Radiology Notes

Monday, August 19, 2013 2:37 PM

http://fitsweb.uchc.edu/student/radiology

http://www.med-ed.virginia.edu/courses/rad/index.html http://www.radiologyassistant.nl/en/p497b2a265d96d/chest-x-ray-basic-interpretation.html#in514d80fcb1408
http://www.stritch.luc.edu/lumen/MedEd/Radio/curriculum/Medicine/Pleural_effusion1.htm

TEST 2 hours - 80 questions Management, next step, cases with images, just an image Images repeated on exam that we saw in class

Introduction to Radiology/Imaging
Plain Film Plain x-ray is a 2D representation of a 3D object. Only when you see the object in two planes can you see what something is and defi ne its true shape X-rays have 5 tissues you can identify based on absorption coefficient; need difference in absorption coefficient of 5% o Air (black): photo does right through and doesnt get absorbed; -1000 o Water, muscle, blood, soft tissue (gray) o Fat (dark gray) o Bone (white): calcium o Metal (white); +1000 Brightness on x-ray: lead > barium > bone > muscle/blood > liver > fat > air Normal chorinal angle is about 70 degrees. There are subchorinal LNs which can elevate the main stem bronchus PA vs. AP always labeled by direction of path of beam (supine is AP, anterior to posterior) o routine lateral is called left lateral, beam goes from right to left Collimator lead square used to limit boundaries of x-ray beams; triangulation: use images with history and physical Too much light = over exposed, so looks black; not enough light = underexposed (energy cant quite penetrate)

MRI

Non-ionizing radiation, Great for looking at soft tissues Contraindication with pacemakers/ferromagnetic devices T1 - fluid is black T2- fluid is white

Fluoroscopy
Continuous stream of x-ray to watch whats going on in real time; can watch motion Downside is higher dose of radiation Can use with contrast agents o Inulin gets picked up by the kidney; Intravenous Pyelogram = inulin tagged with iodine

CT
X-ray in thin slices; very sensitive; each line = ray; 1000 slices of 1mm cuts Each slice has three dimensions Orient yourself look at patients feet, upward

Nuclear Imaging Outgrowth of Manhattan project (development of first atomic bomb) Radiation with alpha/beta/gamma PET (Positron Emission tomography) scan: tag positron with glucose and look for metabolically active tumors o Hope is to one day tag it so it can destroy these areas
Ultrasound High frequency sound waves in water (know speed of sound in water) No ionizing radiation, relatively inexpensive, real time evaluation, can utilize color Doppler to look at flow Applications: liver, gallbladder, biliary system, kidney; terrible with bowel Radiation Dangers and Protection Unit of energy in x-ray is called a Rad o Difference in absorption in different types of tissue Sievert is the amount of radiation a particular unit of tissue receives For the average CT of chest or abdomen, dose is 10-15 milliSieverts (CXR is .01 mSv) o CTA is 15-20 milliSieverts o Average CXR is 0.01 milliSieverts o 10milliSieverts = 1/1000 risk of developing cancer o Abdominal CT scan: 1/143 risk o Normal radiation from natural sources normally 1-3 mSv/year In areas of high background, 3-13 mSv/year o Over 50 mSv at one time is high risk for developing cancer Radiation injury: When you get a photon of energy that comes through the tissue at the right amount, it knocks out one of the outer electrons and creates and ion (in water, activates hydroxyl ion). This can potentially cause damage to your DNA. Photon can actually damage the DNA or break the strand if it hits it directly.

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hydroxyl ion). This can potentially cause damage to your DNA. Photon can actually damage the DNA or break the strand if it hits it directly.
Optimization of protection by keeping exposure as low as reasonably achievable; dose limits for occupational people Medical, occupational, and public exposures all exist

CHEST
40% of all imaging done in US are CXR Adequate film: o CXR ideally done in PA position, which is better for heart size (10 -20% overestimation when do an AP). Done at 72 inches at maximal inspiration Normal heart should be less than 50% of cardiothoracic ratio o Adequate inspiration: 9 posterior ribs on R side; if see 11-12 ribs, likely COPD 2nd anterior rib follow-up, corresponds to 2 nd posterior rib o Non rotation: clavicles should be equidistant from clavicles If spinous process closer to left clavicle, then rotated left anterior oblique o Degree of penetration: densitometer, vertebral bodies through the density of heart, pulm vascularity to LLL through heart o Routinely take left lateral (want heart on left side of chest closest to the film) Systematic Approach o Bony framework Bony structures: cervical spine, clavicles, AC joint and acromion, scapula, glenoid, coracoid process, humeral head, ribs, vertebrae, pedicl es (will often see

metastatic disease here)

o Soft tissues Soft tissue: calcification of carotid, LN calcification, masses, abdomen, stomach bubble, splenic flexure, neck and chest wall o Lung fields and hila (see his tutorial) Right upper, middle and lower lobes; left upper and lower lobes Left The right lung comprises 10 segments: 3 in the right upper lobe (apical, anterior and medial), 2 in the right middle lobe (me dial and lateral), and 5 in the

right lower lobe (superior, medial, anterior, lateral, and posterior).

1 fissure- oblique Right The left lung comprises 8 segments: 4 in the left upper lobe (apicoposterior, anterior, superior lingula, and inferior lingul a) and 4 in the left lower lobe

(superior, anteromedial, lateral, and posterior).

2 fissures

TB likes posterior segment of upper lobe Immunocompromised- superior segment of lower lobe
o Diaphragm and pleural spaces Right hemidiaphragm is higher than the left if left higher may have loss of lung volume (e.g. atelectasis) o Mediastinum and heart o Abdomen and neck o Pit falls Poor inspiration Over or under penetration Rotation Lungs o Upper, middle, lower lung field; hilar structures including PA and PV; pulmonary vascularity, diaphragm, costophrenic sulcus; right hemidiaphragm is usually higher than left

(if left higher, might be phrenic nerve palsy but most commonly loss of lung volume such as atelectasis; tumor). Then compar e one side to the other
o Carina

Look for lymph nodes in this area (e.g. stage 4 lung cancer, no longer operable)
Silhouette/Structure Contact with Lung

Upper right heart border/ascending Anterior segment of RUL aorta Right heart border Upper left heart border Left heart border Aortic knob RML (medial) Anterior segment of LUL Lingula (anterior) Apical portion of LUL (posterior)

Anterior hemidiaphragms

Lower lobes (anterior)

(right anterior oblique = left posterior oblique) Medial segment of middle lob abuts the heart

