MODULE-20: PRODUCTION AND PROPERTIES OF X – RAYS

Learning objectives

This module deals with

 Types of X-ray apparatus

 Parts of X-ray machine

 Production of X-rays

 Properties of X-rays

BASIC INTERACTION OF X-RAY WITH MATTER

 For an x-ray examination, the part to be examined is kept between the x-

ray source and an x-ray film. Thus the x-ray beam emitted by the machine
 traverse through the part to be examined to reach the film, carrying useful
information that is recorded as a image on the film. While passing through
the patient.

 Some x-rays are differentially transmitted through the patient carrying

[Link] photons are absorbed and least to exist.

 Some are deviated from their course as scatter radiation which decreases
the quality of a radiograph by causing fog on the film.X ray photon can
interact with matter in five ways of which the Photoelectric effect and
Compton effect are important in diagnostic radiology.

o Coherent scattering
 o Photoelectric effect

o Compton effect

o Pair production

o Photo disfiguration

Photoelectric effect

 The effect is mostly produced when x-ray photos interact with inner shell
electrons of a atom (KLM). It occurs more with low energy incident
photons and high atomic numbers element, provided that the photons have
sufficient energy to over come electron building energy with atom.

Compton effect
 As an incident photon encountered a free electron of the outer shall of the
atom, the photon travel in a new direction as scatter [Link]
effect produce almost all the surface radiation encountered is diagnostic
[Link] is the major radiation hazzard y fluorspar examinations.

 Photon defected at a narrow angle is electron to reach the film being

exposed to cause [Link] an incident photon with energy slightly greater
than the binding energy of a k shell electron encounter the scatter, the k
shell electron is affected from its shell. The photon disappears as most of
its energy is utilized to over come the binding energy of k shell electron.

 The free electron flies off as photoelectron. Another electron from an

adjacent or outer shell of another atom immediately fills in to the void
 created by an ejected electron. As this electron drops in to the created void,
it gives off energy is the form of characteristic radiation.

Uses in diagnostic radiology

 Contrast of the image is enhanced.

 No scatter radiation – Excellent quality of radiology

 Increases radiation ion of patient.

TYPES OF X-RAY APPARATUS

Portable apparatus

 Portable x-ray machines are widely used in veterinary practise.

 The advantages are

 o They are less than other types of machines.

o They need little maintanence.

o They can be operated from any 15 A electrical point .

o They can be easily transported.

o They are light and easily manoeuvered .

 The disadvantages is their low milliamperage necessitates longer exposure

time and it predisposes to movement blur. Maximum output is 70 - 90 Kv
and 15-30 mA.

 Uses

o Suitable for x-raying of limbs below stifle and elbow of large animals
 and abdomen and skeletal system of small animals.

Mobile x-ray apparatus

 In machines of this type the transformer are larger to permit higher output
and hence cannot be transported easily. They are mounted on wheels , and
are cumbersome to use for restive animals. The output varies from 40-60
mA and 90Kv. (the maximum of 125 kv and 300mA)

 Uses

o Can be used for large animal for radiographing head , neck, and limbs
and this machine is quite useful for small animal practices

Fixed x-ray apparatus

  This machine requires transformer which have to be built in the room and
special electric connection (3 phase). The output ranges from 300 -
1000mA and 120-200kv. This type of mahcines are suitable only for big
institutions because of high expenses involved. Suitable for both large
animal and small animal radiography.

Properties of x-ray beam

 X-rays are invisible to eye & travel at high speed & at straight lines

 They can penetrate objects depending on atomic no, density, thickness of

the material

 Photographic effect - on photographic emulsions x-rays ionises silver

 halides on the photo film

 Fluoroscent effect - certain chemicals such as zinc sulphide, calcium

tungstate etc fluoresce when exposed to x-rays & emit green or blue light.
This effect is utilised to intensify the x-ray effect by using intensifying
screen in the x-ray cassetes.

 Biological effect - x-rays ionises the atoms & bring about disturbances in
the cells by chemical activity which may cause either destruction or
activation or mutation.

Collimation of X-ray beam

 The x-rays because of diverting property is capable of extending to a

 considerable width. So the X-ray machine incorporate some mean to
collimate or restrict the beam. The purpose is three fold & they are

o To prevent unnecessary radiations of the patients or persons

restraining the animals

o To reduce the scattered radiations.

o To minimize genetrical distortion.

 This is done by using cones or light beam diaphragm in a semi-darkened

room.
PARTS OF X-RAY MACHINE

 It consists of four main parts

 o X-ray tube,

o Transformers,

o Tube stand and

o Control panel.
X-ray tube
 An X-ray tube consists of a large thermionic diode glass tube which has
been evacuated to produce a high vaccum and in to which are sealed two
electrodes, the cathode (-) and the anode (+).

 Stationary or rotating is placed 1 - 3 cm apart. The glass tube is made of

borosilicate to with stand high temperature generated inside.
 The passage of a high kilo voltage electric current across the electrodes
results in the production of X-rays.

 The glass tube isfitted in to an oil filled casing and the whole assembly is
housed in a metal encased with lead covering with a small opening for the
useful X-rays to exit after filtration.

 The vacuum in the tube creates a free flow for the electron beam and also
prevents oxidation of cathode filament.

 This also increases tube life. The oil in the tube helps to dissipate heat
apart from acting as a electrical insulator.

 Cathode
o The negative electrode consists of tungsten filament and a focussing
cup and it serves as the source of electrons. Tungsten is preferred
because of its high melting point ( 3370 c) and high atomic
[Link] tube current is measured in milliampereage and decides
the number of electrons flowing per second from the filament to the
target.

o Modern machines have two filaments made of tungsten -rhenium alloy

to increase the thermionic emission efficiency and hence the tube life.
Focussing cup is a concave cup made of nickel or molybdenum and its
function is to restrict the electron cloud to a small beam.

o Immediately prior to making an x ray exposure the filament is heated

 to create an electron cloud by a low voltage current (average about 10
volts and amperege about 3-5.)The tube current decides the quantity or
intensity of the x rays produced and also can be altered in the control
panel.

