CAMRT Review & Questions

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CAMRT Review and Questions

• What is the use factor for a secondary barrier in a dedicated chest room on the wall opposite chest stand?

  • Use factor for secondary barrier is always 1

    (secondary barrier is only for scattered radiation, NOT for primary beam)

    (the use factor (U), is the fraction of the workload during which the x-ray beam is pointed in the direction under consideration)

• What is the use factor for a primary barrier in a dedicated chest room on the wall 90 degree from the chest stand?

  • 1/4, NOT 0 or 1

    (a wall right behind chest standing (image receptor), where x-ray directly hits. Use factor will be 1 if a wall is exposed by x-ray all the time. For occasional x-ray exposure, use factor will be 1/4. Use factor for ceiling = 1/16)

• What is the occupancy factor for the floor below the x-ray table on a second floor x-ray room?

  • 1

    (adjacent x ray room T (occupancy factor) value = 1 (safety code 35). Places near x-ray rooms will most likely have lots of people so occupancy factor will be high)

    (occupancy factor (T) is fraction of time that the area under consideration is occupied by the individual (employee or public) who spends the most time at that location while the x ray equipment is operating)

• Workload (W), occupancy factor (T), and use factor (U) are factors used to determine lead thickness

• T or F – You clipped a part of the prosthesis when doing x-table lateral hip xray. Do you repeat?

  • True. Must include entire prosthesis in one picture or two pictures

• What is the final tip location for a PICC line?

  • Superior vena cava (just above right atrium) (PICC line inserted through pt’s arm and tip stays at SVC)

• ???What views would you do on a newborn that had spina bifida?

  • AP or PA?& Lateral (lumbar region x rays)

• When you do a 20 degree Caldwell view, where should the petrous ridges be seen?

  • 15 degree Caldwell will show petrous ridges filling 1/3 of the orbit. If you use 20 degree Caldwell, petrous ridges will be located even lower (filling 1/4 of the orbit)

• What type of precaution is TB (tubercle bacillus (tuberculosis))?

  • Airborne precaution (different from droplet precaution)

• On a Townes, what is positional error when you see the dorum sella is on the arch of C1?

  • Central ray was angled more caudally than needed to form a 30 degree angle with the OML or patient chin was tucked down too much. (OML should be perpendicular to the IR and CR should be 30 degree caudal angle with the OML perpendicular to IR)

• If there is a suspected fracture of the inferior pubic ramus, what view other than AP pelvis would be done?

  • Outlet view would be done to see inferior pubic ramus

• If you see both left and right hip fractures on AP pelvis radiograph, how would you perform lateral hip x-ray?

  • Clements-Nakayama method (Modified Axiolateral)

• For frog lateral hip (modified cleave’s method), the greater trochanter is superimposed right over the neck of femur, what is the error and how to fix it?

  • This indicates foreshortening of the femur neck. Patient’s femur was abducted too much towards the imaging table (maximum abduction angle is 20 degrees from imaging table, and recommended femur abduction angle is 45 degrees from imaging table). To fix this error, decrease the degree of femoral abduction until the femur is at a 45 degree angle with the imaging table. (In addition, modified cleave’s method (lateral hip) requires knee flexion of 60~70 degrees)

• What is the external landmark for a swimmers view?

  • Centering point for swimmers view is T1. Either find C7 prominence and  center under or find sternal notch and center 2.5 cm above sternal notch

• On what view of the L spine would you see the foramina in profile?

  • Lateral lumbar spine

• Why would you do a non-contrast scan for kidney stone?

  • Contrast may obscure calcific densities (stones). As a result, noncontrast CT is a choice for initial radiographic assessment for kidney stones.

• What is diaphoresis? What causes it?

  • Diaphoresis is the state of perspiring (sweating). Diaphoresis is a non-specific symptom or sign, which means that it has many possible causes (fever, motions, pathologies; hyperthyroidism and sock, etc)

• What pathology is often associated with parietal lobe?

  • Epilepsy/seizures

• What 2 elbow views would you perform to get the coronoid process in profile?

  • AP oblique (Internal rotation: coronoid process in profile)

  • Coyle Method (axiolateral projection) with coronoid process and trochlea shown

    • Elbow flex only 80 degree (from fully extended position) (more than 80 degree may obscure coronoid process) and hand pronated

    • CR angled 45 degree from shoulder (away from shoulder), into mid elbow joint

    • SID 40”

• What is hemiparesis? Who gets this?

  • Hemiparesis is weakness of the entire left or right side of the body. Hemiplegia is its most severe form, complete paralysis of half of the body. Hemiparesis and hemiplegia can be caused by different medical conditions, including congenital causes, trauma, tumors, or stroke

  • Stroke (cerebrovascular accident (CVA) patients get this condition.

• What is the recommended oblique projection and position for best demonstration of the esophagus?

  • PA oblique projection and RAO position (patient position)

• Daily routine for CR cassettes?

  • Wipe cassette & erase cassette

• What is included in a crash cart?

  • Oximeter

  • Nasal cannula

  • Oropharyngeal airway tube

• ERCP patient has arrived for ERCP procedure. During the procedure, fluoro has shown his/her duct fully filled with contrast media. The surgeon has confirmed that the patient has CT done with contrast just prior to ERCP procedure. What damage can you do to a patient if continue ERCP with injecting more contrast media?

