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I look like people in the participants p for explain it correct. Hello. Can people hear us if you can hear us, please write it in the chart. Any one of the 10 people who have joined? Can, can you see the screen currently? We just need to make sure. Yeah. Yes, I can see. Ok, perfect. Um OK. Yeah, so we'll give it a few minutes and hopefully we can start so no much. By the way, how are um radiology applications going and, and everything? Uh I think the the window is kind of opening um next week in terms of um like it's going to open an ao in terms of uploading things. So I'm trying to collect as much things as I can cause I know it's like extremely competitive like 12 to 1 at the moment. I see. Yeah, so I'll do my best. I'll give it a if not try again next year. Do you have to like have done radiology research and like publications and stuff? Yeah, like audits um and all that stuff like presentations, um publications are not there. They've said that I mean, if it, you obviously get more points if it's obviously radiology based, but I think it's quite difficult to get one of those done, but I'll just put together whatever I have and hope for the best. I see. I see. It's just very, very competitive. It's getting more and more competitive every year. Yeah. What about you? Are you, are you radiology based? Um, so I'm a medical student so I was thinking of, like, maybe doing radiology. But, yeah, what if I get, if I get through the other side you can give me tips. Yeah. Uh Yeah, it creeps up very quickly. What, what year are you in uh final year? So OK. So when are your finals? I assume? Yeah, they're in February. OK. Fine. OK. Yeah. Well, it's out the way but then it's nicer you're done cause then you have, you're elective and everything like that. So, yeah. Yeah, it will, it will be good then. Yeah. And by the way for people who are waiting, we're gonna start in literally uh 605. We're just waiting for any people who are a bit late to join. I can see there's, there's a decent number of people now. Don't worry, we'll, we'll start quickly. Please respond. Catch up session, be shared later on for review. So do you mean will there be another session or will there be, will the slides be uploaded? What do you mean by that? Oh, will there be another session? Yeah, I think there will be another session later on. Um um it'll be in a few weeks, so don't worry about that. So, are you an F two currently? Yeah, I'm an F two. Yeah, so literally. And then, yeah, in London it's very hectic. The, I think it's a big jump from everyone in terms of the, well, in London, particularly the rotors there's a lot of like long days, night shifts and things like that. So it's hard to actually get some time aside. Um, yeah, coming, I got, got one more rotation. Well, yeah, no, two more rotations left actually. Um, one in Chelsea Westminster then GP. And then I'm, then I'm done. I see. You're almost finished. Have you? Uh, so you would know right where you're, you're heading to in terms of your next scenery, right? No, I've got no idea that gets sorted in January. Ok. Fine. Where were you hoping to go to, um, West Midland Central? Ok. Are you from that area? Yeah, I'm from Birmingham. So that's a good, yeah, good. Like a good location to go to. So, we actually have a friend, I have a friend actually who's working there in, around that area. Um, but then they, they've changed everything, haven't they? For the past few years now where it's like random medication. Right. But time, yeah, I don't know how I feel about that, but I think it's, most people get their choice. Yeah, hopefully. And some, someone mentioned will this recording be shared. Yeah, it's recording currently. The recording will be shared. So you don't need to worry about that. That will be available afterwards. Ok. And so, yeah. Which are you in, at the moment? You're in London, I'm guessing. Right. Yeah. Yeah. Yeah, I'm in London, like northwest, so Chelsea area. South Kensington area. It's nice. Quite nice. Um, obviously the commute is a bit of a, on the tubes and things like that. But other than that, it, it's nice. The hospitals are very nice. Um And I'm from London, so it's like nice to be back home. That's nice. Yeah, and so, yeah, everyone, like I promised uh sh should be at 605. We have 20 people now. So I think that's a decent number. Yeah, let's go for it. So, um hi everyone. My name's Brea. Um as you might have heard, I'm an fy two doctor working in London currently at Chelsea and Westminster Trust. Um And this is the first lecture of um radiology series on um interpreting chest X rays. Um So throughout medical school, um throughout your exams, there'll be multiple questions, multiple osteo stations where you're presenting with X rays and they're common pathologies and you need to try and yes, pick out the common pathologies quite quickly. Um So hopefully this should help give you a more structured approach um to X ray interpretation. Um I'm so sorry, Ron's gonna have to help me with the slides. Um So yeah, go to the next slide, please. Sorry, Veronica. I don't think it's moving to the next slide. Is it not for? No, it's just staying on. Uh The fast says the fast, the fast side only. That's so weird. 11 2nd. Sorry for the technical difficulties. How about this? That's moving. Yeah, if we just maybe minimize the notes bit, then it'll probably make it. Thank you. Perfect. Thank you so much. So, a bit about me, as I said, an F two in London, I am interested in radiology and I went to Leicester medical School. Um and I do have a bit of an interest in medical education as well. Um I've also done a teacher, teacher course as well in terms of helping me with my medical education and teaching. So hopefully that helps throughout this crash course we're going to do for radiology. Next slide, please. So as I said, um in your s you're going to be presented with many um X rays in the exams. And I found that when I had a structure approach, it just helped me in that limited amount of time that you have in your exams to be able to pick up key pathologies. Um And I'm sure a lot of you may have come across this before, but an ABCD E FG approach, but it's good to always kind of refresh your memories and go through it. Um Just so you're clear of what