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BleepMe Webinar Series #4 - “This patient’s has concerning AXR/CXR. Can you please review them"

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Summary

This medical on-demand teaching session will provide medical professionals with the knowledge to interpret chest and abdominal radiographs, with an emphasis on knowing the key review areas on a plain film, identifying differences in attenuation between air and soft tissue, as well as diagnosing common pathologies. Trainee doctor Senna will make sure to explain the concepts to everyone involved, from medical students to foundation doctors, with interactive elements such as quizzes and conversations through the chat feature. At the end of the session, medical professionals will be able to confidently interpret chest and abdominal radiographs.

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Description

You’ve been bleeped -

“This patient’s has concerning AXR and CXR. Can you please review them"

Learning objectives

Learning Objectives:

  1. Identify key features on a plain film chest radiograph, such as the orientation of the heart, pulmonary vessels, vertebrae, and diaphragm.
  2. Recognize normal anatomy on a plain film radiology image of the chest and abdomen.
  3. Distinguish between normal and abnormal findings on plain film abdominal and chest radiographs.
  4. Identify common pathologies on plain film abdominal and chest radiographs.
  5. Describe a systematic approach to plain film radiology reporting.
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Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Okay. Um Hi guys. So thank you for joining us today. Um We've got a radiology session on um, Doctor Senna, one of our, um, one of our radiology registrars. Kindly gonna give us a masterclass on chest radiographs and abdominal radiographs when. So if you get called in overnight to um, have a look at that odd looking uh, radiograph. Uh So thank you uh doctor in the fall, uh doing this session. Um And without further a do I'll pass it on and if you guys have any questions or anything like that, please. Do you engage in the chat? Brill? Thank you. Thank you very much. Tell. Uh Can you, can you still, can you hear me? Yeah, fab Okay evening guys. Thank you for, thank you for joining. I'm just gonna come and present to you just for a second to see. Um I believe we've got some people here at the moment. I think other people will be joining in a minute as well. Anyway, um, but we tell her, should we just make a start or do you want to wait a few, couple of minutes? Whatever you prefer? We can, we can we can get started. Uh And then so people as they come and they should be fine. Great. Ok. Uh Said evening everyone. Thank you very much for joining. I know seven o'clock quite a, it's quite a, it's quite a late start, but I'm hoping you're going to find this next hour quite useful. Um So a bit of background, I'm radiology training in Surrey. Um I actually did call medical training before, spent one year as a renal registrar and opted to change specialty to radiology. So I've got a bit of a medical background. Um So at least from that perspective, I'm, you know, aware of the kind of things that you're gonna get called about on call from a radiologist. I've seen both sides. So I've tried to piece that together and give you the most relevant, the relevant teaching um for uncle plain film radiology. Um So see, see how you find this. I'll try and give you a few nuggets of information as we go along. Um So let's make a start, right. I've got a bit of a Christmassy theme here. I wanted to try and keep it on point with everyone here. Try and keep you interested as much as you can. I encourage interaction. So I've got on, on my phone, I've got the chat up here. I think any answers, any questions as we go along, I will be keeping an eye on the chat. So please just, just let me know, okay. Um, my plan for this session is really to break it down because I understand we've got some medical students, some foundation doctors. So you're all relatively early in terms of being able to pick up diagnoses. And what I want to do is trying to still good habits right from the start. Um So 10 minutes I just want to spend on identifying key things on a plain film for a chest and plain film, for an abdomen, just to make sure you're all at a level playing field, then we're going to do a few acute scenarios and then we'll end up with a quiz as well. Okay, for the acute scenarios and the quiz, I'd encourage you to put answers in the chat again. Any questions just pop it in the chat as we go along. Okay. So what we won't cover in this session is going to be how to systematically approach um reporting a test X ray or an abdominal film. I have put links up to radio pedia here. Uh Let me make sure just get the laser pointer or use this as we go along. Um So I have put up links here for how to interpret um chest x rays and abdominal films and assessing quality of plain films. I'm hoping that at least through medical school in foundation years, you're all relatively comfortable with how to adopt a systematic approach. So things like ripe as a pneumonic to assess quality of the film and then a B C D E E as a Pneumonic to try and systematically go through a chest X ray. I'm hoping your although relatively comfortable with this, so I won't be focusing too much on this um as well. Get stuck into some other cases. Okay. But the links are here later on if you do need to need to go back and have to circulate these slides if need be as well. Okay. So by the end of this session, I want you to be able to have a basic interpretation of a chest and abdominal film and then start to identify some common pathologies. So this is an image taken from the radiologist is a Twitter account. They've posted this picture which I find particularly useful just to get an idea of what you can actually see on a chest X ray. Okay. We'll go through a normal chest X ray in a second. But there is a, there is a lot you can glean from a plain film of the chest, particularly when you're trying to identify changes in attenuation between things like air, soft tissue or even if there's multiple areas of soft tissue overlying each other, the densities are going to be different. And as long as you appreciate the normal anatomy, then you can start to piece together what could be going on. Um or if there's any pathology, what the likely pathology is. Okay. So the key part, you know, I'm hoping you guys can, you've either seen something like this before you've gone through it. But the key things that I want to point out are really the orientation of the heart to start off with. Rather, you know, rather than being a flat out left and right side of the heart. As you can see, the right heart border is very much made up of the atrium, the right atrium, sorry, and the left heart border is very much made out of the left ventricle. Okay. So the heart is almost tilted to one side where the left ventricle is essentially one of the most anterior portions of the heart. Um And then as you can see the left atrium is hiding right behind. Usually on the plain film, you can't really tell much about the left atrium, okay. Um But a key distinction is the left heart border is based from the left ventricle, right heart border is the right atrium. Then you want to try and follow all of the silhouettes here. Okay. So if we're looking, if we're going up on the right side, as you can see the right uh superior to the right heart border were coming up and you can see the right hilum. And then you've also got the superior Vena cava here and eventually you'll come onto your right paratracheal stripe, which implies the uh the change in attenuation between the lung and then your trickier. Okay. We might see pathologies related to that a little bit later, okay. And then coming on the left side, you'll be able to see your trachea here. Key thing here is that you've got your aortic arch popping up here. That's another key review area along with your pulmonary trunk. Because this particular window, the aortic pulmonary window