IMM TOACS Feb

2023
By Dr Sobia Ahmed
Dr Farzana Jaffar
1A.
Q1:Lead thickness in wall??
• Ans: 1mm to 3.5mm ,
Q2 :lead thickness in apron??
• Ans: 0.5mm .
• Q3:Describe rule of 4 cm in radiation technique
For every 4 cm increase in patient thickness requires a doubling of
exposure (time) in order to achieve an image of equal density
Q: Describe rule of 15% in radiation technique
The 15% Rule states: when the kVp is lowered by 15% the mAs needs to be
increased by a factor of 2, and when the kVp is increased by 15% the mAs
needs to be multiplied by 0.5 (i.e. divided by 2).
1B
Pt came after trauma
1B

• Xray knee frontal projection.

• Findings: Lateral tibial plateau fracture noted showing intra-articular
extension.No fracture in the rest of the bones.No joint dislocation
seen.
• Diagnosis ; schatzker type II
• Next: CT bone window
• Treatment: open reduction
2A.
Out of Ten Principles and Ten
Commandments of Radiation
Protection write 5.
2B
2B
• Multiple ring enhancing lesions throughout both cerebral
hemispheres, cortical and subcortical location.
• Mild surrounding vasogenic edema.
• No mass effect.
3A
labelling
(3B):Bilateral ovarian dermoid+ two uterine fibroid
in given mri only dermoid cysts are present but in our toacs dermoid cysts with two uterine fibroids were given
4A.
1. What is this?
2. Where it is used?
3. What are the findings?
4. Define quality assurance?
4A
• 1:CT water bath phantom
• 2. it is used in ct scan and Used to test uniformity and HU.
• Used for assessing and comparing various image quality indices
• 3. ring artifact and noise
• 4.quality assurance means the planned and systemic actions that will
produce consistently high quality images with minimum exposure of
the patient and workers.
4B
Pt came after strenuous
exercise.
4B.
In our toacs only
pneumediastinum was
present
 5A

1.what is this?
2.If Cardiac output decrease
what is effect on contrast ?
3.What is ROI for aortogram?
4.What is time for arterial
sequence?
5A:
• Flow rate curve.
• 2: as cardiac out put decreases the time to arrival of the contrast
medium bolus in the aorta and to peak aortic enhancement
increases.
• Decrease cardiac out put= increase peak aortic enhancement.
• 3: descending aorta at level of carina.
• 4: early arterial phase 15-25 seconds late arterial phase 30-40 sec.
 5B
Young patient with
hypertension and headache.
1. What is Technique?
2. What are the findings?
3. What is diagnosis?
4. What is the next
investigation?
1. MRI abdomen coronal
imageT2WI
2. Innumerable varying
sized cysts hyperintense
on t2wi are seen at both
kidneys.
3. Polycystic kidney disease
4. Ct brain angio to see the
berry aneurysm
6A
MAMOGRAPHY XRAY
UNIT
LABELLING.
6B
1.What is Technique?
2.What are the findings?
3.What is diagnosis?
1.Plain CT brain axial
2.Hyperdense area seen in left
thalamus with Intraventricular
extension
3.Left thalamus hemorrhage
with interventricular
extension.
7A:
• Focal spot ???
• Mammography= 0.3mm
• Macro-mammography(magnification mammography)=0.1mm
• macro-radiography = 0.76 mm
• Radiology = general x-ray (1.0mm-1.2mm)
• fluoroscopy=0.6-
 7B
1.What is Technique?
2.Findings ?
3.Diagnosis?
4.What next?
 7B
1.CECT abdomen axial view
2. Large heterogeneous mass arising
from the right kidney, and
displacing the remaining renal
parenchyma anteromedially. The
mass contains mixed solid and cystic
areas only marginally enhances.
No spread into adjacent structures
or involvement of the renal vein or
IVC
No nodal or distant metastatic
disease in the portions imaged.
3.Wilms tumor
4.Lung window to see lung mets
nephrectomy and chemotherapy.
 8A
TRUS USG
1. What is position for prostate biopsy in
trus?
Ans. Left lateral decubitus
2. what’s sextant protocol?
Ans: prostate sampling technique is
based on the sextant protocol, described
by Hodge et al. and modified later, in
which samples are obtained of the more
peripheral zone (where the diagnostic
yield is higher) from the base through the
middle to the apex of the gland,
bilaterally
 8B

