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SMU-DDE-Assignments-Scheme of Evaluation PROGRAM SEMESTER SUBJECT CODE & NAME BK ID SESSION MARKS Q.No 1. A Bachelor/Diploma in Medical Imaging Technology III BMI 303– Radiographic Techniques: Routine Procedures- II B1977 WINTER 2015 60 Criteria Marks Total Marks List the various radiographic views of cervical vertebrae. Explain the lateral views of cervical vertebrae in detail. (Unit 1;Section 1.3;Pg 10-14) Various radiographic views of cervical vertebrae are 2 10 Lateral erects Lateral supine Open mouth AP- third to seventh vertebrae (basic) Axial-supine Lateral-flexion and extension Right and left posterior oblique-erect 3+3+2 A. Lateral erect The cervical spine lateral x-ray should cover from C1 down to the C7T1 joint space and approximately one-third of T1 (first thoracic vertebra). Clinical indications: Indicating possible fracture and arthritis Procedure: The procedure for cervical lateral erect view radiograph is as follows. a) The patient stands or sits with either shoulder against a vertical Bucky. b) The median sagittal plane of the trunk and head are adjusted such that it is parallel to the film. c) The jaw is slightly raised so that the angles of the mandible separate from the bodies of the upper cervical vertebrae d) A point 2.5 cm posterior to the angle of the mandible should be coincident with the vertical central line of the Bucky and the film is centered at the level of the prominence of the thyroid cartilage opposite to the fourth cervical vertebra. e) Two 45 degree pads placed between the patient's head and the Bucky will aid immobilization. If the patient is standing, feet should be separated to aid stability. f) Just before the exposure, the patient is asked to depress the shoulders forcibly as shown in the figure below, so that the dense structures of the shoulders are projected below the level of the seventh cervical vertebra. g) When carrying out the above said movements, the head and trunk must be maintained in position. SMU-DDE-Assignments-Scheme of Evaluation Focus film distance 150 cm kVp 50-55 mAs 12-16 Grid No Cassette size 10” x 12” Breathing Instructions NA Centering The horizontal central ray is centered to a point vertically below the mastoid process at the level of the prominence of the thyroid cartilage. Radiation Protection Lead waist apron is used to protect the gonads Collimation Shutter A: To full of the film Shutter B: Within 1.25cm (half an inch) of the skin line If the entire femur cannot be included in a single image, two must be taken with a minimum of 5 cm (2 inches) overlap. The size of the second film will depend on the coverage required. In this case it may be simply an AP knee. Horizontal central ray to the cassette 90 degrees B. Lateral supine The cervical spine lateral x-ray should cover from C1 down to the C7T1 joint space and approximately one-third of T1. Clinical indications: When the patient is sent to the radiodiagnostic department on a casualty trolley for exclusion or confirmation of injury to the cervical vertebrae, a lateral-supine projection is taken first without moving the patient. This projection must be examined by a medical officer to establish whether the patient can be moved for other projections. Medical supervision of any movement of the patient may be required. If the patient is rotated or moved to an x-ray table, injury may become severe or it may even lead to paralysis. Procedure: The procedure for cervical lateral supine view radiograph is as follows. a) The patient will normally be in the supine position. b) A cassette is supported vertically against either shoulder, parallel to the median sagittal plane of the trunk, and centered at the level of SMU-DDE-Assignments-Scheme of Evaluation the prominence of the thyroid cartilage as shown in figure 1.7. c) It is important to demonstrate the seventh cervical vertebra. The patient's shoulders must therefore be depressed, if necessary, by gripping the patient's wrists and pulling the arms caudally or downwards by a suitable qualified person in this field. d) The person applying such traction must wear a lead-rubber apron and gloves. e) If the patient's head and neck are turned to one side, more than one lateral projection may be required with the cassette parallel to: (a) the median sagittal plane of the trunk; (b) the median sagittal plane of the head and (c) a plane between (a) and (b). Focus film distance 150 cm kVp 50-55 mAs 12-16 Grid No Cassette size 10” x 12” Breathing Instructions NA Centering Direct the horizontal central ray at right angles to the cassette and to a point vertically below the prominence of the thyroid cartilage at the level of the mastoid process. Radiation Protection Lead waist apron is used to protect the gonads Collimation Shutter A: To full of the film Shutter B: Within 1.25cm (half an inch) of the skin line If the entire femur cannot be included