  • Possible adverse reactions to contrast media

• When setting a plain film (cassette) for x-ray during surgical procedures, who do you pass a cassette to? And what do you do to?

  • Either sterile nurse or a surgeon will be holding a sterile plastic bag. Gently pass the cassette to either one of them so that the cassette goes inside the plastic bag. Sterile nurse or a surgeon will position the cassette accordingly. The tech must position the tube head to center properly and then take an exposure (lead apron must be worn. Both tech and surgeon or a sterile nurse)

• Cholangiography shows enlarged gallbladder. What pathology is this?

  • Cholecystitis

• On Water’s view, if petrous ridges are shown in the middle of the orbits, how would you correct patient’s position? And where should petrous ridges be?

  • Petrous ridges should be shown just below the maxillary sinuses. Therefore, must bring patient’s chin up much higher to bring petrous ridges down.

• If maxillary sinuses are shown bright density on a water’s view, what would be the reason for this?

  • maxillary sinuses could be filled with blood or some sort of liquids due to fractures

• What procedures can be performed to examine hiatal hernia?

  • Upper barium swallow/GI series or endoscopy

    • Endoscopy =>Trendelenburg position for hiatal hernia

• Urinary bag must be closed at all time except when doing drainage. Urinary bag must be placed below bladder level when having x-ray examinations or transferring. Must prevent back flow of urine into the bladder to prevent bladder infection caused by urine back flow (or to prevent urinary tract infection)

• Pleural effusion  - collection of fluid within pleural cavity

  

  Lobar pneumonia (known as a non-segmental pneumonia or focal non-segmental pneumonia) is a radiological pattern associated with homogenous fibrinosupparative consolidation of one or more lobes of a lung in response to a bacterial pneumonia.

  

  Pleurisy – also called pleuritis, is an inflammation of the pleura, which is the moist, double-layered membrane that surrounds the lungs and lines the rib cage

• Which vessel do you inject contrast media for right upper limb arteriogram?

1. Brachiocephalic

2. Right subclavian artery

3. Right subclavian vein

4. Antecubital vein

• To maintain air way?

1. Displace mandible (jaw) forward

2. Retract mandible

3. Extend neck

4. Insert bite block

   (When the mandible is displaced forward, it pulls the tongue forward and prevents it from occluding the entrance to the trachea.)

• Straight lucent line on monitor, image rotated 90 degree and still straight lucent line present. What’s causing this problem?

1. IP

2. LCD monitor (because lucent line is still there even after rotating the image 90 degree)

3. Grid

• When doing an xray on a newborn, what would you do to keep the baby clean/safe? Would you cover the cassette? Are there clean & dirty techs? Do you clean all equipment before you enter the room?

  • Yes! The clean tech stays in the room with a newborn, placing cassette & touching a newborn. The dirty tech only manipulate the tube head and take the exposure, no touching baby!

• Patient is on morphine and has abdo pain etc. Patient needs to go to the bath room. What would you do?

  • Morphine makes patient dizzy. Therefore, do not let patient go to the bathroom. Give patient bed pan and stay in the room or on a stretcher.

• If the patient gets nauseous during a CT, what would you do?

  • Stop the CT procedure and give patient anti-nausea medication

• During a CT scan, a nurse walks in the room. How do you proceed?

  • Continue the scan, talk with her supervisor later (if you stop scanning, then you have to scan patient again which means more dose to patient)

• You see another tech touching a patient inappropriately, what do you do?

  • Talk with supervisor

• Frog leg (lateral hip or modified cleave’s method lateral hip), knees should have flexed 60~70 degrees and femur should be abducted 45 degrees with the imaging table.

  3 conditions – option number 2 is the recommended procedure

1. FEMURS R ABDUCTED UNTIL PLACED AGAINST THE IMAGING TABLE

   The femoral necks would be demonstrated on end and the greater trochanters would be demonstrated at the same transverse level as the femoral heads

2. Femurs are abducted to a 45 degree angle with the imaging table

   The femoral necks would be partially foreshortened n the greater trochanters would be positioned at a transverse level halfway between the femoral heads and lesser trochanters.

3. Femurs are abducted only 20 to 30 degrees from vertical

   The femoral necks would be demonstrated without foreshortening and the greater trochanters would be positioned at the same transverse level as the lesser trochanters.

• The apple core sign, also known as a napkin ring sign (bowel), is most frequently associated with constriction of the lumen of the colon by a stenosing annular colorectal carcinoma. 

  • Apple core lesion of the colon can be caused by Crohn’s disease, chronic ulcerative colitis, ischaemic colitis, etc.

    

• Ileus is a disruption of the normal propulsive ability of the gastrointestinal tract; small bowel obstruction and adynamic ileus. (Adynamic ileus is the failure of passage of enteric contents through small bowel and colon that is not mechanically obstructed. Essentially it represents the paralysis of intestinal motility.)