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 Heart o Cardiac shadow/size. Borders of heart, trachea and bifurcation, atria/ventricles o Right atrial enlargement Could be tricuspid regurgitation Right sided strain Lateral view o Square vertebrae, aorta and scapula look a bit different. Lungs should be blacker as you go down in a lateral view. o On lateral, to know which diaphragm youre looking, gastric bubble on left. Left hemidiaphragm has heart on it Silhouette sign two tissues of similar densities that are

next to each other, you wont be able to recognize the difference

o Vertebra should get progressively darker as you go down

Look at segments : o right upper lobe segments superior, anterior, posterior (posterior associated with TB); left upper lobe segments anterior, apical posterior; right lower lobe superior,

anterior, posterior, mediolateral

Pathology / other o Tracheal deviation: thyroid, thymus, teratoma, etc. o Most common cause of perforated viscous is an ulcer (duodenal or gastric). Anytime you suspect a perforation or a leak from an anastomosis etc ----can ONLY use water

soluble contrast!!! Other causes- diverticulitis (unusual), iatrogenic, colon ( intraperitoenum cecum, transverse, sigmoid, jejunum) If patient cannot stand, do Left Lateral Decubitus Do left side down so that air goes up to right side and see air above liver

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 Do left side down so that air goes up to right side and see air above liver o Hiatal hernia can see it hyper dense behind the heart. On lateral, see air pocket o May occasionally have cervical (rudimentary) ribs, air in subcutaneous tissue, absence of clavicles etc. Can use a grid to c lean up scatter. Consolidation and atelectasis (collapsed alveoli can be due to obstructive (plugging), compression (fluid collection), scarring) o air bronchogram can see bronchus clearly because alveoli are filled with something (consolidation or atelectasis, differentiate by clinical f indings) if see bronchograms, cant be due to something plugging up bronchus An air bronchogram is a tubular outline of an airway made visible by filling of the surrounding alveoli by fluid or inflammat ory exudates. Six causes of air bronchograms are; lung consolidation, pulmonary edema, nonobstructive pulmonary atelectasis, severe interst itial disease, neoplasm, and

normal expiration.
o Any time you see loss of volume, post-obstructive pneumonias can occur MUST obtain follow-up x-ray 4-6 weeks o Loss of volume = atelectasis due to endobronchial obstruction lesion (e.g. carcinoma) o Look at level of diaphragms for evidence of loss of volume. Can also have mediastinal shifting due to loss of volume. o *If see heart right border, RIGHT MIDDLE LOBE normal . o Can see growth plates in humeral heads signifies child o Ex. RLL pneumonia --- can see heart border on lateral CXR (posterior border of LV) o Lingula blocks left horder border

Elevated left hemidiaphragm o Loss of volume - atelectasis, PNA o Abdomen mass pushing it up o Ascites (should push up both) o Paralyzed left hemidiaphragm
Tension Pneumothorax If ever a question of pneumothorax, order an expiratory CXR. Tension pneumo decreases venous return o Air inside the pleura, collapses lung See line of visceral pleura Mediastinal shift Bigger than you suspect totally straight line think hydropneumothorax (or hemopneumothorax if see bullets) o Air fluid line- straight line
Can have bullous emphysema - can grow large enough to cause compression of the lung

COPD o Beyond 10 ribs = obstructive disease

Mediastinal emphysema (air in mediastinum = pneumomediastinum) can be caused by esophageal tear or tracheal rupture, iatrogenic from procedure, idiopathic o do a water soluble contrast esophagram if suspect tear o medical emergency because can lead to mediastinitis

Epiglottitis thumb sign, steeple sign Pleural Effusion o opacification of the left hemithorax due to large amount of fluid, with shift of mediastinum likely due to pleural effusion meniscus line pleural effusion fluid PA position: need 200-500mL of fluid to blunt costophrenic sulcus Lateral: 150mL to blunt costophrenic angle If suspect small amounts of fluid in pleural space can get decubitus film If suspect pleural effusion on right, get right lateral decubitus. If suspect pneumo on right, get left lateral decubitus. Effusion is fluid in a potential space, there is no air there normally Can have shift of mediastinum to side of opacification loss of volume (e.g. left pneumonectomy)

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Can have shift of mediastinum to side of opacification loss of volume (e.g. left pneumonectomy)

Masses o Mass (>3cm) vs nodule (<3cm) o Describe characteristics : density (does it contain calcium benign, inflammatory process with dystrophic calcification). Other examples: describing mass: well

circumscribed, smooth and uniform shard borders or irregular spiculated borders or lobulated borders, uniformly dense, speckl ed calcification, ring like, necrosis or cavitation (malignancies break down and run out of blood supply) When you see a nodule or a mass in the lung, check to see if they have older films A lesion that has demonstrated no change over a period of two years is considered to be benign Ghons complex: calcification in hilum (likely to have calcifications in periphery as well) Granulomas calcify If not as dense, is likely tissue density instead of calcification. o If new, will need to biopsy. If biopsy and malignant, do CT scan to check for metastasis o Irregularly shaped lesion that infiltrates into surrounding tissue; air in center so know it is cavitating. It can be a tumor or a lung abscess (fever, white count, etc). If see fissure elevated, have loss of volume. (horizontal fissure is bowed up) When have irregular mass and loss of volume, likely tumor (pneumonias do not often give loss of volume) Air in middle of lesion is necrosis
o Alveolar vs. interstitial processes Alveolar processes are acute - PNA Fluffy, white, not well defined Interstitium- chronic- fibrosis
Cavities o Thin-walled cavity: bleb, bullae, coccidiomycoses (grape-skin cavity) o Thick-walled cavity (fairly well-circumscribed): granulomatous disease, histoplasmosis (ohio), blastomycosis, TB, fungal diseases o Thick-wall and lobulated centrally squamous cell carcinoma NEVER drain a lung abscess because can lead to an empyema (infection in the pleural space, which you have to drain); tx abscess with antibiotics Mediastinum o Ant mediastinum retrosternal goiter, lymphoma, thymus , thyroid, lipoma, germ cell tumors (teratoma), diaphragmatic hernias (lumbocostal, hiatal) 4 T's (teratoma, thymus, thyroid, terrible lymphoma) `Thymoma- Myasthenia Gravis (80-20) ---what percentage of people have thymoma in MG - 20% o post mediastinum neurogenic tumors ( schwanomma), esophagus (diverticulum, neoplasm), diaphragmatic hernia, germ cell tumor (rare) o middle mediastinum enlarged LNs, cardiomegaly, vascular aneurysms , cyst (eg pericardial, GI, bronchial)

sarcoidosis paratracheal adenopathy, bilateral hilar adenopathy hilar adeopathy can also be lymphoma multiple nodules of varying sizes almost always metastases o Vs multiple nodules on same side of chest (granulomatous disease) Posterior segment of upper lobe (avg pt) and superior segment of lower lobe: think TB (old) o Elevated right hemidiaphragm - loss of volume o When also affecting the vertebral column Potts disease Aspergillosis: fungus ball in cavity

5 Categories: Congenital, trauma, infectious, neoplastic, everything else (metabolic) Other:

Direct signs of collapse indicate diminished lung volume: 1) Septae will be displaced TOWARD the collapsed lung 2) The lung will be more radioopaque due to loss of air.

