محاضرات تقنيات التصوير الشعاعي للصدر والبطن PDF

‫الجامعة التقنٌة الوسطى‬ ‫ بغداد‬/‫كلٌة التقنٌات الصحٌة والطبٌة‬ ‫ الثالثة‬:‫المرحلة‬ ‫ تقنٌات التصوٌر الشعاعً للصدر والبطن‬:‫المادة‬ ‫تقنٌات االشعة‬:‫قسم‬ Title:...

‫الجامعة التقنٌة الوسطى‬ ‫ بغداد‬/‫كلٌة التقنٌات الصحٌة والطبٌة‬ ‫ الثالثة‬:‫المرحلة‬ ‫ تقنٌات التصوٌر الشعاعً للصدر والبطن‬:‫المادة‬ ‫تقنٌات االشعة‬:‫قسم‬ Title: :‫العنوان‬ Larynx& pharynx Name of the instructor: :‫اسم المحاضر‬ ‫دنٌا علً مصطفى‬.‫م‬.‫م‬ Target population: :‫الفئة المستهدفة‬ ‫ المرحلة الثالثة‬/‫طلبة قسم تقنٌات االشعة‬ Introduction: :‫المقدمة‬ Radiographic techniques :- It is used to diagnose or treat patients by recording images of the internal structure of the body to assess the presence or absence of disease, foreign objects, and structural damage or anomaly. Pretest: :ً‫االختبار القبل‬ Q What is radiographic positions of larynx? Radiographic techniques for thorax &abdomen Assistant lecturer. Dunya Ali Thorax: larynx Plain radiography is requested to investigate the presence of soft-tissue swellings and their effects on the air passages, as well as to locate the presence of foreign bodies or assess laryngeal trauma. Tomography, computed tomography (CT) magnetic resonance imaging (MRI) may be needed for full evaluation of other disease processes. It is common practice to take two projections, an anteroposterior (AP) and a lateral. Antero-posterior (Fig. 7.1a) Positioning patient and image receptor The patient lies supine with the median sagittal plane adjusted to coincide with the central long axis of the couch. The chin is raised to show the soft tissues below the mandible. The image receptor is centred at the level of the 4th cervical vertebra. Direction and location of the X-ray beam The collimated vertical beam is directed 10° cranially and centred in the midline at the level of the 4th cervical vertebra. Essential image characteristics (Figs 7.1b, 7.1c) The beam should be collimated to include an area from the occipital bone to the 7th cervical vertebra. Lateral (Fig. 7.2a) Position of patient and image receptor The patient stands or sits with either shoulder against the CR cassette or vertical Bucky. The median sagittal plane of the trunk and head are parallel to the image receptor. The jaw is slightly raised so that the angles of the mandible are separated from the bodies of the upper cervical vertebrae. A point 2 cm posterior to the angle of the mandible should be coincident with the vertical central line of the image receptor. The image receptor is centred at the level of the prominence of the thyroid cartilage. Immediately before exposure the patient is asked to depress the shoulders forcibly so that their structures are projected below the level of the 7th cervical vertebra. The head and trunk must be maintained in position. Exposure is made on forced expiration. Direction and location of the X-ray beam The collimated horizontal central ray is centred to a point vertically below the mastoid process at the level of the prominence of the thyroid cartilage through the 4th cervical vertebra. Essential image characteristics The soft tissues should be demonstrated from the skull base to (C7).  Exposure should allow clear visualization of laryngeal cartilages and any possible foreign body. Lungs Radiographic examination of the lungs is performed for a wide variety of medical conditions, including primary lung disease and pulmonary effects of diseases in other organ systems. Such effects produce significant changes in the appearance of the lung parenchyma and may vary over time, depending on the nature and extent of the disease. Positioning The choice of erect or decubitus technique is governed primarily by the condition of the patient, with the majority of patients positioned erect. Very ill patients and patients who are immobile are X-rayed in the supine or semi-erect position. With the patient erect, positioning is simplified, control of respiration is more satisfactory, the gravity effect on the abdominal organs allows for reveal maximum area of lung tissue, and fluid levels are defined more easily with the use of a horizontal central ray. The postero-anterior projection (PA) is generally adopted in preference to the antero-posterior (AP) because the arms can be arranged more easily to enable the scapulae to be projected clear of the lung fields. Heart magnification is also reduced significantly compared with the AP projection. This projection also facilitates compression of breast tissue with an associated reduction in dose to the breast tissue. The mediastinal and heart shadows, however, obscure part of the lung fields, and a lateral radiograph may be necessary in certain situations. Respiration Images are normally acquired on arrested deep inspiration, which ensures maximum visualization of the air-filled lungs. Antero-posterior projection Magnification makes heart size and apical region difficult to assess as well as the mediastinum, which appears artificially widened causing difficulty in interpretation particularly when a traumatic is suspected Exposure Overexposed images reduce visibility of lung parenchymal detail masking vascular and interstitial changes, and reducing the conspicuity of consolidation and masses. Underexposure can artificially enhance the visibility of normal lung markings, leading to them being wrongly interpreted as disease (e.g. pulmonary fibrosis or oedema).  Underexposure also obscures the central areas causing failure to diagnose abnormalities of mediastinum. Soft-tissue artifacts Soft-tissue artifacts are a common cause of confusion. One of the commonest of these is the normal nipple. Other rounded artifacts may be produced by benign skin lesions such as simple seborrhoeic warts. Dense normal breast tissue or breast masses may also cause confusion with lung lesions. Linear artefacts may be due to clothing or gowns, or in thin (often elderly) patients due to skin folds and creases. Radiographic anatomy The lungs lie within the thoracic cavity on either side of the mediastinum, separated from the abdomen by the diaphragm. The right lung is larger than the left due to the inclination of the heart to the left side. In the normal radiographs of the thorax, some lung tissue is obscured by the ribs, clavicles and to a certain extent the heart, and also by the diaphragm in the PA projection. The right lung is divided into upper, middle and lower lobes, and the left into upper and lower lobes. The fissures, which separate the lobes, can be demonstrated in various projections of the thorax, when the plane of each fissure is parallel to the beam. The trachea is seen centrally as a radiolucent air-filled structure in the upper thorax, which divides at the level of the 4th thoracic vertebra into the right and left main bronchi. The right main bronchus is wider, shorter and more vertical than the left, and as a result inhaled foreign bodies are more likely to pass into the right bronchial tree. The bronchi enter the hila, beyond which they divide into bronchi, bronchioles and finally alveolar air spaces, each getting progressively smaller. As these passages are filled with air. The hilar regions appear as regions of increased radio-opacity and are formed mainly by the main branches of the pulmonary arteries and veins. The lung markings, which spread out from the hilar regions, are branches of these pulmonary vessels, and are seen diminishing in size as they pass distally from the hilar regions. The