you're looking for in each of the different parts of the algorithm. And as we go through the presentation, we'll also look at some common pathologies that you'll be expected throughout medical school to pick up um quite confidently. Um And hopefully by the end you'll be confident in interpreting the chest X ray in 30 seconds or at least quite quickly to be able to move forward with your exams next time, please. Um We'll mull over this quickly. We won't do a poll, but it just sort of get an idea of how long it does take for you guys to interpret x-rays. We skip over that slide and we'll get started given the technical difficulties. So first things first, when interpreting an X ray, the most important thing is the principles of X ray interpretation. So the interpretation of an X ray requires, first of all sound anatomical knowledge and also knowledge about understanding that actually different tissue types will absorb X rays to different varying degrees. Um so high density tissue like bone will absorb x-rays to a much greater degree. And that's why they appear white on the film. Whereas low density tissues like the lungs um absorb x rays to a much less in degree. So they're going to appear black on the film. And then you've got things like muscle and fat which will appear shades of gray and that alone will also help you just to interpret the different parts that you see on an X ray. The other thing is um X rays are essentially a two D super imposed view of the body. Um that's being imaged. Um So it may be necessary to take multiple views of the same area from a different angle. So for example, suspected fractures, um they usually do kind of an AP view and a lateral view sometimes just to get a better idea. Um given that it's a two D image and that will help you to gain a full understanding of the injury if present. And the other good thing about X rays, they're, they're used quite a lot um in practice because they've got much lower dosage radiation compared to CT S and they're relatively quick um to use. Um So you can get this snapshot um to help with your kind of clinical diagnostics. Uh Next slide, please. Yeah. So um we're going to go through the ABCD E FG approach. Um I've got a snapshot of it there and this is quite a useful um image that I found that you're gonna see from the slide. It just kind of goes through what each of them mean. Um But we'll be going through each of them in detail, um kind of a listing what you need to know from the different parts of the algorithm or what you should be looking out for. Um So we can get going, so if you go to the next slide and we talk about the first part um which is assessment air and airways. So, one of the really important things in acies which I've actually missed out on and sometimes even failed stations for is the most important thing is actually verifying the patient a lot of the times we walk in and we forget to ask, what's the name, what's the date of birth to help verify that you're talking to the right patient or you're interpreting the right x-ray for the right patient. Um So, patient details are really important. Um So when you're given an image, the first thing you might want to say to your, the examiner is I just want to confirm the name date of birth and the unique identification number. Um Some hospitals like an M RN and you can also look at other things like um previous imaging um for it, which is useful for comparison. So usually on the ward, they'll pull up a previous X ray just to see how things changed, how things got better, how things got worse. Another thing in the assessment is essentially your image quality. Um and we'll talk through image quality in a bit more detail. There is a useful pneumo mnemonic that I used in medical school to help me remember the different aspects of image quality which is ripe and it stands for rotation, inspiration, projection, and exposure. So rotation, um how do we elicit if the X ray has got the correct rotation, I guess. Um And what we look at is we look at the medial aspect of each clavicle and that should actually be equidistant from the spinus processes. Um providing the spinus process is a vertically aligned. So that's how we kind of look at rotation and we'll go through you some examples as well. Um inspiration. So the 5 to 6 anterior rings, ribs, lung apices and both the costophrenic angles and the lateral rib edges should be visible. And that helps us determine as, as appropriate. Um Inspiration projection is essentially AP and pa films. And again, as we go through the presentation, we'll talk a bit more about what we mean by that and finally exposure. Um So with adequate exposure, exposure is essentially how much you can see on the X ray film um to be able to make a diagnosis. So to determine if something's adequately exposed, the left hemidiaphragm um should be visible to the spine and the vertebrae should be visible behind the heart. Again, we'll go through some examples just to kind of elicit what that actually means. Um the other part of a is air. So where air should be and where air shouldn't be. And I'm sure you're all familiar with terms like things like pneumothorax, um and pneumomediastinum, pneumoperitoneum. Um essentially examples of diagnoses where air shouldn't be essentially. Um So, for example, um pneumoperitoneum, you've got essentially air under the diaphragm and that shouldn't really be them and then airway um airway deviation. Um You want the trachea to be central on the X ray and airway deviation can again point towards different pathologies. And we can also look at the carina, the bronchi and hilar structures. The carna being an important point where we're able to um particularly when you're F one and F two on the wards, you might be asked by the nurses to interpret X rays to check if an angio tube is in the correct place or a C BCA central venous catheter is in the correct place. And the carina is an important point that we use to determine if the tube is kind of passing in the correct place. And again, we'll go through some examples. Um So if you go to the next slide, thank you. So this image just kind of highlights the carina to you. And it's basically some cartilage that's situated at the point at which the trachea divides into the left and right main bronchus. Um And if the X ray is