Download AQUIFER RADIOLOGY NEWEST ACTUAL EXAM WITH COMPLETE 300 QUESTIONS AND CORRECT DETAILED ANSW and more Exams Medicine in PDF only on Docsity!
AQUIFER RADIOLOGY NEWEST
ACTUAL EXAM WITH COMPLETE 300
QUESTIONS AND CORRECT DETAILED
ANSWERS
Question-What is a good way to check diaphragm flattening? - answer-Look at the lateral film Diaphragm will be flat like you can set a ruler down on the edge Question-What can a poor inspiration/hypoinflation appear like? - answer-consolidation or PNA Window vs. Reconstruction on CT? - answer-Reconstructions - processing of the raw CT data allows for better resolution of the structures [higher resolution and higher contrast] Reconstruction can be done in 3D (ortho) or in a linear way too (vascular) Question-What is the total range of hounsfield units availabe? - answer--1000 (air) to + (metal) [so range is 2000] Question-What does a typical computer display show for greyscale range? What can the human eye actually distinguish? - answer-256shades (that means each shade of grey covers ~8HU) The can only distinguish 17 shades of grey Question-How to look at the lung fields? - answer-Sweep or a zig zag down the lung field (both in PA and lateral views) Look for focal, diffuse, BL asymmetrical, interstital/vasc markings, lucencies (cavity/bullae/PTX), Compare upper and lower and L/R zones
Middle Lower zones Question-Which hilum should always appear higher on the radiograph? - answer-The LEFT sided hilum should be higher - if its not its pathological Question-What to look for with the heart? - answer-Size of the heart - the cadiac:thoracic cavity ratio LA LV Question-What mediastinal lines should be observed on PA film? - answer-R paratracheal line Azygous area Azygoesophageal line Paraaortic line (all the way down) If you can see these you need to figure out the reason why Question-How to look at the bones on Xray? - answer-Quadrant method [above and below the ribs] (the middle lung section you just Also go down the spine looking for abnormalities, mets, or collapse Question-When should you START looking at OLD films? - answer-AFTER you have COMPLETELY evaluated the new scan Question-What are the ACR appropriateness criteria? - answer-The aim is to provide continuously updated evidence-based algorithms that ensure the safest, most cost-effective, and most efficient path to radiological diagnosis or intervention matched to specific variants of clinical presentations.
- There are other causes for the spine to appear whiter (such as a blastic bone metastasis). Question-What is the lingula aligned with? - answer-The left heart border (this is more visible in the lateral view xray) Question-What are air bronchograms? - answer-Air-filled bronchi within an area of consolidation. These are frequently seen in pneumonia, but can also be seen in some tumors and other lung abnormalities More common in alveolar disease Air bronchogram ≠ pneumonia Can be seen in lung cancer (adenocarcinoma with bronchioloalveolar pattern) Can be seen in lymphoma of the lung Seen in: A. Pneumonia C. Pulmonary edema D. Pulmonary hemorrhage E. ARDS Question-Which patients w/ PNA should have a follow up xray? - answer-All patients > 40 years History of recurrent pneumonia Current/former smokers Patients whose symptoms do not resolve Question-What is the MC cause of solitary pulmonary nodules on CT scan? - answer-Well- differentiated adenocarcinoma (formerly known as bronchioalveolar carcinoma (BAC))
Common in smokers AND non-smokers (esp females) Question-True/False - mycoplasma PNA can cause Kerley B lines as seen in CHF? What are Kerley B lines? - answer-TRUE Kerley B lines (septal lines) represent thickening of interlobular SEPTA Note that sometimes Kerley B lines can be distinguished because they extend and touch the pleura Question-What are ground glass opacities? - answer-"Ground glass" is a radiology descriptive term (used in both chest radiographs and CT imaging) to indicate that blood vessels are not obscured, as would be the case in alveolar lung opacities. Question-Compare ground glass opacities vs. Consolidation opacities - answer-Ground Glass: Blood vessels are not obscured on CT. "Smoke-like" opacity on CT that does not obscure blood vessels Descriptive term (usually primarily used on CT imaging). May represent either interstitial or alveolar disease. Some diseases (like PJP infection in HIV infection, early edema, etc.), often have "ground glass" opacities early in the disease process. Consolidation: BLOOD VESSELS are obscured on CT and air bronchograms are more common. Question-What dosage of radiation in x-rays is 1 CT scan worth? - answer-150 x-rays worth of radiation per CT scan (ON AVERAGE) Some scans use more or less however depending on the application - for example PE scan = 400cxrs Abdominal Scan = 750cxrs V/Q scan = 800cxrs