  • Appearance  - stacked coin appearance or step ladder

    • Step ladder

      • Large amounts of gas and fluid in small and large bowel and usually resolves itself in 36~48 hrs, place NG and balance fluids

        

• Posterior oblique hand position = AP oblique projection of hand

  • For rheumatoid arthritis, ball catcher’s position is used (bilateral hand- AP oblique projection)

• If angio nurse most likely receives 1/20 of annual dose limit (maximum permissible annual dose),  nurse must wear optically stimulated luminescence badge (OSL) or thermos luminescent dosimeters (TLD) badge

• Swimmer view – external landmark? T1 (2.5 cm above sternal notch)

• Accuracy of Loading Factors--The loading factors must not deviate from the selected value, for any combination of loading factors, by more than 10% for X-ray tube voltage

• Advantage of helical CT over Axial?

  • Helical CT has high heat capacity and high cooling rate so less heat!

• Anterior oblique wrist (PA oblique projection) shows scaphoid, trapezium and lunate well.

• ??What projections should you take for a new born spina bifida?

  • AP and Lateral (AP recommended over PA for a new born)

• Why would you perform portable x-ray on neonates?

  • Neonates have higher chances of getting infection + hypothermia issue

• When doing abdomen series on a patient who just had morphine, which view would you choose?

1. Erect AP

2. Erect PA

3. Left lateral decubitus

4. Right lateral decubitus

   (Decubitus replaces ERECT AP abdomen view to see free air. Left lateral decubitus is the right choice, not right lateral decubitus. Can’t do erect AP on morphine patient. Patient will become dizzy after getting morphine and may fall. Lateral Decubitus is the answer)

• If the tube is misplaced during ERCP procedure, where would the tube end be?

1. Bronchus

2. Bronchiole

   (Bronchiole is too small for a tube end place. So bronchus is the right answer)

• To enhance contrast on an obese patient, what would you do?

  • Increase kVp

• Epinephrine, more commonly known as adrenaline, is a hormone secreted by the medulla of the adrenal glands.  Strong emotions such as fear or anger cause epinephrine to be released into the bloodstream, which causes an increase in heart rate, muscle strength, blood pressure, and sugar metabolism.  This reaction, known as the “Flight or Fight Response” prepares the body for strenuous activity.  In medicine epinephrine is used chiefly as a stimulant in cardiac arrest, as a vasoconstrictor in shock, and as a bronchodilator and antispasmodic in bronchial asthma.  Epinephrine is found in small amounts in the body and is essential for maintaining cardiovascular homeostasis because of its ability to divert blood to tissues under stress.

• Antihistamines are mainly used to treat hay fever (seasonal allergic rhinitis), hives (urticaria), itching (pruritus) and insect bites and stings. They may be used to help reduce feeling sick (nausea) and being sick (vomiting). They may also be used in the emergency treatment of a severe allergic reaction (anaphylaxis). The side-effects most commonly experienced are minor.

  (Antihistamines are a group (class) of medicines used in the treatment of allergic disorders and some other conditions)

• During surgery, doctor wants you to take a plain x ray of lateral knee. The cassette is in a sterile bag. Who is going to hold the cassette or where/how should the cassette be positioned?

1. Surgeon will position the cassette in the sterile bag for the lateral knee projection. The tech will position the tube head and expose.

2. Circulating nurse will place the cassette on her legs to hold

3. A Nurse will wear leads and hold the cassette

4. Surgeon will wear leads and hold the cassette

• Kidney ~ from T12 to L3 usually. When doing nephrogram scout, must include from top of kidney to pubic symphysis, to include ureters and bladder.

• Inferosuperior patella view shows vertical/longitudinal fracture (not for transverse/horizontal patella fracture.  In fact, inferosuperior patella view is contraindicated for transverse/horizontal patella fracture)

• Stomach and duodenum study. Spine is obliqued (left zygoapophyseal joints demonstrated). Fundas filled with barium, a portion of duodenum filled with air.  What position is patient in?

1. RAO

2. LPO

3. Supine

• When doing humerus lateromedial projection, how would you position patient?

• Patient’s body slightly rotated towards the affected side to bring humerus and shoulder in contact with IR

• When doing Scapular Y, scapula boards are demonstrated without superimposition. One of the scapular borders is superimposed over ribs. How would you correct patient’s position?

  • Increase the patient obliquity (we are assuming that it’s the vertebral scapular border that is superimposed over ribs, not the lateral scapular border)

• Foreshortened sacrum. How would correct to see better visualization of sacrum?

  • Use more uptilt angle (cephalad) to reduce foreshortening of sacrum

• If pisiform is shown posterior to scaphoid on lateral projection of wrist, how would you correct the positioning?

  • Externally rotate the wrist more so that distal pisiform and scaphoid are accurately positioned for a lateral wrist projection

• Know what joints can be seen when doing oblique foot projection

• Know about different hand oblique positions (AP or PA oblique?? Know position of wrist bones)

• Fluoroscopy/Radioscopy – Lead shield equivalent at 100 kVp? 0.25 mm Pb equivalent (SC35)

• Patient comes in for post operative x-rays of # wrist. What change in exposure techniques?

