemakers, prosthesis, positive oral or intravenous
2. needed for treatment contrasts
3. needed for follow-up
4. needed as guide in procedures

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BPE & IMAGING Introduction to Radiology & Normal Chest Radiograph

➔ Chief uses
◆ skeletal structure
◆ chest
◆ screen for a few intra-abdominal diseases

Figure 4. Visual presentation of the 5 radiographic densities

Figure 5. Sample image produced in plain radiography
G. DIAGNOSTIC MODALITIES 2. Fluoroscopy
**Please see appendix for tabulated summary of diagnostic modalities
➔ uses continuous x-ray beams to create a real-time visualization
-TH
of moving anatomic structures
1. Radiography ➔ an enhanced x-ray that uses an image intensifier and produces
images in a monitor
➔ Plain radiography / x-ray / projectional radiography ➔ “X-ray movie”
➔ term for the static image generated following the passage of ➔ What it reveals
x-rays through the patient ◆ anatomic and functional information
➔ Chest Radiograph = chest x-ray ➔ Advantages
➔ 2 types of radiograph systems based on image processing ◆ Provides images in real-time
1. Analogue system ◆ Widely available
● a.k.a. Conventional System, Plain film or film-screen ➔ Disadvantages
radiograph ◆ radiation dose may be substantial
● utilize screen-film system (silver bromide): uses ◆ more expensive than radiography
transparent film made from polyester coated with ➔ Chief Uses
silver bromide which is x-ray sensitive ◆ GI peristalsis
● film is placed inside a cassette and loaded into the ◆ Movement of diaphragm with respiration
bucket ◆ cardiac actions
○ the exposed film is then processed in a dark ◆ barium studies
room and hanged to dry before interpretation ◆ catheter placements
2. Digital system ◆ can be used during implants
● 2 main types:
○ Computed Radiography (CR)
◆ filmless
◆ use of a detector made of photostimulable
phosphor
◆ after exposure, cassette is loaded into a
CR image reader where images are
converted to digital format and stored in an
archiving system
◆ image reader will then delete the old image
in the detector and eject it for reuse
○ Direct Digital Radiography (DR)
◆ No Cassette
◆ uses flat panel detectors or charge
coupled devices (CCDs)
◆ after x-ray exposure, the image is directly
converted to a digital format and archived Figure 6. Sample image produced in fluoroscopy
for interpretation 3. Ultrasound
➔ What it reveals
◆ bony and soft tissue anatomy ➔ a.k.a. sonography
➔ Advantages ➔ uses high frequency sound waves to characterize tissue in
◆ Low radiation dose real-time
◆ Inexpensive ➔ useful and flexible modality in medical imaging and often
◆ Readily available provides an additional or unique characterization of tissues
◆ quick ➔ relies on properties of acoustic physics
◆ minimal preparation needed (compression/rarefaction, reflection, impedance, etc) to
➔ Disadvantages localize and characterize different tissue types
◆ provides basic anatomic information for only a few tissue ➔ Medical ultrasound is in the range of millions of cycles per
densities second (megahertz, MHz)
◆ i.e., if two adjacent structures are of different densities, it ➔ uses a handheld device called a transponder which sends
will be difficult to differentiate the two structures in a sound waves through human tissue
radiograph; may appear as a single entity

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◆ sound waves bounce back from denser tissue to the
transponder to create an image
◆ time it takes for the pulse to be received determines the
tissue’s location
➔ acoustic property of the tissue determine the nature of the
image
➔ Color Flow Doppler/Color Doppler Imaging/Color Doppler
◆ sonographic procedure that allows the visualization of
flow direction and velocity
➔ What it reveals
◆ real-time evaluation of soft tissues (intra-abdominal
organs) and vessels
➔ Advantages
◆ widely available
◆ some units are portable
◆ has no harmful effects
◆ causes no pain
◆ requires no sedation
◆ requires no preparation except for gallbladder exams
when a patient should fast and pelvic studies
◆ No radiation
➔ Disadvantages
◆ evaluation of lungs and bone marrow is limited due to
how sound is scattered by air and reflected by dense
structure
◆ operator-dependent: images obtained are highly
dependent on sonographer’s expertise
◆ more expensive than radiography
➔ Chief uses
◆ neonatal intracranial pathology
◆ suspected hepatobiliary disease
◆ evaluate most abdominal organs
◆ musculoskeletal imaging
◆ neck imaging, ECG, vascular sonography
○ eliminates the need for contrast media
● used as an alternative to CT Angiography and/or
Conventional angiography
➔ can also be categorized by the organ/area of interest (i.e.,
cerebral angiography)
➔ Conventional and Digital Subtraction Angiography are
gold standard for the evaluation of most vascular
pathologies
◆ procedure is carried out by an interventional radiologist
who will insert a microcather through the radial or femoral
artery before advancing it (the catheter) proximal to the
site of interest before injecting a radio-opaque contrast
for vascular evaluation or deploy embolizing agents for
treatment
➔ What it reveals
◆ vascular structures
➔ Advantages
◆ can be diagnostic and therapeutic
➔ Disadvantages
◆ renal insufficiency and hypersensitivity to iodinated
contrast media are relative contraindications
◆ uses ionizing radiation
➔ Chief uses
◆ Diagnosis and treatment of vascular pathologies

Figure 7. Sample image produced in ultrasound

4. Angiography
➔ medical imaging technique used to visualize blood vessels
➔ can be categorized by the modality used to obtain the image
◆ Conventional Angiography
● fluoroscopic technique
● requires IV contrast
◆ Digital Subtraction Angiography Figure 8. Sample images produced in different modalities of angiography.
● Fluoroscopic technique
● difference with conventional angiography: digitally 5. Computed Tomography
deletes bony structures for accurate depiction of
➔ Uses a computer to reconstruct a cross-sectional image of the
blood vessels
body from measurements of x-ray transmission through thin
◆ CT Angiography
slices of tissue.
● uses CT scan
➔ Measurements are systematically repeated many times from
● with ionizing radiation
different directions while the x-ray is pulsed as it rotates.
● requires IV contrast
➔ X-ray beam moves in a circular manner around the body,
◆ MR Angiography
allowing for many different views of the same organ or
● can be done with or without IV contrast
structure → provides much greater detail

