BASIC RADIOLOGIC DENSITIES & IMAGING Fluorosco ✅ Yes Real-time Dynamic

MODALITIES py motion studies using

(e.g., GI contrast
THE 5 BASIC RADIOOGRAPHIC DENSITIES (Least to contrast agents
Most Dense) studies)
Densit Appearan Examples Notes Nuclear ✅ Yes Functional Radioisotope
y ce Medicine (internal) imaging s target
1. Air Blackest Lungs, GI Least dense; (e.g., specific
gas absorbs least thyroid, organs
X-rays bone scan)
2. Fat Dark gray Subcutaneou Slightly more
s fat, retro- dense than air 📝 TAKE-HOME POINTS
peritoneal  Radiographic densities: Metal > Calcium > Soft
fat Tissue/Fluid > Fat > Air.
3. Light gray Heart Indistinguisha  Conventional radiographs show limited
Fluid / muscle, ble on X-ray contrast – ideal for bones, lungs.
Soft blood, liver,  CT & MRI offer detailed, multiplanar imaging.
Tissue muscle,  Ultrasound is safe, especially for pregnancy &
organs paediatrics.
4. White Bones, Most dense  Nuclear medicine gives functional +
Calciu calcifications naturally anatomical data; patient becomes temporary
m occurring radiation source.
substance  Choose imaging based on clinical context,
5. Brightest Prosthetics, Absorbs all X- safety, & necessity.
Metal white bullets, rays; not
barium normally in ✅ Pro-Tip Mnemonic for Densities (White → Black):
body "My Cat Sits For Air"
Metal → Calcium → Soft tissue → Fat → Air
🧠 Key Concept
 Soft tissue = Fluid on RECOGNIZING A TECHNICALLY ADEQUATE CHEST
X-ray (e.g., heart muscle RADIOGRAPH
vs. blood inside heart 🧠 Why It Matters
cannot be  A technically flawed chest X-ray can mimic
differentiated). disease, hide pathology, or mislead
 Metallic densities are diagnosis.
artificial, e.g., contrast  Mastering technical adequacy lets you
media, orthopaedics differentiate real pathology from image
implants. artifacts.
 Especially important in ER, ICU, and pre-operative
☢️Radiation Safety assessments where decisions are made on single
 X-rays use ionizing radiation → potential for radiographs.
DNA damage, cancer, fetal anomalies.
 Avoid imaging during pregnancy unless I. 📌 FIVE TECHNICAL PARAMETERS (Mnemonic:
medically necessary. PIRMA)
 Use ALARA principle: “As Low As Reasonably ✅ Key Features of a
Achievable”. Technically Adequate PA
Chest X-ray
💡 PACS – Picture Archiving and Communication  Penetration: Adequate-spine
System is visible through the heart.
 Modern radiology images are digitally stored  Inspiration: Sufficient-~10
and viewed electronically on PACS. posterior ribs can be counted.
 Eliminates film; allows easy sharing and remote  Rotation: None-spinous
access. process is equidistant between
clavicle heads.
⚙️MODALITIES OVERVIEW  Magnification: Minimal- due
Modality Radiatio Key Use Cost & to proper PA technique.
n? Notes  Angulation: Absent- clavicle’s medial end overlies
X-ray ✅ Yes Bone, chest, Cheap, the anterior first rib.
(Plain initial portable,  Diaphragm Visibility: Left hemidiaphragm is clearly
film) trauma limited to 5 seen.
densities
CT ✅ Yes Cross- Moderate 1. Penetration
(Compute sectional cost; fast, Goal: Enough X-rays pass through the chest so that all
d imaging; excellent anatomical structures can be appreciated in their correct
Tomograp organs, detail contrast.
hy) trauma, ✅ What’s Adequate?
lungs  Spine visible through the heart shadow on
US ❌ No Pregnancy, Safe, PA view.
(Ultrasoun soft tissues, portable, ❌ Underpenetrated ("Too White")
d) blood flow widely used  Causes:
MRI ❌ No Brain, spine, Expensive; o Insufficient X-ray dose
(Magnetic joints, best for soft o Thick chest wall or obesity
Resonance ligaments tissue  Effects:
Imaging) contrast
 o Heart appears too dense; spine and left Suboptimal inspiration is indicated by only eight visible
diaphragm obscured posterior ribs. This may exaggerate lung markings at
o Lung bases look opaque → can mimic the bases and give the illusion of an enlarged heart.
LLL pneumonia or effusion Such changes can mimic pneumonia or aspiration. A
o Pulmonary markings exaggerated → can lateral view helps confirm or exclude basilar airspace
mimic pulmonary oedema/fibrosis disease.