3) The bronchi will appear crowded together.

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3) The bronchi will appear crowded together. Indirect signs of collapse:

1) Hilum/Mediastinum will be displaced TOWARD the collapsed lung.

2) Ipsilateral hemidiaphragm will be elevated. 3) Rib cage size will appear diminished. (Compare with old films!) 4) Compensatory emphysema:contralateral lung appears more radiolucent.

Patterns of collapse:
Lobe Direction of collapse Shift of fissures RUL/LUL Superiorly, medially, anteriorly On right, minor fissure shifts upward and medially (PA)

RML

Inferiorly and medially

Minor fissure shifts downward (PA)

RLL/LLL Inferiorly, medially, posteriorly Major/oblique fissures shift downward and backward (LAT)

HEART

can see calcium in intima of aortic aneurysm o Atherosclerosis of intima can see prominent ascending aorta on RSB (Marfans if 66, syphilis rare, post -obstructive aortic dilatation, atherosclerosis) o Aortic stenosis CHF with pulmonary edema; CAD/ischemic myopathy is most common cause of pump failure o Normally can see hilar vessels o Pulm edema- see bat wing configuration o Nl LVEDP - <12 Increased venous pattern in the apical segments ( cephalization) (increased in blood flow to the upper lung veins) (cephalization goes away if patient lays down?) o Vasoconstriction around lower lobe veins shunts blood to the upper lobe veins o Fluid around vessels cause perivascular cuffing; mediated by oncotic and osmotic forces o will eventually lead to interstitial fluid leading to kerley b lines (lymphatics taking fluid away); kerley b lines are best seen in lower corners of the film , horizontal lines Patient gets Paroxysmal nocturnal dyspnea Will hear a wheeze b/c there is fluid in interstitium = CARDIAC ASTHMA LV pressure 18-20 Then see Frank pulmonary edema (pressure 24-25) - fluid everywhere including the alveoli Fluid gets dumped into pleural space --> pleural effusion (EF = percentage of blood ejected in each stroke---decreased in HF) MR: holosystolic murmur at apex radiating toward axilla. See left ventricle and left atrial enlargement o Elevation of left main stem bronchus (normal angle should be about 70 degrees) Can get fluid in pericardial space pericardial effusion (dx by ECHO) o Globular heart (water bottle shaped)

MITRAL STENOSIS: If left ventricle is normal but left atrium is enlarged, likely Mitral Stenosis (diastolic murmur); sometimes can see left atrium on right side of heart. Also

see large PA due to secondary pulmonary HTN

*Left atrium enlargement from mitral regurgitation and mitral stenosis o Mitral stenosis - diastolic murmur LV not enlarged o Mitral regurgitation- holosystolic murmur radiating to axilla Left ventricle is enlarged **Left border- aortic knob, main pulmonary artery, left atrial appendage (left atrium), Left ventricle Unable to see arch of aorta o Coarctation of aorta o Notching of the ribs normal pacemaker should be in apex of right ventricle o Trabeculated o ICD o Bipolar pacer- two leads

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o Bipolar pacer- two leads Central line complications: thrombosis, infection, PTX (central lines should go in distal superior vena cava just proximal to the entrance into the entrance of the right atria- 2 cm above junction of SVC and RA) - needs to be past valve in brachiocephalic o Right atrium not a good place b/c tricuspid valve is there and can cause arrhythmia ; non infectious endocarditis

Other - VSD o - ASD o o o - PDA o

RV and LA will be enlarged LA is normal to small RA will be enlarged RV will be enlarged

LA enlarged and LV enlarged

What Radiology tests to order and when!

ACR website has appropriateness criteria - clinical modules GI o Acute massive hemorrhage- significant bloody aspirate, hematemesis, hematchoezia or severe melana o Upper GI bleeding - s1. stabilize, 2. endoscopy Ulcers, varices are most common causes Endoscopy - to find ulcer and sclerose it or varix o Lower GI bleeding MCC- diverticulosis (also AVM) Technetium labeled Radionucleotide RBC scans LLQ - left hemicolectomy Colonoscopy vs barium enema Enteroclysis for small bowel studies (usually do to polyps---tube down inject barium to see where it goes) o Angiography Diagnostic: AV malformations, angiodysplasia Treatment Chronic blood loss o Fe def anemia or positive stools for blood Air contrast barium enema Role of colonoscopy Air contrast GI series Small bowel study Angiography Diverticulitis o Symptoms: LLQ pain, fever, occasional diarrhea o CT abdomen AND pelvis with and without contrast (delay imaging two hours after contrast) With oral contrast and IV contrast Gallbladder disease o U/S, HIDA scan HIDA shows you if cystic duct is open or closed; drug tagged with radioactive Body treats substance like bile ---if it goes into gallbladder you know the cystic duct is patent and does not have acute cholecystitis o Gall bladder wall thickening- 3mm or more is indicative of gall bladder wall inflammation o US- look for stones, wall thickening, cholecystic fluid Urinary Tract o NON CONTRAST CT bc stone is white on x ray and contrast is same color o Calculi: helical CT most accurate o Obstructive uropathy: U/S will tell you size, configuration of kidneys, and if obstruction exists Could do plain xray to see if you can see the stone If small and can't see it it will pass by itself Postmenopausal bleeding o History question hormone use o U/S transabdominal if question transvaginal o If questions remain, MR Adnexal masses o U/S transabdominal and/or transvaginal Ectopic pregnancy (hormone levels, U/S with color Doppler imaging) o MR imaging Chest lesions o Solitary pulmonary nodule CXR (previous films, age, hx, nodule size and configuration) o CT o PET scanning (benign vs malignant); nodule has to be 2cm in size to be seen Positive nodule must be biopsied b/c high probability of malignancy o Pulmonary Embolus CXR (other causes), V/Q scan, spiral CT, angiography, role of MRA suspect PE, before CTA do a plain film xray to rule out other causes do v/q scan for pregnant patients, contrast allergy (half the amount of radiation in CTA) Ventilation - breathe in radioactive xenon- perfusion- give tagged albumin to see if there is an area that doesn't perfuse Acute stroke o NON CONTRAST MRI o Most strokes are embolic --- obstruction to blood vessel o MR after 24 hours o Angiography Most often for therapy Catheter into common carotid and inject tPa- helps prevent GI bleeding Encephalitis o Differentiate b/w hemorrhage, abscess, tumor o MR imaging o If unavailable in area then CT with contrast Sinusitis o Coronal CT (non contrast) o First 30 days you don't image o Imaging to see where blockage is so surgeon can go in Low back pain o Dont image unless red flags o If not better after 30 days- MR imaging