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BPE & IMAGING Introduction to Radiology & Normal Chest Radiograph

➔ CT scan reveals:
◆ Anatomical informations in almost all organ system in the
body
➔ Advantages
◆ Greater anatomic detail, especially with IV contrast
◆ Very fast exam time
◆ Can provide 3D information
➔ Disadvantages
◆ High radiation dose
◆ Many require oral / rectal / IV contrast.
◆ More expensive than x-ray and ultrasound
◆ Dense bone (Petrous ridge for example) and metal
causes severe artifacts
➔ Chief uses
◆ Screening evaluation of nonspecific symptoms Figure 10. Comparison between the detail of an ordinary Abdominal x-ray (left)
● Example: and one slice of abdominal CT scan (right)
○ Evaluation of the fat content of the liver 6. Magnetic Resonance Imaging
○ Assessing bone mineral density
◆ Evaluate for infectious / trauma related pathologies ➔ Produces tomographic images by means of magnetic fields
● Example: and radio waves.
○ Investigate internal Bleeding ➔ Can produce 1.5 teslas (more than enough to pick up an
○ Tissue or fluid biopsy averaged size car)
◆ Diagnose and monitor cancer ➔ Analyze multiple parameters
➔ Hounsfield Unit (HU) ◆ Hydrogen proton density
◆ Dimensionless units universally used in CT scan used to ◆ t1 and t2 relaxation times of tissue
express units to standardized and convenient form ◆ Blood flow with in tissues
◆ Obtained from linear transformation of a measured ➔ Why are Hydrogen ions important in MRI?
attenuation coefficient (air and water) ◆ The hydrogen nucleus has an unpaired proton which is
➔ An increase in tissue density will have an (directly positively charged which produces a small but noticeable
proportional) increase
appearance whiter. ❗ effect in HU, thus making its magnetic field.
◆ Only atom in the body that is MR sensitive
◆ Abundant in the body in the forms of water and fat
➔ How does an MRI work
◆ Detect changes of magnetic field in you body (specifically
Hydrogen atoms) to take high detailed images of soft
tissues and other organs of the body.
➔ MRI reveals:
◆ Detailed High contrast resolution pictures of organs
➔ Advantages
◆ Allows multiplanar and 3D evaluation.
◆ Does not require routine use of IV contrast material for
imaging of abdomen and pelvis (Unlike CT)
◆ Superior depiction of soft tissue and organ contrast
difference
◆ No radiation exposure
Figure 9. Simplified Hounsfield Scale showing air, water and other structures
with their corresponding HU values and appearance.
➔ Disadvantages
◆ Lengthy procedural time
Table 1. Structures and their corresponding HU value according to ◆ Often requires sedation in children younger than 7yo and
Figure 9 some in adults
Structure Hounsfield Unit ◆ Expensive
◆ Scanner is noisy
◆ Picture quality highly susceptible to movement
Air -1000 ➔ Chief uses
◆ CNS exams
Fat -50 ◆ MSK evaluations
◆ Cancer evaluation and surveillance
Water 0 ➔ Absolute contraindications:
◆ Cardiac pacemaker
Soft tissue +40 ◆ Intracranial vascular clips
◆ Neurostimulators of any kind
Blood +40 - +80 ◆ Intraocular metallic foreign body
◆ Ossicular implants
Stones +100 to +400 ◆ Any metallic implant, rods metal plates and pins
◆ Heart failure
◆ Surgical clips on arteries and wire sutures
Bone +1000

Metal +3000

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➔ Chief uses
◆ Detection of cancer
◆ Cancer localization and spread
➔ Therapy response and monitoring
➔ Limitations:
◆ Pet scans are very expensive form of imaging, and not
readily available
◆ PET Scan can sometimes show up in areas of high
activity which may be mistaken for cancers
◆ Inflammatory conditions like rheumatoid arthritis or
tuberculosis absorb a lot of the tracer, and so can cause
confusing results
◆ The radioactive substance has a very short decayn and
therefore appointments must run on schedule
◆ A PET scan is less accurate in certain situations:
● Slow-growing, less active tumors may not absorb
much tracers.
● Small tumors (less than 7mm) may not be
Figure 11. Sample images produced in brain MRI detectable
7. Nuclear Medicine ● High levels of Blood sugar can cause the cells to
absorb this normal sugar rather than be injected
➔ Entails the use of: radiotracers
◆ radioactive materials + carrier molecules =
radiotracers/radiopharmaceuticals
➔ Radiotracers are usually given via injection, but they may also
be swallowed or inhaled
➔ Radiotracers
◆ most common: F-18 fluorodeoxyglucose (FDG)
◆ after being injected, it builds up in the area of the body
that needs to be examined (i.e., cancerous tumor,
inflamed area)
➔ Used in diagnosis, evaluation, and treatment of various
diseases of the:
◆ heart
◆ lungs
◆ kidneys
◆ liver
◆ gallbladder
◆ thyroid
◆ bones
➔ Determines how the body is functioning at a cellular level
➔ Is able to
◆ find disease in its earliest stages Figure 12. Sample images produced in a brain PET scan
◆ target treatment to specific cells
◆ monitor response to treatment H. CONTRAST MEDIA
➔ 2 Common uses ➔ Chemical agents developed to aid in the characterization of the
◆ Radioactive Iodine Therapy anatomy and pathology by improving the contrast resolution of
◆ Brachytherapy an imaging modality.
8. Positron Emission Tomography (PET/CT) and Single Photon ➔ How does structures becomes more visible when contrast
Emission Computed Tomography (SPECT)
➔ Main difference of PET and SPECT is the Radiotracer
media is administered:
◆ Alters the way of x-rays passing through patients ( The
high density of Contrast media makes some anatomies
❗
◆ SPECT - Detects gamma rays from radiotracers that are like blood vessel and alimentary canal look like
injected into the patient. radiopaques)
◆ PET - Detects energy from annihilation of an Electron ◆ Alters response of tissues to ultrasound or magnetic field

