FUNDAMENTALS OF MEDICAL IMAGING
suggesting the ff tx preventions. Then ang mga
BRIEF HISTORY OF RADIOGRAPHY
• Discovered accidentally in 1895 by Professor
Wilhelm Konrad Roentgen while he was
experimenting on cathode ray tubes with a machine
that is unknown to him which produced x-rays
• Prof. Roentgen saw the bones of his own hands in
the shadow cast on a piece of cardboard in his
laboratory.
• tube was emitting not only light, but also a new kind
of radiation, which he called X-rays because of their
mysterious nature
IMAGING IN PHYSICAL THERAPY
• Imaging techniques will give more comprehensive
evaluation to the patient’s case.
• Success of rehabilitation depends on the
effectiveness of the clinician’s evaluation.
o The more thorough the evaluation, the more
substance the clinician has on which to build the
rehabilitation program.
o The more comprehensive the evaluation is, the
more you’ll be wise in treatment planning, precise
assessment and make doable plans.
• Multifocal views
o information the PT clinician seeks is different
nature from the information the physician seeks
and of a different nature from what may be
described in the radiologist’s report
o e.g. the physician might only be after with the
presence of the callus in a fracture seen on
radiograph to decide whether to remove or
retain the cast, however, on the PT’s point-of-
view, he must be after with the type of callus
and the progress of its formation to determine
the subsequent rehabilitation program
o Ex. Pt is requested for an x-ray of the limb, tapos
ilalagay ni radiologist – there is a fc with 50%
callus formation. Sasabihin naman ni rehab
doctor, we are already on 50% callus formation
PTs naman, assess si px first hand tapos makikita
na although may 50% callus formation, meron
ding apprehension during the exercise proper.
Suggest the ff status/recommended exercise to
downgrade other exercise programs. Ex. If
nilagay sila sa FWB, ilagay muna sila sa PWB.
Our body will try to repair the hematoma by the
formation of angiogenesis or new blood vessels in order
to increase the reparative process of the injured area - in
the case that they will form internal calluses. Then they
will recruit the formation of external callus. When there’s
good callosities, and good supply, there will be a healed
fracture.
FIELD OF RADIOLOGY
• Radiology is the branch of medicine concerned with
radiant energy and radioactive substances, including
x-rays, radioactive isotopes, and ionizing radiation,
and the application of this information to
prevention, diagnosis, and treatment of disease.
o Is radiology harmful? Radiation can cause
disruptive processes of our genetic material.
Some might be forming
malignancy/hematopoietic disruptions like in the
formation of blood vessels thereby causing bone
marrow cancer.
o Nuclear power plant eruption (Ukraine). Do you
think the radioactive materials present in
Ukraine this time are compatible to life? No. It
would take a lot of years before they diminish.
That is why the gov’t prohibited everyone to go
into the vicinity.
• Physicians specializing in radiology are called
radiologists subspecialties exist within radiology
 • INTERVENTIONAL RADIOLOGY
o ability to image areas of the body that had
previously been inaccessible to nonsurgical
evaluation
o they do things like ultrasound-guided
biopsy/radiologic interventions – ex. May
mask, then they will use diagnostic approach
and get a sample and send it to the laboratory
- detailed type of specialty