appropriately exposed, it should be clearly visible. And as I said, that's really an important landmark when we're assessing NG tube placement because an NG tube should dissect the carina if it's correctly placed in the gastrointestinal tract. And then from this picture over here, we can see the right main bronchus and the left main bronchus. And you can see from the picture that the right main bronchus is generally wider and shorter and it's a lot more vertical um than the left main bronchus. And a common thing um to be aware of is actually because of that anatomy, it's more common for inhaled foreign objects to be lodged in the right main bronchus. Um So that's quite useful to be aware of. Um And if you've got a really good quality chest X ray, sometimes you might be able to see um the main broncho branching into further subdivisions um of the Bronchi as well. Uh Next slide, please. So I've got an X ray over here. Um If not, don't worry, does anyone feel brave enough to interpret this x-ray based on the principles we've discussed so far? Um in terms of a, so using essentially assessment and then the right mnemonic we talked about so rotation, inspiration, projection and exposure and air and airway. If not, we can go through it together but or you can put some answers in the chat as well. OK. Yeah. OK. OK. Don't feel shy. It's a, it's a nice learning environment. Any wrong answers are fine. OK. No, if not, we can, we can go through it together maybe later on. So it might be a bit more brave. Um So first things first, um I mentioned to you guys um I lost marks and ay for not looking to see if there's any patient data or confirming that I'm speaking to the correct patient. Um So patient data. So check um on this x-ray, there's no patient data whatsoever. Um Then we talked about rotation and how actually when we talk about rotation, you know that the medial aspect of each clavicle should be equidistant from the spinus processes. So here we can see that um the film is actually rotated because we, we're not able to see that on the X ray, they're not equidistant. Um It's rotated to the right. Um And we can also see that actually this x-ray is um under inspired as well. Um The other thing was projection, we spoke about projection. So we can see that it's got a ap projection as we can see in the top right hand corner, um the exposure is adequate. Um So in terms of er exposure, um we can see the left hemi diaphragm visible to the spine and we can see the vertebrae visible behind the heart as well. So we can say that the exposure is adequate for this X ray um and things that we can spot on the X ray. So I mentioned an NG tube and how we essentially use X rays to determine that if NG tubes are in the correct place as part of our assessment. And here you can actually see that the NG tube tip is too high and it's likely that the tip is likely actually within the distal esophagus, um which is quite as opposed to being in the correct place. Um So another thing that we can see here is there's also an increased density in the apical and the right upper zones with some elevation actually of the um the horizontal fissure in that area. Um And these features are in keeping with a right upper lobe collapse as well. There's a lot you can tell from X rays. Um And if you go to the next slide, I've got the answer there. Anyway. So you said no patient data rotated and under inspired. And you can see actually in terms of the rotation, the distance is not equidistant between the two clavicles. So rotations likely here, um we know the end TBE tips too high. And also we've mentioned about the increased densities as well um in the right upper zones. One thing to point out at this point is actually that we're going to talk about, we spoke about tracheal deviation. And actually, if the tra central in our air part of the mnemonic, actually, rotation is going to be a bit wary of because rotation can give the appearance of an apparent tracheal deviation. So the tr is not deviated in this x-ray, but rotation can give that apparent appearance. Um So that's just something to be cautious of. Um we'll talk about tr deviation in the next slide actually. Um So here's another example um where we've got the trachea deviated. So another important thing to look at in the airport is if the trachea is deviated, um and if it is, is anything essentially pushing or pulling on the trachea. So this X ray shows basically a pleural effusion and we've got some tracheal deviation and with pleural effusions or tension pneumothorax. Another really important clinical diagnosis, the tia is essentially pushed away um from that effusion and or the tension pneumothorax, um which I'm sure you guys know what tension pneumothorax is, but it's basically when air enters the pleural space but cannot escape. So you get that increased intrathoracic pressure and it can cause patients to have a lot of different symptoms, including hypertension, um tachycardia and decreased breast on that affected side. But the two conditions, pleural effusion and tension pneumothorax push the tia away. Whereas if you've got a consolidation um and some lobar collapse as we saw on the previous X ray that can actually pull the tia towards it. So, looking at as to whether the trachea essential or not is a really important part of the, a part of the algorithm um because it can help pick up all these different pathologies. Um And then the next slide um I've got another picture of um attention me or wax. Um So we just go to the next slide if that's OK. Thank you. Um So we've got another example here of tension pneumothorax, um which you can see is essentially pushing the trachea away and you can see that you've got lots of all the lung markings um in the right lung field here on the left lung field, sorry, in the left lung field here. Um So that's quite a large tension pneumothorax. Um So that's just another example of tracheal deviation. Um We'll go to the next slide. Um If anyone's feeling brave enough, do they know what condition causes? Um, this particular pathology over here that we can see here, we've got some on the chart. Uh Is there some decreased density on the left as well? I'm so sorry. Was that the previous I've gone quite was that I'm sorry, she was that the which x-ray was that, was that the uh pleural