Question-Who qualifies for a preoperative CXR? - answer-Two main indications for preoperative CXR:
- Acute cardiopulmonary findings by H&P
- Chronic cardiopulmonary disease in older adults, with no previous CXR within 6 months available Question-How much overlap do you look at of the L upper/L lower lobe on the CXR? - answer- A huge amount of overlap - you need to check the LATERAL film to get a sense of the depth Left Lower lobe drops BELOW the costophrenic angle and the Left UPPER lobe nearly ends AT the level of the diaphragm Question-In which lobe is the lingula found? - answer-Left UPPER lobe (its thought to be the REMNANT of a Left middle lobe that no longer exists) Means "tongue" Question-What is a dual energy X-ray? - answer-- Dedicated digital chest unit
- Two exposures are obtained milliseconds apart
- The imaging parameters are chosen to display bone and calcium on one image, and soft tissues on another image
- The two images are then combined (you can look at all 3 images separately too) Question-If you find an nodule on CT or CXR what is your next move? - answer-FIND THE OLD CT and CXR imaging - you need a comparison - this is the key This will help you figure out if its malignant/risky/ect.... Question-At what diameter does a pulmonary "nodule" become a "mass"? - answer->3cm is called a "mass"
Question-What lung nodule characteristics should be assessed to guide management? What about patient factors that influence risk for cancer? - answer-Nodule factors: Size of the nodule (malignancy increases over 1 cm) Edge (smooth, lobulated, spiculated, ill-defined) Presence and pattern of calcification (some patterns are benign) Growth (any change from prior images?) - fast growth is concerning Patient factors: History of lung fibrosis, asbestosis, etc. Age (over 40 the risk of malignancy increases) Smoking history (greatly increases risk a nodule is malignant) Travel history and history of living in areas where granulomatous disease is endemic (over 40% of people have nodules in some endemic histoplasmosis regions) History of other malignant diseases (could it be a metastasis?) Question-What is the management strategy for <4mm nodules with no risk factors? What if there are risk factors (smoking)? - answer-If <4mm and no risk factors - no followup needed If <4mm and risk factors - followup at 12 months (no imaging rec yet however) Question-How is the management of a nodule >8mm handled? - answer-RISK stratify first Low risk (<5%) of malignancy - serial low dose CT 3,6,9,12 months Intermediate risk (5-60% chance) - FDG PET/CT - if neg then serial cts to track it, but if positive then get biopsy High risk (>60% risk) - straight to biopsy or surgical resection
IV contrast MAY be necessary in larger tumor masses, particularly if there is concern for hilar or mediastinal nodal involvement. Question-Cost of a non-contrast CT of the chest? - answer-~$ Question-Give a quick description of the reimbursement practices for imaging studies? - answer- Reimbursement: How much an insurance company will reimburse for a particular study also varies between companies and geographical area. The reimbursement by Medicare and Medicaid is significantly less than most insurance companies (about 30 cents per $1 charged). Most institutions have contractual agreements with individual insurance companies and reimbursement is modified accordingly. Charges are usually split into technical fees (from the hospital) and interpretative (professional) fees (from the radiologist). Patients often get two bills and this may be confusing for them. Technical fees vary most and are generally higher except for some procedures. Question-What conditions can make a PET scan unreliable? - answer-Infections - body is in a state of increased metabolic activity Diabetes - the cells dont take up insulin and/or the body isnt making insulin (need to time this right and there are special methods) Some adenocarcinomas dont take up the FDG Some hamartomas dont take up the FDG
