This document provides a detailed analysis of an AP erect abdomen radiograph. It evaluates the image for HIPAA compliance, marker placement, radiation safety, completeness of anatomy shown, identification of artifacts, image quality, accurate positioning of the anatomy, and use of judicious exposure techniques. While some criteria are not perfectly met, such as inclusion of the 8th thoracic vertebra, the overall image quality is good and shows all necessary anatomy clearly. The evaluator would accept this image but provide recommendations for a repeat study.

1. AP ERECT ABDOMEN
FINAL PRESENTATION
BRIANA GRABER
IMAGE EVALUATION
APRIL 30, 2017

2. TECHNICAL PREPARATION

3. HIPAA COMPLIANCE
• THE IMAGE IS HIPAA COMPLIANT. THERE IS
NO PATIENT OR HOSPITAL INFORMATION
INCLUDED IN THE IMAGE THAT WOULD
VIOLATE HIPAA PROTOCOLS.

4. MARKER & PATIENT ID
• THE CORRECT ANATOMICAL SIDE MARKER IS
INCLUDED IN THE IMAGE.
• THE SIDE MARKER IS PLACED CORRECTLY ON THE
VIEWER’S RIGHT SIDE, BUT COULD BE BETTER
PLACED ON THE INFERIOR EDGE OF THE IMAGE TO
AVOID SUPERIMPOSITION ON ANATOMY OF
INTEREST.
• AN ERECT MARKER MUST BE INCLUDED IN THE
IMAGE.
• BOTH MARKERS ARE SLIGHTLY SUPERIMPOSED
OVER ANATOMY OF INTEREST.
• THE IMAGE IS DISPLAYED CORRECTLY IN
ANATOMICAL POSITION.

5. RADIATION HYGIENE
• THERE ARE NO SIDES OF BEAM RESTRICTION
PRESENT IN THE IMAGE.
• NO EVIDENCE EXISTS OF PROPER SHIELDING. FOR
AN UPRIGHT ABDOMEN, PUBIC SYMPHYSIS DOES
NOT HAVE TO BE INCLUDED BUT REPRODUCTIVE
ORGANS ARE MORE THAN LIKELY GOING TO BE
INCLUDED IN THE RADIATION FIELD.
• A MALE PATIENT SHOULD BE SHIELDED WITH A
FLAT CONTACT SHIELD. A FEMALE PATIENT IS
UNABLE TO BE SHIELDED BECAUSE THE SHIELD
WOULD SUPERIMPOSE OVER ANATOMY OF
INTEREST.

6. COMPLETENESS OF
POSITION / PROJECTION
• ROUTINE VIEWS FOR AN ABDOMEN SERIES:
• PA/AP CHEST
• KUB SUPINE
• ERECT ABDOMEN
• THIS IMAGE COMPLIES WITH THE ERECT
ABDOMEN.
• ALL ANATOMICAL PARTS ARE INCLUDED IN
THE IMAGE.

7. ARTIFACT
IDENTIFICATION
• WITH ADJUSTING THE WINDOW WIDTH AND LEVEL,
THERE IS AN ARTIFACT IN THE LUQ OF THE
ABDOMEN. THE ARTIFACT IS THE RADIOPAQUE TIP
OF A NASOGASTRIC TUBE.
• NO BODY PARTS ARE SUPERIMPOSED THAT
SHOULD NOT BE.
• HOSPITAL PARAPHERNALIA IS PRESENT IN THE
IMAGE DUE TO THE CONTRAST IN THE PATIENT’S
BLADDER.
• PATIENT CLOTHING IS VISIBLE NEAR THE CRESTS
WHICH COULD BE THE WAIST BAND OF THEIR
UNDERGARMENTS.
• THE ARTIFACT IN THE LUQ IS AN INDWELLING
ARTIFACT.

8. ASSESSMENT OF IMAGE INTEGRITY

9. ARTIFACT
IDENTIFICATION
• EXCESS FOG IS NOT VISIBLE IN THE IMAGE.
• NO CR/DR ARTIFACTS VISIBLE.

10. IMAGE SHARPNESS
• VOLUNTARY MOTION IS NOT VISIBLE DUE TO THE
TRABECULAE OF THE PELVIS, SPINE AND RIBS APPEAR
SHARP AND WELL DEFINED.
• QUANTUM MOTTLE OR IMAGE NOISE IS NOT VISIBLE.
• EVIDENCE OF DOUBLE EXPOSURE OR GHOSTING IS
NOT PRESENT.
• NO GRIDLINES, GRID ARTIFACTS OR GRID CUTOFF IS
SEEN BECAUSE A RECIPROCATING, OSCILLATING OR
HIGH FREQUENCY GRID WAS MOST LIKELY USED.
• SIZE DISTORTION IS NOT GREATER THAN EXPECTED.
• SHAPE DISTORTION IS NOT BEING CAUSED BY POOR
CR/IR/PART ALIGNMENT.