• DIAGNOSTIC IMAGING OR MEDICAL IMAGING
o uses imaging studies produced by ionizing
radiation and nonionizing studies, such as
diagnostic ultrasound and magnetic resonance
imaging (MRI)
o typical specialty – radiologists interpreting the
results and medical conditions/status of the
medical condition of the patient
RADIOGRAPH
• Defined for over a century as an x-ray film containing
an image of part of a patient’s anatomy
• Production of a radiograph requires three things:
o x-ray beam source
o patient
o x-ray film
• Conventional radiograph is commonly referred to as
the patient’s “plain films,” “films,” or “x-rays.”
- Components of a basic xray imaging system:
- Central ray – targeted to the anatomic body part
that you want to focus on
- Primary radiation – pre-patient status
- Remnant radiation
o Attenuation: Reduction of force
o Process wherein the force of a certain material is
being reduced by the body
o Diba xray is a type of energy wavelength that is
used medically to look for the body parts needing
diagnostic procedure/assessments and pre-
recorded to a certain image receptor (e.g., film).
o Kapag nagpapa-chest xray: pinapatanggal yung
bakal ng bra, jewelries, barya kasi they could
attenuate energy. Mangyayari sa image
receptor, marerecord din sila – obscure yung ax
pag nagkataon.
RADIATION
• Energy that is transmitted through space or matter
• Different forms of energy used in medicine including:
o mechanical
o electrical
o thermal
o nuclear
o electromagnetic
• All these energy forms can be transmitted as
radiation, such as:
o mechanical energy – eg. ultrasound waves
o Thermal – eg. infrared lamp
§ Superficial ba or deep? Wala? Ok.
§ Superficial dry heat
§ For Bell’s Palsy
o nuclear energy – eg. gamma rays or alpha
particles
o electromagnetic energy – eg. visible light or x-
rays
• The higher-energy forms of radiation, such as x-rays
and gamma rays, have the ability to ionize atoms in
matter
• Ionization is the process by which a neutral atom
gains or loses an electron, thus acquiring a net
charge.
o has the ability to disrupt the composition of
matter
o as a result, it can disrupt life processes
o Nangyari sa powerplant explosion: There’s
some ionization processes happening to the pt
na na-expose sa film na ‘yun. They noticed na
may newly formed malignancies on the
residents living nearby.
• Protection against excessive exposure to ionizing
radiation is of utmost importance in radiology
o Yes, radiation is harmful. But it can be used
medically but with some precautions.
o Kapag abdominal xray, may pinpasuot na
mabigat na covering sa waist. Yung mabibigat
na ‘yun, barriers ‘yun for radiation to protect
genitourinary tract and reproductive tract are
highly sensitive for radiation. It might cause a
px to be impotent
o Pwede naman daw ang multiple xrays in a day
basta dapat alam yung risk and benefits and
dapat according pa rin sa case ni px.
 o If you are generally well, you should not be o the highest energy hard x-rays and soft
exposed to ionizing radiation in every 6 mos. gamma rays are used in the therapeutic
Dapat in 6 mos, merong maximum of 1 treatment of deep tissue tumors
exposure to ionizing radiation. Risk over o Soft xray aka superfical
benefits. o Hard xrays aka deep tissues
o So kunware nakita sa xray na may pulmonary
tuberculosis, okay lang na i-xray ulet the next
three months para ma-monitor yung
progression. Mas dangerous namana ng
bacterial infection kesa sa radiation.
o Day to day basis exposure of ionizing radiation?
- Gadgets