1. 15% increase in kVp

2. 30% increase in mAs

   (to xray through dry cast (post op) for small extremities, 15% increase in kVp (or 2 x mAs) is needed (big extremities = 3 x mAs). For wet cast small extremities, 3 x mAs is needed (big extremities = 4 x mAs)

• Using a wedge filter in a BE. Where would wedge filter be placed?

  • Thick part over thin body structure, and thin wedge filter part over thick structure

• 2 year old with left hip fracture. How would you place gonadal shield?

  • Shield midline on right side (must cover right side completely)

• You have saggital CT images and you want to change Sag images to Coronal images. What is this process called?

  • Formatting or reformatting

• Patient is 6 week pregnant but has planned to have an abortion. What do you do?

  • Continue with the examination

  • See radiologist for guidance

  • Shield and do examination

  • Rebook for after the abortion

• **L-spine at 90 kVp. When will back up timer cut out?

  • 400 mAs

  • 500 mAs

  • 600 mAs

  • 700 mAs

(Radiographic equipment that is equipped with an automatic exposure control must have a means to automatically terminate the irradiation when the current time product exceeds 600 mAs per irradiation, if the operating x-ray tube voltage is 50kV or more)

• Patient needs to urinate while in the room but patient is drowsy. What should you do?

  • Let them go to the bathroom unattended

  • Give them a pan and leave the room

  • Use pan but keep a watch

• When imaging an immunosuppressed patient, the tech should:

  • Position patient with gloves on and then take gloves off  to position the equipment

  • No gloves

  • Position equipment with gloves on and then take gloves off  to position patient

(must wear gloves to reduce the patient’s infection chances.  If two techs are involved, clean tech will do patient positioning and dirty tech will do equipment positioning. This is opposite when dealing with contact precaution patient)

• Mrs. X (86 years old) is having a BE. She came in with her friend. After the procedure, her friend got very angry and told the radiographer how badly Mrs. X has been treated. What do you do?

  • Ask her to wait outside

  • Ask Mrs. X, if this is true and tell her how to make a formal complaint

  • Direct her anger towards the business manager

• **A patient just had ERCP done. And this patient is having a CT scan with contrast later. A patient needs to be NPO (nothing by mouth) for 1 hour before the CT scan. Why?

  • Aspiration

  • Overdose of Contrast

(**Patient’s throat is anesthetized prior to ERCP (endoscopic retrograde cholangiopancreato graphy). They reason why NPO for 1 hour before CT scan is because  patient’s throat is still anesthetized and if patient eats and swallows food, the patient wouldn’t have much feeling in throat, and therefore, aspiration (breathing in foreign objects (food) into airway) can possibly occur and airway can be blocked)

• Patient with COPD. What change in technical factors?

  • Increase

  • Decrease

(COPD is a destructive pathology – asthma, bronchitis, pulmonary emphysema, barrel chest. So Reduce mAs/technique!!)

• Closed urinary bag – transferring to x-ray table

  • Between patient’s legs

  • On table

  • On floor

  • Give to patient to hold

    (Urinary bag must be put lower than bladder level)

• 2 day old neonate in ICU – has spina bifida; myelomeningocele (most serious form of spina bifida. Myelomeningocele is a neural tube defect in which the bones of the spine do not completely form, resulting in an incomplete spinal canal. This causes the spinal cord and meninges (the tissues covering the spinal cord) to protrude from (stick out of) the child's back.). How do you prepare?

  • Sterile cloths

  • Sterile gown and gloves

  • Clean cassette

• A Patient is having a CT chest with contrast. Patient has had a right mastectomy and has severe lymphedema (tissue swelling cause by lymphatic obstruction). How are you going to inject contrast?

  • Use left arm for contrast injection

  • Apply hot compress on right arm

  • Apply cold compress on right arm

  • Use right arm for contrast injection 

• 3 year old with epiglottitis from A&E and you are very busy. What do you do?

  • Tell A&E to send immediately with physician and do erect views

  • Come over in the morning

  • Come over with parents and do supine

• Patient with COPD. What is the correct flow rate?

  • 2-3L/min via nasal cannula (it should be low flow rate for COPD patients)

• Nurse in radiology. What is minimum dose level required to wear a badge?

  • 1/40 maximum permissible annual dose limit

  • 1/20 maximum permissible annual dose limit

  • 1/10 maximum permissible annual dose limit

  • 1/15 maximum permissible annual dose limit

• ??DR flat panel influences patient dose and what?

  • Spatial resolution

  • Contrast resolution

  • Dynamic range

  • Detects quantum efficiency

• ??AP hip with a grid ratio of…

  • 6:1

  • 12:1

  • 10:1

  • 16:1

    (low kVp is used for AP hip so 6:1 or 8:1 grid ratio is appropriate)

• Indication for starting CPR?

  • No pulse

  • Unconscious

• If the film comes out of the processor with crystals on it, what does that mean?

  • There is a problem with fixing stage. Fixing solutions should have removed unexposed crystals.

• Pixel line dropout artifact, how do you correct it?

  • Repeat, call service

• A reading of 2mSv on a tech TLD badge (or OSL), what would be the action?