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o If not better after 30 days- MR imaging o MR imaging, CT, plain films only if trauma, lumbar discography o Fever (osteo), malignancy (mets), and trauma (compression fx) are red flags

Child Abuse o Skeletal survey To include skull, chest, lumbar spine, and extremities (single large x -ray inadequatE) Multiple fractures at different stages of healing Most common are stripping of the periosteum and avulsions at growth plates (small avulsion fractures at metaphyses of bones) View with suspicion- fracture in an ambulatory child; metaphyseal avulsion fractures

LAO- right heart becomes more prominent FLUID GIVES MENISCUS

ICU Lecture
reading ICU CXR o check it is an adequate film o check for tubes, lines, catheters 30% placed incorrectly

ICD- thick wire portion

HEART VALVES

Tricuspid and mitral valve below line Aortic and pulmonic above struts of prosthetic valves go in direction of flow

endotracheal tube o End should be 4cm above the carina o complication of trach tubes stricture, most common is aspiration pneumonia, atelectasis if placed too far and ends up in RMSB Flexing head moves NG tube downward, could enter RMSB o cuff can press against trachea and can compress blood supply (to prevent this, drop cuff every hour); when drop it, secretion s accumulate above the cuff (can lead to aspiration

pneumonia)
o halfway between chorine and thoracic inlet

A portable chest x-ray and close-up of a properly placed endotracheal tube (arrows) and location of carina (^).
Chest tubes o Removing air or fluid o PTX- up higher b/c air up higher o Fluid- lower Central Line o The intravascular volume status of critically ill patients is crucial to their management. A CVP can be obtained directly via central vein catheters placed either through the

subclavian veins or the internal jugular veins. Similarly, intravenous catheters may be used to infuse large volumes over lon ger periods of times with little chance of thrombosis.
o Ideally the catheter tip should lie between the most proximal venous valves of the subclavian or jugular veins and the right atrium. o How far from the brachiocephalic vein are these valves? o Approximately 2.5 cm from where they join to form the brachiocephalic vein. Usually the last valve in the subclavian vein is at the level of the anterior portion of the first rib. Therefore, the tip should be medial to this point.

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Therefore, the tip should be medial to this point.

Dophoff tube o thin tube used for feeding with radiopaque end (metal tip) o Smaller Swan ganz catheter o should be in either right of left pulmonary artery at the edge of the cardiac shadow o Can be inserted in femoral, subclavian or jugular o Triple lumen o 2 complications: thrombosis of vessel or hemorrhage o Need to decompress balloon after you wedge the catheter, otherwise will occlude blood flow and create a wedge -shaped infarct

After open heart surgery, want to put in mediastinal drains (otherwise accumulation of blood can cause tamponade) o Underneath heart on pleural surface

Film - Cannot see through the left heart to the pulmonary vessels - Large white thing behind heart- not pleural fluid b/c can see costophrenic sulcus - could be consolidation or atelectasis of left lower lobe - PNA vs. atelectasis - clinical difference

ARDS o damage to type II pneumocytes and endothelium of alveoli, fluid leaks across cell membrane PAS positive membrane cant oxygenate o Sepsis, hypoxia, trauma, shock, hypovolemia o Patchy alveolar infiltrates

alveolar disease looks like patchy clouds in the lung interstitial disease looks like linear pattern Atelectasis o fissures will be moved over o do not confuse with fluid o often due to mucus plugging o Radiographic Appearance of Atelectasis Radiographically, atelectasis may vary from complete lung collapse to relatively normal-appearing lungs. For example, acute mucus plugging may cause only a slight diffuse reduction in lobar or lung volume without visible opacity.Nevertheless, the physiologic effects can

be significant. In the so called mucus plugging syndrome, the association of sudden hypoxia with a normal or quasi-normal chest radiograph can lead to the suspicion of a pulmonary embolus. Mild atelectasis usually takes the form of minimal basilar shadowing or linear streaks (subsegmental or "discoid" atelectasis) and may not be physiologically significant. Atelectasis may also appear similar to pulmonary consolidation (dense opacification of all or a portion of a lung due to filling of air spaces by abnormal material), making it difficult to distinguish from pneumonia or other causes of consolidation. The distinction between atelectasis and other causes of consolidation is important, and certain clues exist to aid in making that determination. Atelectasis will often respond to increased ventilation, while pneumonia, for example, will not. Crowding of vessels, shifting of structures such as interlobar fissures towards areas of lung volume loss and elevation of the hemidiaphragm suggests atelectasis. Another key for distinguishing b/w atelectasis and consolidation is recognition of the typical patterns that each pulmonary lobe follows whencollapsing.

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Right upper lobe atelectasis is easily detected as the lobe migrates superomedially toward the apex and mediastinum. The minor fissure elevates and the inferior border of the collapsed lobe is a well demarcated curvilinear border arcing from the hilum towards the apex with inferior concavity. Due to reactive hyperaeration of the lower lobe, the lower lobe artery will often be displaced superiorly on a frontal view.

The left lung lacks a middle lobe and therefore a minor fissure, so left upper lobe atelectasis presents a different picture from that of the right upper lobe collapse. The result is predominantly anterior shift of the upper lobe in left upper lobe collapse, with loss of the left upper cardiac border. The expanded lower lobe will migrate to a location both superior and posterior to the upper lobe in order to occupy the vacated space. As the lower lobe expands, the lower lobe artery shifts superiorly. The left mainstem bronchus also rotates to a nearly horizontal position. LEFT UPPER LOBE- blur left of heart border

Right middle lobe atelectasis is difficult to detect in the AP film (left). The lateral (right), though, shows a marked decrease in the distance between the horizontal and oblique fissures. Right middle lobe atelectasis may cause minimal changes on the frontal chest film. A loss of definition of the right heart border is the key finding. Right middle lobe collapse is usually more easily seen in the lateral view. The horizontal and lower portion of the major fissures start to approximate with increasing opacity leading to a wedge of opacity pointing to the hilum. Like other cases of atelectasis, this collapse may by confused with right middle lobe pneumonia.