 Anode

o Anode is the target made up of thin sheet of tungsten embedded in a

copper block serves to obstruct the electrons to make them give up
their energy. As 99 % of it is converted in to heat, the heat produced at
the target is rapidly transferred to the copper block and hence to the
oil. The anode angle differs according to individual tube design and
may vary between 10 deg and 20 deg and the size of the focal spot
 may vary from 0.3mm to 2 mm.

o It is important that the x ray beam should arise from the smallest
practical portion of the anode. This area is often termed as target or
focal spot.

o Larger x ray tubes possess rotating anode to with stand the heat
generated due to large exposure.

o There are two types of anode - stationary and rotating.

o The stationary one is used in dental x ray machines.

Transformers

 This consists of an auto transformer, a step down or filament transformer

 and a high tension transformer.

 A auto transformer corrects the fluctuations in input voltage, step down

transformer permits the suitably reduced current to the cathode, and the
high tension transformer produces a high voltage current for the
production of x rays.

Tube stand

 This is to support the x ray tube during the exposure.

Control panel

 This contains the meters switches, on and off voltameter, kilovoltage

selector, milli amperage selector the timer, and exposure button.
PRODUCTION OF X-RAYS
  X rays are produced by energy conversion when a fast moving streams of
electrons is suddenly decelerated in the target anode of the x-ray tube,or
by bombarding a tungsten target with an electron beam it gives up some of
electron of its energy .

 Most of the energy (over 99A) will be transformed into heat; the reminder
of the energy will be converted into x-rays.

 As x-ray beam passes thriough the patient differential absorption takes

place depending on the tissue density and shadowgraph is obtained.

Electron orbits and energy level

 Electrons are negatively charged particles revolving round the

 [Link] an atom is electrically neutral in its normal state, it must
contain an equal number of protons and electrons.

 The atom resembles a tiny planetary system with the nucleus as the sun
and the electrons as the orbiting planets.

 X rays are generated by two different process when high speed electrons
lose energy in the target of the x ray tube due to radiative interaction.

Characteristic radiation or Line radiation

 When the projectile electron interacts with the electron in the K shell of
the traget atom rather than the electron in the outer shell it results in the
ejection of electron in the K shell if the energy of the projectile electron
 exceeds the binding energy of the ejected electron. This results in transient
electron vacancy in the K shell into which an electron from the outer shell
or from another atom falls and this process continues till the atom
becomes stable. This shifting of electrons results in emission of X-ray
photon which possoses an energy equal to the difference between the
binding energies of the electrons involved. Hence the X-ray photon energy
is characterisitic of the shells involved in an element and so called as
characteristic radiation.
Bremstrahlung radiation or Breaking radiation
 When the projectile electron approaches the nucleus of the atom avoiding
the orbital electrons, it slows down, due to the opposite charges, and gets
 difflected from its original course. During this the incident electron loses
its kinetic energy, due to its slow down, and this loss of kinetic energy is
emitted as X-ray photon.

 The X-ray produced by this type is called bremstrahlung or breaking

radiation. The incident electron may also collide with the nucleus at times,
converting all its kinetic energy to a single X-ray photon.
TYPES OF X-RAY APPARATUS

 X-rays remain the main domain in diagnosis although various other

imaging specialities were later explored and being practiced.

 The main reason behind this is the cost of the equipment involved in the
latest imaging techiniques. This makes use of X-rays for its wide
 application amd so also its potential harmful effects. Hence physics of X-
ray production and priciples involved must be explained.

 Matter in the universe is a substance made up of mass and occupies space.

Einstein law of conversion of energy states matter and energy can neither
created nor destroyed as its mass, energy or charge remain unchanged Like
matter, energy may exist is many forms eg: Kinetic energy, electric energy,
potential energy, chemical energy, nuclear energy, heat energy, electro
magnetic energy etc. energy of one form can easily be converted into
another form. For example X-rays are produced in X-ray machine from
electrical energy.

MODULE-21: FACTORS INFLUENCING PRODUCTION OF X-

 RAYS

Learning objectives

This module deals with

 Factors affecting radiographic quality

FACTORS AFFECTING RADIOGRAPHIC QUALITY

 An good diagnostic radiograph is one is which there excellent details,

correct density and the proper scale of contrast. The proper use of various
radiographic exposure factors KVP, mA Time and FFD are employed.

Detail

 Detail is the degree of definitions of an object on a radiograph. Good

detail is the true reproductions of an object. The factors affecting the detail
are:

o Shorter Focal Spot film distance. (FFD)

o Closeness of the object to the film.

o Use of intensifying screen.

o Movement of either the patient, cassette on movement of the machine.

o Screens, film contrast.

o Over exposure or under exposure.

o Focal spot size.

 o Any condition fogging the film will bring out loss of detail.

Density

 Radiographic density is determined by the amount of light absorbed by an

exposed x-ray film and is a measure of the degree of blackness of the film.

 Radiographic density is affected by te subject density which the weight per

unit volume of different body constituents.

 The density of the radiograph varies directly with milliamperage, provided

all other factors remains constant.

 Higher milliamperage produces more x-rays and thus more density and
lower milliamperage results is less density. Radiographic density varies
 directly with exposure [Link] contrast is the difference in
density between the image of parts or structures on the radiograph.

Contrast

 Contrast is the difference between blacks, grays and whites. There can be
long scale contrast and short scale contrast. Radiographic contrast varies
inversely with the kilovoltage. The lower the kv produces a radiograph
with a “short scale of contrast”. Secondary radiation and scattered
radiations causes lack of contrast. Improper development of film and use
of warm developer cause lack of [Link] get good radiograph in
veterinary patients the following technique should be followed

o Fastest exposure time possible (To prevent movement blur)

 o Higher kvp.

o Constant distance

o Constant milliamperage

Viewing of the radiograph

 Radiograph should be viewed on a good, evenly lit viewing box, in a semi

darkened room.

 Over exposed film should be viewed against bright light. Though

provisional diagnosis can be given on a wet film, it is advisable to wait till
the film is dry, before giving final diagnosis.

 When viewing radiographs of the dorsoventral or ventrodorsal or skull, the

 left side of the film should be facing the viewers right side and when
viewing the lateral views it would be better that the anterior aspect should
be directed towards the left side of the viewers. Always follow the same
conventions.

 To give radiological interpretation the viewer must have a comprehensive

data of clinical and physical examinations and also have a knowledge of
the range of radiological animal anatomy and for this a library of normal
films taken in the standard position is an asset.
MODULE-22: PRINCIPLES OF VIEWING AND INTERPRETING X -
RAY FILMS

Learning objectives
This module deals with

 Handling of X-rays

 Viewing of X-rays

 Interpretation of X-rays
HANDLING, VIEWING AND INTERPRETATION OF X-RAYS

Handling

 Cassettes with exposed film should be opened in a dark room and the film
is removed by holding the corners. The film is loaded in a suitable size
cassette and stored in lead lined boxes.