RADIATION UNITS OF MEASUREMENT

- Visivle light: between 10-6 / 10-7

- Xrays shorter wavelength compared to radiowaves
and microwaves.

HOW X-RAYS ARE PRODUCED

• The production of x-rays requires three things:

o source of electrons – xray itself
o force to move them rapidly – vacuum/collimator
- Usually daw ginagamit ang SI units (Pero di aask ni
o something to stop that movement rapidly – image
sir)
receptors
• conditions are all met by the x-ray tube and an
electrical supply
X-RAYS
• x-ray tube consists of a cathode (negative terminal)
• form of ionizing electromagnetic radiation, similar to and an anode (positive terminal) enclosed within a
visible light but of shorter wavelength glass envelope, which maintains a vacuum
• x-rays are almost always of human origin
o our bodies have own radioactive matter, but not
as toxic as what is present to other radioactive
materials.
• various form of radiant energy is grouped according
to their wavelengths in what is called the
electromagnetic spectrum
• the shorter the wavelength in the electromagnetic
spectrum, the higher the energy of the radiation and
the greater its penetrating power
• Soft x-rays are the longer-wavelength x-rays, located
near the ultraviolet band in the electromagnetic
spectrum X-RAY INTERACTION WITH PATIENT
o used for treatment of superficial malignancies
• X-rays produced in the tube are beamed through a
such as those of the eye and skin
series of lead shutters and travel out of the tube
• Hard x-rays are the shorter-wavelength x-rays, through a collimator.
located closer to and overlapping the gamma-ray
• collimator controls the size and shape of the x-ray
range.
field coming out of the x-ray tube.
o used in general diagnostic radiography
• Prior to making the actual exposure, the
radiographer uses a light source on the collimator to
project a representation of the x-ray field onto the
patient.
o Cross hairs on the light source help define the
position of the focal or central ray, the
theoretical center of the x-ray beam.
• The central ray is positioned over the area of
anatomic interest
• The patient is then exposed to the x-ray beam.
• The primary x-ray beam then passes through the
patient and undergoes a process of attenuation.
o Then remnant radiation is produced, adapted by
the image receptor, and the film is invisible pero
will be processed with some chemicals
(phosphoric acid)
• The remnant beam is intercepted by an
interpretation device called an image receptor.
• The information gathered at the receptor, known as
the latent image, is, at this point, invisible.
o The latent image information is processed by a
method specific to the type of image receptor
used, and a visual image is produced, which is the
radiograph.
UNDERSTANDING THE IMAGE
• Radiographic image is the result of the interaction of
x-rays with body tissues.
• Radiographic identification of anatomy by different
shades of gray is dependent on each tissue’s varying
attenuation of the x-ray beam.
• More attenuation, more absorption, more visible

• Collimator is the one on the aperture, just like in the

camera. It limits the light source/xray source
• The primary x-ray beam then passes through the
patient and undergoes a process of attenuation.
o Attenuation is a reduction in the number of x- - Viral pneumonia- patchy; diffused infiltrates
ray photons in the beam
§ result of x-ray photons interacting with
matter and losing energy through either
scattering or photoelectric absorption
• X-ray beam passes through the patient, it is
attenuated in different amounts, depending on the
density of the tissue it has passed through.

- Vacuum- A force to move them rapidly

- The more we attenuate the more we absorb
radiation
- Directly proportional ang attenuation rate and
absorption of the xray. - Green = trachea yung tinuro ni sir na una
- The more we attenuate the more dangerous kasi - Second na tinuro ni sir Spinous process ng thoracic
mas higher ang exposure sa radiation area
- Pero the more we attenuate ofc mas visible yung - Red - diaphragm
image - Yellow - pleural cavity
• x-ray beam that emerges from the patient, referred - T6 – aligned sa xiphoid
to as remnant radiation, which contains an aerial
image of the patient

- Abnormal: Cardiomegaly + pleural effusion
- Cardiomegaly: left lang dapat prominent pero pati sa
right sakop
- Cardiothoracic ratio must not be more than 50-55%
on a PA view
SPOT THE DIFFERENCE!!!
• Cardiothoracic ratio must not be more than 50-55%
on a PA view – more than ½ to
• Cardiomegaly: more than 50% - right pic
Normal: Left
ABCD (Asymmetry, Bony borders, Cardiothoracic ratio,
Diaphragm)
RADIODENSITY
• combination of physical qualities of an object that
determine how much radiation it absorbs from the x-
ray beam.
• determined by a combination of:
o composition (in terms of effective atomic
number and volume density)
o thickness
• the greater an object’s effective atomic number
volume density, and/or thickness, the greater its
radiodensity
- Is solid a compact atomic component? Yes. Highly
compacted ang molecules kapag solid.
RADIOGRAPHIC DENSITY
• refers to the amount of blackening on the radiograph
o Ano mas mataas ang radiographic density? bone
o Bone - White ang appearance
o Steel – white ??
o Shades of gray lang makikita, walang pink/red
RADIOPAQUE vs RADIOLUCENT
• RADIOPAQUE is impenetrable to x-rays
o great radiodensity that it will attenuate almost all
the x-rays from the beam
o radiographic description is mostly WHITE
(INCREASE RADIODENSE)
o e.g. bone, metallic implants
• RADIOLUCENT is easily penetrated by x-rays
o radiolucent object attenuates very small amounts
of x-rays from the beam
o radiographic representation of the object is DARK
(DECREASED RADIODENSE)
o e.g. air, soft tissues, water
- Pleural fluid- dark ang color
- Kapag radiolucent- dark grey or light grey
- Which is more radiolucent? air or lead
- Which is more Radioopaque? Lead
RADIODENSITY AS FUNCTION OF COMPOSITION
(ANATOMY IN FOUR SHADES OF GRAY)
• arranged from radiolucent to radiopaque
• Air (black)
o least radio-dense; most radiolucent
o normally in the trachea, lungs, stomach, and
digestive tract
• Fat (gray-black)
o Normally present subcutaneously, along muscle
sheaths, and surrounding the viscera
• Increasing radiodensity > increasing atomic number
> density also increases = directly proportional
• Fat is more radiolucent than water – True
• Muscle is more radioopaque than water – True
• {pero nagtanong si Lorenz if ang air daw ang least
radiolucent tapos sabi ni Sir, oo?}
• It is believed that lungs is composed of intercostal
spaces, and composed of condensed amterials of
air/air densities
• Bones – spongy and compact
• Since air is the most radiolucent, is it also the most
radio opaque? – Least radioopaque. Lead ang most
radioopaque.