💡 Clue: If unsure, check lateral film.
❌ Over-penetrated ("Too Dark")
 Lung fields become overly black:
o Pulmonary vessels not visible → may
mimic emphysema 3. Rotation
o Nodules may become invisible Goal: Patient is not rotated, to prevent asymmetric
o May look like pneumothorax distortion of thoracic structures.
✅ What’s Normal?
Underpenetrated chest
radiograph shows poor
 Spinous process aligned midway between
medial ends of clavicles.
penetration— spine is not
❌ Rotated Patient
seen through the heart
shadow. The left
 Unequal distances → confirms rotation
hemidiaphragm is also not
 Effects:
visible, making it unclear
o Trachea appears shifted
whether there's disease at o Heart borders seem displaced
the lung base or just o Hila/diaphragms may appear abnormal
technical artifact. A lateral o May mimic mediastinal shift or
chest view can help clarify cardiomegaly
this ambiguity. 💡 Rule: In rotated films, avoid interpreting heart size or
mediastinum.
Overpenetration in a frontal
chest radiograph makes
lung markings faint or
invisible, potentially
mimicking emphysema or
pneumothorax. Lung
lucency alone isn’t reliable
for diagnosing emphysema
due to technique artifacts.
Patient rotation can be assessed by checking the
Emphysematous lungs often
position of the spinous process between the medial
appear hyperinflated with a
ends of the clavicles. If it's equidistant, there's no
flattened diaphragm. For
rotation. If it's closer to the left clavicle, the patient is
pneumothorax, identification requires a visible pleural
rotated to the right. If it's nearer the right clavicle, the
white line.
patient is rotated to the left. These principles apply to
both PA and AP chest radiographs.
2. Inspiration
Goal: Full lung expansion to assess lung fields and
cardiac size properly.
✅ What’s Adequate?
 8–10 posterior ribs visible above the
diaphragm on frontal CXR.
o Posterior ribs run horizontally and are
clearer.
o Anterior ribs slope downwards; harder to
count. Rotation is assessed by comparing the distance
❌ Poor Inspiration between the spinous process and the medial ends of
 Lung bases become crowded → may mimic both clavicles. If the spinous process is centered
pneumonia between clavicular heads, there's no rotation. If it's
 Heart appears enlarged due to upward closer to the left clavicle, the patient is rotated to the
diaphragm displacement right. If it's closer to the right clavicle, the patient is
 Common in: rotated to the left. This visual cue applies whether the
o ICU patients image is PA or AP.
o Paediatric films
o Uncooperative or dyspnoeic patients Severe rotation in a
Adequate inspiration is frontal chest radiograph
confirmed by visibility of ten can distort key thoracic
posterior ribs above the structures. When rotated
right hemidiaphragm. In to the patient's right, the
hospitalized patients, 8 to 9 left hemidiaphragm
ribs are generally sufficient. appears elevated due to
The second rib often its increased distance
overlaps the first, so careful from the cassette.
counting is essential. Rotation may also enlarge
the apparent size of the
hilum and shift the heart
and trachea toward the right hemithorax, altering
their normal contours.
 An apical lordotic chest
4. Magnification radiograph often results from
Goal: Use correct projection to avoid size distortion. portable imaging in semi-
Key Concept: recumbent patients. It causes
 Closer the object to the cassette, less the clavicles to appear elevated
magnified it appears. and straight, distorts the heart’s
Projection Effect shape, and obscures the left
PA Heart near cassette → true size hemidiaphragm. These
(posterior- technique-related artifacts can
anterior) mimic pathology if not properly
AP (anterior- Heart far from cassette → magnified recognized.
posterior)
 Portable X-rays (ICU) are mostly AP → Expect II. 🧪 Diagnostic Pitfalls (Clinical-Grade Insights)
apparent cardiomegaly. Technical Mistaken for Correction/Action
 Tube-to-patient distance: PA ~72 in vs AP ~40 in Issue
→ More magnification in AP Under- LLL pneumonia, Correlate with lateral
Heart size penetratio pleural effusion, view or repeat CXR
can appear n pulmonary
slightly oedema
larger in an Over- Pneumothorax, Reassess exposure;
AP chest penetratio emphysema compare with
radiograph n previous films
compared Poor Cardiomegaly, Recheck rib count;
to PA. This inspiration basilar infiltrates confirm with lateral
is primarily view
due to the Rotation Tracheal Use clavicle-spinous
shorter deviation, distance check
distance between the x-ray tube and patient in portable mediastinal shift
AP views (~40 inches) versus standard PA views (~72 AP Cardiomegaly Don’t judge heart size
inches). Less source-to-patient distance results in greater projection on AP view
magnification. With equal inspiration, actual heart size Lordotic Apical Recognize elevated
differences are minimal between projections. angle opacity/mass, clavicles; suspect
misplaced tilt/angle
5. Angulation clavicles
Goal: Beam is horizontal to body → avoids lordotic
distortion. THE NORMAL FRONTAL CHEST RADIOGRAPH —
❌ Apical Lordotic View Summary Notes
 Happens if: 📌 Approach to Reading Chest X-Rays (Box 3.1):
o Beam is angled cephalad (upward)  Best System?