 The loaded cassettes and the exposed film cassettes are kept with
 radiopaque surface upwards. Unexposed film boxes are always kept in
lead lined boxes.

Viewing

 Radiography should be viewed on a good evenly lit viewing box in a semi

darkened room.

 Dorsoventral chest, ventrodorsal abdomen or skulls are viewed with a

right side of the film facing the viewer’s left side.

 Lateral view radiographs are viewed by placing it facing left. Radiographs

of extremities are viewed with lateral aspect on left side of the viewer.

Interpretation
  The three important factors to be considered before interpreting a
radiograph are

o Case history,

o Physical examination and

o Correct radiographic technique.

Radiographic diagnosis

 Radiographic diagnosis consists of two parts namely location of the lesion

and classification of the lesion. Location of the lesion requires knowledge
of normal radiographic anatomy, basic radiographic signs in terms of
changes such as size, architecture, contour, density, position and function.
 A systematic and methodical examination of each radiograph will prevent
overlooking unexpected lesion.

Classification of Lesion

 The lesions in the radiograph are classified as developmental, metabolic,

traumatic, infectious, neoplastic, and degenerative.
MODULE-23: RADIOGRAPHIC LESIONS - THORAX

Learning objectives

This module deals with

 Radiological pathology of thorax

RADIOLOGICAL PATHOLOGY OF THORAX

Cardiomegaly

 Outline of the heart becomes more rounded.

 Occupies a much larger area of the thorax.

 Trachea and major blood vessels are seen displaced.

 Posterior border of heart becomes straighter.

 Cardiac silhouette in contact with sternum and diaphragm.

Bronchitis

 Slight increase in the radio-density of the bronchial tree

Pneumonia

 Areas of increased density of lung substance.

 Areas of consolidation can be visualized

Pneumothorax

 Collapse of the lungs.

 Presence of air in the pleural cavity

 Floating heart shadow

Fluid in the pleural cavity

 Fluid shadow will be masking the structures in the thorax.

  Fluid level appears as area of increased density.

 Typical leafy appearance

Diaphragmatic Hernia

 Disappearance of the normal diaphragm line.

 Displacement of lungs and visualization of part of GI tract in thoracic

cavity.

Tuberculosis

 Areas of opacity in lung parenchyma

 Recognition of cavitations and calcified nodules in the lung parenchyma

or pleura.
 MODULE-24: RADIOGRAPHIC LESIONS - ABDOMEN

Learning objectives

This module deals with

 Radiological pathology of abdomen

RADIOLOGICAL PATHOLOGY OF ABDOMEN

Gastric torsion

 Greatly distended gas filled organ occupying the major portion of the
anterior abdomen. Compartmentalization of stomach.

Oesophageal achalasia

 Distended organ occupying the upper half of the chest in the lateral view
  Dorsoventral view-distended organ projecting beyond the shadow of the
spine

Oesophageal foreign body

 Thickening of the oesophageal wall

 Increased density from that of the surrounding tissues.

Pyloric Obstruction

 Enlargement of the stomach

 Accumulation of fluids/material (accumulation of barium) in pyloric area.

Intussusceptions
  Sausage shaped mass with increased density

 Thin layer of gas outlining the layers of intussusceptions

 Barium enema- ‘coiled watch spring’ pattern.

Hydronephrosis

 Large mass with a smooth outline in the anterior abdomen filled with
fluids, with appearance of homogenous density

Kidney calculi

 Small irregular dense areas roughly central to the kidney outline

Cystic calculi
  Radiopaque cystic calculi easily visualized slightly radiopaque calculi can
be demonstrated by using penumo cystography.

Prostate enlargement

 Relatively dense mass just anterior and ventral to the pelvic brim in the
position normally occupied by the bladder, which is displaced anteriorly.

Metritis and pyometra

 Slight thickening and enlargement of uterus- may be uniformly tubular or

sacculated.

 Displacement of the colon.

MODULE-25: RADIOGRAPHIC LESIONS - LIMBS
Learning objectives

This module deals with

 Radiological pathology of bones and joints

RADIOLOGICAL PATHOLGY OF BONES AND JOINTS

Radiographic signs of bone diseases

 Altered contour of the bone

 Altered size of the bone

 Decreased one density

 Change in trabecular pattern

Radiographic signs of joint diseases

 Widening or narrowing of the joint space

 Cystic changes

 Swollen joint capsule-soft tissue swelling

Osteoporosis

 Diminished density of the bone.

Small animals

 Hip dysplasia

o Bony exostosis, new bone formation involving acetabulum- thickened

 disorganized appearance of the femoral neck-remodeling and
flattening of the femoral head.

 Hip dislocation

o Abnormal width of intra articular space.

 Long bone fractures

o Disruption of the continuity of a bone

MODULE-26: CONTRAST RADIOGRAPHY - CLASSIFICATION,
MATERIALS, INDICATIONS AND CONTRA INDICATION

Learning objectives

This module deals with

 Contrast radiography and its classification

 Intravascular contrast agents and contrast radiography

CONTRAST RADIOGRAPHY - CLASSIFICATIONS

 Radiography is founded upon the principle that an object when exposed to

an incident x-ray beam will absorb a part of the x-ray beam and a part
willpenetrate the object and interact with the film. Radiodense objects
absorb larger percentage of the x-rays than radiolucent objects resulting in
less film exposure and the recording of white object image.

 In other words, the absorption of x-ray by the tissues of the body, and thus
their radidensity, depends upon the atomic weight of the principal
substances of which the tissues are composed. That means absorption
 capacity of an organ or object is directly proportional to the number of
orbital electrons in the atom of the molecule of the absorbing material
(atomic number). Comparison of equal volumes of different tissues/with
their densities.

Density

 Barium - 56

 Bone - 14 (Average)

 Muscle, Organ, fluid

 Soft tissue 7.4 (Average)

 Fat - 6.3
 Gas (Air) - 1 to 2

 The differences in density (radiographic contrast) between bones, muscles,

fat and gas form the basis of plain film radiography. Ex: Kidney is seen
clearly in a plain radiography if there is perirenal fat around the organ.
Bone is clearer because of surrounding soft tissues.