RADIODENSITY AS FUNCTION OF COMPOSITION

(ANATOMY IN FOUR SHADES OF GRAY)
- 1 is air kasi less densed
• arranged from radiolucent to radiopaque
• Water (gray)
o Soft tissues and fluids of the body including
blood, muscle, cartilage, tendons, ligaments,
nerves, and fluid-filled organs—share
approximate the same radiodensity as water
o Water is more radiolucent than muscle
o More radioopaque? Muscle / bone
o Muscle is more radiolucent than the bone

• Bone (white)
o most radio-dense tissue of the body
o least radiolucent kung walang implants si px
- Radio-opaque yung sa outline ng ribcage
o white dapat mag-appear tapos implants - solid
- Radiolucent yung mga spaces
white, pleural effusion – gray, contrast media
- Heart: radio-opaque
(barium enema) – bright white
- Normal to kasi less than 50% lang yung sakop ng
heart
• Other Shades of Gray
- Implication pag enlarged heart: CHF,
o Contrast Media (bright white outline) – most
cardiomyopathy
radio-opaque material over water, mm, bone
because of their increased radiodensity
o Heavy Metals (solid white)

• Kapag mas nag-aappear siya sa radioopaque, is it

- If we increase the object radiodensity, is it more
radioopaque? Yes.
- If we decrease the object radiodensity, is it more
radiolucent? Yes
radiodense? Yes. Mas compact/makapal when you
expose all varying
measurements/diameters/thickness into the xray.
• Most radiodense – bone ; appears white
• Least radiodense – fluid
• Open spaces with potential spaces like trachea, GIT –
least radiodense ; appear black
• If lungs are hyperaerated (air, oxygen, carbon
dioxide) – radiodense
 • Exposed chest or the lungs with xray – some areas • PROJECTION
might be least radiodense ; therefore, radiolucent • describes the path of the x-ray beam as it travels
• The more na makapal sa xray, more na thickness mas from the x-ray tube, through the patient, to the
mataas, more radiodense siya – more na magiging image receptor
radioopaque • most common projection terms are
• The more na manipis, the lesser the radiodensity but v anteroposterior (AP)
increased radiolucency v posteroanterior (PA)
v lateral

- Pag nagaapear as radioopaque mas radiodensed

- GIT least radiodense • most radiodense – most radio-opaque but least
radiolucent
- the more na mas makapal sa xray mas radiodense
• basta radio-opaque – puti; radiolucent – gray/black\
- The lesser the radiodensity increase radiolucency
- Yung picture on the right ng femur is THA • radiodense – makapal; least radiodense -
pinakamanipis
- Yung nasa left na picture- GIT: mga colons
• clue daw: kuwnare anteroposterior
- GOOGLE: barium enema is a radiographic (X-ray)
o antero : xray source
examination of the lower gastrointestinal (GI) tract.
o so ilalagay ang xray tube sa harap
- Barium enema- kapag daw may problems ka with GIT
- Colon wont be visible on a plain xray kasi its composed of
fluid and air and semisolid components (feces)
o Less radiodense sila – radiolucent so they cant be
seen in an xray directly
- Lesser air but more with fluid and semisolid