o Patient is tilted backward in bed (semi- o No single "best" method exists.
upright posture) o Choose any system (outside-in, inside-
How to Spot: out, top-down) as long as you examine
 Clavicles projected higher than usual — above everything.
the 1st rib o Use acronyms/mnemonics if helpful.
 Clavicles lose S-shape and appear more o Always include all views (don’t forget
horizontal the lateral film in 2-view studies).
 Apical lung zones distorted — may hide or  Radiologist Technique:
mimic TB, masses o Experienced radiologists use a “gestalt”
approach (quick overall impression).
o Based on mental “burned-in” images
from years of experience.
o If something looks "off," then they study
systematically.
 Key Radiology Axiom:
"You only see what you look for, and you only look for
what you know."
Apical lordotic effect alters the projection of anterior  Your Goal:
and posterior thoracic structures. In a standard erect o Build knowledge so you can recognize
chest (A), the x-ray beam is perpendicular to the normal vs abnormal.
cassette, maintaining normal structure alignment. In o Reading this book helps you form mental
an apical lordotic view (B), the beam is angled upward, images of normal findings.
elevating anterior structures like clavicles relative to
posterior ones. In semi-recumbent positioning (C), 🫁 Normal Anatomy in Frontal Chest X-ray (Fig. 3.1
backward patient tilt mimics the lordotic effect—again & 3.2)
projecting anterior structures higher than posterior ✅ Normal Lung Markings:
ones.  "White lines" in lungs = pulmonary blood
vessels.
o These branch and taper from hilum to
periphery.
o Cannot distinguish arteries vs veins on X-
ray.
 Bronchi are not usually visible.
 o Thin-walled, contain air, surrounded by Componen Description
air → no contrast. t
Pleura Double-layered membrane: Parietal
(outer) and Visceral (inner) layers.
Pleural Contains a few milliliters of fluid
Space (normally no air).
Visceral Adheres to the lung; forms the
Pleura fissures (oblique and horizontal).
Visibility Normally not visible on chest X-ray
except at fissures (fine pencil-thin
lines).

🩸 Normal Pulmonary Vasculature

Feature Description
Gravity Effect In upright position, blood flow is
greater at lung bases than
apices.
Vessel Size Base vessels > Apex vessels in
size.
Branching Vessels branch and taper
🫁 Key Structures on Frontal Chest X-ray Pattern gradually from central (hila) →
Categor Structure Notes peripheral.
y Changes in May alter normal vascular
Airways Trachea Midline, visible as a Flow/Pressure patterns (explained in later
vertical lucency chapters).
Heart Right Atrium Forms right heart 📝 Note: Differentiating arteries vs veins is not possible
Borders border on plain X-ray.
Left Ventricle Forms left heart
border 📸 Importance of the Lateral Chest Radiograph
Major Ascending Aorta Right upper Why Use It? Benefit
Blood mediastinal contour To localize Confirms location in
Vessels abnormalities seen anterior/posterior chest
Aortic Knob Left upper border, on frontal view
arch of aorta To confirm disease E.g., consolidate suspicions of
Main Pulmonary Left mid mediastinum suspected on frontal mass or pneumonia
Artery image
Right Pulmonary Usually below right To detect disease E.g., subtle lower lobe
Artery hilum not seen on frontal pneumonia
Left Pulmonary Often above left hilum view
Artery Proper Technique Right & left posterior ribs
Superior Vena Right mediastinum should almost superimpose
Cava for true lateral
Diaphra Right Higher than left;
gm & Hemidiaphragm dome-shaped ⚠️Spine Sign (Lateral View Diagnostic Clue)
Angles Normal Spine Appearance Abnormal Finding
Left Lower; may be Spine appears progressively If spine appears
Hemidiaphragm silhouetted by heart darker (blacker) from top to whiter (denser) at
Costophrenic Should be sharp; bottom due to less dense lower levels =
Angles blunting may indicate tissue. positive spine sign.
pleural effusion Seen in left lower lobe Indicates airspace
Cardio-phrenic Where heart meets pneumonia (behind the disease in posterior
Angles diaphragm heart). lower lobes.