is also very important area um to look for potential masses or lymphadenopathy. Usually it's very clear if you lose this um clearness here, if it becomes a pacified, that could suggest pathology there. So that's another key area to look at as well as appreciating the left highland here. Okay. Um Fine. Does anyone have any questions to begin with here? I'll give a moment on the chat. Okay. I can't see any questions. We'll move on for a moment right now. It's about trying to appreciate the anatomy of a normal plain film. Okay, because we've mentioned some of the key review areas from a radiological perspective, but it's also about appreciating what else we can see on the lung here. Okay. So if we're starting from the top, we always, you know, I've gone through the Pneumonic before about airways breathing for A B C D E which is airways, breathing circulation, um disability and then everything else. Okay. So if we're going through things systematically, if we're looking at the airways here, the key parts I'm looking at is trachea, the right main bronchus and left main bronchus I'm hoping you can all appreciate that. There is a lucency around here where you can see the right main bronchus and the left main bronchus. You want to see if the tricky is central and then you're moving on to breathing. So I usually circulate round the lungs here to look for any pathology. Okay. Key thing is you want to look to make sure that you've got all of the lung fields extending right out to the peripheries. If not, you might suspect things like a pneumothorax. Um And then when you're assessing the heart, you're looking for things like heart size and if you can clearly see the heart borders here, okay. So this will tell you if there is any either heart pathology or adjacent lung pathology, that could be obscuring this border here. So the key areas to make sure you're looking for the left and right heart border here as well as the aortic pulmonary window over here. Okay. Um As we're looking through the lungs and the heart, a key review area at this time is to make sure that you can also appreciate that there is lung tissue sitting behind the heart and in a young person or in a healthy lung, you should be able to see the penetration right through the heart and through the lungs where you can see a very clear lung board immediately okay between the vertebra and the medial aspect of the diaphragm as well. Okay. You'll see this on both sides. These are key review areas. As you know, lots of people will start to look at the cost a phrenic angles here. But in reality, this bit, you can quite often see pathology but bits that are often missed areas behind the heart or particularly the apex. So I'd say those are two particular areas to try and look out for as we go through our plain films. Okay. Lastly looking for ribs. Um, if I just to try and get a little bit of engagement here as well to start off with before the cases, if I place my, um, laser pointer, let's do it right here. Okay. It's overlying a rib. Can anyone tell me if this is a posterior rib or an anterior rib that currently the pointer is pointing over? I'll keep an eye on the chat if anyone can give me an answer still yet to see an answer here. I don't know if anyone's happy for anyone to have a stab and have a guess. I don't mind if you're wrong, honestly. Okay. All right. No one's no one's biting at the moment. We'll come back a little bit later. See if anyone feels a bit more comfortable typing in the chat. Oh, yeah. Fantastic. Fatima. Thank you. Posterior. Absolutely. You're 1% right. Okay. A lot of people can sometimes get confused about whether we're looking at a posterior rib or an anterior rib. So if I show you here if you can see all of this horizontal rib over here, this is a posterior rib. So we can trace this actually. So if we're saying this is the first rib, so I'll be one too first rib, second rib, third rib, fourth rib, fifth rib, sixth rib. Okay. So here we're at the sixth rib, this will be the posterior aspect of the rib. It will continue around here and come anteriorly here. Okay. So this is the anterior portion, I may not be projecting too well, but I hopefully you can see this will be the anterior portion of the rib and this is the posterior portion. Okay. So whenever you're looking for potential rib fractures, that will also help you characterize it a little bit more. All right. And the last thing to look out for and plain films is making sure you appreciate everywhere else on the film. Okay. There are soft tissue all over here here. You can see the upper abdomen, sometimes you'll be able to see free air here if it's an erect film and then you've also got bones. So these are all the final aspects that you want to try and account for when you're interpreting a plain film of the chest. Okay. So we've already spoken a little bit about in the important review areas. The four areas I want to remind you all of is number one, making sure you keep an eye around the apex of the lungs. Number two have a look just here. We've mentioned that the heart, that the lung fields come just below the diaphragm as well. So make sure whenever you're reviewing the lungs, you look behind the diaphragm, okay, because the very posterior aspect of the lower lobes will come further down um behind the diaphragm. So it's a key area to look for pathology. Okay. Um So we've done apex, we've done behind the diaphragm. Is you look behind the heart as well. That's number three and number four is making sure you closely inspect the hilar. Okay, bad. Let's go on to abdominal playing films. Does anyone have any questions at all for chest? They've always spent a couple of minutes now on the abdomen. If you do, please just pop it in the chat. Okay. So abdomen playing films, does anyone want to pop in the chat? Now about any indications? Why would you do an abdominal plain film? Because I know there's, there's a lot of debate about how useful abdominal playing films are. Um in radiology, I still think we're able to use it to interpret some things, but it can be limited. Okay. Um Anyone have any ideas on white male, why we may want to do abdominal playing films? So Sarah's mentioned constipation, what you can see constipation on abdominal plain films? Certainly, I agree with that, but usually as a clinical indication, if you mentioned constipation as your main differential, it would probably the radiographers or the radiologist may reject that request because constipation can really be looked at with a number of other ways. So you're taking a history and even examining by doing a rectal examination can prove impaction and would save the patient any radiation to confirm that. Um So yes, sir, we can see it. But if that's the main clinical question, it probably, um you probably wouldn't get an abdominal plain film just for that. Uh Brenda and I should have mentioned a couple of other things as well. So bowel obstruction, perforation of mega colon, all of those, I completely agree with okay bowel obstruction, you can certainly gain some information about that on an abdominal film. Certainly. Um, perforation you can see is better to do an abdominal film along with a direct chest X ray because as you can see at the bottom here, most abdominal films are done supine. So if the patient is lying down and there is free air, all it is going to do is rise up. So wherever the free is, you might, the air will only be visible around the bowels will come onto that in a case later on. Um But if you had an erect chest X ray, all of the free air would then hover up and get trapped where the diaphragm is and that's where you would get pneumopar. Uh You would see pneumoperitoneum then okay. Uh and toxic megacolon. Yes. If you've got a significantly dilated um, transverse colon then yes, you can see that on a plain film as well. Okay. Um And yes, VP has mentioned obstruction here. Yes, very similar as Brenda mentioned. Yes, obstruction is certainly one. Okay. So there are a few indications. Um but you know, you may not see as many abdominal plain films as you do chest plain films. So we'll quickly run over some of the key anatomy and I've