right dome of the diaphragm lies higher than the left mainly due to the presence of the liver on the right and the heart on the left. Postero-anterior – erect (Fig. 7.12a) a 35 × 43 cm CR cassette is selected, depending on the size of the patient. Orientation of a larger cassette will depend of the width of the thorax. Position of patient and image receptor The patient is positioned facing the receptor with the chin extended and centred to the middle of the top of the receptor. The feet are placed slightly apart so that the patient is able to remain steady. The median sagittal plane is adjusted at right-angles to the middle of the receptor; the shoulders are rotated forward and pressed downward in contact with the receptor or vertical stand. This is achieved by placing the dorsal aspect of the hands behind and below the hips with the elbows brought forward, or by allowing the arms to encircle the vertical Bucky device. Direction and location of the X-ray beam The collimated horizontal beam is directed at right-angles to the receptor and centred at the level of the 8th thoracic vertebrae (i.e. spinous process of T7) which is coincident with the lung midpoint. The surface marking of T7 spinous process can assessed by using the inferior angle of the scapula before the shoulders are pushed forward. Exposure is made in full normal arrested inspiration. In a number of automatic chest film-changer devices the central beam is automatically centred to the middle of the receptor. Essential image characteristics (Fig. 7.12b) The ideal PA chest radiograph should demonstrate the following: Full lung fields with the scapulae projected laterally away from the lung fields. No rotation, the medial ends of the clavicles should overlap the transverse processes of the spine. Inferior to the costophrenic angles and diaphragm clearly outlined. The mediastinum and heart central and sharply defined. Common faults and solutions The scapulae sometimes obscure the outer edges of the lung fields. If the patient is unable to adopt the basic arm position the arms should be allowed to encircle the vertical Bucky. Rotation of the patient will result in the heart not being central with assessment of heart size made impossible. Attention to how patients are made to stand is essential to ensure they are comfortable and can maintain the position. The legs should be well separated and the pelvis symmetrical in respect to the vertical Bucky. Notes Careful patient preparation is essential, with all radiopaque objects removed before the examination. Patients with underwater-seal bottles require particular care to ensure that chest tubes are not dislodged, and the bottle is not raised above the level of the chest. A PA side marker is normally used, and the image is identified with the identification marker set to the PA position. Care should be made not to misdiagnose a case of dextracardia. Long plaited hair may cause artefacts and should be clipped out of the image field. Posttest: :‫االختبار البعدي‬ Q What is PA position of chest References: :‫المصادر‬ 1-Lampignano, J., & Kendrick, L. E. (2021). Bontrager's Handbook of Radiographic Positioning and Techniques: 10e, South Asia Edition-E-Book. Elsevier Health Sciences. 2-Rollins, J. H., Long, B. W., & Curtis, T. (2022). Merrill's Atlas of Radiographic Positioning and Procedures-3-Volume Set-E-Book. Elsevier Health Sciences. Title: :‫العنوان‬ Lungs , AP ,lateral , apical view , shown structure, interpretation system, lordotic position Name of the instructor: :‫اسم المحاضر‬ ‫دنٌا علً مصطفى‬.‫م‬.‫م‬ Target population: :‫الفئة المستهدفة‬ ‫ المرحلة الثالثة‬/‫طلبة قسم تقنٌات االشعة‬ Introduction: :‫المقدمة‬ Radiographic techniques :- It is used to diagnose or treat patients by recording images of the internal structure of the body to assess the presence or absence of disease, foreign objects, and structural damage or anomaly. Pretest: :ً‫االختبار القبل‬ Q What is lateral position of chest? Radiographic techniques for thorax &abdomen Assistant lecturer. Dunya Ali Antero-posterior – erect This projection is used as an alternative to the PA erect projection when the medical condition makes it difficult or unsafe for the patient to stand or sit for the basic projection. For the latter, the patient is usually supported sitting erect on a trolley against a vertical Bucky Position of patient and image receptor The patient may be standing or sitting with their back against the image receptor, which is supported vertically with the upper edge of the receptor above the lung apices. The median sagittal plane is adjusted at right-angles to the middle of the receptor. The shoulders are brought downward and forward, with the backs of the hands below the hips and the elbows well forward, which has the effect of projecting the scapulae clear of the lung fields. Direction and location of the X-ray beam The collimated horizontal beam at right-angles to the sternum and centred midway between the sternal notch and the xiphisternum. The exposure is taken on normal full inspiration. Radiological considerations This projection moves the heart away from the image receptor plane, increasing magnification and reducing the accuracy of assessment of heart size. Antero-posterior – supine Position of patient and image receptor The patient lies in supine position, the cassette is carefully positioned under the patient’s chest with the upper edge of the cassette above the lung apices (C7 prominence) to ensure that the lung fields are included on the image. The median sagittal plane is adjusted at right-angles to the middle of the receptor, and the patient’s pelvis is checked to ensure that it is not rotated. The arms should be beside the trunk the head is supported on a pillow, with the chin slightly raised. Direction and location of the X-ray beam The collimated vertical beam at right-angles to the sternum and centred midway between the sternal notch and the xiphisternum. Antero-posterior – semi-erect This semi-recumbent position is adopted as an alternative to AP erect projection when the patient is too ill to stand or sit erect without support. 35 × 43 cm CR cassette is selected. Position of patient and image receptor The patient is supported in a semi-recumbent position facing the X-ray tube. The degree to which they can sit erect will be dependent on their medical condition. The image receptor is supported against the back, with its upper edge above the lung fields. The median sagittal plane is adjusted at right-angles to and in the midline of the image receptor. Rotation of the patient is prevented by the use of foam pads. The arms are rotated medially with the shoulders brought forward to bring the scapulae clear of the lung fields. Direction and location of the X-ray beam The collimated horizontal beam is first directed at right angles to the image receptor and then angled caudally centred midway between the sternal notch and the xiphisternum. The degree of caudal angulation are (5–10°). This will ensure maximum visualization of the lung fields and that the clavicles do not obscure the lung apices. Lateral (Figs 7.17a–7.17d) A supplementary lateral projection may be useful in certain clinical circumstances for localizing the position of a lesion and demonstrating anterior mediastinal masses not shown on the PA projection. However, it is now normal practice to undertake a CT examination if a lesion has been identified. Lateral radiographs are not taken as part of