❗
(negatively charged) and a Positron (Positive electrons). ◆ Malignancies also tend to be more opaque in the image
When an electron and positron meet, they annihilate since they are highly vascularized.
each other thus producing two photons traveling in a ➔ Route of Administration:
different direction equivalent to the energy of the two. ◆ Intravenous
➔ What it reveals: ◆ Intraarterial
◆ Some anatomic detail and functions of organs and soft ◆ Orally
tissues ◆ Rectal / Enema
➔ Advantages: ◆ Urethra / Endocervix
◆ Provide metabolic and functional information ◆ Cavities / Fistula
➔ Disadvantages:
◆ More expensive than CT and MRI 1. Iodinated contrast
◆ Strict scheduling ➔ For x-ray based contrast
◆ May take a longer time and require sedation ➔ contrast agent that contains iodine atoms
◆ offers little anatomic information alone

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➔ presence of the iodine prevents the x-rays from penetrating the ➔ In MRI T1 weighted images show water and fluid tissues
contrast enhanced tissue, resulting in these structures
appearing denser
➔ Example of procedures using iodinated contrast
images shows bones as dark or black ❗
whiter, while T2 shows fat tissue whiter. Both weighted

5. Microbubbles
◆ X-ray / fluoroscopy procedures
● Hysterosalpingography ➔ These are intravenous contrast enhancers used in ultrasound
● Angiography ➔ Consist of gas surrounded by lipid, lipopolymer, or polymer
◆ CT scan procedures shell
● CT angiography ➔ They range from 2-10 micrometers (slightly smaller than red
● Triphasic / Tri-phase contrast exam blood cells)
2. Triple-phase contrast ADVERSE REACTIONS TO CONTRAST MEDIA
➔ Uses Iodinated Contrast ➔ Commonly observed when using IODINATED CONTRAST
➔ Useful examination in assessing the liver for focal lesions, MEDIUM
hypervascularization due to metastasis and endocrine tumors ◆ Renal toxicity is a well known adverse reaction when it
comes to the use of Intravenous contrast. (To undergo
contrast examinations for patients with known renal
diseases, patient must acquire a Renal function test or a
nephrology clearance)
➔ MILD reactions include:
◆ Limited Urticaria / Pruritis
◆ Nasal Congestion
◆ Cutaneous edema
◆ Sneezing / Conjunctivitis / Rhinorrhea
◆ limited itching of throat
◆ nausea and vomitting
➔ MODERATE reactions include:
◆ Diffuse urticaria
◆ Diffuse erythema with stable vital signs
◆ Facial edema without Dyspnea
◆ Throat tightness or hoarseness without dyspnea
◆ Wheezing / bronchospasm, mild or no hypoxia
➔ SEVERE reactions include:
◆ Diffuse edema or facial edema with dyspnea
◆ Diffuse edema with Hypotension
◆ Laryngeal edema with Stridor and/or hypoxia
◆ Wheezing / bronchospasm, significant hypoxia
◆ Anaphylactic shock (hypotension + tachycardia)
PREVENTING, SCREENING, AND MINIMIZING CONTRAST
Figure 13. Triple phase contrast of the liver REACTIONS
3. Barium Sulfate ➔ Awareness of the different types of risk factors and
prescreening for their presence allows for early recognition and
➔ Often regarded as Barium
prompt treatment,
➔ This is an ionic salt barium (ba56)
➔ Pretreatment of patients who have such risk factors with a
➔ Used in the fluoroscopic examination of the GIT
corticosteroid and diphenhydramine decreases the chance of
➔ Barium sulfate is insoluble with water
allergic reactions, including anaphylaxis, renal failure, or a
◆ therefore, very little of the toxic barium metal is absorbed
possible life-threatening emergency.
into the body
➔ Using the smallest amount of contrast material possible.
➔ Absolute Contraindications:
➔ Low-osmolar, nonionic agents are helpful in patients with
◆ Known or suspected GIT perforation
known conditions associated with adverse reactions.
◆ Large volume aspiration risk
➔ Renal insufficiency induced by contrast material may be
◆ Prior allergic reaction (which is rare)
prevented by ensuring adequate hydration and discontinuing
➔ Relative Contraindications:
other nephrotoxic medications before the procedure.
◆ Left side colonic obstruction
➔ Mild reaction treatments:
● If barium can not exit colon it has the potential to be
◆ Occurs in 3% of patients receiving nonionic and low
insspissated and very hard leading to a quiet
osmolality contrast media
problematic constipation
◆ Treatment: Supportive measures are enough
➔ Example of studies where Barium sulfate is used:
➔ Moderate reaction treatments
◆ Esophagogram, Barium Swallow
◆ More prominent and demand medical attention
◆ Barium Enema
◆ Treatment: Antihistamine or Intramuscular epinephrine is
4. Gadolinium Contrast Agents advised in sme situations
◆ In cases of bronchospasm - oxygen should be offered by
➔ Molecular complexes containing rare earth metal gadolinium mask (6-10 liters/min), beta-2-agonists (e.g. terbutaline,
(gd64) chelated on a carrier ligand albuterol) metered-dose inhaler (2-3 deep inhalations),
➔ They are paramagnetic contrast agent and intramuscular epinephrine should be considered if
➔ Brightest in T1 weighted images decreased blood pressure
➔ Severe reaction treatment

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BPE & IMAGING Introduction to Radiology & Normal Chest Radiograph