Question-What are the surgical options for an investigating or treating lung cancers? - answer- Lung biopsy/surgery options: Surgical lumpectomy (wedge resection) - either open or video-assisted through a mini- thoracotomy or VATS procedure Needle biopsy performed using fluoroscopy interventional radiology Needle biopsy performed using CT for guidance Lobectomy Pneumonectomy Bronchoscopy Question-List the surgical procedures for lung removal on the basis of size (smallest to largest) - answer-Wedge resection (bite) < Segmentectomy (smallest true anatomical division that can be removed) < Lobectomy (can be multiple lobes - bi / tri lobectomy) < Pneumonectomy (entire lung L or R removed) Have to assess how much lung function they have to start w/ to decide which is even possible. Question-What are the contraindications to CT guided (percutaneous) lung biopsy? - answer- Relative contraindications: Bleeding diathesis Pulmonary hypertension Severe emphysema Ventilated patient Central lesions Question-What imaging studies are appropriate to order for a suspected (non-tension) pneumothorax? - answer-1. An erect expiratory CXR plus
- A lateral decubitus laying on the OPPOSITE side of the suspected PTX (make the lung fall away and show the gap)
- Large Mass (not ARDS because that would be bilateral?) Question-Compare hydropneumothorax vs. Simple pleural effusion - answer-Air-fluid level in hydropneumothorax appears as a horizontal line, rather than the usual meniscus seen with an isolated simple pleural effusion [meniscus occurs with pleural effusion because there is negative pressure in the pleural space and the fluid tracks up the side] Question-CXR signs of atelectasis - answer-Volume loss in the affected hemithorax (smaller overall) Tracheal deviation to the affected side Hemidiaphragm elevation (but can still be seen) Hazy opacity over the affected hemithorax ('ground glass' - still can see the vascular markings of the lobe through it) Loss of heart border Question-Large white mass pushing everything AWAY from it on CXR? - answer-Huge pleural effusion (missing space pulls trachea and heart TOWARD it) Question-What does an initial "trauma series" group of x-rays include? - answer-Initial radiographic trauma series:
- AP (supine) CHEST on a trauma board (remember your patient would need to stand for an erect PA)
- AP supine PELVIS radiograph
- ± a cross-table LATERAL C-SPINE radiograph
None of these studies requires the patient to be moved from the trauma board. MOST CENTERS JUST USE CT NOW Question-Whats the big risk w. A pelvic fracture? - answer-MASSIVE bleeding Question-CXR findings for aortic injuries? - answer-Findings on chest radiographs which may reflect aortic injury include: Widening of mediastinum, indistinctness of mediastinal contours (don't see normal aortic knob, pulmonary artery, etc.) Inferior displacement of left main bronchus Apical pleural cap (related to dissection of blood over left apex ) Question-CT findings for aortic injuries? - answer-Focal abnormality of aortic lumen Focal bulge Pseudoaneurysm Small dissection flap in aortic lumen Mediastinal hematoma - Usually at level near ligamentum arteriosum Question-What do type A and type B aortic dissections describe? - answer-Type A involves ascending aorta Type B involves descending aorta Intramural hematoma will have blood in the wall of the aorta Question-What is TEVAR? - answer-Thoracic endovascular aortic repair (TEVAR)
This is to prevent reflux and aspiration of the NG feed. Tips of regular nasogastric (NG) or orogastric (OG) tubes should be in the stomach Question-In what conditions should you order "rib films"? - answer-Children with suspected child abuse (nonaccidental trauma) and possible posterior rib fractures on the screening CXR Patients with cancer and abnormalities on bone scans suspected to be benign fractures versus metastases Question-When are rib fractures MOST visible on xray? - answer-AFTER they have begun to heal and become more opaque Question-How does pneumomediastinum appear? - answer-A pneumomediastinum appears as streaky black lucencies in the mediastinum, and will usually appear as a black line along the heart border and aorta. You may see air in the subcutaneous tissues. Question-Causes of pneumoediastinum? - answer-Common causes of pneumomediastinum
- Spontaneous - usually young, fit, skinny men
- Related to high inspiratory or expiratory pressures - asthma, intubated patients (often with high PEEP settings such as acute respiratory distress syndrome)
- Secondary to a pneumothorax or pneumoperitoneum (e.g. Laparoscopy)
- Secondary to esophageal perforation (vomiting, instrumentation, tumor)
- Traumatic from a tracheal or bronchial rupture
- Tuba playing
- Freebasing cocaine Question-Radiographic signs of COPD? - answer-Other radiographic signs of COPD:
- Hyperlucency of the lungs due to destruction of the capillary bed and lung parenchyma, especially in emphysema
