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To see that. Yeah, go for it. Perfect. Ok. So let's get started. So we'll be going through chest x ray interpretation, abdominal x rays and uh Msk x-ray interpretation. Msk is more going to be covered in my part two. And that's going to be focusing specifically on kind of MSK X rays that I think are more like likely to be asked by examiners and we'll try to cover specific ones like hand and wrist x-rays, shoulder x rays and preferably avoiding more of your niche x-rays that you're very unlikely to get. And if they did, then they would be very mean to give you them. Um But I might just give a quick kind of background to them. So things like your lumbar spine, x rays or your cervical spine, X rays are are very high sorry niche and not necessarily going to come up. But I would prefer just to at least mention them to you, but chest xx rays and abdominal x-rays is the focus today and I just want to go through it in a basic sense. So you can approach most x-rays with a good format. So chest x rays and this is kind of the same for a lot of x-rays. A lot of the things I'll say that you need to check. Um uh you should do for a lot of x rays, but some of these things are more specific to chest x rays. So first I wanna check your patient details and if they're not on the film, you tell the examiner, I'd like to check the patient details, like to check when the film was done. Always say that you'd like to compare it to a previous film is the most helpful thing you can do. Even when you're a practicing doctor that an X ray that you're looking at at that time may show a feature and you may think, oh, they have a new pneumonia or they have one thing or another, compare it to a previous film because about that previous film, you don't actually know what their baseline is and what their x-ray is meant to show and what's different. Um So that's always a really good indicator for you. Look to the type of chest X ray, x-rays, no chest X rays normally come in two types in effect. You have your AP and your pa A the only thing you really need to, to know with these, I add a mnemonic that I often like to use to remember uh the two types of film. OK. And I'll miss the difference an AP film, ok? And you'll have to pardon my language is cr ap. OK. It's a crap film. And I always remembered that with the AP at the end, simply because the patient often is lying down, they can't get the best inhalation and it's normally done for your more unwell patients that you can't really stand up to do the X ray. Um And as such, the film that you get, it's, it's all right, you can see bits of the lung but you don't get that best inhalation or effect that allows you to see the film completely. So there's certain things you can't comment on that. Well, when you're looking at an AP film and whereas your pa film is when they're normally well, and they can stand up and they can take good breaths and, and, and that another thing you want to look at is your adequacy of the film. So I always used a mnemonic called Ripe Mangos. OK. It's a bit of a random one, but it always worked for me and I'll go through that in detail and then interpretation, I always did it as an ABCD E because you are familiar with ABCD E kind of formats when you're doing acute management. So I like to keep it er, same ish for doing your X rays. So it's, it's easy to go from and then we'll go through kind of differentials and I'll, I'll do some like quick um kind of spot diagnoses with you guys. Same, here's your normal chest X ray. I want you all to have a good look at what normal looks like. So you're familiar with it. You can look at your lung field both. There, there's no gunk or any, er, increased opacification. Ok? And opacification just means white on a film. So there's no increased whiteness anywhere that I wouldn't want it to be in the center. You've got your, uh, kind of vertebral bodies from your spine. You also have part of your aorta that's coming up, um which is just next to it. It's that little like knuckle that you see just on the right side. I'll speak anatomically with the X ray on the left side of the chest. Ok. Um But that would be on your right when you're looking at it yourself, um just above where the heart is and you've got, obviously you can see your heart border that goes down to the diaphragm and then it's, you can just see it poking out just on the other side of the vertebral bodies on the right side of the x-ray. Uh And then you have your uh lung hilum, which all your branches, your kind of white lines that are sticking out kind of from both sides. Ok. So whenever you're looking at a chest X ray, and once you've done your patient details and said what type of film it is and all of that, then um you can go through your adequacy, I just want to go back because I've not got a slide on it, an AP film and a pa film. The best ways that you can tell is they'll normally be on most x-rays. There's a little two letter that stick out on the top right hand corner or top left hand corner in some trust that tells you whether it's an AP or a PA, if that's not there, then it's no normally up to you to do, uh, to work out which type of film it is the best way to tell which one it is, is an AP film. The heart is often looking more enlarged on it. That's mainly because of the direction in which the radiation has come in from. Ok. So it makes the heart look bigger. Um, but I wouldn't uh worry about kind of what type of film is if you can't tell, um, if they give you the information, great. But if they don't, then, you know, your focus should more be on trying to get the diagnosis, which is what I want you guys to, to focus on. So adequacy of an X ray. So this is something that really in the exam, in most cases, they'll want you to just quickly get to looking at actual