◆ Reactions that usually represent a progression of the

A-B-C-D-E-F-G-H-I / ABC Approach
moderate symptoms and are life-threatening
◆ e.g, respiratory arrest, cardiac arrest, pulmonary edema,
convulsions, and cardiogenic shock A Assessment of Quality
◆ Estimated to occur in 0.04% to 0.0004% of the patients
receiving a non-ionic and low-osmolality iodinated B Bone and Soft Tissue
contrast.
◆ The risk of death is rare (estimated 1:170,000) C Cardiac
◆ current RANZCR guidelines for severe reactions
recommend: D Diaphragm
● supine positioning
● airway protection if required and high flow oxygen E Effusions
● IM epinephrine 1:1000 0.5 mL in thigh
○ smaller doses if pediatric or <25 kg
F Fields and Fissures
● additional measures include albuterol nebulizers,
corticosteroids, apd nebulised epinephrine as
guided by symptoms G Great Vessels

J. KEY POINTS H Hila and Mediastinum

➔ Knowing the principles behind the different imaging modalities
is useful in judgment and management of different pathological I Impression
conditions. **ito daw yung mas ginagamit ni Doc**
➔ Imaging modalities are not created equal. There is no such
thing as a one size fits all modality. Guidelines in Interpreting Radiographs
➔ It is important to know which modalities have ionizing
1. Check patient name, gender, age, requested exam, and
radiations.
tentative diagnosis
➔ Recognizing contrast reactions can be life saving.
● Ensure that the image you are about to interpret belong to
➔ Having contrast reactions does not mean the patient is barred
the patient
for life.
● Some disease entity occurs more commonly in a specific
II. NORMAL CHEST RADIOGRAPH age group, ethnicity, or gender
● May provide clues to certain disease pathology
A. CHEST RADIOGRAPH 2. Check for requested exam and initial Diagnosis
➔ Chest Radiograph ● Certain disease entities are easily detected provided that
◆ Commonly known as Chest X-ray but referred Chest the diagnostic exam is appropriate
Radiograph by Radiologist ● Cost effectiveness
◆ Single most common diagnostic imaging
◆ Easily accessible, cheap, and effective diagnostic tool
○ Example: Cholelithiasis/Cystitis – Ultrasound (Hindi
na dapat X-ray kasi not all stones makikita nun. )
3. Chest X-ray quality
👩‍⚕️
◆ Diagnostic conditions affecting the chest, its contents,
and nearby structures ● Before interpreting a chest X-ray it is important to assess
the quality of the image. Without this step, you may
B. INTERPRETING A CHEST RADIOGRAPH diagnose disease that is not genuine, or you may be
wrongly reassured.
➔ Interpreting Chest Radiograph
● If the image is not of best quality but the clinical question
◆ When trying to interpret radiograph, always be
can be still answered, a chest X-ray need not be repeated
systematic
● Even sub-optional images demonstrate life-threatening
◆ Check patient name, gender, age, requested exam, and
abnormalities which may require your immediate attention.
tentative diagnosis
4. Adequacy of a Chest Radiograph
◆ Check and compare with old films
● Assess for the following parameters:
● ask the patient if they have old films as some
a. Inclusion
patients ask for a new x-ray for a second opinion
○ A chest X-Ray should include the entire thoracic
◆ Check for adequacy – it would give you confidence in
cage
interpreting the image
○ Image quality – anatomy inclusion
◆ Interpret the image systematically
Inside-Out Approach
Kita ba yung First Rib, Costophrenic
Angles, Lateral Edges of Ribs? 👩‍⚕️

Figure 14. Flowchart of the inside-out approach. For example, some would start
with the innermost organs (i.e., the heart) going outward. They would then write
their report in terms of abnormality, types of pattern, and differential diagnosis. Figure 15. Inadequate (left) vs adequate chest radiograph (right)

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BPE & IMAGING Introduction to Radiology & Normal Chest Radiograph

b. Projection
○ The standard chest radiograph is acquired with the
patient standing up, and with the X-ray beam passing
through the patient from Posterior to Anterior (PA
view) (Figure 16)
○ Anterior-Posterior (AP view): X-ray passes from the
anterior to the posterior of the patient; usually taken
because the patient is too unwell to stand (Figure 17)

Figure 18. PA (left) vs AP view (right)

c. Penetration
○ To determine if a frontal chest radiograph is
adequately penetrated you should be able to see the
thoracic spine through the heart shadow.
○ In the Penetrated view, Left hemidiaphragm may be
visible on the frontal film.

Figure 16. How PA view of X-ray is taken

Figure 19. Penetrated (left) vs Unpenetrated view (right)

○ in the Unpenetrated view, Left hemidiaphragm may

Figure 17. How AP view of X-ray is taken
Table 2. AP vs PA view
AP
The heart size is exaggerated
because the heart is relatively
farther from the detector.
not be visible on the frontal film because the left lung
base may appear opaque
○ In the Penetrated view, Left hemidiaphragm may be
visible on the frontal film.
○ In the Unpenetrated Pulmonary marking, which are
mostly the blood vessels in the ling, may appear
more prominent than they really are.
○ If the study is overpenetrated (too dark), the lung
markings may seem decreased or absent.
○ You could mistakenly think the patient has
PA emphysema or a pneumothorax or, if the degree of
over penetration is marked, it could render findings
The heart size is more relative like a pulmonary nodule almost invisible.
to its size since it is nearer to
the detector.

If the radiograph is not You have a larger view of the

labeled, you may check the lungs since the scapulae are
medial scapular edge. AP retracted.
projection images are of lower
quality than PA images.

The scapulae are not

retracted laterally and remain
projected over each lung

Figure 20. Overpenetrated view

d. Rotation
○ Significant rotation may alter the expected contours
of the heart and great vessels, the hila and
hemidiaphragms

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BPE & IMAGING Introduction to Radiology & Normal Chest Radiograph

○ Assess by studying the position of the medial ends of

each clavicle relative to the spinous process of the
thoracic vertebral body.