in a single image, two must be taken with a minimum of 5 cm (2 inches) overlap. The size of the second film will depend on the coverage required. In this case it may be simply an AP knee. Horizontal central ray to the cassette 90 degrees C. Lateral-flexion and extension These projections may be required only at the request of a medical officer to supplement the basic projections in cases of trauma, for example subluxation, or pathology, for example cervical spondylosis, to assess the degree of movement and any change in the relationship of the cervical vertebrae. If an injury is suspected a medical officer must be present to supervise flexion and extension of the neck. SMU-DDE-Assignments-Scheme of Evaluation Clinical indications: To supplement the basic projections in cases of trauma, for example subluxation (condition where joint begins to dislocate), or pathology, for example cervical spondylosis, to assess the degree of movement and any change in the relationship of the cervical vertebrae. Procedure: The procedure followed for lateral-flexion and extension xray is as follows. a) The patient is positioned as for the lateral basic or lateral-supine projections. However, erect positioning is more convenient. b) The patient is asked to flex the neck and tuck the chin in as far as possible for the first projection. c) For the second projection, the patient should extend the neck and raise the chin as far as possible. d) The film is centered in the mid-cervical region and may have to be placed transversely for the lateral- flexion depending on the degree of movement. Focus film distance 100 cm kVp 60-65 mAs 16 Grid No Cassette size 10” x 12” Breathing Instructions NA Centering Direct the central ray horizontally towards the mid-cervical region (C4). Radiation Protection Lead waist apron is used to protect the gonads Collimation On Vertical cassette 2. central ray to the 30 degree cranial angulation Explain the various projection terminologies used in skull radiograph. (Unit 4;Section 4.3;Pg 83-87) SMU-DDE-Assignments-Scheme of Evaluation A To describe a skull projection, it is necessary to state the relative positions of the skull planes to the image receptor and the central ray relative to skull planes/image receptor and to give a centring point or area to be included within the beam. Traditionally, a centring point has always been given, but this may not always be appropriate.This is because some centring points will lead to the irradiation of a large number of radiosensitive structures that are of no diagnostic interest. Rather than focusing entirely on centring points, it is often better for the radiographer to be mindful of the anatomy that needs to be demonstrated for a diagnosis to be made and to ensure that this is included within the primary beam, while ensuring that it is not obscured by other structures. 10 10 Explanation of following projection terminologies: (a) Occipito-frontal projections: Projections in which the central ray is parallel to the sagittal plane are named according to the direction of the central ray. The central ray enters the skull through the occipital bone and exits through the frontal bone. This is therefore an occipto-frontal (OF) projection. (b) Fronto-occipital projections: Again, the central ray is parallel to the sagittal plane, except that the central ray now enters the skull through the frontal bone and exits through the occipital bone .This is a frontooccipital (FO) projection. 3. A Describe the various paranasal air sinuses x-rays. Paranasal air sinuses occipito-mental (basic) Paranasal air sinuses lateral (basic) Paranasal air sinuses occipito-frontal (Unit 8;Section 8.3;Pg 161-166) 1 10 A. Paranasal air sinuses occipito-mental (basic) This projection is designed to project the petrous parts of the temporal bones below the floor of the maxillary sinuses so that fluid levels or pathological changes in the lower part of the sinuses can be clearly visualised. It is recommended that the patient keeps the mouth wide open so that the posterior parts of the sphenoidal air sinuses are projected through the open mouth. Also the open mouth stretches the upper lip avoiding it causing a confusing soft tissue shadow over the lower antra. Clinical indications: Inflammatory conditions like sinusitis, secondary osteomyelitis and sinus polyps. Procedure: The procedure for paranasal air sinuses occipito-mental (basic) radiographs are as follows: 1. The patient is seated facing an erect Bucky, preferably a universal 3+3+3 SMU-DDE-Assignments-Scheme of Evaluation Bucky or the vertical object table of a skull unit, either of which can be tilted to help in positioning the head. 2. The patient’s nose and chin are placed in contact with the midline of the Bucky and then the head is adjusted to bring the orbito-meatal plane at 45 degrees to the horizontal with the centre of the Bucky at the level of the lower orbital margins. 