Pneumothorax o deep sulcus sign: will see costophrenic angle go very deep o barotrauma trauma induced by the pressure of mechanical ventilation o want to have CT near apex o In the supine patient, intrapleural air rises anteriorly and medially, often making the diagnosis of pneumothorax difficult. o ORDER LLD left side down for Right pneumothorax

Tension Pneumothorax

Tracheostomy tube o Balloon at end of tube - should be same width as trachea (not larger) o Can lead to stricture NG tube o has end hole and side hole (in case end hole gets blocked) o for feeding put post or close to pylorus o for decompression past LES is fine Intra-aortic balloon pump o want marker to be just distal to the subclavian

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bilateral patchy lower lobe infiltrates almost always aspiration pneumonia especially in ICU

o nice air bronchograms = pneumonia, not atelectasis o Balloon tracheostomy dropped down hemoptysis: TB, bronchitis/bronchiectasis, bronchial carcinoma, fungal infection Mediastinal Emphysema

Pneumopericardium

o A. Portable upright chest x-ray before aspiration; B. Chest x-ray 1 hour after aspiration, showing bilateral diffuse alveolar infiltrates, worse at the bases on the right side
Heart Failure Other

o ET tube - Children halfway b/w carina and and thoracic inlet

o AORTA- POSTERIOR SEGMENT

Abdomen
abdominal upright film o rotation: look at vertebrae and ribs. o Supine film Should see bottom of pubis o Erect Should see diaphragms

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 Should see diaphragms

Gas patterns o look for small or large bowel obstruction which would lead to ischemia to necrosis to perforation o do both supine and erect films when looking for obstruction o if pt cant stand, do AP and left lateral decubitus o plicae of small bowel go all the wall across o haustra of large bowel go part of the wall across the wall normal colon can be 5-6 cm in size. Cecum about 10cm ascending and descending are retroperitoneal transverse and sigmoid are intraperitoneal Obstruction o Determine large vs small o Mechanical vs ileus Mechanical air fluid levels at different heights means that there is tone present (so you can be certain this is a mechanical obstruction as opposed to ileus)

Paralytic Ileus

Large Bowel Osbruction o May get dilated small bowel b/c of incompetent ileo -cecal valve o Sigmoid Volvulus Sigmoid Volvulus with a markedly distended loop of colon in the midline of the abdomen. There is a thin vertical band of tissue pointing toward the left upper

quadrant. This tissue band represents the medial walls of the twisted colon and is present in 60-70% of patients. The colon converges toward the pelvis. There is no air in the rectum due to the obstruction.

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o LBO- Sigmoid Carcinoma

Large spleen o ITP, lymphoma, spherocytosis, CLL o Pushes colon medially If enlarged kidney o push descending colon lateral most common visceral structures that rupture: gastric/duodenal ulcer Pyloric ulcer-- can obstruct stomach --- get enlarged stomach o Delayed empyting - gastroparesis - in diabetic Case - PANCREATIC PSEUDOCYST o n/v/ abdominal pain

o Soft tissue mass - 8 cm rounded mass with good sharp borders in LUQ o LUQ- It could be the pancreas, spleen , kidney, adrenal, stomach, or abdominal wall.

Case - pancreatic pseudocyst o Mass- calcified 6-7 cm rounded mass LUQ

o ? Kidney cyst - do oblique and see if it moves with kidney -- could do US o Aneurysm - Splenic artery aneurysm (females) Case - Gallstones + pseudocysts in ducts = Gallstone Pancreatitis o Abdominal pain/ nausea/ vomiting o Calcifications in RUQ Gallstones (20% calficified) Other calcifications look like in the ducts - pnacreatic duct calcifications o Something pressing on stomach Large soft tissue density Also calcifications on the right side o Erect film Can see air fluid levels Calcifications fell down inside something = Gallstones

Case = Appendicitis o RLQ pain + calcifications o Pathophys- obstruction at neck of appendix Case - Aortic Abdominal Aneurysm o Abdominal pain, N/V

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o Abdominal pain, N/V o Calcifications

o
Pneumotosis Intestinalis- Intramural Air o air in the wall of the bowel, caused by ischemia due to obstruction o will see both luminal and serosal side of bowel o NICU babies - necrotizing enterocolitis - air in wall of bowel

Necrotizing enterocolitis with perforation of the terminal ileum.

Free Air o Pneumoperitoneum

Can see retroperitoneal free air around kindney o ERCP, trauma Kidney above liver Uterine Fibroids o uterine fibroids will calcify Soft Tissue Abscess o Abscess - Lesser sac abscess secondary to pancreatitis o The presence of gas and fluid in the lesser sac is usually from a pancreatic abscess, but other organs must be considered suc h as the duodenum, stomach, or an enteric fistula.

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o Abscess in uterus- endometritis air forming abscess looks like cloudy/puffy structure Volvulus o Sigmoid (intraperitoneal)

o Cecum can also volvulate

when looking for free air left lateral decub

Ultrasound

best to do ultrasound over fluid filled area (not lung or bone) we use the terms hypoechogenicty (black), hyperechogenic (white); isoechoic - muscle -- normal Anechoic - fluid filled - gallbladder - no echo TIA - check for carotid doppler Cannot be used for bowel Uses o Liver Mass lesions Portal vein flow o Gallbladder Kidney o Obstruction/hydronephrosis o Aorta o Misc Fluid in abdomen Hepatic vein to IVC Decrease flow by 50%--- need to have lumen narrowed by 70% blood vessels/fluid will be black cant see bowel well can see hepatic vein thrombosis (budd chiari) Benign cyst anechogenic, smooth borders, increased through transmission - increased echoes mass in the breast, thyroid and scrotum are good for distinguishing between solid and cystic lesion Advantage b/c real time so you can have patient sit up to differentiate GB stone vs polyp

GI

video fluoro studies for swallowing problems double contrast GI is done when you are looking for abnormalities in mucosa when small bowel gets inflamed, it gets spikey like picket fence dysphagia: o tumor, diverticulum, schatzkis ring, stricture, achalasia, eosinophilic esophagitis, ulcers o Do swallowing function video study Esophagus o Barium swallow or esophagram - study of esophagus o Done with single or double contrast Double contrast- high density barium (sour cream consistency)- coats mucosa so better view of mucosa If patient is cooperative the standard test is DOUBLE CONTRAST GI study For patient who cannot turn, follow orders, etc- SINGLE CONTRAST GI study o Don't visualize mucosa as well