abnormalities on X ray. So I would quickly er, say, er, kind of a spiel of after you've looked at it briefly to make sure it looks like a roughly good x-ray saying I've looked at the rotation in spirit effort, penetration, exposure and exposure to the film and these all look adequate. So I feel like this is an adequate x-ray. If something doesn't look quite right, then I would comment on it a bit more. And once you've seen enough X rays, you get quite good at it. So we'll start on the first one. So rotation. So I put it's equal, you wanna make sure that there's equal distance between the spinus processes and the clavicles. OK? Um If we go back to the previous X ray, so the normal chest X ray, OK, you can see your clavicles in the top part of the X ray, OK? They're, they're bone, they're the bones that come off from the top down to the middle part of the x-ray. And you can see both of them coming down and then you can see just in the center, you have these like little diverts, uh they're like oval shaped, OK? And that's your spine as process. You want to check to make sure that there's equal distance between one of the clavicles and the other clavicle. OK. So you want to make sure there's equal distance. And in fact, this is a good x-ray to show you what isn't necessarily the best rotation because you can see there's not co distance between that spinus process and the end of the right clavicle and the end of that left clavicle. So it is partially rotated the film. OK? But it's not very significant but it, there is some rotation there. OK? If it was normal, then you would expect that process to be right deadline in the center. OK. Then you want to look at your inspiratory effort. So if you can see the seventh anterior rib going through the diaphragm, OK. Or more of the ribs, then that's an adequately inspired er, film. OK. So whenever we ask patients, when we're doing the chest X ray, we ask them to take a really deep breath in to fill their lungs as we take the image when they haven't inspired quicker, quickly enough to ventilate their lungs. Before we take that x-ray, it might show there's not good iny effort and when that's the case, we don't see enough of the film. So if we go back to this, we can actually count down the number of ribs. So the ones that come over er on the top part, I don't know whether I can edit these slides. I'll just see whether I can cos it's better if I can draw on this. Uh, hold on. So I'll just, I'll just go ahead just because at least then you guys can see what I'm doing. Can, can Jack, can people see me drawing on? Perfect. OK. So this is a lot easier for me. So these here are your post posterior ribs, OK? And you can follow it down, follow it down, follow it down. And this here, this bit here is the anterior part of rib. So the anterior rib, OK? And you can see it, it kind of ends there. Yeah. So you want to count down the number of anterior ribs, you see, so we'll just rub that out because it's gonna block us counting down. Ok? So you can count them down. So they'll be 123456 and seven. So there's good inspiratory effort and you can see it's going to go down into the diaphragm there. So there's good inspiratory effort. OK. And then when we're looking at what we call penetration, OK. What this basically means is, is the film looking like a reasonably good color. OK? When an x-ray has the radiation that goes through, if there's too, um, if there's not, er, if there's too much penetration on a film, OK. Everything will look a bit too, er, white, OK. And if there's a lack of, er, penetration, then everything will look way too dark. Ok. Don't have to worry about it too much. OK. If you look at an X ray and th this is where the exam is quite important, they're not gonna give you a really bad film and that's going to be the test because otherwise it would be a waste of part of the station because then the only thing they're really getting you to do is comment on, er, radiological features. Normally when radiologists do their x-rays, if an X ray has not been done well enough, then they normally repeat it because we don't like those bad films coming to us to see. Otherwise it's a waste of an image. So very rarely will you get a bad film in practice? Which means it's very unlikely that they would like to give that to you as, as the station alone. So all you need to look on a, er, er, a film is if it looks relatively, ok. And you can see most a aspects of the lungs and you can see the, er, ribs demarcated well enough. Um, and you can see the spinus processes delineated well enough. If all those aspects are kind of being tipped, then you've got a decently er, good film in terms of penetration. OK? And then last thing to comment on is exposure. So for a film, when we're looking at exposure, we're just making sure that we can see all parts of the x-ray we'd want to see and this includes the top part of the lungs and the bottom part of the lungs. And that means you're costophrenic animals. And in fact, in this x-ray, which I've given you guys, there isn't the best exposure on the bottom part because I can't see the costophrenic angles. So I would say that the exposure is not adequate enough and I would need more, er, a wider image to actually see those. I think it's just how I've put the image into the slide, it's not giving me the bottom part, but I would want to see those. OK. A normal er, would just be that I would be able to see the cost of FIC. I wonder if I can pull this up. No. OK. So normally the cost of FIC can go, it should be a nice delineated dip hair and also a dip hair. OK? And I shouldn't see any white stuff building up here. It should be a nice kind of, er, darkish color and you might see a couple of white specks where the R VA line your airspaces are, but it shouldn't be white, like white it out at any point. Ok. And that's