 But the kidney pelvic is not visible or the mucous pattern of bladder or
stomach are not seen normally due to lack of contrast.

 Artificial methods of delineating such organs are required and so a suitable

contrast medium is employed. The contrast medium may have either high
atomic weight and provide positive contrast or a low atomic weight and
provide negative contrast. Examples of positive contrast media re Barium
 sulphate, organic iodine compounds. Examples of negative contrast media
area co2, o2 and N20 or atmospheric air.

Positive contrast agents

 Positive contrast agents can be precisely classified and may be divided

into five main groups.

 Agents used for the demonstration of Alimentary tract.

 The substance used for this purpose should be insoluble and non
absorbable and inert. The substance used routinely for this purpose is
barium sulphate.

Water soluble agents

 These form the largest single group of contrast agents. The ideal criteria
for the contrast media included in this group are that they should be (1)
opaque to x-rays and they all contain iodine (2) pharmacologically inert
(3) very water soluble so that they can be injected at high concentrations
(4) chemically stable so that the iodine is not released in the body (5)
rapidly excreted by the kidneys; (6) of low viscosity for injecting quickly
through a small catheter and (7) of low toxicity and irritancy so that large
quantities can be employed.

 The conventional water soluble contrast media are ionic and are therefore
hypertonic and their osmolality ranges from 4 to 7 of that of blood. The
newer low osmolar non-ionic contrast agents have ratio 3 contrast as
 compared to the conventional high osmolar ionic contrast agents which
have only ratio 16. Contrast property. Ex: Conray, Urografin (Ionic agent);
Iohexol, Iopamidol metrizamide (non-ionic)

 Agents excreated selectively through biliary system to study the gall

bladder, after absorption from alimentary system or intravascular injection.
Ex: Biligrafin and Ipodate calcium powder (solu-Biloptin) (Scheringe).

Viscous and oily agents

 These agents are developed to overcome immediate climination which

occure with the water soluble preparation. Viscous solution are used to
demonstrate bronchial tree and the uterus.
  Oily solutions are used in those situation in which it is essential to avoid
even the slightest local irritation once introduced they are slowly
climinated.

Radiographic quality

 Gaseous agents: Are those most frequently employed. They are cheap easy
to administer and are comparatively safer.
INTRAVASCULAR CONTRAST AGENTS AND CONTRAST
RADIOGRAPY

CONVENTIONAL IONIC MEDIA

Generic name Proprietary name
Meglumine iothalamate Conray-280
 Sodium iothalamate Conray-420
Meglumine diatrizoate Urografin-150
Sodium diatrizoate Urografin-370
NEW LOW OSMOLAR NON-IONIC MEDIA
Metrizamide Amipaque
Iopamidol Niopam
Iohexol Omnipaque

Angiography

 The radiographic demonstration of the vascular system by the injection of

a water soluble organic iodide compound into a suitable vessel.
 Specialized techniques

o Arteriography-Arteries

o Venography-Veins

o Aortography-aorta

o Portal venography–Portal vein

o Angiocardiography-Heart and vessels

o Cerebral angiography–Cerebral vessels

Technique

 Contrast agents are injected rapidly by means of a syringe of an

 appropriate volume connected to a hypodermic needle or cannula or
catheter which is inserted into a suitable blood vessel. Radiographs are
taken immediately on completion of the injection.
MODULE-27: CONTRAST RADIOGRAPHY - THORAX AND
ABDOMEN

Learning objectives

This module deals with

 Radiography of alimentary tract

RADIOGRAPHY OF ALIMENTARY TRACT

Indications
  To reveal obstruction of the alimentary tract. Ex: Tumour or stenosis.

 To find out distorsion of the wall of alimentary tract such as enlargement.

Ex: Dilatation of stomach or oesophagus.

 To find out displacement of the alimentary tract. Ex: Hernia.

 To reveallesions in the wall of the alimentary tract. Ex: Neoplasms –

Ulcer.

Procedure

 Oesophaqus

o No preparation is required. Take plain radiography and administer

Barium sulphate paste about 50 to 100 Gms. Orally (Braium Swallow)
 and taken with lateral and ventrodorsal projections immediately after
administration.

o Normal oesophequs should not retain bacium. Only a thin streak of

barium indicating the position of the oesophegus and outlining the
mucous surface is seen as normal oesophagus is a collapsed tubular
structure.

 Stomach

o 50 to 100% suspension of about 15 to 100 ml. Is given orally observed

under fluoroscopy or x-rays are taken at regular intervals 10 minutes,
30 mts, 1 hr. and 4 hrs. etc. at different angles like left lateral, right
lateral, ventro dorsal and oblique if necessary to demonstratethe
 different areas of stomach and mucosal surface.

o The stomach should be empty by starving overnight or by

administering laxative or enema if necessary.

o Normal stomach start emptying the barium within minutes after the
administration. Space occupying lesions or obstructive lesions can be
easily demonstrated.

 Small Intestine

o To promote easy passage of the contrast agent 25% suspension is

preferred. Repeated x-rays at interals could demonstrate lesions inside
or outside the intestine easily. Intestinal motility can be assessed.
  Large Intestine

o To demonstrate large intestine barium is best given by enema. Double

contrast gastrography or colonography can be obtained by combining
air (negative contrast agent)

 The functional and anatomical abnormalities could be better assessed by

means of flucroscopy apparatus, if available.
MODULE-28: CONTRAST RADIOGRAPHY - URINARY SYSTEM
AND SPINAL CORD

Learning objectives

This module deals with

  Myelography

 Urography

MYELOGRAPHY

Indication

 To outline the neural canal

 To demonstrate disc lesions and other space occupying lesions.

 Contrast agents used

o Oily fluid containing 40% iodine (Ex. Myodil).

o Water soluble: Metrizamide soluble. Iohexol, Iopamidol solution.

Technique

 Cysterna puncture

 Lumbar puncture

 Under general anaesthesia the contrast agent is injected into the sub-
arachnoid space. In the first method cisterna magna is punctured and in the
second method sub-arachnoid puncture is made using a spinal needle
between 4th and 5th Lumbar vertebral space in lateral recumbent [Link]
myodil is used the quantity is 0.5 to 2 ml. Per animal.

 The animal may be positioned in an inclined plane for easy flow caudally.
Pictures are taken at 5 mts. And 10 mts. Interval under lateral and
 ventrodorsal projection. If Metrizamide or any other water soluble agent is
used, 0.3 ml. To 0.5 ml/[Link] wt. Is injected into the subarachnoid space
and x-rays are taken immediately.