Hx of renal transplant
1.?
2.Findings?
3.Diagnosis?
4.What next?
 8B
1.T1WI coronal MRI pelvis
2.Bilateral femoral heads
show early collapse with
subchondral fracture and
diffuse sclerosis.
The proximal femur shows
diffuse edema.
3.AVN of B/L femoral heads
 9A.
CTPA ROI ??
Ans: below the carina at the level
of the pulmonary trunk with an
ROI on the pulmonary artery
What is threshold HU.?
Ans: 100 HU
Uses: for pulmonary embolism
9B
Pt with fever and abdominal pain
9B
• Technique: CECT abdomen axial and coronal images.
• findings: polypoid mass is visible in the caecum with surrounding fat
stranding and locally enlarged lymph nodes. A solitary pathologic
lymph node is also visible adjacent to the interlobar fissure of the
liver.
• DX: ca cecum
• What next: Biopsy, surgery, cect chest for staging and pet ct for mets
 10A.
What is this graph show?
Molybdenum decay curve
Procedure?
99mTc is supplied in a generator shielded with lead.
The generator contains an alumina exchange
column on which has been absorbed a compound of
the parent 99Mo. At the time of arrival, the activity of the
'daughter' 99mTc has built up to its
maximum, equal to that of the parent 99Mo.
–It takes approximately four daughter half-lives to
reach equilibrium.
–After 24 h (4 x 6 hours) → the activity has grown again
to a new maximum (equilibrium)
value. (After 6 h it has reached 50% of the maximum;
after 12 h, 75% and so on.)
Uses of Technetium-99m
• 1. Thyroid (trapped but not fully metabolized).
• 2. Gastric emptying studies (mixed with bran porridge)
• 3. Gastric mucosa (localization of Meckel's diverticulum)
• 4. Testicular imaging.
• 5. Salivary glands.
• 6. Cerebral blood flow.
Uses of MO:
• used in anodes in some x-ray tubes, especially in mammography
• Used filter in mammography
• molybdenum generators are important as a source for technetium
 10B.
15 yrs old lower limb pain
Diagnosis: osteomyelitis
Findings: X-ray of the fibula showing periosteal reaction and partial
lysis and interruption of the fibula.
• Other xray findings: regional osteopenia
• Periosteal reactionthickening (periostitis): variable; may appear
aggressive, including the formation of a Codman's triangle
• focal bony lysis or cortical loss
• endosteal scalloping
• loss of trabecular bone architecture
• new bone apposition
• eventual peripheral sclerosis
• In chronic or untreated cases, the eventual formation of
a sequestrum, involucrum, and/or cloaca may be seen.
NEXT: CECT, scintigraphy, MRI, ultrasound.
Differentials :
Charcot joint
Metastases,Ewing sarcoma,osteosarcoma,lymphoma
Langerhans cell histiocytosis (LCH)
 11A.
Enteroclysis
contrast ?
Ans: Barium sulphate and methylcellulose.
Q2. tube placement region?
Ans: If a single-contrast or double contrast
enteroclysis is to be performed, the tip may rest
in the second portion of the duodenum.
If methycellulose is to be used, the tip should be
in the proximal jejunum.
Q3. uses in our area?
Chronic diarrhea, weight loss, mucosal details,
tumor, inflammatory disease.
Q4. contraindication?
Ans: obstruction and suspected perforation
 11B
• heterogenous echotexture of left
testis
• reactive thickening of the scrotal
skin
• reactive hydrocele
• peripheral testicular decrease flow
on color Doppler examination
• Right testis is normal
• DX:Testicular torsion (left)
• Next: organ sparing orchidectomy
 12 A
Idendify the view?
Positioning?
Centring?
indication?
 12A.
• Ankle mortise view
• Positioning: the patient may be supine or sitting upright with the leg
straightened on the table
• the leg must be rotated internally 15° to 20°, thus aligning the
intermalleolar line parallel to the detector. This usually results in the
5th toe being directly in line with the center of the calcaneum
• internal rotation must be from the hip; isolated rotation of the ankle will
result in a non-diagnostic image
• foot should be in slight dorsiflexion
• centering he midpoint of the lateral and medial malleoli
• indication. Too see the Tibial plafond fracture, medial collateral ligamet
 12B:
• k/c of peptic ulcer presented with abdominal pain.
mall perforated ulcer in the lateral aspect of
the second portion of the duodenum.
Multiple locules of free intraperitoneal air in
the upper abdomen. Small amount of
perihepatic fluid and stranding, and a small
amount of ascites elsewhere. Perihepatic
fluid is high density (75 Hounsfield units),