that. And then the last thing I comment on which is the um, the mangoes bit is markings, it's unlikely that they would give you this but how it used to be back in the old days, they don't really do this so much anymore because as, as doctors, we have to interpret the X rays ourselves. Now they would before put a red mark on a film kind of in the top corner like this. And that was to gain your attention to say there's something abnormal and often than not, it was usually to say there's something er, seriously abnormal, something that immediately needs your attention. So if there's, you know, a massive tension near my thorax or there's a um, giant tumor that's sitting somewhere something that needs your attention is quite urgent. Ok. So we'll go on to interpretation of an x-ray. So the A and your A two A is starting off with your airway. Ok. So when you're looking at your airway, you want to make sure that there's a nice kind of central trick here that's going down the hallway. Ok. So when we go to the normal x-ray, obviously, it's rotated. Ok. So it isn't great. But in an, in a uh an ideal x-ray, I would like to see that it's a nice trickier going all the way down. Ok. And no spinus process is in the center. I don't want to see it veering off to the side like this and I don't want to see it going off like that. If there is that happening, then it tells me that there's some kind of either force that's pushing it in this direction. So if it was going this way, it either tells me that there's something forcing it that way and that can be fluid that's building up here, it could be a tumor that's causing it to be pushed there or if it's not a, a volume increase on this side, then it's a volume loss on this side and it's going to the area of least pressure. So that can be if there's an airway collapse. Ok. So this whole airway has collapsed all of a sudden or there's a, um, um, sometimes you can have particular fibrotic kind of expiratory conditions that cause um this like tractional pull of the airway doesn't always happen very rare, but that can happen. A quick, a quick kind of like question for you all. Um Which way would a tia deviate an attention pneumothorax? OK. And you can put your comments for Jack and, and rsma to answer because that's a really important thing to uh to get. So you can put your guesses in the, in the comments. OK. So we've gone through the trachea. So you want to make sure that it's central, there's nothing deviating anywhere. You then want to look in your hilar regions and the hilar region shown quite nicely here is this point and this point. So that's your right hilar and that's your left hilar and the hilar is the, the other region is just the area of where you have all your pulmonary vasculature and your bronchi. OK. And it all situates around there, which is why it's quite whitish because it's got a lot of density around that area with uh big important vasculature structures. Isn't that important thing to note, your left hilum is often higher than your right. If the um, er right hilum is slightly higher than the left, then you know that there is something slightly wrong. Ok. It won't necessarily tell you that there's an immediate pathology, but it might tell you that there's something not quite right there. The other thing you can look at in your hilar regions is something uh or look for something called bilateral hilar lymphadenopathy. I'm sure you've all heard of that before BHL. There's a niche number of conditions that cause BHL. And I'll allow you guys to look at that in your own time. But it's things like sarcoidosis and uh certain malignancies can cause it. Ok. So after we've done a, so your airway, once you've assessed those things, you then want to go on to your b, which is breathing. Ok. And that'll be looking at your lung fields and basically assessing them kind of in thirds. So whenever we talk about the lungs, we like to call, uh, we like to refer to them as your zones. Ok. So you have your upper zone, your middle zone and your lower zone. Ok. Cos it's quite easy then to describe it, your lungs actually are separated into your lobes if you go back to your kind of anatomy from, uh, early in medical school. And, uh, you'll know that your right lung has, er, er, three lobes, correct me if I'm wrong. II might have actually misspoken there, but I'm pretty sure three lobes for your right and two for your left. Ok. So it would be a bit awkward then to kind of try and talk about that uh, in an exam because it's very difficult to delineate what is happening in your up, er, in your er, upper lung zone in your lower lung zone, cos sometimes if you have like a consolidation, so like a chest infection, it might be partially in the middle. So you don't know which side it is. That's why you prefer to call, uh talk about them in zones because it means that everything kind of matches, you can er describe it almost locationally, which is quite nice. So, on your normal chest X ray, I would kind of say that that's your upper zone, this is your middle zone and this is your lower zone and whatever's in these are, the zones is basically, you know how you describe it. So firstly, you want to make sure that your kind of airway, your um kind of air um uh I've lost the wording the um oh gosh, um your airways, that's, that's what I'm looking for. So the airways like your small kind of uh bronchioli and an alveoli. Basically, these are all what these like white little dots are kind of throughout the chest X ray scattered. Ok. You want to make sure that they go right up to the lung border and if you see that there's a, a bit where they don't go all the way to the edge. So it's the long edges you're looking for, then it can tell you that there's possibly like a pneumothorax. So air that's built up in between the er, or in, in effect air building