effusion one or was that the uh tension pneumothorax x-ray? Sorry, I went ii missed your comment. In the meantime, is also able to um what condition causes um what we can see on the X ray right now? OK. Let see. OK. I'll let you guys know. So this is um an X ray from a patient with sarcoidosis. Um sarcoidosis is a condition that causes lar um bilateral hilar adenopathy. Um You've got some kind of diffuse retic nodule, parenchymal involvement as well. But you can see here bilaterally on this X ray. Um You've got this kind of um adenopathy picture um which you see from a patient with sarcoidosis. That's one of the X ray features um that you can use to pick up the condition next slide, please. So we go on to the next part of the algorithm. Um Don't worry, towards the end, you'll be able to piece everything together and it will take quicker. I just thought we'd go in a bit of detail with each of the different parts of the algorithm. Um So B stands for bones um particularly if there are any fractures. So any clavicle or rib fractures, um any sorts of deformities we think about the body wall um and any soft tissue outside the chest. So any sorts of um swellings or masses, but that's kind of outside the chest. Um So, on the next slide, um I've got another X ray um that you guys can see if you can interpret, go to the next slide if possible. So, if anyone's able to interpret this is quite an easy one. I'll give you a clue, look towards the right um side. Um Any anything going on with the bones over here? Ok. Yeah. OK. Mhm Sure. I will go back to your um question at the end as well. Um Well done. Mohamed. Yeah, a fractured clavicle. It's exactly that there's a right clavicle um shaft fracture that we can see over here and some isolated segmental displacement. Um And the important thing with fractures actually is to think about um pneumothorax. Um So we can see the l field markings um extend to the edge. Um So there's no findings compatible with pneumothorax on this X ray as well. So that's really important to think about as well. Um If we go to the um next, we can go to the next. So we've gone through the answer. Um So next part of C is the cardiac silhouette size. Um So essentially the, so this x-ray is kind of out lining the cardiac silhouette that you see on the X ray. Um And the key point here is um that should occupy no more than 50% of the thoracic width, but that will only applies for pa images and we'll discuss why in a second. Um And you can see that the border includes kind of the left ventricle and the right atrium as well as the atrial appendages. So you can, that's kind of nicely marked on this diagram here. Um And actually, the reason why the cardiac is important is because you could actually have reduced definition of the right heart border. Um when someone's got a pneumonia with a right middle lobe consolidation, for example, or you could have reduced definition of the left, left heart border um associated with some sort of lingual um consolidation. So you should be able to clearly see these heart borders and the left ventricle and the right atrium and the atrial appendages in a normal X ray. And there are other things that we can also see on the X ray that we'll talk about in detail um as we go along, including the aortic knuckle and the aortopulmonary window as well. Um So they have some important clinical context. So the aortic knuckle um is important um because actually reduced definition of the aortic knuckle, for example, um can occur in the context of some sort of aneurysm. So that's quite why it's important to be wary of these different parts um on the X ray. So if you go to the next slide, um as mentioned, um with the cardiac silhouette size, it just goes into a bit of um a bit more detail here. We know that it should be less than 50% of the greatest diameter of the rib rib cage. And we measure that from the inner portion of the ribs over here. And as I said, that only appears applies to pa chest films because the AP films exaggerate the heart size. So it's really important that you don't draw any conclusions about heart size from an AP film. And there are many reasons um why, for example, um heart might be enlarged in a patient, some conditions like valvular heart disease, cardiomyopathy, um or even a pericardial effusion or left ventricular hypertrophy. Um And if we go to the next slide, we'll discuss it in more detail about um AP versus pa view. So in simple terms, looking at the two images there, um pa the X rays pass from kind of posterior to anterior, whereas in AP the X rays pass from the anterior part, um the anterior of the patient to the posterior and ap projections are usually used in kind of sick patients who aren't able to maybe stand and they're essentially in bed. And you're kind of taking a portable X ray, for example. Um So in terms of an ap projection, the heart size is usually exaggerated because the heart is relatively kind of further from the detector. And also because the X ray beam is more kind of divergent as a source is nearer to the patient as you can see in the diagram. Um Whereas with pa projection, the apparent heart size is nearer to the real size, um because the heart itself is relatively nearer to the detector, but you get magni magnification of the heart is also minimized. Um because you've got a, a narrow beam produced by the increased distance between the source and the patient. Um as we can see by the diagrams over here, um it's kind of a little bit of a hard concept um to get your head round. But um I think the main things to remember, I don't think you'll ever get asked the reasons why it's just that ap be a bit cautious about interpreting the heart size in that particular film. Um Whereas pa A we can confidently make conclusions about the heart size. Um and whether there's any sorts of cardiomegaly and any conditions that are contributing to that. Yeah, I wouldn't get your head. Um II wouldn't be bogged down with the, the reasons behind it just make sure you remember those particular reasons. Um Those particular things go to the next slide. So we're um nicely making our way through. Um We get to D which is diaphragm. Um So the diaphragm should not be too flat. Um And again, it should not be too raised. Um It should be fairly symmetrical. Um But being obviously thinking