11. RADIOGRAPHY OF THE ANATOMICAL PART

12. ACCURATE PART
POSITIONING
• THE PART IS ADEQUATELY ALIGNED TO THE
IMAGE MEDIA.
• THE PART IS ADEQUATELY ALIGNED TO THE
IMAGE MEDIA.
• THE CR IS CENTERED TO 1 CM OF THE
ANATOMICAL PART.
• THE CR IS ADEQUATELY ALIGNED TO THE IMAGE
MEDIA.
• THE CR DOES NOT CONFORM TO AN ACCEPTED
EXPOSURE FIELD RECOGNITION TEMPLATE
BECAUSE THERE IS NO COLLIMATION IN THE
IMAGE.

13. ACCURATE PART
POSITIONING:
PART POSITIONING
• POSITION THE PATIENT AGAINST THE UPRIGHT IR IN
AN AP PROJECTION.
• PLACE THE SHOULDERS, POSTERIOR RIBS AND THE
ASISS’ AT EQUAL DISTANCES FROM THE IR, ALIGNING
THE MIDCORONAL PLANE PARALLEL WITH THE IR.
• CENTER THE MIDSAGITTAL PLANE TO THE IR AND
GRID.
• PLACE THE TOP OF THE IR AT A LEVEL OF THE
AXILLA. (CR 2 INCHES ABOVE THE CREST)
• CENTER A HORIZONTAL CR TO THE GRID AND IR.
• TAKE EXPOSURE AFTER A FULL SUSPENDED
RESPIRATION.

14. ACCURATE PART
POSITIONING:
EVALUATION CRITERIA
• AN ARROW OR “WORD” MARKER, INDICATING
THAT THE PATIENT WAS IN AN UPRIGHT POSITION
IS PRESENT.
• SPINOUS PROCESSES ARE ALIGNED WITH THE
MIDLINE OF THE VERTEBRAL BODIES, WITH
PEDICLES AT EQUAL DISTANCED FROM THEM.
• ILIAC WINGS ARE SYMMETRICAL
• EIGHTH THORACIC VERTEBRA, LATERAL BODY
SOFT TISSUE AND ILIAC WINGS ARE INCLUDED IN
THE EXPOSURE FIELD.

15. ACCURATE PART
POSITIONING
• ACCORDING TO THE EVALUATION CRITERIA,
THE IMAGE IS NOT POSITIONED CORRECTLY.
• THE 8TH THORACIC VERTEBRA IS NOT
INCLUDED IN THE IMAGE BUT THE IMAGE
MEETS THE REST OF POSITIONING CRITERIA.
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16. JUDICIOUS EXPOSURE
TECHNIQUE
• THE MOST RADIOLUCENT STRUCTURE IS THE GAS IN THE
BOWEL AND AIR FLUID LEVELS.
• THE MOST RADIOPAQUE STRUCTURE IS THE CONTRAST IN
THE BLADDER AND THE NG TIP OF THIS PATIENT IN
PARTICULAR AND ALSO THE BONY CORTEX OF THE PELVIS.
• THE IMAGE’S WINDOW WIDTH (CONTRAST) SHOULD HAVE
LONG SCALE CONTRAST TO SHOW AIR FLUID AND GAS IN
THE ABDOMEN AND IS ADEQUATE IN THIS IMAGE.
• THE IMAGE’S WINDOW LEVEL (BRIGHTNESS) IS CONSTANT
THROUGHOUT THE IMAGE AND ADEQUATE TO SEE ALL THE
STRUCTURES.
• THERE IS NO EI VALUE PRESENT ON THE IMAGE, SO IT IS
DIFFICULT TO TELL IF THE IMAGE WAS OVER, UNDER OR
ADEQUATELY EXPOSED.

17. ACCEPT / REJECT IMAGE

18. ACCEPT / REJECT IMAGE
• I WOULD ACCEPT THIS IMAGE.
• FOR A REPEAT, I WOULD REMOVE THE PATIENT’S
UNDERGARMENTS TO REMOVE THE CLOTHING
ARTIFACT, MOVE THE PATIENT SLIGHTLY TO
THEIR LEFT TO ENSURE ALL ANATOMY IS VISIBLE
AND MOVE THE MARKERS ONTO THE INFERIOR
EDGE OF THE IMAGE.
• ALTHOUGH ALL THE EVALUATION CRITERIA IS
NOT MET, I WOULD NOT CENTER HIGHER TO
INCLUDE T-8 BECAUSE ALL ANATOMICAL
STRUCTURES ARE SEEN IN THE IMAGE.

19. SOURCES
• HTTP://LIFEINTHEFASTLANE.COM/INVESTIG
ATIONS/AXR-INTERPRETATION/
• EVOLVE
• RADIOGRAPHIC IMAGE ANALYSIS BY KATHY
MCQUILLEN MARTENSEN