consistent with a mixture of oral contrast and
reactive fluid. Moderate distention of the
stomach with oral contrast. Few oval filling
defects surrounded by oral contrast within
the lumen of the pylorus and first portion of
the duodenum could represent ingested
material or intraluminal clot from the ulcer if
bleeding is present.
13A.
• 1.Continous vs pulsed Doppler
• 2. stearing angle?
• 3.Doppler angle and psotion of patient
13A:
• Continuous wave Doppler
• Continuous wave Doppler simultaneously transmits and receives sound
waves with separate piezoelectric crystals, recording every velocity
received along a path defined by the operator. It is capable of recording the
direction and velocity of flow even at high velocities but is unable to
localize from where individual velocity elements originate 1.
• Pulsed wave Doppler
• In pulsed wave Doppler, the user defines a small area (the sample "volume"
or "gate") within the B-mode image, and (based on pulse repetition
frequency, or the time required for returning sound waves) only the
Doppler shifts from that area are recorded. While avoiding the range
ambiguity of continuous wave Doppler, the intermittent sampling of pulsed
wave Doppler, especially at targets that are further away from the
transducer, renders the modality vulnerable to aliasing at higher
velocities 4.
• Doppler angle corrects for the usual clinical situation when an ultrasound
beam is not parallel to the Doppler signal.
• For instance, if one wants to evaluate an artery, the best angle for
evaluation would be at zero degrees (parallel to the vessel). The strongest
signal and best waveforms would be at zero degrees. Zero degrees is not
usually clinically feasible, however, so instead the probe is at some angle
between 0 (parallel) and 90 degrees (perpendicular) when evaluating the
vessel (usually between 30 and 60 degrees).
• The ultrasound machine can correct a Doppler signal appropriately if the
transducer is angled less than 60 degrees from a vessel. It does
not, however, know what angle you are using, so you have to provide this
information to the machine, usually via a knob on the control panel.
• If you try to correct for an angle above 60 degrees, then there will be a high
rate of error with your spectra: up to 20% to 30% 2. If serially evaluating
blood flow velocity in a vessel, try to maintain a similar Doppler angle from
study to study 3.
13B: otomastoiditis.
14A.
Image intensifier , fibroptics,
lense system , light output
phosphor read as ----
plumbicon/vidicon.
14B: hx of smoking, weight loss and fever.
• Not found the image…………………..
• Xray chest with right sided deep sulcus sign pneumothorax and left
lower lobe opacity could be mass…..
15A.
Neonatal brain u/s labelling
15B:Hx of fever cough
• There are multiple tiny branching centrilobular nodules
noted in right lower lobe in keeping with a tree-in-bud
appearance.
16A:
towns view xray labelling
17A:
shoulder joint MRI
 17B
Findings :Massively enlarged
prostate with marked
surrounding inflammation and
central liquefaction indicative of
abscess.
Next :MRI, drainage of abscess,
antibiotics cover, PSA levels
• Differential: cavitary prostitis
from chronic prostatitis
• Cystic prostatic carcinoma
18A
A: eversion (B) neutral, (C) Inversion
Q2: which one is best among them patient’s position?
B??
18 B
• HSG labelling.
19 A:child with headache.
• Partial opacification of the
maxillary sinuses with air-
fluid levels are seen
bilaterally.
• Right frontal sinus is not
pneumatised. The other
paranasal sinuses are
unremarkable.
• Nasal septum appears
normal
19B:
• Findings: The CBD is
dilated, with multiple
signal voids identified in
its mid and lower
portions. This is
associated with mild
intrahepatic biliary
dilatation.
• Diagnosis:
choledocholithiasis.
20A:
• Barium meal
labelling.
20B:MLO and CC Mammogram
FfWell-defined lobulated high density lesion with
fine speculations in the lower inner quadrant of
the right breast. No parenchymal distortion,
pleomorphic microcalcification clusters, abnormal
skin thickening, nipple retraction or significant
axillary lymphadenopathy is seen.
Diagnosis : Birads 4 Breast lesion.
Next :u/s and u/s guided core biopsy. fine
spiculationspleomorphi
microcalcification clusters, abnormal
skin thickening, nipple retraction or
significant axillary lymphadenopathy
is seen. No suspicious abnormality is
seen in the left breast.