  • Maximum permissible annual whole body dose limit for radiation workers is 20 mSv. Therefore, no action is required to be made. However, since 2 mSv is more than 1/20^th of the annual dose limit (which is 1 mSv), the tech should always be wearing dosimeter (TLD badge)

    (The use of a personal dosimeter (TLD badge) is a must if techs are likely to receive a dose in excess of 1/20^th of the dose limit to radiation workers ( whole body annual dose limit for radiation workers is 20 mSv, so 1/20^th of 20 mSv is 1 mSv which is equivalent to maximum permissible annual dose limit for members of public))

• You are about to do acute abdomen series on a patient who has a left hip prosthesis. Patient is not able to neither stand nor roll on to left side for a left lateral decubitus position. What views are you going to perform?

  • Supine abdomens (diaphragm to symphysis pubis) & dorsal decubitus with horizontal x ray beam (to see free air)

• What types of pathologies are unique to most often found in the parietal lobe?

  • Stroke (cerebrovascular accident) and epilepsy (seizures)???

• Guide shoe artifact lines run parallel to the film direction. IP artifact lines run perpendicular to the film direction

• After cystogram, how do you remove the catheter?

  • Deflate the balloon first (Foley catheter)

  • Take it out slowly (straight catheter)

• ??C-Diff patient in waiting room next to chemo patient. What do you do?

  • It’s ok. Chemo patient has mask on

  • It’s ok. C-diff patient has mask on

  • It’s ok. C-diff patient is not touching the chemo patient

  • Move C-diff patient immediately

    (C-diff is a contact precaution. Technically, as long as there is no direct contact between patients, it’s okay not to move the c-diff patient. However, C-diff patient is in the waiting room, possibly sitting on a chair next to chemo patient. Other patients might touch or sit where c-diff patient sat and become contaminated. It would be much better to move c-diff patient and have c-diff patient sit on a wheel chair instead)

• During voiding cystogram, the patient does not want to continue with the exam, what should you do, advocate the patient or talk to radiologist and if radiologist says keep going, continue the procedure?

  • Patient has the right to withdraw the procedure/examination at any time, before or during the procedure. Must respect patient’s right

• What is the ratio of one-man compression for CPR?

  • One rescuer/two rescuers for adult = 30 compressions and 2 breaths (30:2)

  • One rescuer for baby = 30 compressions and 2 breaths (30:2)

    Two rescuers for baby = 15 compressions and 2 breaths (15:2)

• Will pneumonia appear on a radiograph as an area of decreased lung markings (increased radiograph density (more blackening)?

  • NO. Pneumonia will appear as decreased radiographic density (bright white image in general)

• How much technique will be needed to ensure the same amount of radiation at the image receptor if 30 mAs at 70 kVp worked with an 8:1 grid, but the new grid in your department is 12:1?

  • New mAs = old mAs x (new bucky factor/old bucky factor)

    New mAs = 30 mAs x (5/4)

                            New mAs = 37.5 mAs

Grid Ratio	Bucky Factor
No Grid	1
5:1	2
6:1	3
8:1	4
12:1	5
16:1	6

• ???What is listed in an emergency cart/crash cart? (look up in the patient care text book)

• ??how does cold/hot barium affect stomach for GIFT (SBFT or barium enema)?

  • Room temperature barium should be used for patients

    • Cold/hot barium advantages & disadvantages??

• Entrance skin dose/exposure of the patient decreases if II is placed close to patient body

  • What about scatter? Does this affect scatter amount??

    (fluoroscopy – undertable tube method is good for technologists. Reduces radiation dose to technologists (tube head (source) is under the table and II is above the table level (on top of patient)))

• MPD (maximum permissible dose) for student?

  • 1 mSv (students = members of public. 1/20^th of annual dose limit (whole body dose=20 mSv for techs) = 1mSv)

• For occupationally exposed women, once pregnancy has been declared, the foetus must be protected from X-ray exposure for the remainder of the pregnancy. For women who are also occupationally exposed, an effective dose limit of 4 mSv must be applied, for the remainder of the pregnancy, from all sources of radiation

• ??Paediatric abdominal x-ray diagnosis??

• Wrist with cast – technical factor adjustment

  • Plaster Cast

    • Dry Plaster Cast

      • Small extremities  - mAs x 2

      • Big extremities – mAs x 3

    • Wet Plaster Cast

      • Small extremities – mAs x 3

      • Big extremities – mAs x 4

  • Fiberglass Cast

    • No change in techniques required

• Shoulder Axial image anatomy – radiography (check book)

• C-spine & L-spine oblique images anatomy and positioning adjustment

• Patient has elbow pain when doing acute flexion since 2 weeks. What is the problem?

  • This happens when there is a problem with/around elbow fat pads –indication of elbow joint effusions. To see elbow fat pads well, true lateral elbow projection is required.

    (know elbow positions thoroughly, especially lateral view (how to correct patient’s positions to achieve a perfect lateral elbow view. Ex) wrist down/up, elbow too high/low, shoulder too low/high, etc)

• Know chest pathologies. Know various catheters, lines, chest tubes, etc. Know their placements and locations of their tips, and their uses.

• Distinguish between battery and malpractice

  • Battery - The basic definition of battery as “touching without consent.” In medicine, a surgeon commits battery when he or she operates on a patient without consent. Given these litigious times, surgeons would be wise to think defensively when securing a patient's consent.