highlighted it here. Ok. We'll go on to um highlighted version afterwards, but you usually can see a fair few of this solid solid organs if you look very closely. Okay. Um Trouble with abdomens is the fact that a lot of the organs within the abdomen are all soft tissue. So whenever you try to differentiate soft tissue versus soft tissue, you're not really going to be able to make heads or tails of much. Um The reason why the chest X ray is so good is because you've got a huge amount of air within the lungs and then you've got heart and other things which are soft tissue. So you rely on that contrast of x rays between air and soft tissue. You don't really get much of that on plain, on abdominal films, okay. But you do see bones and you can see a few of the solid organs, okay. So if we're looking at bones, you can certainly make um if there is any incidental findings around the pelvis, you would be able to see any obvious fractures there. You would certainly be able to make a comment on vertebral body height as you can see, probably on the right hand image here, you can certainly see the outline of the lumbar vertebral reasonably well and you can see spinous processes. A key marker here is also to look for the pedicles. So these are also termed as owls eyes because if I can convince you, you might be able to see some allies here along with, along with the nose here. Okay, if you get a discontinuation of these allies or pedicles, that can indicate a fracture around the pedicle. So that's something you can see on an abdominal film. Um but most importantly where there's areas of air, you will be able to make some interpretation. So if there's dilated bowel, got, you will see um an increase in size of the large bowel or the small bowel key differentiators here is that small bowel is usually more central in the abdomen. Large bowel is more focused around the peripheries. Okay. A couple of other defining features as well is the presence of um how astra and valve Elocon Aventis. Okay, key thing here is in large bowel, you will be able to see that the soft tissue will only extend part way across the whole lumen. Whereas in small bowel, you will be able to see bowel markings all the way across. Okay. Well, come on to that a little bit later. Fine. I think there's enough grounding from everyone here. Any questions, if not, we've already spoken about most of this anyway here. Okay. We're looking for obstruction. We're looking for free air which you couldn't, can see around here. Oh, and lastly foreign bodies as well. Okay. So, um, there, there's often patient's that might be recurrent attenders to emergency department where they've swallowed, you know, for example, batteries, I've seen a number of those and you can make sure your tracing it through the bowel where you'll be able to see batteries visible in the bowel because there is a, again a difference in attenuation between a battery and air in the bowel as well. Okay. Um So yes, those are the main things here. Fine. I can't see any questions here. So I think we should crack on and go straight into some clinical scenarios here. Okay. I'm looking for you guys to help me through all of these. Okay. So I will be your radiology reg here for the evening. We've got you all as ward cover. Okay. I've tried to vary it for specialties as well as we go down these cases. Okay. But what I'll be doing is I will be calling you about this plain film and I'm hoping you're all going to be able to tell me a few things about it because um, I haven't got enough information and I am looking to make a diagnosis along with you as we go along. Okay. So you are the orthopedic junior who is on call. You get a bleep from me because I have got a chest X ray for a lady, a 68 year old lady who has had a total knee replacement where day zero or at least I presume is day zero. Um, where the request pretty much just says D zero, total knee replacement unwell. I haven't really got much to work with apart from this X ray. No, what I'd like you to do, you give yourself 30 seconds now, everyone have a look and go through this X ray systematically as you can. I've given you some points to look out for after that. I'll let you know in 30 seconds are up, please. Just if you've got any comments to make you just pop it in the chat and we can go through there. Okay? Uh Cool. So if anyone's got any comments about the points to consider or you got a diagnosis, do you want to pop it in the chat if anyone needs a few extra seconds, um just minimize the chat or turn off it. Um and just keep looking at the screen, make your own. I'd encourage you to try and everyone to make your own mind up about what you think is going on before having a look at what anyone else comments in the messages. Okay. As I said, I don't mind if you, if you get things wrong, I think we're all here to learn. Okay. So, have a stab at what you think is going on and we'll talk through it. I'm waiting on the first answer from anyone. Mhm. Fine. If I give you a bit more information here, let's say that after speaking to you on the phone, I found out that this patient actually six hours POSTOP while they're on the ward. Now, they're currently on two liters of oxygen and they're saturating 94% on two liters when pre op they were 98% on remote. Does that help your soul? Also, if you think the chest X ray is normal by all means you can write normal go and someone give us an answer if I were to help you one step further the diagnosis. So we've got one person mentioning normal Stefania. If I were to say, what did we mention about key review areas. So review areas are usually very helpful whenever you haven't found anything strikingly obvious. Okay. You know, we've got a few normal's here. I agree that most of the chest X ray looks okay. But if we focus on the review areas because those are usually the parts where if you know if you've got clinical information here saying the patient's unwell, we have mentioned that they're on a couple of liters of oxygen. You start to think okay. If the chest X ray looks normal is there anything that I may have missed or anything hiding somewhere that um isn't immediately obvious? Okay. So the four areas I mentioned we're looking behind the diaphragms behind the heart around the hilar and in the apex. Okay, Brenda will come on to your comment in a second as well if it helps, let me just quickly take you back to the normal chest X ray and 10 seconds having a look at this and then let's go back to here. Okay. Let me go into Brenda's comment. So blunted costophrenic angle on the left hand side with cardiomegaly. So the costophrenic angle, it's I would say you still can see it, it maybe ever so slightly blunted. But I think there's one particular thing you need to be aware of here and it's the fact that this is an AP projection. Um So A P projections can make the heart occasionally look bigger than it actually is. So measuring heart size on an AP film is not the best. Okay. Um is difficult without pictures is difficult to explain why. Um But essentially due to the where the X rays are coming from in an AP film. Let's imagine if you'll focus up here. Imagine this telephone is your patient? Okay. And imagine where I'm drawing a line here is your detector. Okay. See the distance between the um detector in the patient. And let's say your X ray starts here. Okay. So your X ray is going to shoot through the patient's front, through the patient's back and then hits the detector at the back here. Okay. So the heart sits quite close to the front of the patient because the X rays are coming this way and they diverge outwards like this. It's almost like a cone of ice cream. It goes out in this direction, it makes the heart look larger than it actually is where as a pa projection or a posterior anterior projection will minimize the size of the heart and give you a true a true reading of it. Okay. So in a P projections, the heart can appear slightly enlarged. Okay. So no one else has made a comment hip. So I'll move on to, can you all appreciate this area here? Actually, you can't really see much of the lung behind this heart. Okay. This actually represents