RADIOGRAPHIC POINTS

• POSITION
• Used to discuss the patient’s physical position in two
ways:
v in reference to general body positions, such as
upright, seated, supine, prone, erect, recumbent,
or Trendelenburg
v in reference to specific radiographic positions
that describe which body part is closest to the • Kung saan yung first word na nakita:
image receptor or on which surface the body is o Plantodorsal – beneath ng foot are nakaposition
lying ang xray source
• decubitus position o Anteroposterior: xray source sa harap ng px
• upright § Would the heart be more magnified in this
• weight-bearing view? Than posteroanterior?
v usually for pxs with fx and try to assess how hard
the callus is
- Yung first word sa projection dun itatapat yung xray
- Mas common daw ginagawa yung PA
- Xray source at the back, yung image receptor nasa
front
PAV or AP view?
- Tanong ni sir dito saang position daw mas magnified
ang heart AP or PA? 1:19:11 pls pakicheck nalangz
kase medj naguluhan din aq
- Frequently, for well persons – PAV; AP View -
bedridden
- PA yung nasa right na pic
- AP is left
- The closer the subject is to the source the larger yung
image will be….hence sa PA position mas magnified
ang heart kasi mas malapit yung image receptor
• Bony structures din are more contoured
• If PAV, bakit di nakikita scapula?
• With the positioning, there are AP oblique
projections and PA oblique projections –
depends which anat structures you want to see
(D) The nearer it is on the xray source and the farther the
image receptor is, the more it will be magnified
(A) If balanced, it will appear as more balanced
(B) the closer the object is to th exray source, the larger
it will appear. If balanced naman, tapos nilapit mo pa sa
xray source yung gusto mo na makita, mag-aappear talag
siya as bigger.
(C) may bony prominence on an area over the other end,
but they appear the same. The thing is that mas malapit
sa x ray source yung isang mas maliit na object, kaya
balanced silang nakikita
IDENTIFICATION MARKERS ON IMAGING
• minimum of two markers is usually imprinted on
every radiograph
v patient identification markers
o name, age, sex, case number, date, and
institution
v anatomic side markers
o radiopaque letters that identify the
patient’s right or left side of the trunk, or
right or left limb
BIOLOGICAL EFFECTS OF IMAGING
• Biological effects of x-irradiation are due to the
recoiling electrons
o electrons may damage DNA molecules directly
or produce free radicals
§ can cause chemical damage to genetic
material either effect may result in cell
death or mutation
§ yes, theya re strill present but they have this
absurd exponential rise in multiplication of
the celss that result to mutation
§ so kapag nagkaroon ng disruption sa
genetic material, yung replicative potential
to create another cell na kamukha niya is
maging mas disrupted > clinical condition
• Magnetic resonance imaging and ultrasonic imaging - Sa XRAY daw opaque ang presentation ng R lung
do not utilize ionizing radiation, and there is no kapag may covid
significant evidence that any biologic damage results - Diba kasi tinatanong dito ni Guinto ano ginagamit na
from these imaging modalities. imaging mod for confirmation ng COVID…. Basically
v Least radiation dose – US for aid lang naman daw ang mga imaging mods then
v Most radiation dose – CT Scan you still have to correlate clinically
• In pregnant patient, fetus consists of rapidly dividing - Revisit activities ni px, get their PSMHX tsaka mga
cells; hence, it is more sensitive to radiation, clinical presentation
particularly in the first trimester.
v Cancer induction
v Malformation
CONVENTIONAL RADIOGRAPH
v Mental retardation
- Higher chance of malformation during first trimester
(first 3 mos) + because of organ formation happens
this time
- Continue lang with precautions kapahg pregnant
• May shield daw yung buntis para ma-diminish
yung exposure
- Not recommended and unprotected sa exposure sa
buntis ofc