 The advantage of the new water soluble non-ionic solution is that it gives
better visualization of the spinal canal and the agent gets eliminated within
few hours. In the case of oily agents the contrast material will tend to
globulate and remain in the canal for longer period causing at times
undesirable side effects.
UROGRAPHY: (PYELOGRAPHY AND CYSTOGRAPHY)

Intravenous urography (Intravenous pyelography, IVP)

 Pyelography is used to demonstrate kidney shadow when it cannot be

 demonstrated in a straight radiography.

 To show the presence or absence of lesions in the renal pelvis.

 To get a rough indications about renal function.

 Contrast agents used

o Ionic contrast agents such as sodium Iothalamate (conray-420);

Meglumine Iothelamate (conray-280); Sodium and Meglumine
diatrizoate (Uregrafin 60% or 76%); Sodium diatrizoed (Hypoque).
Non-ionic contrast agents such as Iohexol (Omnipaque-300);
Iopamidol (Niopem) Metrizamide have also been used.

 Dosage: To give better demonstration upto 600 mg to 1200 mg/kg. Body

 weight may be administered I/V usually 1 to 2 ml/kg. Body weight.

 Preparation: With hold food for 24 hrs. and water for 12 hrs. Empty the
bowels with enemata. Anaesthesis as optional

 Technique

o Inject the dyeasa single bolus I/V by taking about 1 minute. Straight
firms may be taken before injection and subsequent to injection at 1
mt. 5 mts., 10 mts. And 20 mts. With ventrodorsal and lateral
projections. Use of a compression bandge over the abdomen will
enhance the clarity of renal pelvis and ureter.

o This technique is popularly known as intravenous pyelography or

 excretory urography. Another method to carry out this procedure is to
mix the contrast agent about 1200 mg/kg. With 150 to 250 ml. Of
normal saline and given by drip taking about 20 to 40 mt. Time to give
more accurate evidence of kidney function and is a safer method.

Cystography

 Indications

[Link] recogrise radiolucent small calculi

[Link] demonstrate space occupying lesions in the bladder.

[Link] demonstrate abnormal prostate gland.

 Preparation: The G.I. tract should be empty. Iodine compund 10 to 20%

 about 40 to 100 ml. Are employed after catheterizing the bladder.

 Procedure:After evacuating the bladder, inject the contrast agent either

iodine solution or air (100 to 300 ml). Radiography is taken (lateral &
ventrodorsal projections). For double contrast small quantity of iodine
solution followed by air may be used for better visualization of the interior
of bladder.
MODULE-29: BIOLOGICAL EFFECTS OF RADIATION, RADIATION
HAZARDS AND THEIR SAFETY MEASURES

Learning objectives

This module deals with

 Biological effects of radiation

  Radiation hazards and safety measures

RADIATION HAZARDS AND ADOPTION OF SAFETY

INCREASERS

Dangers of radiations

 Ionising radiation used in diagnostic radiography is potentially harmful

and if proper protective measure are taken the risk is small compared with
the benefit to the patient.

 Certain tissues especially those which contains many multiplying cells,

such as blood forming organs (bone marrow, lymphoid tissue, spleen), the
gonads, embryos and cetain tumours are radiosensitive.
  X-rays have long term effect of producing Cancer, long after irradiation
injury has healed.
MODULE-30: ULTRASONOGRAPHY - PRINCIPLES AND ITS
APPLICATION IN VETERINARY PRACTICE

Learning objectives

This module deals with

 Principles of ultrasonography

 Properties of ultrasound waves

 Different modes of echo display

PRINCIPLES OF ULTRA SONOGRAPHY
Introduction

Medical sonography is the only diagnostic imaging modality that does not use
electromagnetic radiation. Modern ultrasound instruments are highly
sophisticated pieces of equipment. A basic understanding of the physics of
ultrasound, its interactions with tissue and the functions of the controls are
important while using the machines. In 1957 – Ian Donald invented – scanner
or diagnostic ultrasound.

What is ultrasound?

 Sound waves of frequencies greater than audible to the human ear i.e
greater than 20- 20,000 Hz. is called Ultrasound waves. Diagnostic
ultrasound uses frequencies between 1 to 10 MHz
  A sound wave travels in a pulse or a wave and when it is reflected back it
becomes an Echo and this pulse-echo principle, is used for ultrasound
imaging. A transducer is a device that converts one form of energy to
another. The piezoelectrical crystal in an ultrasound transducer generates a
pulse. When this crystal is stimulated electrically it changes its shape and
produces sound waves of a particular frequency. Mechanical transducers
are devices where the movement of crystals suspended in a coupling
medium generates [Link] as electronic transducers also called
array transducers do not have intrernal coupling medium and are fired
electronically.

How is ultrasound generated?

 When a high voltage electrical current is applied crystals in the transducer
are vibrated and this is called piezo electric effect.

 A sound wave travels in a pulse and when it is reflected back it becomes

an Echo.

 It is this pulse-echo principle, which is used for ultrasound imaging. A

pulse is generated by one or more piezoelectrical crystal in an ultrasound
transducer.

 When this crystal is stimulated electrically it changes its shape and

produces sound waves of a particular frequency.

 As the transducer is placed in close contact with the body surface through
 a coupling medium it undergoes continuous modification, which occurs
through three processes those are absorption, reflection and scattering.

 By means of the echo principle, an image can be produced on the display

of the scanner which relates to the acaustic independence of tissues
encountered by the ultrasound beam and the depth / distance of tissue
interfaces.
PROPERTIES OF ULTRASOUND WAVES

 Frequency, wavelength and velocity are parameters used to describe the

sound waves.

 Diagnostic ultrasound frequency ranges between 2 mega Hertz and 13

mega Hertz.
  Wave length is the distance travelled by the sound in one cycle and is
expressed in millimeters and is important for image resolution.

 Velocity is the rate at which sound travels through an acoustic medium. As

a rule it is greatest in solids, lower in liquids and lowest in
[Link] sound waves travel fastest in bone and slowest in gas
filled structures.

 This causes a problem for diagnostic ultrasound machines, because they

use the average velocity of sound in soft tissue 1540m/s.

Interaction of ultrasound with matter

 Absorption: It occurs when the tissues absorb heat energy in the sound
 beam. Absorption process forms the basis of therapeutic ultrasound.