something called left lower lobe collapse. Okay. Now, I've intentionally put this one, this one in early. I know it's a little bit tricky, but it's really to highlight the importance that once you've had a look around, try and focus on your review areas as well. Okay. Some of the other things will go on to later on will be a little bit easier. Okay. But I wanted to put this in first just to really hammer home that as you systematically go through all of the films we look at today. Um If you think it's normal, have a look at these review areas as well. Okay. Um So at least that talks about the diagnosis here, okay. The reason this is left lower lobe collapses when the left lower lobe moves in or collapses in on itself, then the oblique fisher brings because it usually sits over. Uh it usually kind of sits over here. You can't often see it, but then when your lung collapses in on itself, you will get all of this denser pacification here. Um And this constitutes left lower lobe collapse, okay. Um In the context of someone who's just come out of an operation, um it could just be from mucus plugging or something along those lines. Okay. A key thing I also wanted to mention here and this is going to be a theme that's going across all of these cases is at least from a radiology perspective. Whenever we see requests for um any imaging, particularly plain film imaging, these are the kind of information we get. It's kind of very little information and sometimes, you know, that makes, you know, you've tried to interpret this chest X ray. Um Having just this amount of information can actually make it pretty difficult, especially when you don't think there's, you know, nothing obvious immediately jumping out at you. Um So definitely having better clinical information can help you pick up a diagnosis a lot quicker. Okay. Otherwise, I think the adequacy of the film is pretty good. Um The lung fields, we've mentioned the key abnormality here and we've mentioned that heart sizes very difficult to comment on when it's an AP projection. Okay. This is just putting both of them side by side now to really drive home the point that you can see the lungs behind the heart here. Whereas here there is definitely in a pacification that makes it, that obscures that particular part of the lung and indicates the left lower lobe collapse. Okay. The, the way to remember this is we call this a sale sign. I don't know if anyone has come across that word before as well. In revision sale sign essentially means that I hope you can see that there is a slight density and this line completely goes down straight here, almost like a boat sail and comes around in a triangle like this indicating that as the sales sign here. Okay, fine. Really? Now, before we move on to the next case, I wanted to touch upon two other really common problems that you can see after as a POSTOP. So particularly, you know, any surgery, if any of you lot are going to be on surgery rotations or you're interested in surgery, then certainly getting used to some pathology here would be good. Um, in the chat again, I can give you 10, 15 seconds here. Does anyone want to comment on what they think is going on in either of teas, two x rays? They're both two very common pathologies that you can get after an operation file to hover around here on the left hand fill and on the right hand film over here, anyone have any ideas on what could be going on if we were to focus on this one first, what's probably one of the most common lung pathologies that, you know, if I gave you a bit of a history for this patient, we can say that they are, you know, there are five days post their operation and now they've got a productive cough and a fever. What do you think the diagnosis could be on this film? Yeah. Absolutely. Rihanna's got that one right? Pneumonia or a hat. Absolutely. Absolutely. Okay. So this one has certainly got pneumonic changes. Okay. You can see that there is an a pacification in the right lower zone and it certainly looks a little bit patchy over here and more dense over here. So it's a little bit a Trojan iss okay. This one would certainly classify as a hap in that setting. This one here looks very much more, looks smaller, it looks a little bit more dense and it's very straight and linear. So if I were to describe this as a linear attenuation or horizontal linear attenuation, let's say this patient is one day POSTOP and they're needing one liter of oxygen, does anyone know what this could be? Not quite getting anything from the chat here? So this one that's okay. So this one here is called atelectasis. Iss okay. Essentially. At me, it's very common. It's probably the most common cause of a patient d saturating immediately after an operation, particularly big operation. Because if they've been sedated or had that the general anesthesia, um you know, they haven't been aerating their lungs as efficiently as they would have done when they were fully awake. So what tends to happen is you get collapse of some of the Alvesco lie and they coalesced together here. So this is an area of persistently collapsed Salvio Line. Um So you might get a small bit of the saturation after uh after a big operation and after some physiotherapy, chest physiotherapy or just a patient really doing what they normally do, they will slowly be able to fully a rate and recruit these Salvio lie and open them back up and they should, they should clinically improve then. Okay. So certainly on this X ray, there is no sign of pneumonia, there is only a linear band of atelectasis that is usually nothing to worry about and it will get better by itself. Okay. Uh Okay. So my take home points for POSTOP imaging on call is really correlate with the clinical history. I know it's a radiologist, favorite word, favorite phrase. But trust me, it really makes a huge difference here. Okay, the better clinical history you get or the better clinical history you provide even when you're on call and you're taking a phone call, not just from a radiologist, but from anyone being able to get a good history from them is really important because it helps you interpret anything you see. Okay, consider what the common differentials are. So I think this will come with a bit of revision and a bit of time knowing what is the most likely things to be causing a problem after an operation and always check your review areas. Okay? If something looks normal, make sure that you pay close attention and double check those particular areas that we spoke about. Okay, fab if there's any questions, please pop that in the chat. Otherwise, um What if anyone is typing? We'll just, I'll give you the history for this next patient. Okay. Right. So this time you guys had a medical junior on call, all I've got for you now is you've got a 75 year old patient with a cough. That's all that one word has been put on the request and this is your chest X ray. This is what I'd like you to pay close attention to tell me what again, I'll give you 30 seconds systematically go through this chest X, right? And two main things I want you to put in the chat. First one can be diagnosis. But second thing is, are there any particular radiological findings that you see on this? But you think is important to mention. So I'll give you 30 seconds and then I'll let you know when to pop things in the chat. Lovely. So if anyone else wants to pop stuff in the chat, Sarah, I'll come onto your uh your comment in a moment. Okay. I'll just give 10, 15 more seconds for anyone else to put in some answers. Okay, Sarah, while I wait 5, 10 seconds more for anyone else. Are you happy to put in chat? Why did you pick I L D? Is there one or two defining features that's made you put it in? Tal has made a very good comment here about blunting of the cost of phrenic angles. That's something I do agree with is a very important radiological sign here and we'll come onto that in a moment as well. Anyone else? Any comments? Okay, fine. So yes, Talas very right here in mentioning blunting of the costophrenic angles here. So previous X rays you can see in fact back and quickly just show you here. So in these, you can see a