Figure 21. The sample figures shows blurry or distorted caption due to excessive
movement due or when the patient is agitated or anxious.

ROTATION

Image A Image B Image C

If the spinous If the spinous If the spinous

process appears to process appears process appears
lie equidistant from closer to the closer to the
the medial ends of medial end of the medial end of the
each clavicle on left clavicle, the right clavicle, the
the frontal chest patient is rotated patient is rotated
radiograph, there is toward their own toward their own
no rotation. right side. left side.

Vebs, Ito daw yung Figure 22. The figure shows a foreign body. Some books refer to this as a
tama. Dapat wala Jewelry Artifact.
talagang rotation!
C. NORMAL X-RAY CHEST ANATOMY
Pitfall of Excessive Rotation ➔ Each anatomical structures should be viewed using a
● Marked rotation can introduce errors in interpretation: systematic approach
○ The hemidiaphragm may appear higher on ➔ Many structures of the chest are readily visible on a chest
the side rotated away from the imaging X-ray, but others are difficult to see
cassette. ➔ Some important structures are not clearly visible at all
○ The costophrenic angle appears blunt. ➔ Other anatomical structures only become clearly visible when

e. Inspiration
abnormal
➔ Structures that you do not see on the normal chest X-ray
◆ Sternum
❗
○ A full inspiration ensures a reproducible radiograph
from one time to the next and eliminates artifacts that ◆ Esophagus
may be confused for or obscure disease. ◆ Spine
○ The degree of inspiration can be assessed by counting ◆ Pleura
the number of ribs visible up to the level of the ◆ Fissures
diaphragm on the frontal chest radiograph. ◆ Aorta
○ Full or adequate inspiration related to diaphragm at the ◆ Phrenic nerves
level of the 9th to 10th posterior rib or 5th to 7th
anterior rib.
Table 3. Differentiating Anterior from Posterior Ribs:
Posterior Ribs Anterior Ribs

- Immediately more apparent - Harder to visualize

- More or less horizontal - Oriented
- Each pair of posterior ribs downward/Obliquely.
attached to the thoracic
vertebral body

f. Motion and Artifacts

○ Patient motion may cause abnormal shadows or cause
image distortion.
Figure 23. Radiograph of a normal chest x-ray

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fissures or you have other signs that would indicate location of

➔ Airways: Trachea, bronchi
◆ The large airways are visible on most good quality chest
X-ray
the mass or the nodule then you can say the exact location.
Otherwise, it is preferable to use zones instead.” ) 👩‍⚕️
◆ They contain air and so are of lower density (blacker)
than the surrounding soft tissues
➔ Hilum (plural: Hili)
◆ Complicated structures consisting of the major bronchi
and the pulmonary veins and arteries.
◆ Majority of the shadow comprises the pulmonary arteries
and to a lesser extent veins
◆ The vessel margins appear smooth
◆ The hila are not symmetrical but contain the same basic
structures on each side
◆ The left hilum should never be lower than the right

👩‍⚕️ ❗
hilum (“pwede sila pumantay but never would the right
be higher than the left” )

Figure 26. Color coded visualization of the lung zones with the middle zone
highlighted with a red box.

Figure 24. Visualization of the anatomical position of the trachea, aorta and
pulmonary artery (left) and their actual presentation in a normal radiograph. Figure 27. Visualization of the lung zones.

➔ Each of these zones occupies approximately one third of the

height of the lungs
➔ The lower zones reach below the diaphragm because the
lungs pass behind the dome of the diaphragm into the
posterior sulcus of each hemithorax
➔ Each zone is compared with its opposite side paying attention
to any asymmetry.
➔ If the lungs appear asymmetrical, it should be determined if
this can be explained by asymmetry of normal structures,
technical factors such as rotation or lung pathology.
Fissures
➔ Invaginations of visceral pleura
➔ Each lung has an oblique fissure
◆ separates the upper from the lower lobe
➔ The right lung has a horizontal fissure
◆ separates the right upper lobe from the right middle lobe
➔ Accessory Fissures (nice to know only)
◆ Azygos Fissure - most commonly seen accessory fissure
◆ Inferior Accessory Fissure
◆ Superior Accessory Fissure
Figure 25. Visualization of the anatomical position of the trachea, left atrium, and
◆ Left Minor Fissure
pulmonary arteries. ◆ RIght Minor Fissure
➔ Are not readily visible
◆ Both hila should be of the similar size and density ➔ There are probably three common relevant factors that
◆ If either hilum is bigger and more dense, this is a good contribute to visibility of fissures
indication that there is an abnormality. 1. Variability in the orientation of the horizontal fissure
Lung Zones between individuals.
● of particular relevance is the variability of the
➔ It is difficult to fit the whole of both lungs into your field of view horizontal fissures.
➔ When describing the lungs it is conventional to divide them into 2. Patient posture
three zones- upper, middle and lower (“Unless you can see the

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BPE & IMAGING Introduction to Radiology & Normal Chest Radiograph

● They are not always perfectly erect for PA/AP chest ◆ For most cases this degree of accuracy is not clinically
radiography. important, unless further action such as biopsy or surgery
3. Presence of disease which either pushes or pulls the is required, in which case other imaging such as CT
fissure (i.e., RML collapse) would probably be performed.
Pleura and Pleural Spaces
➔ Only visible when there is an abnormality present.
◆ Divided into 2: Parietal and Visceral
◆ “If you look at the pleura, you need to check on the
edges of the lung. They are the anatomical structures

present.” 👩‍⚕️
that will only be visible when there is an abnormality

➔ Pathologies may include thickening of the pleura or insinuation

of air/fluid.
➔ ASSESSING THE PLEURA
◆ Abnormalities can be subtle and it is important to check
carefully around the edge.
◆ Make sure you can see lung markings that taper all the