a routine examination of the lung fields, because of the additional radiation patient dose. 35 × 43 cm CR cassette used. Position of patient and image receptor The erect patient is turned to bring the side under investigation in contact with the image receptor. The median sagittal plane is adjusted parallel to the image receptor. The arms are folded over the head or raised above the head to rest on a horizontal bar support. The mid-axillary line is coincident with the middle of the Bucky, and the receptor is adjusted to include the apices and the lower lobes to the level of the 1st lumbar vertebra. Direction and location of the X-ray beam The collimated horizontal beam is directed at right-angles to the middle of the image receptor coincident with the midaxillary line. Apices Opacities obscured in the apical region by overlying ribs or clavicular shadows may be demonstrated by modification of the PA and AP projections. Direction and location of the X-ray beam With the patient in the position for the PA projection, the collimated beam is angled 30° caudally and centred over the 7th cervical spinous process coincident with the sternal angle. With the patient in the position for the AP projection, the central ray is angled 30° cranial towards the sternal angle. Lordotic This technique may be used to demonstrate right middle-lobe collapse or an inter- lobar pleural effusion. The patient is positioned to bring the middle-lobe fissure horizontal. Position of patient and cassette The patient is placed for the postero-anterior projection. Then clasping the sides of the vertical Bucky, the patient bends backwards at the waist. The degree of dorsiflexion varies for each subject, but in general it is about 30–40 degrees. Direction and centring of the X-ray beam The horizontal ray is directed at right-angles to the cassette and towards the middle of the film. Posttest: :‫االختبار البعدي‬ Q What is Apices of lungs? References: :‫المصادر‬ 1-Lampignano, J., & Kendrick, L. E. (2021). Bontrager's Handbook of Radiographic Positioning and Techniques: 10e, South Asia Edition-E-Book. Elsevier Health Sciences. 2-Rollins, J. H., Long, B. W., & Curtis, T. (2022). Merrill's Atlas of Radiographic Positioning and Procedures-3-Volume Set-E-Book. Elsevier Health Sciences. Heart and aorta, main branches ‫دنٌا علً مصطفى‬.‫م‬.‫م‬ Target population: :‫الفئة المستهدفة‬ ‫ المرحلة الثالثة‬/‫طلبة قسم تقنٌات االشعة‬ Introduction: :‫المقدمة‬ Radiographic techniques :- It is used to diagnose or treat patients by recording images of the internal structure of the body to assess the presence or absence of disease, foreign objects, and structural damage or anomaly. Pretest: :ً‫االختبار القبل‬ Q What is the position of patient and image receptor of lateral position of the lung ? Radiographic techniques for thorax &abdomen Assistant lecturer. Dunya Ali Heart and Aorta Radiography of the heart and aorta is a common examination. It is performed in the routine investigation of heart disease and to assess heart size and the gross anatomy of the major blood vessels. Radiographic anatomy In the postero-anterior radiograph of the chest seen opposite features of the heart and associated vessels have been outlined and labelled. The aortic knuckle is shown as a rounded protrusion slightly to the left of the vertebrae and above the heart shadow. The prominence of the aortic knuckle depends upon the degree of dilation and the presence (or absence) of cardiac disease. It also alters shape as a result of deformities in the thorax, intrinsic abnormalities and with old age. a, superior vena cava b, ascending thoracic aorta c, right atrium d, inferior vena cava e, left subclavian vein f, aortic knuckle g, main pulmonary artery h, left ventricle. Postero-Anterior The size of the cassette will depend of the size of the patient. Position of patient and cassette The patient is positioned erect, facing the cassette and with the chin extended and resting on the top of the cassette. The median sagittal plane is adjusted perpendicular to the middle of the cassette, with the patient’s arms encircling the cassette. Alternatively, the dorsal aspects of the hands are placed behind and below the hips to allow the shoulders to be rotated forward and pressed downward in contact with the cassette. The thorax must be positioned symmetrically relative to the film. Direction and centring of the X-ray beam The horizontal central beam is directed at right-angles to the cassette at the level of the eighth thoracic vertebrae (i.e. the spinous process of T7). The surface markings of the T7 spinous process can be assessed by using the inferior angle of the scapula before the shoulders are pushed forward. Exposure is made on arrested full inspiration. Essential image characteristics The ideal postero-anterior chest radiograph for the heart and aorta should demonstrate the following: The clavicles symmetrical and equidistant from the spinous processes. The mediastinum and heart central and defined sharply. The costophrenic angles and diaphragm outlined clearly. Full lung fields, with the scapula projected laterally away from the lung fields. Radiological considerations An artifact increase in the size of the heart may be produced by a number of factors, including: – poor inspiration – supine posture lead to a more horizontal cardiac orientation. Left lateral Position of patient and image receptor The patient is turned to bring the left side in contact with the image receptor. The median sagittal plane is adjusted parallel to the receptor. The arms are folded over the head or raised above the head to rest on a horizontal bar. The mid-axillary line is coincident with the vertical midline of the receptor, which is adjusted to include the apices and the inferior lobes to the level of the 1st lumbar vertebra. Direction and location of the X-ray beam The collimated horizontal beam is directed at right-angles to the middle of the receptor in the mid-axillary line. Exposure is made on arrested full inspiration. Essential image characteristics The thoracic vertebrae and sternum should be lateral and demonstrated clearly. The arms should not obscure the heart and lung fields. The anterior and posterior mediastinum and heart are defined sharply and the lung fields are seen clearly. The costophrenic angles and diaphragm should be outlined clearly. Radiological considerations A lateral radiograph may help to locate cardiac or pericardial masses, e.g. left ventricular aneurysm and pericardial cyst. Also these are assessed better by echocardiography or CT/MRI. Posttest: :‫االختبار البعدي‬ Q What is the direction and location of x-ray beam for lateral position of heart and aorta? References: :‫المصادر‬ 1-Lampignano, J., & Kendrick, L. E. (2021). Bontrager's Handbook of Radiographic Positioning and Techniques: 10e, South Asia Edition-E-Book. Elsevier Health Sciences. 2-Rollins, J. H., Long, B. W., & Curtis, T. (2022). Merrill's Atlas of Radiographic Positioning and Procedures-3-Volume Set-E-Book. Elsevier Health Sciences. Title: :‫العنوان‬ Bones of the thorax (upper ribs) Name of the instructor: :‫اسم المحاضر‬ ‫دنٌا علً مصطفى‬.‫م‬.