  • Malpractice - Medical malpractice is professional negligence by act or omission by a health care provider in which the treatment provided falls below the accepted standard of practice in the medical community and causes injury or death to the patient, with most cases involving medical error.

• Know types of shocks. Know vital sign, blood pressure, temperatures, breath rate, etc.

• Know meanings of L, E & LgM.

• Digital radiograph - Relationships between window width, window level, contrast and brightness

• AEC – know how it works. Patient status/shapes. Detector settings, etc. under or over exposure

• Film – fog, density, contrast relationships. Know film artifacts

• Read Legislation package

• Fluoroscopy – know parts, and how it works. Know about image intensifier

• Know how to calculate film repeat rate

• Density (mAs) is directly proportional to collimation size

  • If you change 5x5 coned view to 14x17 field of view (collimation size), you must increase mAs by a factor of 9.5

    • 5x5 = 25, 14x17 = 238

    • 238/25 = 9.5

• It is known that patient has pleural effusion. If the patient cannot stand for chest x-rays, what views would you do to demonstrate this pathology?

  • Left lateral decubitus (if fluid is in left lung)

  • Right lateral decubitus (if fluid is in right lung)

    (pneumothorax is opposite)

• Know how externally rotated lateral ankle would look like.

• Water sinuses – if petrous ridges are seen in the maxillary sinuses, what is the positioning error?

  • Patient didn’t bring chin up high enough

• Dropout artifact on an image – how would you do to correct this artifact?

• Dropout artifacts -Dropout is a reduction in image resolution that may be in a specific area or an all over reduction in image quality. Dropout artifacts are usually caused by dust accumulation in the CR reader and can be avoided with regularly scheduled QA and cleaning of the equipment.

• Know the exact positional critique for an accurately positioned oblique hand

• Right posterior oblique C spine – what is the positional error (under or over rotation?) know what under/over rotation of oblique c-spine looks like and know what it would look like if incorrect beam angles are used

• Medial oblique foot – know if the foot is obliqued enough or not enough.

• Head CT – there is a blood in the brain (intracerebral hemorrhage) know all brain hemorrhage types and radiographic looks (epidural, subdural, intracerebral and intraventricular)

• Abdomen CT- know structure names: arteries, veins, organs, parts of aorta, IVC, pancreases, etc

• Chest CT – recognize pleural effusions and pneumonia

  • Pleural effusion tends to be used as a catch-all term denoting a collection of fluid within the pleural cavity. This can be further divided into exudates and transudates depending on the biochemical analysis of aspirated pleural fluid (see below). Essentially it represents any pathological process which overwhelms the pleura's ability to reabsorb fluid. 

     

  • Pneuomina is an inflammatory condition of the lung affecting primarily the microscopic air sacs known as alveoli. Its usually caused by infection with viruses and bacteria and less commonly other microorganisms, certain drugs and other conditions such as autoimmune disease

     

     

    Left upper lobe pneumonia                                                   Right upper lobe pneumonia

    Reference: radiopaedia.org

• Know QC test for spatial resolution for fluoroscopy

• Axial shoulder- there was a question regarding acromion. Ex) what structure in the image is acromion and is it an anterior or posterior structure? Know location of acromion from different shoulder views.  (refer to radiology master class tutorials website (saved under radiology folder)

• Sacrum AP axial – know proper angle of sacrum AP axial and what it looks like and also what it looks like when improper angles are used. Know position of the legs for Sacrum AP axial. Ex) are legs flat or bent or slightly bent?

  • Legs must be bent so that L5S1 joint can be opened. (to open intervertebral disk spaces by bringing down lumber spine closer to the table)

• Know possible grid errors with Lateral lumbar spine projection

  • If off centered?? Then underexposure may occur

• ??other than hand and wrist, what other images do we do for bone age?

• ??What pathology is contraindicated by latex gloves?

  • Spina bifida

  • Someone who is immunocompromised..

  • Or…

    • (spina bifida patients are at high risk for latex allergy and therefore, remain latex-free)

• ??What is the optimal kV for an abdomen?

•  Know dose limits for the public, technologist, student and pregnant tech for the whole body, lens, hands, other organs.

Table AI.1: Annual Dose Limits
Applicable Body Organ or Tissue	Radiation Workers (mSv)	Members of the Public (mSv)
Whole Body	20	1
Lens of the eye	150	15
Skin	500	50
Hands	500	50
All other organs	500	50

• ??Know vessels (locations, etc. check cross-sectional anatomy) in the neck. Ex) brachiocephalic, vertebrals and carotids. Where they come from and go to and what they supply.

• What view would you do to see the radial head in profile?

  • Colye method (CR 45 degrees towards shoulder) = demonstrates radial head + capitulum

    (elbow routine views show radial head too: but particularly lateral oblique position of elbow (external oblique elbow projection) demonstrates radial head free of superimposition)

• ??What view would best demonstrate the coronoid process (elbow) in profile?

  • AP internal oblique elbow projection (medial oblique position) best demonstrates the coronoid process in profile. (coyle method also shows coronoid process, but not best??)