 Reflection: The reflection gives rise to an echo and forms the basis for
ultrasound scanning. Interfaces between tissues of different acoustic
impedence give rise to different echoes. These echoes are converted by
piezoelectric effect into electrical signals and displayed onto a
oscilloscope screen.

 Scattering: It occurs when the beam encounters an interface that is

irregular and smaller than the sound beam. The portion of the beam than
interacts with this interface is scattered in all directions. Since the
scattering interfaces are small, only a small portion of the beam is
involved. Once the echoes are converted into electrical signals, these are
 processed and transformed into a visual display of the measure of the
amplitude of the echo. This is known as echo quantification.

Generation of images on the display

 Two basic shapes of ultrasound images are encountered: images made in

sector fashion are pie shaped and linear fashion are rectangular

 Images are usually generated from the systemic scanner converter or

frame store which processes the reflected ultrasound in to a form required
for screen presentation.

 Information is displayed regarding distance and amplitude. Each echo

position is represented as a dot on the screen. Thus a two dimensional
 image is generated.

 The brightness of each dot is related to the amplitude of the reflection and
is referred as a grey scale display.

 Resolution is the ability of the ultrasound machines to distinguish echoes

on the basis of time, space and strength.

o Axial resolution: Ability to differentiate two objects lying closely

together in the direction of the beam.

o Lateral resolution: Ability to different the two objects lying side by

side. The ultrasound beam is refracted when it enters a tissue of
different acoustical density.
  The image of refraction depends on the relative velocity of sound in the
two tissues.

 Depth of sound wave penetration varies inversely with frequency.

DIFFERENT MODES OF ECHO DISPLAY

Different modes of echo display

 Different modes of echo display are Brightness mode, B – mode B scan or

grey scale used commonly for abdominal scanning and cardiac imaging.

 Static B mode: Transducer is moved in the scanning plane by hand.

 Real time B mode: Sound beam automatically and rapidly moves in the
scan plane. In this method the image is continuously updated to allow
 movement.

 Motion mode: M–mode mainly used for echocardiography.

 A MODE or amplitude mode is simplest form of display. It displays two

parameters of the echoes in the form of spikes, ie., distance from the
transducer and the amplitude. The horizontal line shows the distance and
the amplitude is depicted on the vertical line. It is used for ocular
biometry.

Different types of basic probes

 Linear curvilinear and sector probes

 Transducers are classified based on the location of crystals on the scan

 head. When elements are located at the end of the probe they are called
end fire transducers and they are used in abdominal and cardiac scanning.
Side fire trasducers are used for intracavity scanning like large animal
reproductive scanning.

Doppler ultrasonography

 The pitch of a siren in a train changes with the proximity of the train
movement, due to difference in the sound wave frequency, called Doppler
shift, the principle used in imaging the direction and velocity of blood
flow. It was first proposed by Johann Christian Andreas Doppler in 1842.

 Four Doppler modes are used in medical ultra sonography. They are
Continous wave Doppler, pulsed wave Doppler colour Doppler and power
 Doppler.
MODULE-31: RADIATION THERAPY - PRINCIPLES, ISOTOPES
AND THEIR USES IN DIAGNOSIS AND THERAPY

Learning objectives

This module deals with

 Radiation therapy and its methods

 Complications 0f radiation therapy

RADIATION THERAPY - INTRODUCTION

 Radiation therapy for the treatment of neoplasm of domestic animals has

been used since the discovery of X-ray. Dr. R. Eberlin was the first to
 report on the use of radiotherapy in veterinary practice.

 Radiotherapy is usually indicated for localised solid neoplasm’s that

cannot be excised completely. It is not indicated if neoplasm has the
potential of high incidence of metastasis.

 The other indication are :

[Link] surgery is expected to or has already failed.

[Link] the regional or distant metastasis not occurred.

[Link] radical surgery is unable to remove whole of the neoplasm.

[Link] bulk of the neoplasm needs reduction in size so that it can

subsequently be removed surgically.
  Radiotherapy is not done by a single dose, rather multiple treatments are
given over a period of time, termed fractioned therapy. In animals, it is
usually in 10-12 fractions of a radiation dose of 4-5 Gy each time, usually
three times per week.
METHODS OF RADIOTHERAPY

Teletherapy

 The radiation source is kept at a distance from the lesion. It is of four types

o Superficial X-ray therapy: Given through X-ray machine with energy

range of 60-100 keV.

o Deep X-ray therapy: Given through X-ray machine with energy range
 of 100- 200 keV.

o Super voltage therapy: Provided through (i) X-ray machine having

linear accelerator or betatron or cyclotron, (ii) isotropic X-ray machine
with cobalt or cesium. It is used in deep and substantial lesions

o Particulate beam therapy: Electron, neutron or proton beam can also

be used as a mode of teletherapy.

Brachytherapy

 It is the therapeutic use of radioisotope either within the interstitium or on

the surface of a neoplasm. The isotopes used are 198 Au , 60 Co, 125 K.
Specific methods of brachytherapy are
 o Interstitial brachytherapy: Sources of radiation are within the
interstitium of the neoplasm.

o Pliesotherapy: It is surface brachytherapy for superficial lesions.

o Systemic brachytherapy: 132 I and 32 P can be used systemically. It is

used in extensive lesions and specific malignant conditions.
COMPLICATIONS OF RADIOTHERAPY

 Complications of radiotherapy are

o Immediate (minute to days): epilation, erythema , hematological

depression and GI disturbances and chromosomal aberration.

o Latent (months to years): leukemia , life span shortening , cancer,

 lethal gene expression etc.
MODULE-32: SCAN AND MRI - PRINCIPLES AND THEIR
APPLICATION

Learning objectives

This module deals with

 Digital Radiography (DR)

 Computed Tomography (CT)

 Magnetic Resonance Imaging (MRI)

 Nuclear Medicine
 DIGITAL RADIOGRAPHY (DR)

Basic principles

 DR involves translating x-ray energy into an electric signal that is in turn

converted to digital data (numbers). The process may be direct, indirect, or
hybrid. In direct DR, the x-ray energy is converted directly into an
electrical signal. In indirect DR, the x-ray energy is first converted to light
by using a phosphorescent plate; the light is then converted to an electrical
pulse.