- Narrowing of the cardiomediastinal silhouette secondary to hyperinflated lungs, especially in emphysema
- Bullae which are often apical chest radiograph corresponding CT
- Coarse and distorted bronchovascular and interstitial markings, more common in chronic bronchitis than emphysema
- Peribronchial cuffing, more common in chronic bronchitis as the walls of the bronchi are thickened (related to hypertrophy of mucus glands and inflammation)
- "Saber sheath" trachea due to compression of the mediastinum and trachea; Question-Complications of COPD that can be seen on CXR? - answer-Signs of complications of COPD: Cardiomegaly - especially right-sided chambers (can result in cor pulmonale) Enlarged central pulmonary arteries due to pulmonary hypertension Pneumomediastinum Pneumonia Pneumothorax Question-What are pulmonary bullae? - answer-Bullae represent thin-walled gas collections in the lung periphery (we typically call them "blebs" if they are smaller than 1.0 cm in diameter). Bullae (singular is bulla - it means bubble in Latin) are common in emphysema, but may also occur in people with no emphysema. They are most common at the lung apices. They are a common cause for PTX in young patients (particularly tall males). Question-In which type of COPD is the DLCO DECREASED? - answer-Emphysema
- Severe claustrophobia. (Requires sedation, usually with p.o. Valium. Sedated patients cannot drive after the exam and will need a ride home.)
- Ferromagnetic aneurysm clips. (Most clips placed in the last 15 years are non-ferrous, but need an operative report to confirm non-ferrous nature.)
- Morbid obesity > about 300 lbs, depending on scanner. (Some newer scanners will allow up to 400 lbs.)
- Tattoos with ferromagnetic ink. Question-How many Hounsfield units is water? - answer-Water = 0 HU Metal: >1, Bone: 500 to 1, Soft tissues (e.g., Liver, spleen, bowel wall, muscle, brain parenchyma): 30 to 60 without contrast Fluid (e.g., cysts, gallbladder and bladder contents, CSF): 10 to 20 Water: 0 Fat: - 50 to - 100 Air: - 1, Question-What is the technical explanation for using contrast? - answer-Intravenous contrast will increase the density (thus increasing the HU) of many soft tissues, as well as that of blood, depending on the blood flow to the tissue and the time that the scan was acquired relative to the contrast injection. Complex fluid collections (infection, hemorrhage, etc.) Can measure higher than water density Question-Why isnt D-dimer good for hospitalized and post procedural patients? - answer-They already have fibrinogen products active in their body so theres a high likelihood for a meaningless positive test (just go to CT or US in these cases) Question-Explain a V/Q scan - answer-The perfusion is performed by injecting technetium- labeled macroaggregated albumin particles intravenously. These "stick" in the smaller pulmonary
capillaries as they are larger than the capillaries, and remain there for several hours until phagocytosed. The particles only occlude a small percentage of precapillary arterioles and capillaries (we certainly don't want to occlude them all!), but the distribution of the particles provides us with a perfusion map of the lungs. The ventilation study can be performed in various ways, most commonly by the patient inhaling another Tc-99m labeled tracer (DPTA), which is aerosolized with a nebulizer or radioactive xenon gas. Question-When is a V/Q scan indicated? - answer-When looking for a pulmonary embolism but the patients kidney's cant handle the contrast needed for a CTA (CT angiography / helical CT) Question-What is the "weakness" of a V/Q scan? - answer-IF the lungs are already abnormal - eg. BAD emphysema or COPD - then the scan is going to look very confusing Intermediate probability scans basically tell you NOTHING (probability of a PE is 20-79%) These ARE good for a rule out though - if totally normal then you nearly are CERTAIN theres no PE Question-What features you looking for on a V/Q scan? - answer-"Matched Defects" - where there is a matched decrease in both ventilation and perfusion (as in PNA or emphysema) Or "Mismatched Defects" - only 1 flow is decreased as in PE where the blood isnt flowing despite good ventilation Question-What is Visipaque™? - answer-Visipaque™ is a non-ionic iso-osmolar iodinated contrast that may have less renal toxicity (although this is controversial and this contrast agent still has nephrotoxic potential in high-risk patients). Question-What strategies can be used to decrease the toxicity and negative effects of contrast? - answer-A. Pre scan hydration (best method) B. Post scan hydration (best method)