👩‍⚕️
Figure 28. Visibility of the horizontal fissure. way to the edge of the chest wall - “Usually paliit ng paliit
➔ “The only time the fissure would be visible on a frontal chest kaya tapered.”
👩‍⚕️
radiograph is when the horizontal fissure is perpendicular to
the x-ray beam”

Figure 31. Visualization of the pleura and pleural spaces

Figure 29. Displacement of the horizontal fissure
➔ “When the horizontal fissure is likely oblique, whether it’s due Costophrenic Recesses and Angles
to the posture of the patient or variant anatomy of the patient

chest radiograph” 👩‍⚕️

then that’s the time you cannot see the horizontal fissure in a

➔ Azygos fissure (as observed in Figure 22)

➔ Formed by hemidiaphragms and the lateral chest wall. The
angle formed is called the costophrenic angle and it should be
an acute angle.
◆ “Binanggit ko to because you might mistaken this for

👩‍⚕️
fibrosis or presence of a nodule so akala mo may TB
yung patient.”

Figure 32. Visualization of the costophrenic recess and angle

➔ Lateral View
Figure 30. Visualization of the azygos vein and fissure in a normal radiograph ◆ the costophrenic recesses are seen in the region of the
➔ ASSESSING THE FISSURES anterior and posterior costophrenic angles.
◆ Occasionally, lung disease is limited in extent by a
fissure.
◆ This can help locate a disease process more specifically
to a lobe.

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BPE & IMAGING Introduction to Radiology & Normal Chest Radiograph

◆ Below the diaphragm

● Abdominal tumour
● Subphrenic Abscess (abdomen)
● Distended stomach or colon
Heart Size and Contours

❗
➔ The heart size is assess as the cardiothoracic ratio (CTR)
➔ A CTR of >50% is abnormal - PA view only
Cardiothoracic Ratio (CTR)
➔ Cardiac size is measured by drawing vertical parallel lines
down the most lateral points on each side of the heart and
measuring between them.
➔ Thoracic width is measured by drawing vertical parallel lines
down the inner aspect of the widest points of the rib cage and
measuring between them.

Figure 33. Visualization of the costophrenic recesses in lateral view

➔ ASSESSING THE COSTOPHRENIC ANGLES

◆ The costophrenic angles should form acute angles
sharp to a point.
◆ Costophrenic angle blunting may relate to pleural fluid
collection and other pleural disease.
◆ Lung hyper-expansion can also lead to blunting of the
costophrenic angles.
Diaphragm
➔ It separates the comparatively dense (whiter) abdominal
organs below it, from the relatively less dense (blacker) lung
above.
➔ Each hemidiaphragm should appear as a rounded domed
structure with a crisp white edge contrasted against the
adjacent dark lung.
◆ “so yung part ng diaphragm below should not be visible
Figure 35. Sample values for CTR computation.

the liver.” 👩‍⚕️

kasi same sya ng density with your other structures like

➔ The right hemidiaphragm is usually a little higher than the left, 👩‍⚕️
➔ “For example, ang nakuha mo is 15.2 and 32.8 so you get the
ratio. If it is less than 0.5, then it’s still normal.”
to accommodate the liver (within 1 intercostal space).

Figure 34. Visualization of the diaphragm in the AP and Lateral view

➔ How would you tell if it's a right or left hemidiaphragm on a

lateral view? “The only way you can tell is if you look at the

side.” 👩‍⚕️
stomach gas. Normally ang stomach gas natin is on the left

➔ Elevated hemidiaphragm can result from many causes:

Figure 36. Visualization of the heart valve borders.
◆ Above the diaphragm - decreased lung volume
● atelectasis/collapse ➔ “Yung right heart border mo is not actually part ng ventricle. It
● lobectomy/pneumonectomy is not border-forming sa PA view. Ang nagfoform actually ng
● pulmonary hypoplasia right heart border mo would be your right atrium. Whereas the

👩‍⚕️
◆ Diaphragm left heart border would be from the right atrial appendage and
● Phrenic nerve palsy mostly from your left ventricle.”
● Diaphragmatic Eventration
● Contralateral CVA (cerebrovascular accident) -
usually MCA (middle cerebral accident) distribution

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Figure 38. Visualization of the aortic knuckle and the contour of the descending
Figure 37. Visualization of the heart valve borders - lateralview. thoracic aorta.
➔ On the lateral projection, the cardiac silhouette is formed by: ➔ “For example, kapag aneurysm, madidistort yung yellow line or
◆ the anterior border by right ventricle you have consolidation or mass na katabi ang iyong aorta,

👩‍⚕️
◆ the posterior border by left atrium (superiorly) and left then madidistort yung contour ng red line or mawawala yung
ventricle (inferiorly) line. That is what you called a silhouette sign.”

right atrium kasi nasa likod na sya. 👩‍⚕️

➔ Ang hindi naman border forming sa lateral view would be your
Aorto-Pulmonary (AP) Window