‫م‬ Target population: :‫الفئة المستهدفة‬ ‫ المرحلة الثالثة‬/‫طلبة قسم تقنٌات االشعة‬ Introduction: :‫المقدمة‬ Radiographic techniques :- It is used to diagnose or treat patients by recording images of the internal structure of the body to assess the presence or absence of disease, foreign objects, and structural damage or anomaly. Pretest: :ً‫االختبار القبل‬ Q What is left lateral position of heart? Radiographic techniques for thorax &abdomen Assistant lecturer. Dunya Ali Bones of the thorax The thoracic skeleton consists of the ribs and sternum, and thoracic spine. The ribs and sternum may be examined radiographically in the assessment of trauma, but a good PA or AP radiograph will be more important in this setting to exclude intrathoracic complications. Oblique rib views performed for simple trauma cases unless a change in patient management will result, and an AP or PA projection will show much of the anterior and posterior ribs that are projected above the diaphragm. In cases of severe injury to the thorax maintenance of respiratory function is of prime importance. Optimal PA or AP radiographs are required for full assessment of chest wall injury, pleural changes and pulmonary damage. In cases of major trauma, damage may occur to multiple ribs, sternum, lungs and thoracic spine, or any combination of these. Multiple rib and sternal fractures may result in a flail chest, where part of the chest collapses inwards in during inspiration, impairing or even preventing lung ventilation. In this setting a supine AP radiograph may be all that is attainable and it should be of the highest quality possible. A pneumothorax may be obscured on a supine radiograph, and in this situation a lateral radiograph is acquired using a horizontal beam. In major trauma cases injury to the clavicle and 1st ribs may indicate significant vascular injury, and these areas must be examined clearly on any frontal projection. Injury to the lower ribs may be associated with hepatic, splenic or renal injury, and rib projections may be requested in this situation. The ultrasound or CT may be considered more useful, for assessment of possible internal organ damage. Radiological considerations Pain after rib trauma, reduce conspicuity of rib fractures and pulmonary contusion. Optimization of exposure and other factors therefore becomes more critical. Overexposure may allow clearer image of rib trauma, but will tend to obscure associated pulmonary lesions, so should be avoided. Fluoroscopy may be useful to determine whether a peripheral chest lesion is real and whether it is related to a rib, although CT is most likely to be requested in cases of doubt. Figure show x-ray shows a fracture on the left 7th rib at the posterior aspect Upper ribs First and second – Antero-Posterior 18 × 24cm or 24 × 30 cm CR cassette is selected. Position of patient and image receptor The patient stands with the posterior aspect of the trunk against the vertical Bucky. Alternatively the patient lies supine on the Bucky table. When the patient is erect, the cassette, is placed in a cassette holder. The median sagittal plane is adjusted at right-angles to the image receptor. The image receptor is centred to the middle of the clavicle. Direction and location of the X-ray beam The collimated horizontal beam is directed perpendicular to the image receptor and centred to the middle of the clavicle. Cervical – Antero-Posterior (Figs 7.32c, 7.32d) Cervical ribs are normally demonstrated on an AP cervical vertebrae or PA chest projection. 24 × 30 CR cassette is placed transversely on the Bucky tray. Position of patient and image receptor The patient sits or stands with the posterior aspect of the trunk against a vertical Bucky or lies supine on the Bucky table. The median sagittal plane should be at right-angles to the image receptor and coincident with the midline of the table or Bucky. The CR cassette is positioned transversely in the Bucky tray and should be large enough to include the 5th cervical to 5th thoracic vertebrae. Direction and location of the X-ray beam The collimated beam is angled 10° cranially from the perpendicular and centred towards the sternal notch. Fig.7.32d bilateral cervical ribs Posttest: :‫االختبار البعدي‬ Q What is bones of thorax? References: :‫المصادر‬ 1.Whitley, A. S., Jefferson, G., Holmes, K., Sloane, C., Anderson, C., & Hoadley, G. (2015). Clark's Positioning in Radiography 13E. crc Press. 2. Bontrager, K. L., & Lampignano, J. (2013). Bontrager's handbook of radiographic positioning and techniques. Elsevier Health Sciences. Title: :‫العنوان‬ Bones of the thorax (lower ribs) Name of the instructor: :‫اسم المحاضر‬ ‫دنٌا علً مصطفى‬.‫م‬.‫م‬ Target population: :‫الفئة المستهدفة‬ ‫ المرحلة الثالثة‬/‫طلبة قسم تقنٌات االشعة‬ Introduction: :‫المقدمة‬ Radiographic techniques :- It is used to diagnose or treat patients by recording images of the internal structure of the body to assess the presence or absence of disease, foreign objects, and structural damage or anomaly. Pretest: :ً‫االختبار القبل‬ Q What is the position of lower ribs? Radiographic techniques for thorax &abdomen Assistant lecturer. Dunya Ali Lower ribs Antero-posterior (basic) 35 × 43 cm CR cassette used to include the whole of the right and left sides from the level of the middle of the body of the sternum to the lower costal margin. Position of patient and image receptor The patient lies supine on the imaging table with the median plane coincident with the midline of the couch. The anterior superior iliac spines should be equidistant from the couch top.  A cassette is placed transversely in the Bucky tray with its lower edge positioned at a level just below the lower costal margin; otherwise the cassette is positioned to include the area of interest with its centre coincident with central beam. Direction and location of the X-ray beam The collimated vertical beam is centred in the midline at the level of the lower costal margin and then is angled cranially to coincide with the centre of the image receptor. This centring assists in demonstrating the maximum number of ribs below the diaphragm. Exposure made on full expiration will also assist in this objective. Right and left posterior oblique A table or vertical Bucky is employed or alternatively a 35 × 43 cm CR cassette is selected to include either the right or left lower ribs sides. The patient may be examined erect or supine. Position of patient and image receptor The patient lies supine on the Bucky table or stands erect with the mid-clavicular line of the side under examination coincident with the midline of the Bucky tray. The trunk is rotated 45° to the side being examined with the raised side supported on non-opaque pads. The hips and knees are flexed for comfort and to assist in maintaining patient position. The lower edge of the cassette is positioned at a level just below the lower costal margin; otherwise the cassette is positioned to include the area of interest with its centre coincident with central beam.  The cassette should be large enough to include the ribs on the side being examined from the level of the middle of the body of the sternum to the lower costal margin. Direction and location of the X-ray beam The collimated vertical beam is centred to the midline of the anterior surface of the patient, at the level of the lower costal margin. From this position the central ray is then angled cranially to coincide with the centre of the image receptor. Exposure is made on arrested full expiration. Posttest: :‫االختبار البعدي‬ Q What is right and left posterior oblique position of lower ribs? References: :‫المصادر‬ 1.Whitley, A. S., Jefferson, G., Holmes, K., Sloane, C., Anderson, C., & Hoadley, G. (2015). Clark's Positioning in Radiography 13E. crc Press. 