about anatomy, the right is usually gonna be higher than the left because you've got the liver there. And on the left side, it's useful to look out for the gastric bubble, particularly when we're thinking about if an angio tube is in the correct place, you'll see the angio tube kind of um call towards the gastric bubble. And as you mentioned earlier by checking the carina and then we can be quite sure that it's in the correct place. And I mentioned um lateral X rays as well, that can be useful in terms of determining whether the diaphragms are raised or flat. Um So here we can see on the diagram on the left, you've got kind of your symmetrical diaphragms with the left, the right, slightly higher. And then you can see clearly on the right, a non symmetrical diaphragm and there's clearly some pathology over there. So if we go to the next slide, I've got another X ray, um if anyone's confident to write in the chart, what they think is going on there, focusing particularly on the d part of the algorithm and the dia the diaphragm. Um, there is some pathology there. Yes, Mira. That's correct. Well done pneumoperitoneum, well done. So, um the diaphragm, um it should really, in a normal X ray. It should really be in distinguishable from the underlying lobar um on an erect chest X ray. Um But if say free gas is present, um usually secondary to something like a bowel perforation, then air accumulates under the diaphragm and it basically causes it to lift and become visibly separated from the liver underneath. Um And if you see free gas under the diaphragm, then that's something as um an F one or F two, you should seek urgent senior review and usually they'll get further imaging, for example, a CT abdomen um just to elicit what the likely source is of the free gas because that can be a surgical emergency. And an erect chest X ray is a really useful investigation in patients with an acute abdomen, particularly because it can help us find things like um pneumoperitoneum. Um And that's always normal and it suggests some sort of perforated abdominal um fiscus like an ulcer, for example, um that could perforate an urgent surgical view. So if we go to the next slide, got the answer on there that Maram correctly answered Wam. And then another part of um d just I thought I'd mention is the costophrenic angles um because that's a really important place to look when you're interpreting an X ray. So the costophrenic angles are essentially formed by the dome of each hemi diaphragm and then your lateral chest wall and they like the heart borders should be clearly visible as this well defined acute angle. And when we've got lots of the cooper angles, it's called cooper blunt, blunting. And there's different things that can cause that. So you can get pleural effusions um that usually appear as kind of a white um I guess back sign, I guess, well, not ba side, but it appears as essentially a, a wiped out area on the X ray or I've got some examples as we go through and that can cause cost blunting or even some sort of consolidation. So even this X ray that I've got on here, you've got costophrenic blunting secondary to a pneumonia and you can see you've got a lot, a loss of that acute angle. Um And that's suggesting that there's some sort of consolidation in that area. Um So that's just something to be wary about. Um And look at making sure you look in those particular areas if you're struggling to find something on the x-ray and then if we move on to the next slide, so we move on to E um and E is essentially the next part in looking at equipment and effusion. So I mentioned to you that I would have a picture of a pleural effusion that you can see on the left side over here and you can see the meniscus which on the, on the left x-ray, on the right lobe, you can see a pleural effusion and you can see the meniscus over there which suggests that it's a pleural effusion. And we were talking about the densities. So it's kind of, it's wiped out and those are the kind of signs that you see of a pleural effusion. So x-rays, as I said, are really important in terms of interpreting whether also equipment is in a particular right place, as you mentioned, tubes and I'm currently on A I rotation. So I'm commonly having to interpret x-rays to ensure that a central venous line is in the right place. So if you look at the right x-ray, you can see that there's actually a central venous line and that is in the correct place. It should be essentially at the level of the carina. Um So a lot of the times you'll have to interpret these and make tell nurses. Yeah, they're safe to use. You can give um I guess electrolytes for whatever is needed. Um And then as we said, e ultrasounds for fusions that we discussed. Um It's also important to be wary is that sometimes with patients not to get confused in that there are various tubes and cables, particularly with it. Patients that kind of are covering the field of the X ray. And you just have to be wary of what different things are other things that you might come across um and the other things that you might see. So as I said, ECG cables, you might see some pacemakers that can appear on X rays as well. And they're like a radiopaque disc or an oval that you typically see in the infraclavicular region. And they'll be connected to pace pacemaker wires. So it would be useful as well just to familiarize yourself with x-rays with these foreign tubes in them CBC lines, NG tubes, pacemakers, even any artificial heart valves, they can appear as ring shaped structures on a chest X ray within the region of the heart as well, particularly in patients who've had aortic valve replacements. So familiarizing yourself with those will help you, I guess not be scared when you see things like that in the exam and wonder what they are and the next slide. So f stands for lung fields. Um So lung fields are essentially, now, you've kind of looked at everything around the X ray. Now you're looking at the actual lung fields. Um And typically, um with the lung fields, I usually divide, divide the zones into three on either side. Um Obviously, that doesn't correlate with the lung lobes because obviously one side has two hose, one side has three, but it's easy to divide the lungs into three zones and then you can work your way down um the X ray and look for