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 Diverticula

Zenkers Diverticulum

Esophageal Varices

Esophagitis

Duodenal ulcer

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Duodenal ulcer

o Contrast goes into hole in mucosa) Esophageal Tumor

Adenocarcinoma of the Stomach

Polyps

Esophagus - 12 mm or less - need to operate o Barium pill that is exactly 12 mm in diameter o Esophagram with Barium pill Study

Diaphragmatic Hernia

o Malignancy Overhanging shelf (stricture tapers)

Barretts Esophagus

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Barretts Esophagus

o Barrett esophagus with a midesophageal stricture and a reticular pattern. Double -contrast esophagogram shows a focal area of mild narrowing in the midesophagus (black arrow). Note also the distinctive reticular pattern that extends distally a considerable distance from the stricture (approxi mately to the level indicated by the white arrow). This reticular pattern is thought to result from intestinal metaplasia in Barrett mucosa.
Contrast o Barium for esophagus on down thickening of colon wall and blood in submucosa ischemic colitis o shaggy exudative yellow crap C. diff

Ulcerative Colitis o Lead pipe appearnce

Multiple small lesions in colon with no haustra and lead pipe appearance ulcerative colitis o UC generally starts in left colon (rectum) and Crohns in the right colon (terminal ileum) o UC has tiny shallow ulcers and Crohns has large deep ulcers that penetrates o UC rarely has fistulas whereas Crohns often has fistulas o UC is continuous and Crohns has skip lesions o UC has high rate of malignancy and Crohns has lower Crohns have abnormalities of sacroiliac joints and in biliary tree; can manifest anywhere in GI tract UC is limited to the colon o Both happen in the young but Crohns is bimodal and can present later in life as well Crohns Disease o String sign

Enterocolic Fistula

Men can get fistula between colon and bladder and get air in the urine. Women do not because uterus in between. When see narrowing or structuring in UC, think cancer Reserve CT for complication search (fistula, abscesses, etc) Barium study is study of choice for Crohns and colonscopy for UC Can see apple core lesions carcinoma of the colon HIDA

Normal filling o give patient IV drug tagged with tecnichium which is excreted like bile (get outline of liver); if see bile ducts, means the y must be dilated o Dilated common bile duct and dilated pancreatic duct ampulla of Vater obstruction o Double Duct sign Dilated pancreatic and common bile duct Liver o Metastatic disease

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Metastatic disease

Splenic vein runs on dorsal aspect of spleen (lesions of the pancreas like carcinoma or pseudocyst can obstruct the splenic vein and can lead to varices)

CT

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http://fitsweb.uchc.edu/ctanatomy/abdomen/axial.html

same densities but now we can distinguish between water and soft tissue can see enhancing (with blood supply, lighter) with darker fluid in middle likely a pseudocyst contrast o barium inert o gastrographin is water soluble oral contrast o iodine tagged to inulin (for kidney) or other substances o ionic dissociate into component molecules (increased side effects) o non-ionic bound to an organic compound; less side effects o Gadolinium for MR Contrast Need to know GFR If GFR less than 30 it is CONTRAINDICATED to give patient contrast during MRI May develop diffuse systemic sclerosis 30-60 need very good reason to give contrast - life or death situation GFR > 60 to be safe o Stop metformin 12-24 hours before giving contrast and at least 24 hrs after giving contrast IV contrast uses: anatomic clarification, assess perfusion, angiography, lesion characterization, assess defects in BBB, assess for extravasation o MUST CHECK PATIENTS CREATININE Tumor enhances b/c it has blood vessels; a cyst won't o e.g. cecum enhancing - most likely a tumor to do IV contrast CT pt cannot have Cr over 2, between 1.5-2 better have a good reason for CT best way to prevent AKI is hydration patient must be off metformin for at least 12 hours prior to CT and keep pt off for 48h after or patients will often go into lactic acidosis gadolinium is the contrast used in MR must be tagged to organic substance, must check renal fx o if GFR is under 30ml/h it is contraindicated to give contrast o between 30-60ml/h should be a good reason non contrast CT looking for head bleed and looking for stones

ER/MSK
to clear C-spine: cross table lateral through collar,----then can do other views A/P, adontoid Abdominal/Pelvic o AAA CT/US o renal colic non contrast CT/US/IVP o cholecystitis US/HIDA o appendicitis CT/US/plain film o ectopic US o testicular torsion US/nuclear o trauma CT/US SKELETAL RADIOLOGY o ankle: A/P, lateral, oblique

o hip: A/O, frog leg, lateral o Shoulder

o Wrist Colles Fracture

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 Colles Fracture

o soft tissue swelling is often an indication for the location of a fracture o Fracture Base of 5th Metatarsal

o Fracture Descriptions Number of fracture framents (simple or comminuted (more than 1)) Direction of fracture line (transverse right across bone, oblique diagonally, or spiral) Transverse: force applied perpendicular to long axis of bone; fracture occurs at side of force Relationship of one fragment to another (displacement, angulation, shortening, and rotation determines whether will splint or need OR) Open to atmosphere (outside) closed or open (compound) o if you think kid has fracture, splint for 7-10d and then re-xray o Hip fractures

Subcapital (base of head) Most common

Femoral neck If fracture subcapital or higher part of neck, will damage middle circumflex and can develop avascular necrosis Easier to fix If this is the case, they can go in and replace it right away Intratrochanteric Good blood supply still, so go in and nail it

o Green stick/buckle fracture in children bendable bones In children, get a film in the view that you see the abnormality, but look at other side for comparison

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In children, get a film in the view that you see the abnormality, but look at other side for comparison

o increased bone density think avascular necrosis (femoral head and scaphoid) o Abnormal fat pad Most likely an occult fracture

o Dislocations Anterior vs. posterior o Rotator Cuff tear o Scapho Lunate

o Hand Bones

o Lunate dislocation

o Children Look for epiphysis plate fractures Will cause growth problems

o Mallet Finger

o Spinal Anatomy

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 Space should not be more than 3 mm dont miss a c2 fracture of dens Can happen in RA o ACL tear

o liss-frank fracture increased space between first and second metatarsal o cortical thickening Pagets; marketedly elevated alkaline phosphatase (indicates marked anabolic overgrowth in bone)