2. Bontrager, K. L., & Lampignano, J. (2013). Bontrager's handbook of radiographic positioning and techniques. Elsevier Health Sciences. Title: :‫العنوان‬ Sternum Name of the instructor: :‫اسم المحاضر‬ ‫دنٌا علً مصطفى‬.‫م‬.‫م‬ Target population: :‫الفئة المستهدفة‬ ‫ المرحلة الثالثة‬/‫طلبة قسم تقنٌات االشعة‬ Introduction: :‫المقدمة‬ Radiographic techniques :- It is used to diagnose or treat patients by recording images of the internal structure of the body to assess the presence or absence of disease, foreign objects, and structural damage or anomaly. Pretest: :ً‫االختبار القبل‬ Q What is lateral position of lower ribs? Radiographic techniques for thorax &abdomen Assistant lecturer. Dunya Ali Sternum Anterior oblique – tube angled (Figs 7.33a–7.33d) The projection may be performed with the patient prone or erect with the sternum in contact with the image receptor to reduce unsharpness. A 24 × 30 cm CR cassette is selected. Position of patient and image receptor The patient lies prone on the table or stands or sits facing the vertical Bucky. The medial sagittal plane should be at right-angles to, and in the midline of the image receptor. The patient should lie on a trolley, with the thorax resting on the Bucky table. The cassette is centred at the level of the 5th thoracic vertebra. Direction and location of the X-ray beam The collimated perpendicular beam is centred at the level of the 5th thoracic vertebra. The central ray is then angled transversely so that the central ray is directed to a point 7.5 cm lateral to the midline. Anterior oblique – trunk rotated A vertical Bucky is employed a 24 × 30 cm CR cassette is selected. The patient may also be examined prone on the Bucky table. Position of patient and image receptor The patient initially sits or stands facing the vertical Bucky or lies prone on the Bucky table with the median sagittal plane at right-angles to, and centred to, the image receptor. The patient is then rotated approximately 20–30° with the right side raised to adopt the left anterior oblique position, which will ensure that less heart shadow obscures the sternum. The image receptor is centred at the level of the 5th thoracic vertebra. Direction and location of the X-ray beam The collimated perpendicular beam is directed towards a point 7.5 cm lateral to the 5th thoracic vertebra on the side nearest the X-ray tube. Lateral A vertical Bucky is employed a 24 × 30 cm CR cassette is selected. Position of patient and image receptor The patient sits or stands, with either shoulder against a vertical Bucky or cassette stand. The median sagittal plane of the trunk is adjusted parallel to the image receptor. The sternum is centred to the image receptor or Bucky. The patient’s hands are clasped behind the back and the shoulders are pulled well back. Direction and location of the X-ray beam The collimated horizontal beam is centred towards a point 2.5 cm below the sternal angle. Exposure is made on arrested full inspiration.  Radiological considerations The lateral sternal projection can be confusing to read, especially in elderly patients, who often have heavily calcified costal cartilages. Sternal fracture, especially when there is overlap of the bone ends, may be associated with fracture of thoracic vertebrae. It is appropriate to image the thoracic spine if this is suspected. Posttest: :‫االختبار البعدي‬ Q What is radiological consideration of sternum? References: :‫المصادر‬ 1.Whitley, A. S., Jefferson, G., Holmes, K., Sloane, C., Anderson, C., & Hoadley, G. (2015). Clark's Positioning in Radiography 13E. crc Press. 2. Bontrager, K. L., & Lampignano, J. (2013). Bontrager's handbook of radiographic positioning and techniques. Elsevier Health Sciences.  Title: :‫العنوان‬ Abdomen Planes & regions and Image parameters, Abdomen , AP supine, PA erect , lateral view positions Name of the instructor: :‫اسم المحاضر‬ ‫دنٌا علً مصطفى‬.‫م‬.‫م‬ Target population: :‫الفئة المستهدفة‬ ‫ المرحلة الثالثة‬/‫طلبة قسم تقنٌات االشعة‬ Introduction: :‫المقدمة‬ Radiographic techniques :- It is used to diagnose or treat patients by recording of the internal structure of the body to assess the presence :or Pretest: images ً‫القبل‬ ‫االختبار‬ absence of disease, foreign objects, and structural damage or anomaly. Pretest: :ً‫االختبار القبل‬ Q What is lateral position of sternum? Radiographic techniques for thorax &abdomen Assistant lecturer. Dunya Ali Radiographic Techniques of The abdomen Planes and regions (Figs 10.1a, 10.1b) The abdominal cavity extends from the inferior surface of the diaphragm to the pelvic inlet inferiorly and is contained by the muscles of the abdominal walls. To mark the surface anatomy of the viscera, the abdomen is divided into nine regions by two transverse planes and two parasagittal (or vertical) planes.  Fig 10-1a (Planes of abdomen) The upper transverse plane, called the transpyloric plane, approximately midway between the upper border of the xiphisternum and the umbilicus, passes through the tips of the right and left 9th costal cartilages; also in most cases the plane also cuts through the level of the pylorus of the stomach. The lower transverse plane, called the transtubercular plane is at the level of the tubercles of the iliac crest anteriorly and near the upper border of the 5th lumbar vertebra posteriorly. The two parasagittal planes are at right-angles to the two transverse planes. They run vertically passing through a point midway between the anterior superior iliac spine and the symphysis pubis on each side, in the midclavicular line. These planes divide the abdomen into nine regions centrally from above to below epigastric, umbilical and hypogastric regions and laterally from above to below right and left hypo- chondriac, lumbar and iliac regions. Fig 10-1b (Radiographic image of planes and region) The main factors affecting the position and surface markings of organs are: (a) body build, (b) phase of respiration, (c) posture (erect or recumbent), (d) loss of tone of abdominal muscles that may occur with age, (e) change of organ size due to pathology, and (f) the presence of an abnormal mass and normal variants within the population. Individuals have been classified according to body build, into four types – hypersthenic, sthenic, hyposthenic and asthenic. Hypersthenic – massively built. The dome of the diaphragm is high and the lower costal margin is at a high level with a wide angle, resulting in the widest part of the abdomen being its upper part. The stomach and transverse colon are in the upper part of the abdomen as shown in Figure 10- 2a. Asthenic – thin and slender. The elongated narrow thorax with a narrow costal angle is associated with a low position of the dome of the diaphragm. The abdominal cavity is shallow being widest in its lowest region. The pylorus of the stomach is low and the long stomach may reach well below the iliac crests, while the transverse colon can loop down into the pelvic cavity as shown in Figure 10- 2b. Between these two extremes of body build are the sthenic (tending towards hypersthenic, but not as broad in proportion to height) and the hyposthenic (tending towards asthenic, but not as thin and slender. Most common referral criteria Radiographic examination of the abdomen and pelvic cavity is performed for a variety of reasons. These include: Obstruction of the bowel. Perforation. Renal pathology. Acute abdominal pain (with no clear clinical diagnosis). Foreign body localization Toxic mega colon. Aortic aneurysm. Prior to the introduction of a contrast medium, e.g. intravenous urography (IVU) to demonstrate the presence of radio- opaque renal or gall stones. To detect calcification or abnormal gas collections. Typical imaging Protocols The following table illustrates projections used to diagnose common clinical conditions. Recommended Projection Basic Antero-posterior – supine Supplementary Antero-posterior – erect Antero-posterior or Postero-anterior – left lateral decubitus Lateral – dorsal decubitus Image parameters Although the radiographic technique used will depend on the condition of the patient, there are a number of requirements common to any plain radiography of the abdomen and pelvic cavity. Maximum image sharpness and contrast must be obtained so that adjacent soft tissues can be differentiated. Essential image characteristics Coverage of the whole abdomen to include diaphragm to inferior to the symphysis pubis and lateral fat stripe.  