any things, um particularly any masses, um any haziness um any consolidations that we've discussed. Um And it's kind of good to have fields at the end just to make sure that even though you might have come across pleural effusions or come across any consolidations, you're just having another quick check of the fields to make sure there's nothing you missed. For example, this mass over here and the field should be checked in ap and lateral views for the reason we discussed earlier that an X ray is a two D image. Um So you want to kind of make sure you're looking at all views to make sure you're not missing anything. Um So we go to the next slide, essentially what I discussed. So dividing each of the lungs into three zones and that they don't equate to the lobes, um You're making sure the markings are present throughout the rep repeating some of the things we spoke about before, such as presentations like pneumothorax, making sure the lung markings reach the edge of the fields and looking for any asymmetry. Although um some asymmetry can be normal. Um For example, because you've got things like the heart um which contribute to that. Um But with symmetry, I'll just say that some lung pathologies actually symmetrical changes in the lung fields and that can kind of make it a bit more difficult to recognize. So keeping that in mind, so something like pulmonary edema can cause a symmetrical picture. Um any increased airs spray shadowing and airspace shadowing is seen in patients who have kind of consolidations or malignant lesions. Um We've mentioned pneumothorax and so I just want to touch on the pleura as well. So the pleura are not usually visible in a healthy individual. And actually, if the pleura is visible and that indicates some sort of pathology and pleural thickening usually points to um something like a mesothelioma and that's something you can potentially see on x rays as well. So, it's good to familiarize yourself with some of the rare, um, pathologies as well cause they sometimes can come up in exams if you go to the next slide. Um, so we've got some examples here. Um, I can go through them. So we've got on the left x-ray, we've got a right sided pneumonia and as we sometimes you'll hear on the walls, I'll say the lower zones or like the mid lower zones. It just helps to, I guess, describe better where you see that consolidation in the right lung. Um, and then on the right x-ray, we've got a lung tumor that we can see, um, in the mid zone of the left lobe. Um, so that's why it's important to check the lung fields because there's a lot of pathology to find and then we're nearly there, we're coming towards the end. So we've got the next slide, uh, the great vessels. Um, I personally aren't, I'm not normally able to elicit that much of the great vessels when I look at chest x rays, but it's useful to just be aware of. Um So actually, you should be able to see um the superior vena cava, the inferior vena cava, the ascending aorta, the aortic um arch, pulmonary arteries and descending aorta um on an X ray. Um and they should be essentially in the right size and the right location, like I said, I've normally not been able to find these, but if you're able to find them and they have some relevance, we'll go on to the next slide. And we'll mention there are kind of two things that I think are important to be wary of with the great vessels. Just go to the next slide if possible. Thank you. So I'd mentioned earlier, um the aortic knuckle and aortic aortopulmonary window, I think they're two important parts to be wary of. Um So we can see from this x-ray, the aortic knuckle is located at the left lateral edge of the aorta um as it kind of arches back over the left main bronchus, um and an important pathology there. So if you've got reduced definition of the aortic knuckle, which you should be able to see quite clearly on a, in a healthy individual's x-ray that can occur, as I said in the context of aneurysm. So that's an important point to look for. And then you've also got something called the aortopulmonary window. And that's basically the green arrow which is a space located between the arch, the aorta and then the pulmonary arteries. And this space um is usually lost as a result of any sort of media sub or lymphadenopathy which occurs secondary to malignancies. So, those are two important parts I think from the, the great vessels just to be wary of um and the fact that pathology can occur there. So um come to the next slide if possible. Thank you. So, in terms of recap um of the ABCD E FG approach, it's quite thorough, but it means that you won't miss. Um if you go over this approach a couple of times and you can have the slides and you can go through the slides, it just means that you won't miss kind of common pathologies that you see in med school. I doubt you will be able, you will be asked to um look at some of the kind of nitty gritty things, but the common things like pleural effusions, pneumothorax, pneumonia and being able to tell the examiner exactly what zone the pneumonia is and describing it as a consolidation or describing something as edema versus an effusion and just being wary of these common pathologies and common findings would be fine with the X rays that you get presented to in medical school. But this algorithm helps make sure that you don't forget anything, you don't miss it. You think particularly when you're in a high stressful situation like an Ay and you want to just find the pathology and move on. So, a assessment, air and airway B bones and the body wall C we talked about the cardiac silhouette size and being weary that obviously in an AP film, the cardiac silhouettes going to appear a lot larger. So we can't make interpretations about things like cardiomegaly compared to a pa film or we can confidently infer if cardiomegaly is present diaphragm really important in terms of things like um pneumoperitoneum, pneumomediastinum and that there shouldn't be any air on to the diaphragm um equipment and effusions. So I think it is important maybe to look at some X rays with pacemakers in them NG tubes, CVC lines, valve replacements just so that you're aware of what these things are, the lung fields. And there's lots you can pick up there particularly consolidations or malignancies and then the great vessels