 The data are recorded on a plate, which is connected to a computer, and

the x-ray image is available for viewing almost immediately after
exposure. It can then be stored or printed out. Hybrid radiographic
 processes record the output of the phosphorescent plate with a system
similar to that found in a digital camera. CR and DR systems have a
number of advantages compared with film screen systems.

 The linear response of digital systems to the x-ray exposure means that
these systems are relatively forgiving of errors in radiographic technique.
However, the quality of DR images depends on software processing to
produce a degree of contrast that is familiar to the reader. DR and CR
images are stored on a computer hard drive and should be saved as
DICOM (Digital Imaging and Communication in Medicine) files. Some
form of backup device is recommended, ideally at another location.

 The images may be quite large files, but they can be easily transmitted to a
 remote location for review by a radiologist or other specialist. These
images may be manipulated in multiple ways, including adjusting
brightness and contrast, applying sharpening filters, inverting the image,
and magnifying part or all of the image.
COMPUTED TOMOGRAPHY (CT)

Basic principles

 CT is an imaging method that uses the principles of tomography.

Tomography is the demonstration of a slice through the body displayed
without interference from structures lying above or below the level under
examination.

 CT uses x-rays generated by a high-output x-ray tube. The tube is mounted

 on a gantry opposite a series of detectors. The tube and the detectors rotate
in unison around the subject under examination. A fan-shaped beam of x-
rays passes through the body at a predetermined level.

 The pattern of x-rays that reaches the detectors is recorded—a projection.

The entire gantry assembly is then rotated slightly, and the procedure is
repeated, generating a new projection. A series of such projections is
obtained, completely encompassing the body under examination.

 A computer uses complex mathematical formulas to create an image from

the series of projections. This image represents a slice of the body at the
level under examination.

 The advantage of CT is its ability to distinguish different types of soft

 tissue, such as brain white and gray matter or liver and gallbladder. CT
achieves this degree of contrast by being able to measure very fine
differences in the ability of tissues to stop x-rays passing through them.

 CT images are digital, and a computer is used for viewing. The gray scale
can be adjusted to highlight specific features such as bone or soft tissue
(windowing). In CT imaging, tissues and structures are described in terms
of attenuation, which is a measure of the capacity of a tissue to stop x-
rays. Attenuation is equivalent to radiopacity in radiography. The
appearance of a tissue is defined in relation to some reference tissue or its
expected normal appearance. Thus isoattenuating means having the same
attenuation and would be displayed as the same shade of gray. If the tissue
 attenuates or stops the x-rays less than the reference tissue or less than
expected, it is described as hypoattenuating and is portrayed as a darker
shade of gray.

 The term hyperattenuating is used to describe tissues with more

attenuation than expected. These terms are relative rather than absolute,
and the reference tissue or structure is usually stated. Superimposed
structures are eliminated. Iodinated contrast agents such as those used for
myelography or excretory urography may be used by intravenous
injection.

 Lesions with abnormal circulation may show marked contrast

enhancement after such injections. In viewing CT images, brightness and
 contrast are adjusted to highlight specific structures. CT can resolve far
greater contrast than can be displayed on a monitor or appreciated by the
human eye. Therefore the gray scale of the image is adjusted to assign
useful grays to tissues with varying levels of attenuation, referred to as the
window.

 A lung window will show detail within the lungs, but almost all other
structures appear white with little detail. A bone window will display detail
of skeletal structures such as cortex and trabeculae, whereas soft tissues
appear gray with little detail and lungs appear quite black. A soft tissue
window shows good contrast and detail within soft tissue structures such
as the liver.
  Hepatic veins can be distinguished from the gallbladder and other soft
tissues, whereas bone appears white and lungs dark. CT may be used to
image almost any body part. Among the more common applications are
diseases of the nasal cavity, sinuses, and ears. It may also be used to
evaluate the spine, brain, joints, lungs, mediastinum, pleural cavity, and
abdominal masses
MAGNETIC RESONANCE IMAGING (MRI)

Basic principles

 Unlike CT, no ionizing radiation is used in magnetic resonance imaging

(MRI). MRI uses hydrogen atoms to generate an image. Hydrogen is
universally distributed in the body, principally in water molecules.
 Hydrogen atoms are essentially spinning protons and have an electrical
charge. Each atom acts as a tiny bar magnet. Under normal circumstances,
these tiny magnets are arranged randomly.

 MRI uses relatively strong magnetic fields, ranging from 0.05 to 3.0 tesla
in clinical use. In a strong magnetic field, a small majority of the protons
will be forced to point in the direction of the field while spinning at a
specific rate.

 A radio signal pulse at the same frequency as the spin of the protons will
knock them out of their equilibrium state. As the protons return to their
original state, they release energy in the form of a radio signal, effectively
an echo of the original pulse used to disturb the protons. This signal is
 collected by a scanner, processed, and displayed.

 Smaller gradient magnetic fields are used to localize signals from specific
blocks of tissue. Whereas CT offers good soft tissue detail, the contrast
seen with MRI is superb. Different sequences of radiopulses can be used
to emphasize different tissue characteristics. Manipulation of the
parameters such as the timing and duration of the radiopulse and the
interval before an echo is recorded is used to highlight tissue features.

 MRI has superb contrast resolution in soft tissues and is very sensitive to
changes such as edema and hemorrhage. Signal intensity is used to
describe the appearance of tissues in MRI, just as attenuation is in CT
imaging.
 It is a relative measure of the radio signal generated by tissues in response
to the stimulating radio energy pulse. If something is termed isointense, it
has the same appearance as some reference tissue—for example, a mass
might be isointense to the gray matter of the brain.

 Hypointense means less signal and appears darker, whereas hyperintense

means more signal and a brighter appearance. As in CT, these terms are
relative and must be defined in relation to the expected normal
appearance, reference tissue, or appearance before the use of contrast.

 Bones, ligaments, and tendons appear quite dark on all image sequences
because they have very little water content and therefore very little
hydrogen to generate a signal. Nonetheless, MRI can provide useful data
 about these structures.

 Like CT, MRI uses contrast agents that enhance lesion visibility. However,
in the case of MRI, the agents are based on gadolinium, which alters the
local magnetic field and changes signal intensity.