nice pointed appearance of the costophrenic angle even on this side here. Okay. That's what you would usually expect here. You very much don't get that point down. Okay. This area is very much blunted on both sides. Um That's an important feature particularly it's bilateral. Okay. Um Does anyone want to pop in the comments? What blunting of these costophrenic angles could imply? I guess another key thing to consider is that it almost looks if there's a bit of a curve to it here. If I was to use a buzz phrase, you could even see a meniscus here if that helps anyone. Lovely Stefania has also mentioned horizontal Fisher. I'll come onto that in a moment as well. Okay. Um So Sarah, you mentioned I L D, I'm presuming the reason you've mentioned I L D is because rather than very unilateral features that we've seen before, um you're seeing kind of widespread shadowing in both lung fields that it really does appear symmetrical. Um You know, whenever you do see that, yes, you can think of I L D. Um In fact, yes, let's go straight onto this because this will show you if I show you both of these. Can anyone else pop in the chat? One of these films is I L D. Do you want to tell me which one? It is maybe a leading on a leading question? But is it the right hand film of the left hand film? And I'm hoping that we can tease out the differences between both of these? And yes, everyone else is very right in saying the blunting of these costophrenic angles with the meniscus does imply small bilateral pleural effusions. That's very right. Okay. These meniscus or minus chi here are very common features for infusions. Okay, so no other comments yet about. Yeah, so Towel has mentioned. Yeah, Stephanie has got that one as well. The right one is I L D? Okay. Can I convince you here that you've got much more of a reticular, you know, we try to use the phrase reticular pattern of shadowing. You can almost see it's almost a little bit more kind of wiry um irregular. These ones are a bit more linear here. This side looks very fibrotic, very much like interstitial lung disease. Okay. Um With practice and with looking at many and many more plain films, you'll slowly be able to differentiate what would counters reticular nodular shadowing. So you can see here that there are areas where it looks kind of, you know, almost like a little bit sandy, but there's areas where there's higher attenuation areas with lower attenuation, you know, this is very much a reticular nodular uh pattern of shadowing. Whereas here it's about putting things together. So yes, earlier on Stefan, you mentioned the horizontal fissure. I think Stefania probably was talking about here. This is fluid within the horizontal fissure and you have got bilateral pleural effusions. Usually, if you haven't got a marker saying that this is a A P or a PA film, typically, it would be a pa film and we can make an assumption on the heart size. The heart size does look enlarged here. Okay. If we were to try and officially measure it, I would take a measurement from here and take a measurement on here. So I'll give you the cardiac ratio, I would measure from here. And I would measure from here to get a thoracic ratio and then I would divide the to to get a cardiothoracic ratio. And if it's above your 0.5, then it would be cardiomegaly. But this, this heart does look enlarged here. Okay. So you have got symmetrical, bilateral shadowing um probably more predominant in the bases with fusion with bilateral infusions and with fluid in the fissure. Okay. There is also very much a vascular congestion, congestion around the hilar, which is very typical. Does anyone want to pop in a diagnosis for what they think could be going on here? On the left hand screen, left hand flip film. Yeah, absolutely. Stephanie's got their own right heart failure. Okay. So the left hand film is pulmonary edema, the right hand film. Yeah, exactly. Um is uh interstitial lung disease. Okay. So I think when you've got them next to each other, you can tell that almost the pattern of a pacification is subtly different on both sides. Um So once you see more and more of these plain films, you will be able to see that you'll be able to slowly tell the difference apart. Okay. Um As I said, look for secondary features to help you make a diagnosis. Um So here you can see fluid is definitely accumulating here here and here. Whereas with this, you don't really get a meniscus here. You get a little bit of patchy changes here, but you don't get that nice meniscus that you see over here. Okay. So all of this is probably just more um fibrotic changes at the basis as opposed to infusions, the heart size here, the heart borders are just very obscured over here as well. Okay. Um You can see that there is a bit of a curve to the diaphragm here and on this side. Whereas here, the diaphragm is almost very, is almost a little bit flattened. Um Probably because you've got a lot of infusion leveling out here on both sides. Okay. Whereas here there is no pleural effusions. So if we're trying to put the whole picture together, this one wouldn't really fit the picture for heart failure as much. You know, when you're looking at the highly here, there is not a lot of vascular congestion on this film, but there is a lot of vascular congestion on this film as well. Okay. So this one is more in keeping with heart failure. This one is more interstitial lung disease, okay. Um A pneumonic for heart failure is very much the alphabet A B C D E. Um If you haven't come across this, I'd encourage you to go and have a look at it a bit more closely, but we have spoken about a lot of these things here. Okay. The last one I want to mention is curly be lines okay. If I was able to zoom in, I hope that all of you can just see, can you see these horizontal, horizontal white lines around the peripheries at the bases. This constitutes a Dema or fluid within the interstitial as well and they come out as horizontal lines or curly be lines. Um This is quite, you only really see these when you've got fluid that leaked out of the alveolar lie into the interstitial. Um and this is very much in keeping with heart failure, okay, fine. So whenever you've got bilateral changes, and this is quite a common thing, you see, whenever, you know, you're on, when you're on call for medicine or you're doing a medicine job is you've really got to ask yourself if they've got bilateral changes. It's often useful to know the chronicity and severity of their symptoms. If they've got a temperature of 40 they've got bilateral changes and they're coughing up green sputum. Um, um, and they're on 10 liters or 12 liters of oxygen, uh very much is suggested infection and they could have a bilateral pneumonia and it's quite rare to get those, but they can do. Um, whereas if someone had the interstitial lung disease, X ray, so let's say they became more and more short of breath over two years and they had these changes, you wouldn't typically suggest a bilateral pneumonia, um or even heart failure if it's been accumulating over that period of time. Uh Whereas again, in heart failure, it would come on very quickly and, you know, it'll probably be worse at night. So you'd probably be called to see this patient overnight when they're lying flat. So they have orthopnea and paroxysmal nocturnal dyspnea. Okay. Um As we've said, any radiological typical features to point you in one direction. So I've mentioned the different, the difference between the types of shadowing and also looking for those secondary signs. So things like pleural effusions and cardiomegaly. Okay. All of these can help you make uh an educated guess on what you think is going on. If you see bilateral chest X ray changes. Okay. Fine. Let me any questions at all. Brenda has asked, sorry, what are the wiry reticular changes seen in I L D? So these reticular changes essentially what it means is. Um if you think of imagine you've got a balloon and you fill it up with water. Okay, inside the balloon where all the fluid is that is your Alvey the balloon is your alvito lie? Okay. In heart failure, a lot of the edema, uh a lot of the fluid ends up in the alveolar