particularly as we discussed the aortic knuckle and aortopulmonary window. Um So just to finish off, I've got an X ray just to try and um put that all together. Um By the way, should we just send out the feedback forms before everyone leaves and then do this last bit? Yeah. Yeah. Yeah, I should like to Yeah. Thank you. Yeah, we just, just to make sure. So everyone, if you could just fill in the feedback form, I'm just gonna send it out. It really helps us carry out this teaching. I was gonna say on the feedback because this is a series. Um if there's anything that you guys want teaching from, with regards to radiology and please put that in there. So if there's anything, if it's abdominal x rays or ct scans or anything in medical school, you're finding a bit difficult. Um even another section on chest x rays, let me know because I'm going to do a few teaching sessions on this. Thank you. Ok. Ok. Ok. Mhm. Six. Should I, should I continue or do I do I give them a bit of times we just wait like one or two minutes just so people fit it in and then otherwise you're gonna get like zero responses. Thank you. Um Don't know actually hard to find out how many responses we have. Mm OK. Yeah, we just wait like one or two more minutes and then probably continue and then there's not much left anyway. Yeah. Yeah. So I if you guys could, is there any way we can prove the teachings happened is if we get feedback. So it's really important um for us kind of thing. How many people are there? Yes, it 21 people. So there is quite a few people. Let me know if you have any issues filling in the feedback form or if you can't access it or anything. Uh I'm assuming everyone's able to fill it out, we'll just wait like one more minute and then we'll restart. Um ok. Should we just continue then hopefully fill it out. OK. So this is just a bit of a test. Obviously, it's a lot to take in, but just pretend that you're in a OSK scenario. Um And you've been presented this X ray. Um I'm not going to give any clinical background just because I think it would give it away. Um So just look at this X ray and try and use the ABCD E FG approach. And another tip is it's quite easy to just look at something and be like, oh, I found the diagnosis and just assume it's that. Um but I would go through the approach because it will help you find um kind of other things that you might have missed. Um And it just means that you makes you feel a bit more confident that you've gone through in a method, method, er, methodical way and you'll get kind of better marks from the OS the examiners because it shows that you really understand what you're looking for. So, yeah, give it a go. Um If anyone feels confident enough, you can write in the chart essentially an ABCD E FG approach. Um a short summary of the X ray, just a practice. Um But I would encourage doing that in your own time as well if you don't feel confident doing it today. Um Just to get in the swing of how to present x-rays, I'll give you a minute just to have a look at the X ray and try and work through the algorithm we discussed. Yeah. Are people able to unmute their mics and talk? Yeah, you should be able to. OK. Mm I'm assuming by the silence and the messages that people are able to unmute the mic? Mm Yes. OK. OK. Mhm. You. No, thank you. Mhm. OK. OK. Another like 20 seconds. OK. OK. OK. OK. I'll go for it. Um So I'll give it to you as an example. We'll go for it in terms of an A to G approach. If you're in an OS scenario, I won't go into it too deeply because obviously, you won't have as much time when the examiners are asking you a question. Um So I'm presenting with this x-ray. Um I'm going to use an A to G approach to analyze the x-ray if that's OK. Um And then I'll say, OK. So in a um so first of all, assessing the X ray, the first thing I want to do is there's no data. So I'm not able to confirm that I'm looking at the right patient's x-ray. Um And then thinking about the right Pneumonic. So there's good rotation, there's an equi distance between the clavicles and the vas spinus processes. Um there's good exposure and um I can essentially see, you know, fine marks in the long field are visible and in terms of air, I don't think at this point there's no air where it shouldn't be, but I'll look further when I get to air and look at the fields part and I'll move on to b so there's no fractures, no deformities um that I can see and then see, I look at the cardiac silhouette so I can't elicit there's no normally and the X ray of this AP or PA um but to me, this seems like um pa given the fact that it is a normal cardiac silhouette size. Um And if I'm assuming it's pa, I can confidently say that there's no things like cardiomegaly on the sex ray. Uh I'll move to the d the diaphragm. So the diaphragms are not too flat, they're fairly symmetrical. I'm not worried about things like pneumoperitoneum pedin. Um And in terms of e um in terms of effusions. So looking at at costophrenic angles, um there's nice acute angles of both of them can't see any sorts of pleural effusions that would collect there. In terms of equipment, I can't see that this patient has any ND tubes in CBC S pacemakers, aortic valve, things like that f for the lung fields. Um I can see that essentially on the right side, there's a right sided middle lobe consolidation. Um And I can also see, yeah, so that's kind of the main findings there. And then in terms of the great vessels, um I can see the aortic knuckle and the aortic pulmonary window um quite clearly on this x-ray, but there's nothing coming out there. So you can see that quite quickly, you're able to interpret the X ray and present it quite clearly to the examiner. Um And then logically you're able to work out what's kind of going on here. So the main finding here is a right sided middle lobe consolidation and usually you're given an answer to them. Um Oh Mohammed, well done. Um That's really, really good. I've just seen your answer. Um Sorry, I should have, I should have gone through your answer, but you've, you've tia nondeviated. Um Perfect. I didn't even mention the TIA in mine. Um Smooth Cor throughout hazy, right? Colic border, smooth diaphragm, no effusion, no equipment, right, lower zone pacification and the knuckle the window. Appreciate it. That's perfect. I'm really glad you've