Hila Right Hilum Slightly lower than left
Left Hilum Slightly higher than LATERAL CHEST X-RAY (NORMAL)
right Essential structures, what to look for, and key
Lung Pulmonary White branching lines; signs.
Marking Vessels taper toward A normal left lateral chest
s periphery radiograph shows a
Bronchi Not usually visible on retrosternal clear space, no
normal CXR distinct hilar shadows, and
Bones Clavicle (Head) Upper chest shadow vertebral bodies of equal
Ribs Help assess rotation height with parallel end plates.
(anterior/posterio and bony The posterior costophrenic
r 3rd ribs) abnormalities angles remain sharp, and the
thoracic spine appears
Scapula (Medial May overlie lungs if
progressively darker from
Border) not repositioned
shoulder to diaphragm due to
Coracoid Process Small hook-like
decreasing tissue density. The right hemidiaphragm is
projection near
typically visible throughout, unlike the left which is
shoulder
often silhouetted by the heart. A clear space between
Soft Right Breast Can obscure right
the heart and spine is normally present and helps
Tissues Shadow lower lung zone
assess cardiomegaly. The major and minor fissures are
often distinguishable on this view.
🫁 Pleura: Normal Anatomy
 On a normal left lateral chest A hilar mass on a lateral chest
radiograph, the left main radiograph appears as a distinct,
pulmonary artery arches over lobulated density in the hilar region.
the air-filled left main bronchus In this example, the patient had
and lies superior and posterior bilateral hilar adenopathy due to
to the right pulmonary artery. sarcoidosis. However, similar
The right main pulmonary findings may result from other
artery typically creates a causes like primary hilar tumors or
shadow anterior to the distal lymphadenopathy from infections or
trachea, but the area behind malignancy. Comparison with a normal hilum helps
and below the trachea should highlight the abnormal silhouette.
show only aerated lung. This configuration helps
confirm normal anatomy and positioning.
When the patient’s arms aren’t 🟦 4. Fissures
raised during a lateral chest  Major fissure: Oblique, from T5 → anterior
exam, the humeri may obscure diaphragm
the retrosternal clear space.  Minor fissure: Horizontal, at 4th anterior rib
Though soft tissue may appear (right side only)
to fill that area, it’s an artifact—  Thickening causes:
not pathology. It should not be o Fluid → CHF (with other signs like Kerley
misinterpreted as anterior B lines)
mediastinal adenopathy. o Fibrosis → Chronic processes (isolated
fissure thickening)
Anterior mediastinal Thickening of the major
adenopathy may fissures on a lateral chest
appear as a soft- radiograph indicates fluid
tissue density filling accumulation, often seen in
the retrosternal clear congestive heart failure.
space on a lateral Normally, fissures appear as
chest view. This faint, pencil-thin white lines or
finding is commonly are not visible at all. Their
seen in lymphoma. typical path runs from the
While thymoma, level of T5 vertebra to about 2
teratoma, and substernal thyroid enlargements can cm behind the sternum on the
also cause anterior mediastinal masses, their anterior diaphragm. In this case, both right and left
radiographic appearance typically differs from this fissures are thickened, and increased interstitial
pattern. markings suggest fluid spread into the lung’s
interstitium.