light. Okay. So you're going to get um if you get patchy changes at the basis, a lot of it is gonna be because you've got fluid in the alveolar light. Okay. Whereas an interstitial lung disease, you're, you have got no fluid within the alveoli. So the Alvesco lie itself for the balloon itself is not filled with water is just filled with air. Okay. But all of the structural parts around the balloon. So all the area outside is all of this fibrotic reticular changes. So this is where you get a lot of fibrous material that stops your lungs fully expanding and breathing improperly. So this is why usually with interstitial lung disease, you will get a reduced expansion and you will get what we call a restrictive pattern on spyrometry. Because when you're alveolitis try to expand, you're not able to because of all the fibrotic tissue around uh around the balloon or around the Alvesco line. Um So I hope that makes sense. Brenda. Okay. If it doesn't, I'll be around afterwards if I need to answer any more questions as well. Okay. Fine. Let's go into a surgical case and then we'll go onto a quick fire quiz right at the end. All right, abdo pain in a 48 year old male, you're a surgeon on call. This is your X ray. I'll give you 60 seconds. Have a look at it. Tell me what you think. Notice the points to consider have changed slightly on this abdominal film. Um Let me know what you think here again to save time. A little bit later. Obviously, the clinical history is a little brief once more, but honestly, this is usually what comes through on request. Um So, you know, for your own purposes and your own learning as well, just think about the kind of extra things you would like to know, on this request, what would help you make a diagnosis here? You know, at least the things for me, it would be nice to know if this is chronic or acute abdominal pain. Um, if the patient has any bowel sounds, if they're passing gas, if they're vomiting at all, if they've got any bleeding anywhere, um, you know, these are the various things and if there's particular blood test that you've already got back. So things like a lactate or you know, any electrolytes or things like that, a couple of those extra important bits to help you make a diagnosis would be useful here as well. We're fine. Does anyone want to pop in a potential? What do you think about the bowel pattern and what do you think about the diagnosis? Anyone want to make a step and what they think could be going on? Lovely. Let's have a look in the chat here. So, apologies. I've, if I've mispronounced this, but uh Dukes C has um mentioned severely dilated widespread loops of bowel. The left hemi diaphragm appears raised query, bowel obstruction. Sarah has also mentioned dilated loops of bowel. So I agree with both of you. Okay. Um There is dilated loops of bow. Can I push either of you or anyone else a little bit further in being able to differentiate what kind of bow is dilated? Yeah, absolutely. So, Towel has got that okay. Small bowel is dilated. Now, can we see here, I think this is probably the area to look at most. Okay, you can see that there are bowel markings all the way across. Yeah, absolutely. These are going all the way across the bowel. Okay. This indicates that this small bowel, if it was large bowel, you would only see markings here and here. Okay, would only go part way across the bowel. But since this goes all the way through, this is most likely small bowel obstruction. Okay. No, let's see. What's the next one we're going on to? Yeah. Okay. If anyone else want to make any comments, I'll give you now that you know that this is small bowel obstruction. Anything else you'd want to look for here or anything else? Making you worry because I think if we're systematically going through these, I mean, adequacy, yes, we can see all of the abdomen that we would like to see. So usually abdominal films I would want to see down to, but just below the bladder. So as long as I can see the whole pelvis, if I can see whole of the upper abdomen and I catch some of the lower lung fields. Okay. Um, that's what I would be interested in. Um, yes, absolutely. There was an elevated left hemi diaphragm. That's a good catch here. That is an abnormal finding. Uh, it's difficult to, um, difficult to know the cause based on an abdominal film, but it's certainly something that you would watch out for. Absolutely. Okay. We haven't got any more comments yet, but we'll come onto one other feature here. That's quite important afterwards. Okay. Um, now this is just to emphasize the fact that yes, you would expect to see your solid organs over here. But because of everything that's going on in the abdomen, differentiating the kidney from the liver to the spleen, you know, even to the. So it's muscles, you can't really make out any of the soft tissue planes here. So this is just emphasizing that if you're asking the question about obstruction, yes. This can, this can tell you that there are dilated, dilated loops about and the patient could be obstructed, but it doesn't really give you much more information than that. Okay. So when we're looking at dilated loops of bowel, a useful rule is the 369 rule. Okay, small bowel. If it's above three centimeters, it is dilated. So, if we're calling this way, it has to be below three centimeters to be normal. If it's above three, it's dilated the large bowel in general. If it's above six centimeters, classified as dilated the cecum, an appendix uh has a bit more leeway okay around this area. Um, the bowel can sometimes be a little bit more dilated. It might have some stool that's stuck there. Uh, but it has a bit more give before there is any imminent risk of perforation. But with the small bowel, there is a lot less leeway. Okay. Um, so yes, this is just something 369 is a very useful rule to remember. Okay. Now we're talking about obstruction. These, can anyone comment on these two films? The left hand film is a small or large bowel obstruction. The right hand, is it smaller, large bowel obstruction? Anyone want to pop in the chat? Yeah, absolutely. Sarah's right. Ok. Left is small bowel obstruction. Again, we've already spoken about how we can see the markets all the way across. But another key feature is that, you know, small bowel predominantly stay central in the abdomen. Whereas on the right hand film, we can see that, you know, this bowel is significantly dilated. Um, but that bowel market is only come part way through. Ok. So, yes, this is large bowel obstruction and this is small bowel obstruction here. Now, the one thing that, um, is difficult to appreciate but was present on the previous film is whenever you see dilated loops of bowel, the one thing we worry about is, yes. Has there been a perforation? Okay. That is a question you should always ask yourself whenever you see dilated loops of bowel. Now, can I convince you, first of all, I'll focus on regular sign in a moment. Okay. But can I convince you first of all that this abdomen too fat plain over here? You can see this sliver of darkness going all the way around. Okay. Shouldn't really see that there. Okay. Here you can see it, but it's encased within the bowel wall. Okay. Here again, I can't really see it, to be honest. Okay, particularly this side, you can't see anything there. Whereas here you've got very much an area of darkness or area of lucency here that indicates that there could be free air in the abdomen. Okay. Riklis sign. Because if you think about it, the patient's lying flat air will rise to the top. Okay. So you won't be able to see any pneumoperitoneum here, okay. But what you can see is usually air would be sitting only within the bowel wall if the bowel was intact, okay. When it's not intact, air can leak out and you will then get darkness tissue darkness. Okay. So you'll be able to see both sides of the bowel wall very clearly. Okay. This is something called rigorous sign. Um If I take you back here, I hope you can appreciate whenever you're looking at the bowel here, you can see one side of the bowel wall, but the other side there is no darkness to make you see both sides, okay. There is no air