Mediastinal Contours ➔ The aorto-pulmonary window lies between the arch of the aorta
and the pulmonary arteries
➔ The mediastinum consists of potential spaces used to describe ➔ This is a potential space in the mediastinum where abnormal
the location of disease processes enlargement of lymph nodes can be seen on a chest X-ray.
➔ These potential spaces are not defined on a normal chest
X-ray, but an awareness of their position can help in describing
the location of disease processes.
➔ Subdivided into
◆ Middle Mediastinum:
● contains the heart and great vessels
◆ Anterior Mediastinum:
● potential spaces in front of the heart
◆ Posterior Mediastinum:
● behind the heart
◆ Superior Mediastinum:
● above the heart
➔ There are several structures in the superior mediastinum that
should always be checked.
◆ aortic knuckle
◆ aortopulmonary window
◆ right paratracheal stripe
Normal Aortic Knuckle
➔ The aortic knuckle (red line) represents the left lateral edge of
the aorta
➔ The contour of the descending thoracic aorta (yellow line) can
be seen in continuation from the aortic knuckle. Figure 39. Visualization of the AP window
➔ Displacement or loss of definition of these lines can indicate Right Paratracheal Stripe
disease, such as aneurysm or adjacent lung consolidation.
➔ From the level of the clavicles to the azygos vein,the right edge
of the trachea is seen as a thin white stripe.
◆ White Stripe: yan ang tinatawag na right paratracheal
stripe.
➔ This appearance is created by air flow density (blacker) lying
either side of the comparatively dense(whiter) tracheal wall.
➔ If this stripe is thickened(normally less than 3mm)this may
represent pathology such as paratracheal mass or enlarged
lymph node.
➔ The left side of the trachea is not so well Defined Because of
the position of the aortic arch and great vessels.
➔ The left side of the trachea is not so well defined because of
because of the position of the aortic arch and great vessels

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Figure 42. Radiograph showing nipple markings

➔ Fat is less dense than muscle and so appears darker,but has a

smooth outline as opposed to subcutaneous emphysema
which are irregular signifying air tracking.

Figure 40. Visualization of the right paratracheal stripe

Soft Tissues
➔ Whenever you look at a chest X-ray, have a look at the soft
tissues, especially around the neck, the thoracic wall and the
breasts.
➔ If a patient has very thick soft tissues due to obesity, underlying
structures such as the lung marking may be obscured.
➔ Large breasts may obscure the costophrenic angles, giving the
impression of the presence of pleural effusions.
Figure 43. Radiograph showing normal fat tissue (left) compared to Emphysema
(right)
Bones
➔ Bones are the densest tissue visible on normal chest x-ray.
➔ Assess the bones on every chest X-ray
➔ Check for abnormalities of single bones and for diffuse bone

👩‍⚕️
◆ minsan nagiging white yung lower lung zones dahil sa disease
dense na breasts ➔ The bones are helpful in assessing the quality of the chest
X-ray.

Figure 44. Radiograph showing normal position of some thoracic bones.

Figure 41. Radiograph showing asymmetric breasts

➔ This should not be mistaken for underlying lung disease or

prior mastectomy unless this known from the history
Nipple Markings
➔ The nipples can be clearly seen on this chest X-ray
➔ If there is any doubt then repeat chest X-ray with metallic
markers to indicate the position of the nipples.
◆ most of the time makikita ang nipples, symmetrical and
halos same size. Pero once may nakita kayo na isang
side lang and then you’re not sure if nipple talaga siya

👩‍⚕️
then you can repeat the chest X-ray with metallic marker
to indicate the position of the nipple.

likely mean nipple talaga yun. 👩‍⚕️

◆ Kung nag overlap ang nodule sa marker,then that most Figure 45. Radiograph showing normal position of shoulder bones.

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➔ ASSESSING BONY STRUCTURES REFERENCES

◆ Minsan, may mimiss talaga ng rib fractures kasi ang
1. Dr. Wee’s ppt
chest X-ray ay hindi para sa fractures para talaga sa
lungs. Iba ang factoring, but you still have to check. 👩‍⚕️ REVIEW QUESTIONS
👩‍⚕️
◆ If the patient is complaining of rib injury, then it is better
to ask to do a thoracic cage (xray).
◆ Acute rib fractures may be missed in the standard chest
1. The anatomical structures on a normal chest x-ray should be
viewed using what approach?
x-rays, therefore are not helpful if there is clinical
A. Clinical
suspicion of aribinjury, unless complications such as
B. Systematic
pneumothorax are suspected.
C. Regional
◆ Request for x-ray of the thoracic cage instead if
D. General
warranted
2. The lungs are divided into how many zones?
◆ Occasionally, you will see an important abnormality of the
A. 2
bones on a chest X-ray such as metastatic deposit.
B. 3
◆ These may be seen in the bones at the edge of the
C. 4
image such as the scapula or proximal humerus. D. 5
◆ Therefore, always look carefully at the bones when 3. Accessory fissure that is usually mistaken for fibrosis or
viewing a chest X-ray. presence of nodule
A. Superior Accessory Fissure
B. Left Minor Fissure
C. RIght Minor Fissure
D. Azygos Fissure
4. It lies between the arch of the aorta and the pulmonary
arteries.
A. Right paratracheal stripe
B. Descending thoracic aorta
C. Aorto-pulmonary window
D. Aortic knuckle
5. What is the hounsfield unit for the most dense part of the body
A. -1000
B. 0
C. +1000
D. +3000
6. During a T2 MRI scan, water is _____
A. Dark
Figure 46. Radiograph with short exposure time (left) vs one with long exposure B. Light
time (right) C. Can not be determined
D. Black
➔ Long Exposure Time: 7. Statement 1: In CT scan, radiofrequency is being used to
time. 👩‍⚕️
◆ Mas sharper ang bones compared to a short exposure

◆ Mas evident yung mga pulmonary vascular markings. 👩‍⚕️

conduct the polarity of hydrogen atoms
Statement 2: MRI uses radiation to create high detailed
images of the anatomies
A. Only statement 1 is true
B. Only statement 2 is true
C. Both statements are true
D. Both statements are false
8. The patient is experiencing nausea after a contrast
examination. What should be the proper response
A. Direct medical attention
B. The patient needed to be brought up to the
Emergency room
C. Immediate administration of Antihistamine to prevent
allergic reactions
D. Supportive measures only
9. Contrast Medium of choice for MRI
A. Microbubbles because of its lipid contents
B. Gadolinium because of its paramagnetism
properties
C. Iodinated Contrast medium because of its
accessibility
D. All can be used in MRI procedures
Figure 47. Example of a radiograph on the left anterior oblique view 10. What can be done if nipples are not clearly seen in the X-ray
➔ Thoracic Cage: A. Nipples are not important in the X ray
B. Repeat the procedure with different angle
◆ “oblique view” (see Figure 47)
●
●
naka-fillet lahat ng ribs 👩‍⚕️
pag may fracture mas madali makita 👩‍⚕️
C. Use metallic marker
D. Assume the most possible placement of the nipple
11. He introduced film as an alternative to the glass photographic
plates that scientists previously used