  • Coyle Method (axiolateral projection) with coronoid process and trochlea shown

    • Elbow flex only 80 degree (from fully extended position) (more than 80 degree may obscure coronoid process) and hand pronated

    • CR angled 45 degree from shoulder (away from shoulder), into mid elbow joint

• A 14 yr old who does not look to have hit puberty. Do you still ask about pregnancy?

  • Yes. SC35 says from age of 11 to 55 (childbearing age), we must ask about pregnancy

• Ba enema on a patient that just had an abdomen series and there was free air seen (possible perforation). What type of contrast would you use?

  • Non-ionic water soluble contrast

• ??Know SBFT prep

• Know different liver pathologies (shapes, density, etc) around, irregular looking? Mets, cirrhosis, cysts, abscesses.

• External landmark for a swimmer’s view? Sternal notch ~ T2

• Oblique L-spine = LPO shows Left zygoapophyseal joints & RPO shows Right zygoapophyseal joints

• On what view of the L spine would you see the foramina in profile?

  • Lateral Lumbar spine

• Know anatomy of the biliary track (common hepatic duct(CHD), common bile duct (CBD), cystic duct (CD), pancreatic duct (PD), ampulla, sphincter, etc)

• What vessel do you inject contrast into in CT and why?

  • Antecubital -  easily accessible

• Know the inverse square law for intensity at a certain distance from the source and direct square law for change in mAs when SID changes

• ??How does spatial resolution/contrast resolution change when we change our FOV from small to large

• How would you confirm‎ patient’s identity = arm band, ask patient name and birthdate

• Know proper ranges for breathing rate, blood pressure, heart rate, pulse rate, etc

• ??What types of QC do you do in mammo everyday?

• When do you L5S1 spot image, instead of conning the collimation, you leave collimation wide open. What would the result image look like?

  • Wide collimation => more scatter productions => degraded contrast =>also scattered photons hit detector and AEC terminate exposure faster =>overall underexposed picture

• Know how to maintain density when you change SID, kVp, mAs, etc

• Know how to adjust beam angle for a supine odontoid view, when the patient is in a collar and the teeth are higher than the occiput (back of skull). Ex) if teeth are shown higher than the back of skull (occiput) then you need to angle the beam down (caudad). Never move the chin or head if the patient is in a collar

• Axial calcaneous. The patient can only flex the foot 80 degrees instead of 90 degrees. So you would fix this by angling the beam50 degrees down instead of 40 degrees down to compensate for the lack of flexion

• Know at what point someone who is occupationally exposed (ex.angio nurse) would have to start wearing a TLD(OSL)badge.

  • It is when that person receives 1/20^th of the annual dose limit (20mSv) so 1/20^th of 20 mSv = 1mSv

• When you have an agitated patient (very dizzy), to optimize the image decrease the time to as short as possible.

• Medical asepsis – reduces or inhibits number and growth of microorganism (non sterile procedure)

1.       600 mA 100 cm SID 1.5 mm focal spot 0.05 seconds 5.0 cm OID 35 cm X 43 cm field size 70 kV 8:1 grid ratio CR system               What will be the effect if the field size is adjusted to 10 cm X 10 cm?
		a)      Intensity maintained, scatter production increased
		b)      Intensity maintained, scatter production decreased
		c)       Intensity decreased, scatter production increased
		d)      Intensity decreased, scatter production decreased

(intensity from the xray source remains the same, however smaller field size will decrease scatter production)

1.  A change from a large x-ray field to a small x-ray field will have what results for the following factors?

1. density on the film -- decrease

2. radiation intensity at the image receptor -- decreases

   (change to a smaller field => less scatter production => decreased overall radiation intensity at the image receptor => decreased overall radiographic density)

• Case Study - #left hip – requested AP pelvis-leg rotated 15 degrees and shorter. Which AEC do you select?

  • Centre

  • Left

    (doesn’t matter whether patient can move or not, the area of interest is always going to be centered right in the middle. We use floating table to move patient anatomy position but anatomy part will be on a centre cell)

• You see a displaced intertrochanteric #. What do you do?

  • Send back patient home

  • Inform requesting physician

  • Ring nurse’s station

    (intertrochanteric fracture is a crack/fracture in the proximal femur between the greater and the lesser trochanters that usually requires surgical intervention)

    

    Technically must inform emergy doctor about this but since its not included in the options so just inform requesting physician.

• Know how you would move image intensifier (II) to reduce radiation dose during fluoroscopy

• Know how to calculate repeat rate (know equation)

• Know inverse square law, know how to calculate according to kV, mA, BF, distance, etc changes

• Know magnification & penumbra equations

• What does Valium medication do?

  • Decreases breath rate

• Carotid Artery Angiogram

  • Carotid angiography is an invasive imaging procedure that involves inserting a catheter into a blood vessel in the arm or leg, and guiding it to the carotid arteries with the aid of a special x-ray machine. Contrast dye is injected through the catheter so that x-ray movies of your carotid arteries (the arteries that supply your brain with oxygen-rich blood) are taken. This procedure is considered the "gold standard" for imaging the carotid and cerebral vessels.