Frontal radiograph of the pelvis shows marked sclerosis of the sacroiliac joints, as well as the iliac bones, left greater than right (correlating with the bone scan findings). Additionally, there is severe osteoarthrosis of the hip joints, with joint space narrowing and remodeling of the femoral heads. o Sickle cell: 17yo with enlarged heart due to anemia and high output failure, dense white bone due to sickling Dense ribs Cortical infarcts
o Arthritis degenerative arthritis most common bone abnormality (osteophytes, narrowed joint spaces, sclerosis) involves DIP joints (in contrast to rheumatoid, which involves PIP) rheumatoid erosions in early rheumatoid subchondral increased lucency/destruction and sclerosis characteristic of aseptic necrosis Scleroderma

o Metastatic disease / pathologic fracture o Increased bone density = Osteoblastic metastases or avascular necrosis (dead bone) o Neurofibroma

o Bone tumors irregularity with stuff growing out into soft tissues osteosarcoma bone is irregular and periosteum is elevated; one area growing into soft tissue osteoid tumor living in epiphysis osteoblastoma in middle phalanx along medial aspect, can see sub periosteal resorption associated with hyperparathyroidism benign tumor expands bone but has a sclerotic rim (body walls it off) Well defined edges Malignant Tumor Cortex eroding, edges not well defined

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o Deposition Arthritis of abnormal substance in joint Gout inability to metabolize purines, so uric acid is deposited in soft tissues, classically in synovium; classically in first pha lanx o thin periosteum in fingers (lacy-like) osteoporosis (not enough mineral in bone) o thickening of bone can be osteoblastic metastases (eg prostate) o SCFE draw line perpendicular to middle; if femoral head extends outside of line, SCFE can lead to avascular necrosis Normal - head comes over neck

Klein lines are drawn along the superior cortex of the femoral neck. A normal Klein line will intersect the epiphysis. An abnormal Klein line does not intersect the epiphysis, as the femoral neck has moved proximally and anteriorly relative to the epiphysis o Scapula Fracture

IR
INTRAARTERIAL AND INTRAVENOUS CONTRAST o Angiograms (arteriograms and venograms) are obtained by injection of radioopaque contrast material directly into a blood vess el via a needle or catheter. The contrast is comprised of high density iodine, which attenuates the x-ray beam and makes the lumen of the blood vessel visible. The iodine is subsequently filtered through the kidneys and excrete d in the urine. o The fluoroscopic images are displayed digitally, and can be manipulated such that the vessel lumen appears white or black. Th e image on the right is "subtracted" which means that the bones and other structures have been subtracted from the image so that only the blood vessels are seen. o The forward movement of the contrast bolus that occurs concurrent with venous return (venogram) or arterial pulsation (arteri ogram) is observed fluoroscopically. Without the injected x -ray dye, the blood vessels would not be visible. Intra-arterial infusion therapy o Hemorrhage control o Thrombolysis o Chemotherapy infusion o Relief of vascular spasm Vessel Occlusion

o Clot from somewhere else- Heart- Afib o Atherosclerosis - vessel thrombosis Occlusion Therapy o Hemorrhage o AV malformations and fistulas o Tumors o Organ ablation o Varicoceles - more common on L than right o IVC filters Percutaneous Trnasluminal angioplasty o Peripheral vascular system o Renal arteries o Distal aorta o Visceral arteries Need 70% narrowing to reduce blood flow by 50% Need to decrease flow by 70% to feel symptoms Thoracentesis o Stay at top of rib b/c underneath rib is artery, nerve, vein o Could create a fistula check GFR before giving gadolinium most common cause of IVC filter is recurrent DVT/PE that fails medical management IVC Filter o must be distal to renal vein; dont want clot to propogate back into kidney o Once open it additional clots can occur so don't want to clot renal veins Fibromuscular Hyperplasia o String of beads sign Subclavian steal syndrome o retrograde flow in vertebral artery; due to a proximal stenosis (narrowing) and/or occlusion of the subclavian artery. The arm may be supplied by blood flowing in a retrograde direction down the vertebral artery at the expense of the vertebrobasilar circulation.

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retrograde direction down the vertebral artery at the expense of the vertebrobasilar circulation.

o Contrast-enhanced magnetic resonance angiogram showing the aortic arch (AA) and the arch vessels in a right anterior oblique projectio n. The proximal segment of the left subclavian artery (LSA) does not enhance and is occluded. The arrowhead indicates the site of origin of the LSA. BCA indicate s brachiocephalic artery;

Ileocolic is the last branch of SMA- goes to ileo-cecum w Celiac artery branches

Aortic arch and subclavian angiogram The x-ray dye is injected through a catheter which is located in the aortic arch. Any evaluation of the upper extremity

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 The x-ray dye is injected through a catheter which is located in the aortic arch. Any evaluation of the upper extremity arteries must include an evaluation of the aortic arch and the brachiocephalic trunk. The aortic arch can be seen, with its three branches: the brachiocephalic trunk, the left common carotid and the left subclavian arteries. The brachiocephalic trunk divides into the right common carotid and the right subclavian arteries. The subclavian artery give off several branches, including the vertebral arteries. The subclavian artery becomes the axillary artery at the lateral border of the first rib.

http://www.dartmouth.edu/~anatomy/Head-neck/vessels/angiograms/CTAarch.htm

Nuclear Medicine

dont need to worry about harming liver or kidneys because loading dose is so small can pick up stress fractures Checking for further lesions - osteosarcoma--- may change plans for chemo/radiation/ surgical candidacy Bony metastasis - seen in prostate cancer, breast cancer To look for edema in bone marrow - MRI - but cannot do a whole body MRI study Galium 67 citrate- spine infection, interstitial nephritis Indium labeled WBC- soft tissue infections- thoracic pelvic region Technetium labeled- good for extremities

Neuroimaging

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 Gray white junction helpful to tell health of brain

Brain MIRI

o T1 Very good for looking at anatomy o T2 o T1 Gadolinium o Flair Compare cortex to ventricle? o Central sulcus sign

Vasogenic edema o Neoplasm (GBM or met) o Cerebral abscess o Hematoma Omega: site where hand is on homunculus o In front: frontal o Behind: parietal o Central sulcus is the first one that interrupts and goes deepest Anterior commissure o Holes below = around CSF/vessels o Holes above = infarct Most commonly injured nerve in head trauma is CN1 (olfactory) Syrinx causes o Tumor o Trauma

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o Trauma o Congenital (eg Chiari malformation) How to approach CT of the head o Is there geometric distortion? Is something the wrong size, shape, or position? o Soft tissue abnormality? o Abnormal enhancement? Subdural hematoma (goes along skull); if not white, means old o Midline shift

Cerebral Amyloid Angiopathy

o Sensitivity of GRE imaging for hemosiderin in an 80 -year-old man with dementia that has progressed over the past 4 years. (a) Axial GRE MR image shows multiple foci of signal loss in cortical-subcortical locations. In a patient with a diagnosis of probable CAA, these foci are consistent with chronic microhemorrhages .
Ventirculomegaly o Hydrocephalus (obstruction) o Volume loss (atrophy, surgical) o Congenital (never developed) o If both lateral and third ventricle are enlarged, obstruction is in aqueduct of Sylvius aqueduct stenosis (post inflammatory?)