outside of the bowel. Whereas on this film, you can see dark white, dark, okay. So you can see both sides of the wall. This is rigorous sign and it's a sign that there is significant pneumoperitoneum going on. Okay. So, always ask yourself, is there a complication that you can see on the plain film. Okay, because this can often be, um, you know, more than enough information for a surgeon to come and review now. Okay. So my take home points that dilated loops about is firstly, if you see it, can you see anything that's life threatening? Can you differentiate between small and large belt and occasionally you can look for a cause. So sometimes you might see, um, you know, a twist in the bowel or sometimes you might see excessive amounts of stool that could be causing obstruction. So it could be various causes that you can see. All right, but those are my take home points for that. Now, Christmas quiz, I know we are running a few minutes late here. Um If any of you need to go, please feel free. That's fine. Otherwise this quiz is only going to take probably less than 10 minutes. Ok. All it is is quick fire questions. Um And you know, there's a few interesting cases here where you know, where as we're talking through, the other ones, we go into a bit more detail. But with these, we go straight to the pathology each time and focus on some key bits of management as well. So as just under 10 minutes for these questions, okay, fine. Firstly, we'll leave this open to the chat. So type in whenever you want. Okay diagnosis. What do you think is going on in this plain film? Anyone have any ideas? Yeah. Absolutely. Fatima's got that one right, right sided pneumothorax. Completely agree. Okay. You can see long markings here all the way out to the peripheries. We come on to the right side. Absolutely. No long markings coming out this way. Okay. We can see lung tissue border all the way here and you can see that there is much more darkness all over here compared to this site. Okay. So, this is a large pneumothorax. Okay. Now, when you see a pneumothorax, the next question, very similar to dilated bowel is what is there any complications that you need to think of straightaway? So whenever you see pneumothorax, your next thing you should look for is what's the trachea doing? Okay? I hope everyone can see here. The spinous processes are relatively in the midline. I think we can see the medial border of the clavicle over here and here. Okay. So it's relatively in the midline. Exactly. Sarah's got that one right. The trachea is deviated slightly away from the side of the pneumothorax. So I would turn this attention pneumothorax. Okay. Um And yeah, absolutely. Stefan has got that one. My attention hemothorax, immediate management is usually needle decompression, second, intercostal space. So 1st, 2nd intercostal space, midclavicular line. So you know, if you were looking at to try marking out, you've got your first rib, your second rib here. So this is sorry, first intercostal space, second, intercostal space, midclavicular line. This is where you'd be popping a needle in, okay, immediate decompression to um prevent any other complications from happening. Because when you start getting tension here, your main problem is that you're actually pushing everything over and compressing your vena cava. So your, your blood supply getting into your heart is impaired and your, your complete circulatory collapse. Okay. So, immediate decompression and then your definitive treatment is popping in a plural drain so that you can get rid of all of this excess air. Okay. I've left, left this one blank here because there's a bit of debate about where you measure new math or it ease from the one that I want to highlight to you is that the British Thoracic Society have suggested when it's a large pneumothorax like this, you measure from the hilum to the edge of the lung. Okay. So that's where you find out how many centimeters it is. And based on that, you can start working out how you want to treat this. Okay. Um But yes, fine. Last note for any kind of pleural drains is just think about common, just use common sense whenever you're looking at this and whenever you're trying to figure out what type of drain and what position you should use, okay, the pneumothorax air always rises okay. So if a patient sitting up or standing up for most of the day, the air is going to rise to the top of the lung. So therefore the tip of your drain should be pointing towards the apex, whereas fluid always drops down. So your tip of your, uh, the tip of your drain always should be pointing downwards as close to the base, as close to the base as you can. So that you can get all of the fluid you can, um, to be removed for a pleural effusion. Okay. Fine. What do you think about this kind of briefly touched upon it before? Yes, Sarah. Exactly. Right sided pleural effusion and Stefania. Absolutely right sided pleural effusion. You can see that there's a meniscus over here once more. Okay. But the left side is almost completely clear. Okay. If you ever have an unexplained unilateral pleural effusion, do you know what should be at the top of your list to rule out any ideas? So, as we said, heart failure can affect both sides. Yeah, Suman, you know, absolutely synthes cytology. So you're thinking cancer, that is exactly right. OK. Whenever you've only got one sided pleural effusion, you got to think what, what's going on here to make all of this fluid accumulate here. Okay. You want to do a plural tap and send off for some fluid to make sure it's not malignant. Sarah's mentioned hemothorax, I would agree with you if I saw fractures. So if someone had a trauma and you can see clear rib fractures, then yes, I completely agree with you. There could be a hemothorax. But if you see a pleural effusion. Then there is no other obvious cause you should be thinking about cancer. Okay. Lovely. So we've covered this one here. So I'll uh we'll move on to the next one. This one essentially a small bowel obstruction. The reason I wanted to mention it to you here is because usually abdominal films are supine. Okay. Whenever you see an erect abdominal film, you've got airway will always rise to the top fluid will always drop to the bottom. We've seen that in chest, in the chest X rays just previously here. This is a very good example of what we call an air fluid level. Okay. So air will rise to the top of the bell fluid will drop to the bottom. And when you've got dilated loops of bowel, this becomes a lot more obvious, okay. In small bowel obstruction, what you will typically see in a an erect abdominal film is you will see multiple air fluid levels. Um And that's very indicative of small bowel obstruction. Okay. You can see here that there is dilated loops of bowel with bowel market's going all across the bowel here with multiple air fluid levels. So this is small bowel obstruction. Okay. An immediate management is a nasogastric tube in fluid and ask the surgeons to come and see. Okay. Anyone want to hazard a guess on this last couple and then we're done. Ok. I pop these in mainly so that they're very, they're not that common. But yeah, absolutely. Yes. So both of these are examples of all villi okay or a Volvulus. Now, the left one absolutely is a yes. So um Roubini has mentioned that quite rightly okay. A coffee bean sign. This is very much a coffee bean sign here. The reason Roubini that the left one is a sequel Volvulus and the right one is a sigmoid is mainly in the direction that this coffee bean is pointing in. Okay. So if it's pointing towards the left iliac fossa where the sigmoid is, that's the sigmoid Volvulus. If it's pointing here towards the right iliac fossa, it will be a sequel Volvulus. Okay. That's just a very simple layman's way of looking at it. Um It will take a bit more time to explain exactly how it twists around them, why it looks like that. But just as a quick screening on making a guess on whether it's a sequel or a silk sigmoid Volvulus, um you would just try and look at the direction that the coffee bean or the volvulus is pointing in. Okay. Fine, very important diagnosis. Anyone want to