    • Carotid angiography is used to:

• eval‎uate or confirm‎ the presence of narrowing or blockage in your carotid arteries
• determine risk for future stroke
• determine the need for further treatment (angioplasty or surgery)
• perform a minimally invasive procedure, carotid stenting, to fix the narrowing in the carotid artery

• CT Artifacts

  • Artifacts can degrade image quality, affect the perceptibility of detail, or even lead to misdiagnosis. An artifact is a distortion or error in an image that is unrelated to the subject being imaged

  • CT artifacts can arise from a number of sources, including the patient. Inappropriate selection of protocols, reconstruction processes, equipment malfunction or imperfections, and the limitation of physics

  • Ring Artifact – ring artifact is caused by a miscalibrated or defective detector element, which results in rings centered on the center of rotation. This can often be fixed by recalibrating the detector

  • Noise – noise is due to the statistical error of low photon counts and results in random thin bright and dark streaks that spear preferentially along the direction of greatest attenuation. Also known as photon starvation

  • Metal artifact – metal streak artifacts are caused by multiple mechanisms, including beam hardening, scatter, Poisson noise, motion, and edge effects

  • Beam Hardening – beam hardening and scatter both produce dark streaks between two high attenuation objects (such as metal or bone), with surrounding bright streaks

  • Out of filed “artifact” – out of field artifacts are due to a suboptimal reconstruction algorithm, and can be fixed using better algorithm

  • Motion – patient, cardiac, respiratory, bowl, all cause blurring and double images, as well as long range streaks

    • Ring artifact – a miscalibrated or defective detector element creates a bright or dark ring centered on the center of rotation. This can sometimes simulate pathology. Usually, recalibrating the detector is sufficient to fix this artifact, although occasionally the detector itself needs to be replaced

      

    • Noise (photon starvation) – noise is influenced partially by the number of photons that strike the detector. Photon starvation can occur as a result of poor patient positioning or poor selection of exposure techniques. The image below gives representation of how photon starvation visualized

      

      (today’s modern scanners virtually eliminate this effect due to mA modulation. Smart mA, sure-exposure…etc. however for those scanners that still employ manual techniques, this effect can be reduced by an increase in mA)

    • Metal Artifact – Metal streak artifacts are caused by multiple mechanisms, including beam hardening, scatter, Poisson noise, motion, and edge effects. Metal artifacts can be reduced using iterative reconstruction

      

    • Beam Hardening – Beam hardening in CT arises due to the polychromatic (varied energies) X-ray beam. As the beam passes through the body, lower energy photons are attenuated more easily, and the remaining higher energy photons are not attenuated as easily causing what we see as an artifact. So by increasing the overall energy of the beam (kV) we can reduce this artifact

       

      • Motion Artifact – can be anything from voluntary motion (caused by the patient, ex) head movement, improper breathing etc) to involuntary motion such as peristalsis or cardiac motion. Proper patient education can only reduce voluntary motion or by applying immobilization techniques. Improved techniques such as faster pitch can reduce the presence of involuntary motion

         

• Know grid cut off types

  • When do you get total grid cut off when using focus grid? Decentering

• What is the direction of guide shoe mark/artifact (film artifact)?

• If you spot Fine white lines (artifacts seen on image), what do you do to remove these lines?

  • Clean IP reader

• Know what lookup table is and what it is used for

• Barium Enema - Right lateral decubitus position demonstrates what?

• Hiatal Hernia Examination – what x-ray examination do you perform for Hiatal Hernia? And what patient positions are required?

• Know ethmoidal sinus location on CT coronal view

• If the patient is having type II diabetic shock, what should you do?

• What medication is needed to treat anaphylactic shock from an iodine contrast medium?

  • Epinephrine is the drug of chose to treat anaphylaxis

• What is Anticholinergic medication used?

• Anticholinergics are a class of drugs that block the action of the neurotransmitter acetylcholine in the brain. They are used to treat diseases like asthma, incontinence, gastrointestinal cramps, and muscular spasms. They are also prescribed for depression and sleep disorders.

• Which view demonstrates urethra in profile?

• Spina bifida patient is in NICU. What preps do you do prior to portable xrays?

  • Wash hand for 20 seconds (or use hand sanitizer). Must clean cassette and portable equipment since this would be a reverse isolated case. Clean portable machine and cassette with antiseptic. Fully equip PPEs. Clean tech will be in the room positioning the patient and dirty tech will be outside the room or away from the patient doing the exposure

• Know concepts of dirty tech & clean tech for isolated patients (contact, droplet precautions) and also for reverse isolated patients (neonates, immunocompromised, burned, etc)

• What views demonstrate radial head in profile or best demonstrate radial head?

  • AP oblique projection (external rotation) of elbow or Coyle method

• A young kid was extremely mad during the x-ray examination, what do you do?

  • Listen to his/her story well

• Lateral knee is not perfect, how do you fix?

• Ankle lateral is not perfect, how do you fix?

• Know elbow lateral position really well. Know how to correct patient positioning to get perfect lateral elbow view

• Ac joint x-ray – acromion location?

• Coracoid process – is this a posterior structure or anterior?

  • Coracoid process is an anterior structure whereas Acromial process is located posteriorly in relation to Coracoid process

• Clavicle x-rays, erect vs supine?? Which one is better?

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