Magnetic resonance image obtained in a patient treated with ETV for hydrocephalus due to aqueductal stenosis, revealing an open sylvian aqueduct (arrow).

Noncontrast axial head CT (A) and GRE (B) demonstrating microhemorrhages and lobar hemorrhage consistent with cerebral amyloid angiopathy.
o Meningiomas are isointense to brain parenchyma (so need contrast to see)

o Meningitis Leptominigiomia enhancement o MCA > PCA > ACA/PICA Glioblastoma Multiforme

Medulloblastoma

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Medulloblastoma

Vestibular Schwanoma

Chronic ischemic changes o Gliosis (proliferation of glial cells), encephalomalacia (hole in brain) o Loss of parenchymal volume

Scalp Lymphoma Prolactionoma

Pinealoma

Ischemic change o Ischemic small vessel disease o Hypertensive vasculopathy o Branch vessel infarcts (MCA)

MCA infarct

DWI takes 30 minutes to show up

o Embolic infarcts (often cardiac) Often out in periphery Subcortical white matter and adjacent cortex

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Subcortical white matter and adjacent cortex

o Border zone infarcts (b/w MCA and ACA) / Watershed

Intracranial hemorrhage

o Intra-axial or extra-axial? Look for relationship to the cortex/skull Widening of extra-axial space = extra axial o Extra-axial Epidural, subdural, subarachnoid Shape of collection? --- e.g. crescent Smooth interface with brain (does it fill sulci)? Does it respect (aka not cross) the sutures? Epidural Hematoma Biconvex; most are middle meningeal; a/w with fracture

Subdural Hematoma Usually due to tearing of veins; no consistent a/w fractures Common in infants and elderly Crescent shape along surface of brain; crosses suture lines Smooth interface with the brain Acute is bright white Iso to CSF = chronic Chronic SDH becomes low density as the hemorrhage is further reabsorbed. It is usually uniformly low density but may be locul ated. Rebleeding often

occurs and causes mixed density and fluid levels.

Subacute

Subacute SDH may be difficult to visualize by CT because as the hemorrhage is reabsorbed it becomes isodense to normal gray m atter. A subacute SDH should be suspected when you identify shift of midline structures without an obvious mass. Giving contrast may help in diffic ult cases because the interface between the hematoma and the adjacent brain usually becomes more obvious due to enhancement of the dura and adjacen t vascular structures. Some of the notable characteristics of subacute SDH are: - Compressed lateral ventricle, Effaced sulci, White matter "buckling", Thick cortical "mantle"

Subarachnoid hemorrhage Most commonly from trauma; also ruptured aneurysm Blood in subarachnoid space, cisterns, and ventricles Crosses sutures; fills sulci

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High density blood (arrowheads) fills the sulci over the right cerebral convexity in this subarachnoid hemorrhage. o Intra-axial (ICH) Intra axial is a term that denotes lesions that are within the brain parenchyma, in contrast to extra axial, which describes lesions outside the brain, and intra

ventricular, which denotes lesions within the ventricular system.

Is there associated trauma? Contusion vs. diffuse axonal injury If there is no known trauma: Lobar hematoma or hypertensive hemorrhage (deep)

TRAUMA

1. Contusion Half of intra-axial post traumatic lesions Typically punctate or linear hemorrhages along gyri Characteristic locations- 1/2 temporal lobes, 1/3 frontal lobes

2. Diffuse Axonal Injuries Seen with sudden accel/decel Often at gray white junction Typically lose conscoiusness at moment of injury Hard to see on CT scan NON TRAUMA 1. Lobar Hematoma a) Into extraaxial CSF space Supratentorial hemorrhages In patients over 55 most likely due to Cerebral amyloid angiopathy Consider arterial vascular malformation , tumor and cavernous malformations in younger patients

Cavernous angioma- popcorn lesion

AVM

Arteriovenous malformation (AVM) of the brain. A CT scan of the posterior fossa demonstrating a hemorrhage in the fourth ventricle, with extension to the left cerebellum.

2. Hypertensive hemorrhage Deep intracerebral hemorrhage Basal ganglia 60-65 Thalamus 15-25 Pons and Cerebellum

MRI
Non-ionizing radiation and non-invasive; low side effects Based on spin of atoms (dependent on hydrogen nuclei) T1: water is black, bone is white

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 T1: water is black, bone is white o More like anatomy o When do head CT, use T1 o Vessels look black because of the flow o All post contrast sequences are T1 T2: water is white, bone is black o Very good for detecting abnormality; sensitive but not specific Greatest advantage is better contrast resolution than CT, esp for soft tissue Check GFR (>60, dont worry about it; 30 -60 need a REALLY good reason) o To avoid diffuse systemic sclerosis Unit of magnetism = tessla Three sequences that highlight the brain are T1, T2 and flair Shoulder MRI

Knee o If see fibular head you know it is lateral

Avascular Necrosis

Psoas o Inserts on lesser tronchanter Tuboovarian Abscess

Angiography

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Mammography
Mammomgraphy is the single most largest reason for lawsuit of radiologists If woman has dense breast on mammogram, must have U/S distribution of calcifications o grouped, cluster (5 calcifications in a 1cm) o pleomorphic o fine and branching feel breast mass, first test do U/S for cystic or solid if cystic it has to be anechoic, posterior wall is sharp, increased through transmission dont have to aspirate it unless it is painful

GU

look for kidney size, shape and position nephrogram outline of kidney 7-10minor calyces there is peristalsis in the ureter loss of volume chronic infection/scarring, hydronephrosis pyelonephritis blunted calyx renal cysts are very common bilateral big kidneys adult polycystic kidney disease, hydronephrosis, amyloid, renal vein thrombosis small kidneys atrophy from HTN, multiple infarcts, chronic pyelo men are more likely to get strictures of urethra one of the most common causes of hematuria in the elderly is transitional cell carcinoma work up of pt with hematuria and renal mass = pre and post contrast ct stones less than 6mm pass without intervention calcification in the renal parenchyma nephrocalcinosis renal failure first imaging study is ultrasound

Womens Imaging transabdominal U/S needs very distended bladder to see uterus transvaginal U/S is more detailed but transabdominal is more broad view endometrium can be up to 1.5cm in premenopausal female post menopausal woman should have endometrial stripe ovarian follicles are not cysts/tumors o thick wall, unilocular, no papillae in secretory phase, avoid drastic measures, rescan later ovarian carcinomas are complex, thick walled

Radiation Oncology

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