The whole of the urinary tract (kidneys– ureters–bladder (KUB) should be demonstrated. High resolution and the adequate contrast to demonstrate the interface between air- filled bowel and surrounding soft tissues. Radiation protection Exclusion of pregnancy unless it has been decided to ignore it in the case of an emergency. Gonad shielding can be used for males. Antero-posterior – supine(Figs 10.6a, 10.6b) A 35 × 43 cm CR cassette is selected. Position of patient and image receptor The patient lies supine on the imaging table with the median sagittal plane at right- angles and coincident with the mid- line of the table. The pelvis is adjusted so that the anterior superior iliac spines are equidistant from the tabletop. If a CR cassette is selected it is placed longitudinally in the cassette tray and positioned so that the region below the symphysis pubis is included on the lower margin of the image. The center of the image receptor will be approximately at the level of a point located 1 cm below the line joining the iliac crests. This will ensure that the region inferior to the symphysis pubis is included on the image.  Fig. 10.6a Patient positioning. Direction and location of the X-ray beam The collimated vertical beam is directed to the centre of the image receptor to include the lateral margins of the abdomen. Using a short exposure time, the exposure is made on arrested respiration. Ideally respiration should be arrested on full expiration to allow the abdominal contents to lie in their natural position. Fig. 10.6b Normal abdominal radiograph Common faults and solutions (Fig. 10.7a, Fig. 10.7b ) Failure to include the region inferior to the symphysis pubis and the diaphragm on the same image. This may be due to patient size, in which case two images are acquired, i.e. if using CR the cassettes are placed transversely (landscape) across the abdomen to include upper and lower abdominal regions. Respiratory movement unsharpness may be reduced by rehearsal of the arrested breathing technique prior to exposure. Rotation may be evident when the patient is in pain. Presence of artifacts such as buttons or contents of pockets if the patient remains clothed for the examination. Fig. 10.7a Inadequate/incomplete abdomen radiograph with right ureteric stent lower abdominal margin not visualized. Fig. 10.7b Rotated abdomen radiograph with distended small bowel loops with faecal loading and gas in rectum indicative of small bowel obstruction. Antero-posterior – erect (standing or sitting) (Figs 10.8a–10.8c) If possible the patient is examined standing or seated against a vertical Bucky, or alternatively may be examined on a tilting table. If necessary the patient may be examined sitting on a trolley or on a chair using a 35 × 43 cm CR cassette. Position of patient and image receptor The patient stands/sits with their back against the receptor/ vertical Bucky. If standing the patient’s legs are placed well apart so that a comfortable and steady position is adopted. If seated care must be taken to ensure the flexed knees are not obscuring the lower abdomen. The median sagittal plane is adjusted at right-angles and coincident with the midline of the vertical Bucky. The pelvis is adjusted so that the anterior superior iliac spines are equidistant from the image receptor. The upper edge of the image receptor (35 × 43 cm CR cassette) is positioned at the level of the middle of the body of the sternum so that the diaphragms are included. Direction and location of the X-ray beam The collimated horizontal beam is directed so that it is coincident with the centre of the receptor in the midline. An exposure is taken on normal full expiration.  Antero-posterior – left lateral decubitus This projection is used if the patient cannot be positioned erect to confirm the presence of subdiaphragmatic gas. It should only be undertaken as a specific request when other modalities such as ultrasound/CT cannot be used. It may also be used for con firming a bowel obstruction. With the patient lying on the left side, free gas will rise to be located between the lateral margin of the liver and the right lateral abdominal wall. To allow time for the gas to collect the patient should remain lying on the left side for a short while (e.g. 10 minutes) before the exposure is made. Position of patient and image receptor The patient lies on their left side, on a trolley, with the elbows and arms flexed so that the hands can rest near the patient’s head. The patient is positioned with the posterior aspect of the trunk against a vertical Bucky with the upper border of the image receptor high enough to project above the right lateral abdominal and thoracic walls. Alternatively, a 35 × 43 cm CR grid cassette is supported vertically against the patients back. Direction and location of X-ray beam The collimated horizontal central beam is directed to the anterior aspect of the patient and centred to the centre of the image receptor. Patient positioning for antero-posterior Fig.10.9b Antero- posterior left lateral decubitus images of the abdomen Showing free air in the abdominal cavity left lateral decubitus. Lateral – dorsal decubitus (supine) (Figs 10.9c, 10.9d) Occasionally the patient is unable to sit or even be rolled on to their side, thus the patient remains supine and a lateral projection is taken using a horizontal central ray. Position of patient and image receptor The patient lies supine with the arms raised away from the abdomen and thorax. A 35 × 43 cm CR grid cassette is supported vertically against the patient’s side to include the  thorax to the level of mid-sternum and as much of the abdomen as possible. Care should be taken that the anterior wall of the trunk is not projected off the resultant image. Direction and location of the X-ray beam The collimated horizontal central beam is directed to the lateral aspect of the trunk at right angles to the receptor. Lateral dorsal decubitus image of the abdomen used to demonstrate free air in a patient who cannot move from supine position Patient positioning for lateraldorsal decubitus.. Urinary tract – kidneys– ureters–bladder Plain radiography of the abdominal and pelvic cavity is undertaken to visualize: The outline of the kidneys surrounded by their perirenal fat. The lateral border of the psoas muscles. Opaque stones in the kidney area. Calcifications within the kidney or within the bladder. The presence of gas within the urinary tract. Any other acute abdominal pathology. Preparation of the