hazard a guess on what you see here? Yeah, absolutely. Assuming you're absolutely perforated bowel. Okay. So this is an example of pneumoperitoneum, okay. You may have seen a um air within the stomach occasionally here. So that's this, this is the gastric bubble. Okay. That's usually the only air under the diaphragm that you will see whereas here you can see that's clearly air being trapped underneath the diaphragm on this side and air trapped underneath the diaphragm on this side. Okay. This is pneumoperitoneum, suggestive of bowel perforation, okay. Or at least air in the abdomen. Right. Last interesting one. And I think more call that day there actually second to last one, the last one is a take home point X ray. It's very odd. I'll be surprised if anyone's seen this. It's only the reason why I'm putting this in is more the fact that you may not see much of this um, in exams. But when you're looking after patient's particularly elderly patient's, you might come across this and it's very interesting. Okay. So this one here, I'll just go very quickly. This is plum barge because of TB. So tuberculosis has an affinity for the upper lobes. Okay. A cotton wool, not quite, it's, these are actually inert, almost plastic balls that you uh when cardiothoracic surgeons used to treat TB, that were stuck in the apices, you would actually shove these inert balls in during an operation to crush the lung and kill off the TV and cut off its blood supply. Um, because in the olden days you wouldn't have anti antibiotics. Um, so they very, you're quite right, Brenda, they look like Buller. But in fact, these are just in er, gas ball inner balls that you push in and crush to kill off active TB in the olden days. Okay. It's not a treatment that's done now, but you might look after patient's on the respiratory wards. Um, that will have this. Okay. So, if you're interested by all means it's called Plum Barge, you can have a look on radio pedia or anything on Google. Um, but this is, uh, it's something interesting that you may come across in the future and if you do, you'll sound pretty good if you, if you've got an idea of what it shows. Okay. Right. Promise. This is the last one. This is only a take home point. I'll make it quicker for everyone. There is no problem within the lungs. Okay. What else can you see when you're systematically going through your whole X ray? If all the lungs look clear, where else do you have to look at to make sure you can't see any problems? Not just your review areas. I know I've banged on about that but it's not, it's not the review areas in the lungs this time. Try and have a look around the outside. Yeah. Absolutely. Bones zoom in. Do you have any idea on where can you give me a diagnosis or anyone else? Give a diagnosis? Yeah. So, not quite a dislocation. But you can see here that there is a clear disruption of the cortex over here. Okay. So there's a displaced fracture. It's difficult to age it or know exactly how long it's been there, but you can see here, humeral shaft, humeral shaft. Oh, absolutely nothing. Here. The rest of the humeral head is over here. Okay. So, even though you've been given a chest X ray, always remember that once you finish looking at the chest, have a look at the soft tissue and bones around just in case there's anything else going on. Okay. Um, because if you miss, you know, it won't be great for the patient. If you miss this, they might be a confused patient. They can't actually tell you about the pain here, but if you pick it up, it'll be a pretty good catch. Okay fab if there's any questions, please just pop it in the chat otherwise, thank you very much for listening. I would love it if you could fill out some feedback to help me improve anything here. Um, please as well. If there is anything you'd want in the future, I can liaise with tower and I can, I'm happy to do another talk. Um, if there's anything else that you want a bit more teaching on, but I hope you found this useful and uh yeah, I hope you have a good rest of the evening. Thank you for sticking around till quarter past eight and uh you know, I hope you have a good Christmas as well. Um Thank you. Thank you so much. Are, that was really good. Um I mean, picked, picked up a lot of, of points to uh need a refresher and thank you so much for taking the time. Like you said, it's a, it's a, it's a late evening. So we do appreciate your time. We know you're, you're busy and thank you everyone for joining as well. I, we appreciate your taking out your time from your evening as well. I hope you learned lots. Um, and please do fill out the feedback. It helps us improve and help showers as well. So, um please do fill that in. Um I've popped the link. I'll pop it again. Um So before you leave, please do fill in the feedback and bro, lovely. Thank you all. I'll be sticking around for a minute or two in cases. Any questions? Okay. Brenda. Let me just see. It just messaged, isn't it? Yes. So if anyone else is around Brenda, I'm assuming you're still on the call here as well. Happy to answer this. So your question was, you know, are you right in saying that a meniscus would not be seen in pulmonary edema? Let me just go back to my pulmonary edema slide. Okay. Yeah. So Brenda, whenever what this meniscus shows, let me get the pointer, what this meniscus shows is that there is fluid within the costophrenic angle uh or this fluid within the pleural space, overlying the costophrenic angle. Okay. So this signifies that there is a pleural effusion present, okay. If you have, it's quite common for you to get pulmonary edema. So pulmonary edema is where fluid is stuck within the Alvesco lie. Um This is what we're all seeing here. Okay. All of this haziness is um pulmonary edema. This here or the meniscus terms is the pleural effusion. Okay. It's quite common that patient with heart failure or fluid overload will have both pulmonary edema and the pleural effusion. You can get occasions where patient's don't have it, but it's quite common for them to have both. But they are two separate pathologies. Okay. Pulmonary edema is where you get all of this um haziness within the lung and that's fluid stuck within the Alvesco lie and a little bit in the interstitial space but predominantly in the alveolar. I um whereas the meniscus here is where there is fluid within the um pleural space. Okay. So both of them represent different things. One is fluid in the alveoli. One is fluid in the pleural space. I hope that answers your question any more questions or food. I think the chat looks okay at the minute, which is good. I see. There's a still a few people lingering around here. So I'll, I'm happy to stick around for a few more minutes and I'll keep on pestering, pestering them for feedback. Oh, don't worry, don't worry. Yeah, I mean, any feedback is good, but that's fine. I understand it. It's already late in the evening. So, are you in work tomorrow? Uh Yeah. Are you working? I assume you're working as Well, yeah. Yeah, I think there's a, there's an ultrasound list or something in the morning. Okay. Um, yeah. Really? Really? Do appreciate you taking the time until, oh, don't worry. It's actually, to be honest, you shouldn't have a lot of trouble getting people to do teaching because for most, for most things they need to get a teaching a one or two teaching sessions done a year. Sure. Um, so, you know, um, at least for radiology I need to do to for the year. But you know, wherever that teaching happens isn't a problem. Sure. You know, for me, it also helps me, you know, fair enough. Yeah, maybe and we will certainly keep in touch and um if people are sort of requesting more. Yeah, just, just let me know. That's okay. Um Understand particularly for med school. Sometimes radiology isn't the highest priority. But yeah, if, if there's appetite for it and wouldn't that be ok? Tell her I might peel off now. Okay. Yeah. Feel free to. Yeah, if there's, yeah, if there's any, if there's any questions that anyone postponed means happy to answer an email, but hopefully it's all ok now. Yeah, perfect. Thank you so much. No worries. No worries. Cheers. You too. Bye bye.