3. To ensure that the median sagittal plane is at right angles to the midline of the Bucky, check that the outer canthi of the eyes as well as the external auditory meatuses are equidistant from the film. B. Paranasal air sinuses lateral (basic) Lateral radiograph of sinus should cover sphenoid sinuses, superimposed frontal , ethmoid and maxillary sinuses, sella turcica and orbital roofs. Clinical indication: Inflammatory conditions like sinusitis, secondary osteomyelitis and sinus polyps. Procedure: The procedure for paranasal air sinuses lateral (basic) radiograph is as follows: 1. The patient sits with one side of the head against the vertical Bucky, the arm of the same side extended comfortably by the trunk and the arm of the opposite side flexed to grip the Bucky support to help immobilisation. 2. The head and the Bucky heights are adjusted so that the centre of the Bucky is 2.5 cm along the orbito-meatalline from the outer canthus of the eye. 3. The median sagittal plane is brought parallel to the film by ensuring that the interorbital line is at right angles to the Bucky and the nasion and external occipital protuberance are equidistant from it. C. Paranasal air sinuses occipito-frontal To demonstrate the maxillary antra and anterior ethmoidal sinuses, the horizontal central ray is parallel to the orbito-meatal plane. Clinical indication: Pathology of maxillary antra and anterior ethmoidal sinuses. Procedure: The procedure for paranasal air sinuses occipito-frontal view is as follows: 1. The patient is seated facing an erect Bucky table with the nose and SMU-DDE-Assignments-Scheme of Evaluation centre line of the forehead in contact with the vertical midline of the Bucky table. 2. The height of the Bucky table is adjusted so that its horizontal central line is at the level of the infra-orbital line. 3. The position of the head is adjusted so that both the median sagittal plane and the orbito-meatal plane are at right angles to the Bucky table, and the head is immobilised in this position 4. Discuss the various radiographic views of urinary tract. A (Unit 10;Section 10.3;Pg 202-206) Explanation of all the radiographic views of urinary tract with 4+3+3 10 radiographic techniques. Antero-posterior Procedure: The procedure for AP view of the urinary tract is as follows: 1. The patient lies supine on the x-ray table with the median sagittal plane of the body at right angles to and in the midline of the table. The hands may be placed high on the chest or the arms may be by the patient’s side slightly away from the trunk. 2. The size of film used should be large enough to cover the region from above the upper poles of the kidneys to the symphysis pubis. For the average adult this will be a 35 x 43 cm film. 3. The cassette is placed in the Bucky tray and positioned so that the symphysis pubis is included on the lower part of the film, bearing in mind the fact that the oblique rays will project the symphysis downwards. 4. The centre of the cassette will be at the level of the lower costal margin in the mid-axillary line, and the upper edge of the cassette is at the level of the xiphisternum. 5. A wide immobilisation band is applied to the patient’s abdomen and depending on the patient's condition, compression is applied. 6. This compression is more effective if a long pad is placed along the midline under the compression band before tightening the band. Right posterior oblique Additional information about the relationship of opacities to the renal tract may be obtained with posterior oblique projections. The right posterior oblique projection shows the right kidney in outline and the left kidney facing forward. Similarly the left posterior oblique projection shows the left kidney in outline and the right kidney facing forward. Procedure: The procedure for right posterior oblique is as follows: 1. The patient lies supine on the table and then the left side of the trunk and thorax is raised until the coronal plane is at an angle of 20-30 degrees to the table. 2. The patient is moved across the table until the vertebral column is SMU-DDE-Assignments-Scheme of Evaluation slightly to the left side of the midline of the table and then the patient is immobilised in this position. 3. For the kidney area alone a 24 x 30 cm cassette is placed transversely in the Bucky tray and centred to a level midway between the sterno-xiphisternal joint and umbilicus. 4. For the whore of the renal tract a 35 x 43 cm cassette might be required and this is centred at the level of the lower costal margin. Lateral The procedure for lateral view is as follows: 1. The patient is turned on to the side under examination. The hands rest near the head and the hips and knees are flexed to help stability. 2. With the median sagittal plane parallel to the table, the vertebral column (about 8 cm anterior to the posterior skin surface) is positioned over the midline of the table and an immobilisation band applied. 