patient The patient should micturate to empty the bladder prior to the examination. If possible, the patient should have a low residue diet during the 48 hours prior to the examination to clear the bowel of gas and faecal matter that might overlie the renal tract. In the case of emergency radiography no bowel preparation is possible. The patient wears a gown. Antero-posterior (Figs 10.10a, 10.10b) Position of patient and image receptor The patient lies supine on the X-ray table with the median sagittal plane of the body at right-angles to and in the mid- line of the table. The patient’s hands may be placed high on the chest or the arms may rest by the patient’s side slightly away from the trunk. The Bucky detector used should be large enough to cover the region from above the upper poles of the kidneys to the symphysis pubis (or a 35 × 43 cm CR cassette is used). The image receptor is positioned so that the symphysis pubis is included on the lower part of the image. The center of the image receptor will be approximately at the level of a point located 1 cm below the line joining the iliac crests. This will ensure that the symphysis pubis is included on the image. Direction and location of the X-ray beam The vertical collimated beam is directed to the center of the image receptor with the lateral margins collimated within the margins of the image receptor. The exposure is made on arrested expiration. Patient positioning. Anterior-posterior KUB abdominal image with adequatedemonstration of kidney outline.  Posttest: :‫االختبار البعدي‬ Q What is radiographic position of abdomen? References: :‫المصادر‬ 1.Whitley, A. S., Jefferson, G., Holmes, K., Sloane, C., Anderson, C., & Hoadley, G. (2015). Clark's Positioning in Radiography 13E. crc Press. 2. Bontrager, K. L., & Lampignano, J. (2013). Bontrager's handbook of radiographic positioning and techniques. Elsevier Health Sciences. Title: :‫العنوان‬ Urinary bladder Name of the instructor: :‫اسم المحاضر‬ ‫دنٌا علً مصطفى‬.‫م‬.‫م‬ Target population: :‫الفئة المستهدفة‬ ‫ المرحلة الثالثة‬/‫طلبة قسم تقنٌات االشعة‬ Introduction: :‫المقدمة‬ Radiographic techniques :- It is used to diagnose or treat patients by recording of the internal structure of the body to assess the presence :or Pretest: images ً‫القبل‬ ‫االختبار‬ absence of disease, foreign objects, and structural damage or anomaly. Pretest: :ً‫االختبار القبل‬ Q What is AP position of abdomen? Radiographic techniques for thorax &abdomen Assistant lecturer. Dunya Ali Urinary tract The right posterior oblique projection shows the right kidney and collecting system in profile. Similarly, the left posterior oblique projection shows the left kidney in profile. A lateral projection may be necessary to confirm the presence of opacities anterior to the renal tract, which will be seen superimposed on the antero-posterior projection. Right posterior oblique Position of patient and cassette The patient lies supine on the table. The left side of the trunk and thorax is raised until the median sagittal plane is at an angle of 15–20 degrees to the table. The patient should be in the midline of the table; and immobilized in this position. For the kidney area alone, a 24 _ 30 cm cassette is placed transversely in the Bucky tray and centred to a level midway between the xiphisternal joint and umbilicus. For the whole of the renal tract, a 35 _ 43-cm cassette might be required; this is centred at the level of the lower costal margin. Direction and centring of the X-ray beam The vertical central ray is directed to the centre of the cassette. Note Excessive rotation of the patient will show the right kidney projected over the spine. Lateral Position of patient and cassette The patient is turned on to the side under examination, with the hands resting near the head. The hips and knees are flexed for stability. With the median sagittal plane parallel to the table, the vertebral column is positioned over the midline of the table. The cassette is placed in the tray and, for the kidney area, about 5 cm superior to the lower costal margin. Direction and centring of the X-ray beam The vertical central ray is directed to the centre of the cassette and the exposure made on arrested expiration. Urinary bladder Calculi within the urinary bladder can move freely particularly if the bladder is full whereas calcification and calculi outside the bladder, e.g. prostatic calculi, are immobile. AP and oblique projections can be taken to show change in relative position of calculi and bladder. To examine the bladder region, caudal angulation is required to allow for the shape of the bony pelvis and to project the symphysis below the apex of the bladder. Antero-posterior 15° caudal (Figs 10.13a, 10.13b) Position of patient and image receptor The patient lies supine on the Bucky table with the median sagittal plane at right- angles to, and in the midline of the table. A 24 × 30 cm CR cassette is commonly used; this is placed transversely in the tray with its lower border 5 cm below the symphysis pubis. Then adequate collimation to demonstrate this area is required. Direction and location of the X-ray beam The collimated central ray is directed 15° caudally and centred in the midline 5 cm above the upper border of the symphysis pubis. (e.g. midway between the anterior superior iliac spines and upper border of the symphysis pubis). Right or left posterior oblique (Figs 10.13c, 10.13d) Position of patient and image receptor From the supine position one side is raised so that the median sagittal plane is rotated through 35° to the right or left side. To help stability, the knee in contact with the table is flexed and the raised side supported using a non-opaque pad. The patient’s position is adjusted so that the midpoint between the symphysis pubis and the anterior superior iliac spine on the raised side is over the midline of the table/receptor. A 24 × 30 cm CR cassette is placed longitudinally in the tray with its upper border at the level of the anterior superior iliac spines, then adequate collimation to demonstrate this area is required. Direction and location of the X-ray beam The collimated vertical central beam is directed to a point in the midline 2.5 cm above the symphysis pubis. Alternatively a caudal angulation of 15° can be used and the receptor displaced downwards to accommodate the angulation and allow for better demonstration of the apex of the bladder.  Posttest: :‫االختبار البعدي‬ Q What is radiographic position of urinary bladder? References: :‫المصادر‬ 1.Whitley, A. S., Jefferson, G., Holmes, K., Sloane, C., Anderson, C., & Hoadley, G. (2015). Clark's Positioning in Radiography 13E. crc Press. 2. Bontrager, K. L., & Lampignano, J. (2013). Bontrager's handbook of radiographic positioning and techniques. Elsevier Health Sciences. Title: :‫العنوان‬ Mammography, main position, finding, image interpretation Name of the instructor: :‫اسم المحاضر‬ ‫دنٌا علً مصطفى‬.‫م‬.