🧩 1. Five Key Areas to Evaluate
Region Normal Appearance 🦴 5. Thoracic Spine
Retrosternal Lucent crescent behind sternum;  Vertebral bodies: rectangular, equal height
Clear Space no soft-tissue mass (→ anterior  Disk spaces: uniform or taller lower down
mediastinal mass)  Degeneration: Disk narrowing + osteophytes
Hilar Region No discrete mass; composed  Compression fracture: Superior endplate
mostly of pulmonary arteries collapse (e.g., osteoporosis)
Fissures Thin, sharp white lines; not
thickened (fluid/fibrosis = 🌫 6. The Spine Sign
abnormal)  Normal: Spine gets blacker toward diaphragm
Thoracic Spine Rectangular vertebrae; endplates (less tissue)
parallel; spine becomes darker  Abnormal: Whiter at base = left lower lobe
(air-filled lung) pneumonia or mass
Diaphragm & Right hemidiaphragm higher;
Costophrenic posterior sulci sharp and pointed 📉 7. Diaphragm Anatomy
Angles Side Appearance on Lateral CXR
Righ Visible full length (anterior to posterior);
🔍 2. Retrosternal Clear Space t slightly higher than left
 Lucent area behind sternum and anterior to Left Visible posteriorly, silhouetted anteriorly by
ascending aorta heart
 Filled-in = Anterior Mediastinal Mass (e.g., Belo Air in stomach or splenic flexure
lymphoma, thymoma, teratoma) w
 Pitfall: Arms down = humeral shadows may Left
mimic pathology Belo Liver (no visible bowel gas)
w
🫀 3. Hilar Region Righ
 Difficult to assess on frontal view t
 Normally no distinct mass in lateral view
 Hilar mass = lobulated shadow (e.g., 🩸 8. Posterior Costophrenic Sulci
sarcoidosis, lymphoma)  Sharp, acute angles at lung bases
 Blunting = Pleural effusion (fluid settles in
lowest recess when upright)
o Lateral CXR: 75 mL can blunt posterior
angle
o Frontal CXR: Needs 250–300 mL to blunt
lateral angle
 A small right-sided pleural suggests potential enlargement of the left
effusion is seen blunting the atrium ("double-density sign")
posterior costophrenic sulcus on o Right heart border: Right atrium
the lateral chest view. The  Left Side Contours:
opposite sulcus remains sharp. o First contour: Aortic knob formed by
The effusion’s location is foreshortened aortic arch and proximal
confirmed by tracing the right descending aorta
hemidiaphragm farther forward o Below the knob: Main pulmonary artery
anteriorly, whereas the left o Indentation beneath the pulmonary artery:
hemidiaphragm is obscured by Where an enlarged left atrium/appendage
the heart and not visible in might be visible
front. o Last contour: Left ventricle
 Descending aorta: Typically fades into the spinal
⚠️9. Diagnostic Pitfalls shadow
 Humerus overlap → mistaken for anterior mass
 Thick fissures = either fluid (CHF) or fibrosis 📌 3. Key Radiologic Rules & Values
 Always correlate with clinical findings and Structure Normal Appearance
frontal CXR
Ascending Should not extend beyond the right
Aorta heart border (RA)
📚 10. Key Mnemonic for Lateral CXR Review
Aortic Knob < 35 mm from the left tracheal
R-H-F-T-D
border; may shift trachea slightly
 R – Retrosternal clear space
right
 H – Hilar region
Main Flat or concave (convex in some
 F – Fissures
Pulmonary healthy young females)
 T – Thoracic spine
Artery
 D – Diaphragm & posterior costophrenic angles
Left Atrium Not visible unless enlarged → fills in
❤️ Evaluating the Heart on Chest Radiographs (PA (LA) indentation left of main PA or double
View) density right side
(Normal Size, Contours, and Diagnostic Clues) Left Forms the lower left border of the
✅ 1. Cardiothoracic Ratio (CTR) Ventricle cardiac silhouette
Paramet Definition (LV)
er Right Located anteriorly → not visible on
CTR Ratio of the widest transverse Ventricle frontal CXR
diameter of the heart to the widest (RV)
internal thoracic diameter (rib-to-rib at Descending Parallels spine; barely visible; swings
diaphragm level) Aorta leftward if tortuous or uncoiled
Normal < 50% (i.e., heart is < half the width of
Value the chest) ⚠️4. Abnormal Signs to Remember
Valid PA View with full inspiration (≥ 9 Sign Possible Cause
Only On posterior ribs visible) CTR > 50% (on Cardiomegaly
PA)
To estimate cardiothoracic Double Density Left atrial enlargement
ratio, measure the widest Sign
diameter of the heart and Loss of left heart Left atrial/appendage
compare it to the widest notch enlargement
internal thoracic diameter, Bulging/convex Pulmonary hypertension or
typically at the diaphragm level. On a properly inspired MPA volume overload
PA chest radiograph, the ratio should be less than 50% Uncoiled Aorta Aging, Aneurysm, Hypertension
in most healthy adults.
🧠 5. Mnemonic for Cardiac Borders (PA View)
🫀 2. Normal Cardiac Contours (Frontal View) 🧭 “A-R” (Right) and “A-P-L” (Left)
Side Contours (Top to Bottom)  Right: Ascending Aorta → Right Atrium
Rig 1. Ascending Aorta → 2. Slight indentation  Left: Aortic knob → Pulmonary Artery → Left
ht (double-density site) → 3. Right Atrium Ventricle
Left 1. Aortic Knob → 2. Main Pulmonary Artery
→ 3. Left Atrial Appendage Area → 4. Left
Ventricle

On a normal frontal
chest radiograph, the
cardiac contours help
identify key anatomical
landmarks:
 Right Side
Contours:
o First contour:
Ascending
aorta
o Indentation
between
ascending aorta
and right atrium