3. The cassette is placed in the tray and for the kidney area it is centred 5 cm superior to the lower costal margin. 5. A Discuss radiograph of foreign bodies. (Unit 11;Section 11.3;Pg 218-222) 1. Percutaneous foreign bodies: These are commonly metal, glass or 2+2+2+2+2 10 splinters of wood associated with industrial, road and domestic accidents. Generally two projections at right angles to each other are required without movement of the patient between the exposures, particularly when examining the limbs. The projections will normally be antero-posterior or postero-anterior and a lateral of the area in question. A radio-opaque marker should be placed adjacent to the site of entry of the foreign body. The skin surface and a large area surrounding the site of entry should be included on the films since foreign bodies may migrate, for example, along muscle sheaths and high-velocity foreign bodies may penetrate some distance through the tissues. Compression must not be applied to the area under examination. Oblique projections may be required to demonstrate the relationship of the foreign body to adjacent bone. Profile projections may be required to demonstrate the depth of the foreign body and are particularly useful in examination of the skull, face, thoracic and abdominal walls. 2. Ingested foreign bodies: A variety of objects, such as coins, beads, needles, dentures and fish bones, may be swallowed accidentally, or occasionally intentionally, particularly by young children. The patient should be asked to undress completely and wear a hospital gown for the examination. The approximate time of swallowing the object and the site of any localised discomfort should be ascertained and noted on the request card along with the time of the examination. However, any discomfort may be due to abrasion caused by the passage of the foreign body. It is important to gain the patient's co-operation, especially young children, since a partially opaque object may be missed if there is any movement during the exposure. The patient should practise arresting respiration before commencement of the examination. SMU-DDE-Assignments-Scheme of Evaluation If the patient is a young child, the examination is usually restricted to a single antero-posterior projection, where the whole alimentary tract is included on the film. The examination of older children and adults may require a lateral of the neck to demonstrate the pharynx and upper oesophagus, a right anterior oblique of the thorax to demonstrate the oesophagus and an antero-posterior abdomen to demonstrate the remainder of the alimentary tract, exposed in that order 3. Inhaled foreign bodies: Foreign bodies may be inhaled, for example, infants and young children habitually put objects into their mouths and these may be inhaled. Teeth may be inhaled after a blow to the mouth or during dental surgery. Such foreign bodies may lodge in the larynx, trachea or bronchi. The patient should be asked to undress completely to the waist and wear a hospital gown for the examination. A posteroanterior projection of the chest, including as much of the neck as possible on the film, and a lateral chest projection will be required initially. A lateral projection of the neck, including the naso-pharynx, may also be required. In the case of a non-opaque inhaled foreign body, postero-anterior projections of the chest in both inspiration and expiration will be required to demonstrate the possible lack of change in density of a lung segment (obstructive emphysema or atelectasis) or mediastinal shift. The kVp must be sufficiently high to demonstrate a foreign body which might otherwise be obscured by the mediastinum. A fast film/screen combination and short exposure time should be employed. 4. Inserted foreign bodies: Foreign bodies are sometimes inserted into any of the body orifices. Infants and young children, for example, may insert objects into the nasal passages or an external auditory meatus. In these cases, radiography is only occasionally required since most of these objects can be located and removed by alternative methods without radiography. When radiography is requested, two projections at right angles to each other of the area concerned will be required. Swabs may be left in the body following surgery. Such swabs contain a radio-opaque filament consisting of polyvinylchloride impregnated with barium sulphate for radiographic localisation. It is sometimes necessary to check the position of an intrauterine contraceptive device. In this case ultrasonography should be used to avoid irradiating the gonads. 