‫م‬ Target population: :‫الفئة المستهدفة‬ ‫ المرحلة الثالثة‬/‫طلبة قسم تقنٌات االشعة‬ Introduction: :‫المقدمة‬ Radiographic techniques :- It is used to diagnose or treat patients by recording images of the internal structure of the body to assess the presence or absence of disease, foreign objects, and structural damage or anomaly. Pretest: :ً‫االختبار القبل‬ Pretest: :ً‫االختبار القبل‬ Q What is mammography? Radiographic techniques Assistant lecturer. Dunya Ali Mammography Techniques Mammography is the radiographic examination of the breast tissue (soft tissue radiography). To visualize normal structures and pathology within the breast. A low kVp value, typically 28 kVp, is used. Radiation dose must be minimized due to the radio-sensitivity of breast tissue. Mammography is carried out on both symptomatic women with a known history or suspected abnormality of the breast and as a screening procedure in well, asymptomatic woman. Consistency of radiographic technique and image quality is essential, particularly in screening mammography. Whilst other techniques such as magnetic resonance imaging (MRI) and ultrasound have a role in breast imaging. Recommended projections Basic 45-degree medio-lateral oblique Projections (Lundgren) Craniocaudal A mammography system comprises: A high-voltage generator X-ray tube tube filtration compression device image-recording system automatic exposure control (AEC) system. Radiological considerations Lesion characteristics Four main types of lesion are visible mammographically, namely masses, calcifications, architectural distortion and density, each of which is assessed according to a variety of features: Masses Masses are assessed by shape, margin and density. The shape may be round, oval, irregular or lobulated. Benign lesions tend to be round or oval and well-defined, whereas malignancies tend to be irregular in shape and are often hyperdense. A low-density lesion suggests fat and is usually benign. Calcifications Calcifications vary in size, shape, number, grouping and orientation. There are many typically benign forms of calcification, such as dermal, vascular and popcorn calcifications. Milk of calcium has a characteristic teacup shape on the oblique projection. Many types of rod- and ring-like calcifications are also benign. Malignant calcifications are often grouped, linear and irregular in size, shape and separation. Architectural distortion Architectural distortion is a feature of many carcinomas. It also occurs with benign conditions, such as sclerosing adenosis. In most of these cases, it can be proven benign only by histology. Focal increased density Focal increased density may be a sign of malignancy, but it has low specificity unless combined with other features. Benign disease may also cause asymmetric increased density, but focal density is regarded with suspicion. Other features Other features may be present, such as skin thickening, and nipple retraction. These are assessed with the main features outlined above. Other techniques Ultrasound Ultrasound is the most widely used and readily available alternative imaging technique. It is the best test for determining whether a lesion is a cyst. Other fluid- containing diseases may also be detected, such as abscesses. Ultrasound gives different tissue information from that obtained by X-ray (e.g. homogeneity of tissue, acoustic shadowing), making this a useful supplementary tool. It also allows assessment of surrounding tissue and vascularity. It may be used, therefore, to assess mammographically indeterminate masses or to guide core biopsy. In younger patients, where the density of breast makes mammography less sensitive and where suspicion is lower, ultrasound has an important role in diagnosis and avoidance of radiation exposure. Being a real-time technique, ultrasound is simpler and faster and will be the guidance method of choice for most techniques. Magnetic resonance imaging MRI is expensive, relatively time-consuming and not available widely. Some patients cannot tolerate it due to claustrophobia. In addition to showing the morphological features demonstrated by other modalities. 45-degree medio-lateral oblique (MLO) basic – Lundgren’s oblique Position of patient and cassette The mammographic equipment is routinely angled at 45 degrees from the vertical. However, the precise angulation required will depend on the woman, e.g. for a very thin woman, the breast-support table will be almost vertical. The marker is oriented vertically to prevent confusion of the image with those produced by other mammographic projections. The woman faces the equipment, with the breast about to be examined closer to the breast-support table. The woman’s arm is placed on the top of the table, with the elbow flexed and dropped behind it. The table height is adjusted so that the lower border of the breast is 2–3 cm above the edge of the film. The radiographer places his or her hand against the rib cage and brings the breast forwards, with his or her thumb on the medial aspect of the breast. The breast is gently extended upwards and outwards to ensure it contacts the breast-support table. This is aided by leaning the woman forward. The shoulder on the side under examination extended to ensure inclusion of the axilla, the axillary tail and as much as possible of the breast tissue. The compression plate is applied to fit into the angle between the humeral head and the chest wall. When the compression is almost complete, the breast is checked for skin folds. The nipple must be in profile. To ensure that the entire breast back to the chest wall margin is included. Essential image characteristics The axilla, glandular tissue, pectoral muscle should be demonstrated. When both medio-lateral oblique projections are viewed together ‘mirror image’, they should be symmetrical, matching at the level of the pectoral muscle as a deep ‘V’ and at the inferior border of the breasts. Cranio-caudal – basic Position of patient and cassette The mammography equipment is positioned with the X-ray beam axis pointing vertically downwards. The woman faces the machine, with her arms on her sides. She is standing and is rotated 15–20 degrees to bring the side under examination close to the horizontal breast-support table. The table is at the level of the infra-mammary crease. The radiographer stands on the side of the woman that is not being examined and lifts the breast up in the palm of the hand to form a right-angle with the body. It is rested on the breast support table. The nipple should be in the midline of the breast and in profile. Film makers are placed on the axillary side of the film close to the woman’s axilla and well away from the breast tissue. The woman’s head is turned away from the side under examination, and the shoulder on the side under examination is dropped to coverage the lateral posterior portion of the breast, to bring the outer quadrant of the breast in contact with the breast-support table, and to relax the pectoral muscle. Remove any skin folds of the breast and is also stretched carefully across the film support. The breast is compressed firmly to a level that the woman can tolerate. This should result in an equal thickness of tissue anteriorly and posteriorly. Care must be taken when the compression is applied to ensure that exposure is immediate. Compression must be released as soon as the exposure ends. Essential image characteristics No overlying structures should be seen. The nipple should be in profile and shown in the midline of the film. There should be no folds in the breast tissue. Radiograph of patient with pacemaker in situ Posttest: :‫االختبار البعدي‬ Q What is cranio-caudal position? References: :‫المصادر‬ 1.Whitley, A. S., Jefferson, G., Holmes, K., Sloane, C., Anderson, C., & Hoadley, G. (2015). Clark's Positioning in Radiography 13E. crc Press. 2. Bontrager, K. L., & Lampignano, J. (2013). Bontrager's handbook of radiographic positioning and techniques. Elsevier Health Sciences.