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BPE & IMAGING Introduction to Radiology & Normal Chest Radiograph

A. James Robertson
B. Wilhelm Conrad Rontgen
C. Thomas Alva Edison
D. George Eastman
12. The following are examples of imaging modalities that use ionizing radiation EXCEPT
A. Fluoroscopy
B. Angiography
C. Ultrasound
D. CT scan
13. Deterministic Effects of radiation are probabilistic effects that happen by chance
A. True
B. False
14. The bombing of Nagasaki and Hiroshima is a famous example of this type of radiation
A. Non medical, Man-made Radiation
B. Natural Background Radiation
C. Medical Radiation
15. Represents the left lateral edge of the aorta
A. aortic knuckle
B. aorto-pulmonary window
C. cardiothoracic ratio
D. right paratracheal stripe

Answers: 1B, 2B, 3D, 4C, 5C, 6A, 7D, 8D, 9B, 10C, 11D, 12C, 13B, 14A, 15A

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 APPENDIX
Appendix A. Summary of Diagnostic Imaging Modalities
MODALITY WHAT IT REVEALS ADVANTAGES DISADVANTAGES CHIEF USES LIMITATIONS

RADIOGRAPH / X-RAY Bony and soft tissue ● Low radiation dose Provides basic anatomic ● Skeletal structure
● Static image anatomy ● Inexpensive information for only a ● chest
generated following ● Readily available few tissue densities ● diagnosis/detection of
the passage of x-rays ● Quick a few intra-abdominal
through the patient ● Minimal preparation diseases

FLUOROSCOPY Anatomic and functional ● Provides images in ● Radiation dose may ● GI peristalsis
● Uses continuous x-ray information real-time be substantial ● Movement of
beams to create a ● Widely available ● More expensive than diaphragm with
real-time visualization radiography respiration
of moving anatomic ● Cardiac actions
structures ● Barium studies
● Guide for catheter
placements

ULTRASOUND Real-time evaluation of ● No radiation exposure ● Operator dependent: ● Neonatal intracranial

● Relies on properties of soft tissues ● Painless images obtained are pathology
acoustic physics (intra-abdominal organs) ● May be portable highly dependent on ● Suspected
(compression/rarefacti and vessels ● Widely available sonographer’s hepatobiliary disease
on, reflection, expertise ● Evaluate most
impedance, etc) to ● More expensive than abdominal organs
localize and radiography ● Musculoskeletal
characterize different imaging
tissue types ● Neck imaging
● ECG
● Vascular sonography

ANGIOGRAPHY Vascular structures Can be diagnostic and ● Renal insufficiency ● Diagnosis and
● Conventional & Digital therapeutic and hypersensitivity to treatment of vascular
Subtraction iodinated contrast pathologies
Angiography: gold media are relative
standard for contraindications
evaluation of vascular ● Uses ionizing
pathologies radiation
● CT angiography: uses
 CT and ionizing
radiation; requires IV
contrast
● MR angiography: can
be done with or
without IV contrast;
used as an alternative
to CT and/or
conventional
angiography

COMPUTED Anatomical information ● Greater anatomic ● Higher radiation dose ● Screening evaluation
TOMOGRAPHY (CT) from almost all organ details, especially with ● May require oral/ of nonspecific
● Uses a computer to systems in the body IV contrast rectal/ IV contrast symptoms
mathematically ● Very fast exam ● More expensive than ● Evaluate for
reconstruct a duration x-ray and ultrasound infectious/
cross-sectional image ● Can provide 3D ● Dense bone (e.g., trauma-related
of the body from information petrous ridge) and pathologies
measurements of metal cause severe ● Diagnose and monitor
x-ray transmission artifacts cancer
through thin slices of
tissues

MAGNETIC Detailed high-contrast ● Allows for multiplanar ● Often requires ● Examination of the Absolute
RESONANCE resolution pictures of and 3D evaluation sedation in children CNS Contraindications:
IMAGING (MRI) organs ● Does not require younger than 7 years ● Musculoskeletal ● Cardiac pacemaker
● Produces tomographic routine use of IV and some in adults evaluation ● Intracranial vascular
images by means of contrast material for ● Expensive ● Cancer evaluation and clips
magnetic fields and imaging of abdomen ● Scanner is noisy surveillance ● Neurostimulators of
radio waves and pelvic (unlike CT) ● Picture quality is any kind
● Superior depiction of highly susceptible to ● Intraocular metallic
soft tissue and organ movement foreign body
contrast differences ● Ossicular implants
● No radiation exposure ● Any metallic implants,
● Painless rods, metal plates,
and pins
● Heart failure
● Surgical clips on
arteries and wire
 sutures

POSITRON EMISSION Some anatomic details ● Provides metabolic ● More expensive than ● Detection of cancer ● Can sometimes show
TOMOGRAPHY (PET) / and functions of organs and functional CT and MRI ● Cancer localization areas of high activity
SINGLE PHOTON and soft tissues information ● Strict scheduling and spread → may be mistaken
EMISSION COMPUTED ● May take a long time ● Therapy response and for cancer
TOMOGRAPHY and require sedation monitoring ● Conditions like
(SPECT) ● Offers little anatomic rheumatoid arthritis or
● Uses radiotracers to information alone TB absorb a lot of the
show both normal and ● Not readily available tracer and can cause
abnormal biochemical confusing results
activity ● Can be less accurate
in certain situations
(i.e., less active
tumors may not be
detectable, etc)