 Lesions that accumulate gadolinium appear bright (hyperintense) with

some sequences. MRI is capable of distinguishing or resolving objects of
approximately 1 mm in size, which is termed spatial resolution. This is
similar to CT but compares poorly to radiographic systems, which can
resolve objects of 0.1 mm in size. MRI has excellent contrast, showing
different soft tissues as distinct shades of gray, which creates the
impression of much finer detail.
  Unlike CT, which is limited to images in the plane of the gantry, images
can be obtained in any plane, so slices can be varied infinitely to highlight
lesions. MRI applications include imaging disease of the central nervous
system, nasal cavity and sinuses, joints, and the abdomen.
NUCLEAR MEDICINE (SCINTIGRAPHY)

Basic principles

 Scintigraphy is a branch of nuclear medicine. It is an imaging technique in

which radionuclides (radioactive elements emitting gamma rays) are
administered to a subject.

 The radionuclides are attached to chemicals to form radiopharmaceuticals

that accumulate in the tissue of interest. Most radiopharmaceuticals are
 analogues of physiologic substances or biologic organic molecules. Their
presence, and their concentration, can be detected by gamma-ray detection
equipment—usually a gamma ray camera.

 The gamma rays are converted by the camera into signals from which a
computer produces a digital format that is used to construct an image of
the area under examination. Nuclear medicine images are described in
terms of uptake of the radiopharmaceutical.

 The degree of uptake is subjectively assessed in some techniques, while in

others quantitative analysis is performed. In this way normal and abnormal
tissues can be identified by the selective accumulation of the radioactive
substances within them.
MODULE-33: ECOCARDIOGRAPHY - PRINCIPLES AND ITS
Learning objectives

This module deals with

 Doppler Ultrasound

 Types of Doppler Ultrasound

 Applications of Doppler Ultrasound

DOPPLER ULTRASOUND

 A Doppler ultrasound test uses reflected sound waves to see how blood
flows through a blood vessel. It helps to evaluate blood flow through
major arteries and veins, such as those of the legs and neck.

 It can show blocked or reduced blood flow through narrowing in the major
 arteries of the neck that could cause a stroke. It also can reveal blood clots
in leg veins (deep vein thrombosis, or DVT) that could break loose and
block blood flow to the lungs (pulmonary embolism).

 During pregnancy, Doppler ultrasound may be used to look at blood flow

in an unborn baby (fetus) to check the health of the fetus.

 During Doppler ultrasound, a handheld instrument (transducer) is passed

lightly over the skin above a blood vessel. The transducer sends and
receives sound waves that are amplified through a microphone. The sound
waves bounce off solid objects, including blood cells.

 The movement of blood cells causes a change in pitch of the reflected

sound waves (called the Doppler effect). If there is no blood flow, the
 pitch does not change.

 Information from the reflected sound waves can be processed by a

computer to provide graphs or pictures that represent the flow of blood
through the blood vessels. These graphs or pictures can be saved for future
review or evaluation. See a picture of a Doppler ultrasound.
TYPES OF DOPPLER ULTRASOUND

The basic types of Doppler ultrasound are

 "Bedside" or continuous wave Doppler: This type uses the change in pitch
of the sound waves to provide information about blood flow through a
blood vessel. The veterinarian listens to the sounds produced by the
transducer to evaluate the blood flow through an area that may be blocked
 or narrowed. This type of ultrasound can be done at the bedside in the
hospital with a portable machine to provide a fast estimate of the extent of
blood vessel damage or disease.

 Duplex Doppler: Duplex Doppler ultrasound uses standard ultrasound

methods to produce a picture of a blood vessel and the surrounding organs.
Also, a computer converts the Doppler sounds into a graph that gives
information about the speed and direction of blood flow through the blood
vessel being evaluated.

 Color Doppler: Color Doppler uses standard ultrasound methods to

produce a picture of a blood vessel. Also, a computer converts the Doppler
sounds into colors that are overlaid on the image of the blood vessel and
 that represent the speed and direction of blood flow through the vessel.
Power Doppler is a special type of color Doppler. Power Doppler can get
some images that are hard or impossible to get using standard color
Doppler. Power Doppler is most commonly used to evaluate blood flow
through vessels within solid organs.
APPLICATIONS OF DOPPLER ULTRASOUND

 Non-invasive

 Generally painless

 Does not use radiation

 Can show if you have any blocked arteries in neck, arms, abdomen,
 coronary arteries and limbs

 Can show if you have any blood clots in the veins in limbs

 Can show the amount and speed of blood flow in your veins and arteries

 Can be used instead of some more invasive procedures further reading

MODULE-34: PRINCIPLES AND APPLICATIONS OF
SCINTIGRAPHY, GAMMA CAMERA, XERORADIOGRAPHY AND
DOPPLER

Learning objectives

This module deals with

 Nuclear Scintigraphy
NUCLEAR SCINTIGRAPHY
 Scintigraphy ("scint," Latin scintilla, spark) is a form of diagnostic test
used in nuclear medicine, wherein radioisotopes (here called
radiopharmaceuticals ) are taken internally, and the emitted radiation is
captured by external detectors (gamma cameras) to form two-dimensional
images.

 The principle is based on the use of pharmaceutical labelled with

radioisotope which after entry into the blood stream get localised in
particular tissue or organ. Thus the localisation of radioisotope can be
detected by using camera due to emission of gamma rays. Most widely
used radioisotope is Technetium-99m. This isotope has the advantage of a
short half life of 6hrs and thus animal can be discharged next day after the
 scan . in addition, radiation exposure is minimum.

 The distribution of the labelled isotope can be detected by a gamma

camera or a hand held detector. In both the case sodium iodide crystalis
used which absorbs gamma rays emitted by the radioisotope from the
patient and converts it to light flashes. The light is converted to an
electrical impulse. This impulse is shown on a oscilloscope or converted to
an image. Image can be produced in colours or in a grey colour.

 A scan appears as a image formed of dots. The interpretation is based on

the appearance of increased (hot spots) or decreased (cold spots)
radioactivity region. Active process produces hot spots where as cold spots
observed in case of abscess.
 It is mainly used to detect functional disorders of kidney, liver , GI tract,
lungs thyroid glands etc. Using this technique it is easier to detect
localised increase or decrease in bone turn over as a result of trauma or
disease. Any inflammatory or pathological process that causes increased
bone activity can be diagnosed by scintigraphy. Usefull in diagnosing
occult lameness. It has also been used to study renal, cardiac, lung
functions , images of vertebral column and detecting the neoplasms.

 Problems associated with scintigraphy are

[Link] of the gamma camera

[Link] and strict safety precautions required.

[Link] specificity to the aetiology and difficulty encountered some times
in interpreting the scan especially skeletal system