SCOPE OF DIAGNOSTIC IMAGING: Image Receptors -

Ways to Capture
• Three major classifications of diagnostic radiographic
imaging, based on the type of image receptor used
to capture the x-ray image are:
o film/screen radiography
o contrast studies (barium enema – single and
double contrast)
o fluoroscopy imaging
o computed or digital imaging
• Conventional Radiology/Film/Screen Radiography
o refers to plain radiographs that are generated Ano daw yung image? Dextrocardia sabi ng iba pero di
when x-ray film is exposed to ionizing radiation cinonfirm ni Sir
and developed by photochemical process.
o has been considered the gold standard against
which all new imaging technologies are
measured.
§ Due to good image quality, cost, reliability,
and ease of use of film/screen technology
§ Case to case basis
§ Gold standard: Fracture kunware Xray.
§ Kapag muscle rupture??
§ Covid-19 – RT PCR, chest xray (imaging) to
see if there’s a viral type of pneumonia
o Plain radiography relies on natural and physical
contrast based on the density of material through
which the x-ray radiation must pass.
- Then XRAY for imaging, then kinukuha ang history…
formation of covid
 Ø Fluoroscopy
• dynamic or continuous radiographic
examination
• provides real-time imaging of physiological
function that allows for active diagnosis during
the examination
• radiologist is present and controls the
examination during interventional and contrast
study procedures
o almost the same with xray, but they
provide real-time, series of xrays - Cephalocaudal
kaagad - Image will be on top of the target organs
• imaging process begins as the radiologist moves - CT scan machine aperture will be on the top – mas
the carriage over the patient to the region to be malaki R lung over L lung (based sa pic)
examined - Other structures are seen in the cross-sectional area
• x-rays are generated, the patient attenuates the - Even for the other MSK d/o, they use ct scan to easily
x-ray beam, and the image intensifier delineate condition.
transforms the remnant x-ray beam into an
electronic image displayed on a television
monitor.

Ø Contrast Studies
• Contrast media are commonly used to evaluate
the gastrointestinal tract, the urinary tract, the
vascular system, and solid organs.
• Barium suspension (single vs double contrast),
water-soluble contrast media (high vs low
osmolar agents)
o Used to see/delineate an anat. struct in
detail – for example may bukol

Ø Computed Tomography
• an axial tomographic technique, produces - May bony erosions and formations that are beyond
source images that are perpendicular to the the integrity of the N bone + joint space narrowing =
long axis of the body baka OA

Sagittal section – nerve impingement / cervical

spondylosis / hernation of nucleus pulposus / herniated
disk on IV foramen

- Hemorrhagic stroke
- LEFT CVA WITH RIGHT HEMIPARESIS
- Cranial CT – view parang nasa baba ka ng head niya
(majority)
Ø Ultrasonography
o Non-invasive imaging technique that uses high-
frequency sound waves greater than 20
kilohertz (kHz).
o A device known as a transducer is used to emit
and to receive sound waves from various tissues
in the body.
§ Reverse piezoelectric effect, but sound
waves emitted by the transducer produces
an image
o The transducer is placed against the patient’s
skin with a thin layer of coupling gel
Ø Magnetic Resonance Imaging
o a cross-sectional imaging technology that uses a
magnetic field and radiofrequency signals to
cause hydrogen nuclei to emit their own signals,
which then are converted to images by a
computer
- MRI is more defined than CT and US pero mas higher
ang radiation
- mga ibang chena ni sir yung nung si chloe nagsshare
screen
- check Costrophrenic blunting
- tension pneumothorax- deviated ang trachea
- hyperirrated sa isang side so nagmomove ang
trachea sa side with lesser air
- Tinatanong ni sir dito if yung pic is may disk
narrowing daw… answer wala
- Yung mga images nasa CHAPTER 5 ng McKinnis
- Herniated nucleus pulposus – protruding ang IV disk
- T2 image: no significant narrowing
• Film based – isang kuha lang, di dynamic so di pwede
repetitive
• Digital based – such as in the case of US/fluoroscopy,
pwede yung ganitong repetitive testing w/o too much
radiation exposure. Quality of the image, too, is better
– defined structural configuration. Highly sensitive
pero more expensive pero di naman sila ang gold
standard all the time. May conditions na mas okay
film-based kesa digital.
BASIC IMAGING MODALITIES