5. Transocular foreign bodies: Foreign bodies which enter the orbital cavity are commonly small fragments of metal, brick, stone or glass associated with industrial, road or domestic accidents. Ultrasound is used increasingly in their detection and localisation and may demonstrate associated soft tissue damage. However, the resolution is not sufficient to demonstrate very small foreign bodies and radiography may be requested. Computed tomography is particularly useful when it is necessary to demonstrate the location of multiple foreign bodies and foreign bodies in the posterior part of the orbital cavity. SMU-DDE-Assignments-Scheme of Evaluation 6. A Describe radiography in the theatre. (Unit 14;Section 14.3;Pg 218-222) Theatre radiography plays a significant role in the delivery of surgical 10 10 services. The following settings are typical examples where the radiographer is required. a) Non-trauma corrective orthopaedic surgery b) Trauma orthopaedic surgery c) Interventional urology d) Operative cholangiography e) Specialized hysterosalpinography procedures f) Emergency peripheral vascular procedures. Liaison: The radiographer should contact the theatre superintendent on arrival in the theatre, and maintain a close liaison with all persons performing the operation. Radiographers should have a working knowledge of the duties of each person in the operating theatre, and check on the specific requirements of the surgeon who is operating. Personal preparation: In many modern theatre suites it is normal for xray equipment and darkroom processing facilities to be housed within the complex. The first thing that each radiographer must be concerned with is their own personal preparation before entering an aseptic controlled area. Uniform and any jewelry is removed and replaced by theatre wear. The hair is completely covered with a disposable hat, and theatre shoes or boots worn. Special attention is then made to washing the hands, using soap, paying particular attention to the nails with a scrubbing brush. A face mask is put on. If the skin has an abrasion, this should be covered with a clean plaster. A film monitoring badge is pinned to the theatre garment. Equipment: Portable or mobile x-ray units are selected, depending on the requirement of the radiographic procedure. This may mean a highpowered mobile x-ray unit for abdominal radiography, or a mobile image intensifier for screening of orthopaedic procedures, such as hip pinning. Before a unit is removed from its store, it is switched on and tested. It is then disconnected from the electrical supply and dusted with a dry absorbent cloth to remove superficial dust. Using a cloth moistened with a suitable antiseptic solution in alcohol base, all parts of the mobile unit are cleaned with special attention to cables and wheels. After the unit has dried, it is transferred to the theatre, tested again, and if functioning positioned ready for use. Exposure parameters are then adjusted to those required for screening or image recording on a film. The image intensifier housing or x-ray tube housing is covered with a sterile towel by staffs that are scrubbed for the operation. Darkroom facilities: Processing equipment should be switched on and tested. Adequate levels of replenisher solutions should be prepared if required and a supply of cassettes and films made available for use. Accessory equipment: Cassette holders, stationary grids, cassette tunnels or serial changer devices should be cleaned and checked if SMU-DDE-Assignments-Scheme of Evaluation required. An operating theatre table with an adjustable cassette tray should be checked for movement, and the radiographer should be familiar with the function and be able to position cassettes when requested. Contrast media, if required, should also be supplied to the theatre staff. Radiation protection: Radiation protection is the responsibility of the radiographer operating the x-ray equipment. The radiographer should ensure that film monitoring badges and lead rubber aprons are worn where necessary, and staffs are sent out of theatre if not required during exposure. Use of the inverse square law with staff standing at the maximum distance from the source of radiation, and outside the path of the radiation field, should be made during exposure. The radiation field should be collimated to the size of the film or intensifier and cassette support devices should be used to hold cassettes. The radiographer should use the fastest film/screen combination consistent with the examination and type of processing to reduce radiation dose. Records should be kept of exposure times when screening is employed. The radiographer must give clear instructions to staff before exposures are made regarding their role to reduce the risk of accidental exposure. Sterile areas: The radiographer should avoid the contamination of sterile areas. Ideally, equipment should be positioned before any sterile towels are placed in position, and care should be exercised not to touch sterile areas when positioning cassettes or moving equipment during the operation. *A-Answer Note –Please provide keywords, short answer, specific terms, specific examples (wherever necessary) ***********