taken something away from this. That was really good. Um And thank you for volunteering to write your answer, but you can see that quite quickly. You can, even though this presentation was quite lengthy, you can give a nice explanation in a short period of time to examine it and then move on. Um So I would encourage you to go through these slides again. I'm happy to share them and just get to grips with using that A to G approach whenever you see an X ray just to help you pick up things. And like I said, it looks good to the examiners as well and it looks like you're confident and know what you're talking about and we'll go to the next slide we're done. Um So I just put some useful, there's the answer. Um But Mohammed did a very good job as well and he can see he's quite playing and correct in what he said. But like I said, I'm happy to share these slidess so you can just kind of go through it in your own time as well. Um So in the next slide, I'm just going to mention three really useful resources. I found when I was trying to get my head round x-rays, I'm going to highlight Radiology Masterclass because I found that one really useful, really easy explanations, particularly when I was getting my head around AP and PA X rays, they've got really good explanations there. Um This video and osmosis. Um if you copy and paste that link and put it into youtube, it kind of goes through the A to G approach. If you're a visual learner and you prefer to watch a video, it goes through essentially what we've discussed. It's like a seven minute video and you can watch that and it just basically brings together everything we've discussed. And then radio pia if you want to get yourself familiar with images, as I was saying, um looking at what pacemakers look like, looking what NG tubes and CBC S and things like that or different conditions and radioed has a whole library of images that you can familiarize yourself with. Um So thank you so much for listening. This is part of a series and we will be doing another radiology based talk. And like I said, if you put in the feedback, anything that you want me to teach you, I'm happy to prepare something based on that as well. Um But thank you for joining. Um and we'll send out the new, I guess the new one, the next teaching session out soon. Is that correct? Uh Yeah, we'll be doing one soon in a few weeks time. Ok, perfect. Thank you, Yvonne. Have a good evening. Thank you, everyone. And yeah, that was, that was a really good teaching session. Um How did you find it? I think, um, obviously the first one, there's a few, um, there's a few like hiccups here and there in terms of, I think, like you said, Google Slides, if I prepare the next one on Google slides, hopefully there won't be any issues and I feel so sorry. I feel bad for you. You've had to just click through because it's been, it's been all right. Yeah, I'm very surprised that the powerpoint didn't work, but it's good to see the Google slides, at least, at least, you know, the next time I'll just, I'll just, I'll just do it based on Google slides. Um, and then we won't have a problem again. But yeah, it's, um, I think it's a bit fast but I think it's the first one, you know, the first one you're trying to go through it and everything like that. But, um, yeah. No, I, I'm used to it now and we'll get ready for the next one. I think someone messaged me when I was on holiday though but someone messaged me. I don't know. His name. Is it, is it? Here we go. Yeah, that's it. He said that, um, some, what did he say? He said some uh yeah, touch base. We have an IR consultant and a few registrars keen on also delivering teaching too. I'm happy for them to do because the thing with me is basically for my application as in if you want to do radiology as well, you need like a national teaching um program which is essentially this and obviously at minimum two sessions, I'm happy to if I do a session and then if they want to, I'm happy they can teach us part of this as well. He said an IR consultant and a few registrars keen on delivering teaching too. So I guess after the second session, if they want to do something, they can jump on the series as well and deliver. Yeah. Yeah. So they're also doing something. They're doing another lecture on the 27th. One of them is um but yeah, as we said previously, you're welcome to do two and then leave. That's fine. They're doing like two or three as well. So in the end, we'll have five lectures. So, fairly decent series. Cool. I mean, because I was even thinking, like, also thinking, I don't know what there's on but also like abdominal xrays, there's a lot on abdominal xrays as well because I think in med school you either it's chest x rays or abdominal x rays, um, that you're kind of and ct scans, we don't get much. But I think maybe the radiology registrars and the consultants may be better placed. I don't mind doing one, but they may be better placed in that. Um Yeah, something that I think may be quite good is in a lot of a especially UK medical schools. Now they're becoming integrated so they will have imaging as part of an overlying case. So what you could do is you could show like a case and you could like orthopedics and then how the imaging relates to the orthopedics or like imaging and like neurology and how the imaging relates then to how you perform in a nos and what you're looking for in the clinical context. That would be quite good because like everyone does like chest x ray or abdominal x ray, but no one really ties it in with another speciality basically, which is no, that's actually a really, really good idea. I think I want to do that actually like different cases and because that's what you get in an AUS exactly what you said. You know, I remember my finally o like I had a sub hemorrhage, you know, the key things that you need to know in medical school, I think, called do that and then even constipation or, I don't know, regular sign and all that stuff. So that's actually really good. I think I might do that. Just basically cases through radiology, through cases. Yeah, I think I'll do that. And we said a day, didn't we? We said what day did I say to you? Eighth of November? No. Did it? Let me just double check. Uh, should we, by the way, stop going live? Oh, yeah. I don't know how, how to.