up in the plural space. So outside the lung and that will be seen as kind of like a, a basically, it'll be, it'll be black as, that's just your air, air comes up as, er, as black on a film. Um, and your lung, er, airways won't go all the way to the edge. Another thing you want to look for is obviously any increased opacification. Never in, in an exam, say consolidation, respiratory consultants will hate it because you can never say that something is necessarily consolidation unless you're working with the diagnosis of pneumonia. So consolidation means that there's actually a uh focal infection there. So when um you were saying consolidation, you were immediately saying that there is an infection and you can't always say that with an X ray. So opacification is the better word to say because then you're being a bit more aware of other differentials in your kind of evaluation. So if you saw that there was a kind of increased whiteness here, you would say there's an increased opacification in the right lower lung zone and that's the best way to explain it. And then lastly, um you'll want to look at your claw. This is something that's quite niche. Um I've, I've taken it out, uh I've said shown in the next image, but um I don't think it's something that they would give you guys because it's, it's quite a niche thing to spot on X rays. And really poor thickening can be AAA aspect of things like asbestosis and unless you have a good history to back that up to look for something like that, um It's something that would be quite difficult to diagnose on an X ray. And regardless in those situations, if you were thinking an asbestosis diagnosis, you would be leading into doing something more higher, high resolution such as act. So here I have a different image. OK? Of something that everyone should just be able to see and then kind of say what they're sort of thinking. I'll give you a brief history. It's a patient who's come in. Er, a 46 year old male has been um II gave the answer away cos it's done that um has been feeling relatively short of breath. Um And he's come in to his GP and his GP was a bit concerned cos his oxygen sats were 91% and his respirate was elevated. What do you think could be the cause of this? Chest? X-? Obviously he's gone into A&E and he's had an X ray done. What's everyone put Jack? Why has everyone put their answers in? So some, so someone's put pleural effusion. OK. Um Anybody else wanna have a stab at this? So someone said some right, lower zone pacification. OK. I like it. You didn't fall into the, the pit, a pitfall of saying a consolidation good. Mhm. So we'll go with that. So we'll go cos I quite like those two because they're quite nice to delineate the difference between the two. OK. And I actually think that both could have some grounds. So looking at this X ray, you're quite right to say in the right lower lung zone, there is increased opacification. OK. And I would possibly argue that if uh if, if you look quite closely, there may be some blunting at the right claro angle. However, I can see that it does give me AAA delineation here. I can see the uh the bit that is, is meant to stick out. OK. So a pleura fusion, we look for a specific, like a delineated mark, like uh almost a board and say that's where the fluid is, that's where it finishes. OK. So even if there was some pleural fusion in it, er you could argue this, it's a very small one here because there's whiteness just blunting that angle. So yes, I'd say there maybe is possibly a light polar fusion, a very small one. However, it wouldn't explain all of this other stuff going on here. OK. This is more fluid or er kind of er some something kind of causing that increased density in the I vi don't wanna say fluid because that's a more suggesting that it's like a pulmonary edema, which it, it isn't, I will go through what pulmonary edema sort of looks like. So in this case, based off the history, OK, I would say the most likely differential in, in my in my case would be, this is something like a pneumonia. Ok. Person who's necessarily, er, er, not got a temperature. Ok. Doesn't mean that they don't have a pneumonia. And if someone who's kind of relatively middle aged comes in short of breath, high respiratory rate and they have like this increased, er, density in one part of their lung. Makes me think that this is likely something like AAA, I can, I can say in this case, possibly a consolidation. OK, a chest infection and this hair kind of delineates exactly where all this increased opacification is that you wouldn't want it to be. OK. So all this stuff here good. OK. If you have any questions, drop them in the chart and um or anything that doesn't make sense or, or you want me to go over and Jack can let me know. OK, so what does everyone think is going on here? This one's a bit harder and to be fair, you guys can't see it as clearly cos it's not as focused in what's everyone saying Jack? So we have um OK, so we have a question but I'll leave that. We have, we have pulmonary edema cardiomegaly, but be careful with the cardiomegaly question. Cos look, it's an ap remember that um bilateral pleural effusions can't see the hemi dye from the left clearly. OK. I'll roll with all that. I think all of those are really good er, comments and actual er observations. There. That's really good side in this film. OK. Quite rightly, I'm gonna go with the cardiomegaly point first because it's a really good one that the person's commented on. Yes, it is an AP film and it's very difficult to comment on something like cardiomegaly in an AP film because normally the heart is already enlarged. So whenever we talk about cardiomegaly, we're saying that the heart, the size is greater than 50% of the cardiothoracic ratio. That is the definition. So it would basically be if I drew a line from hair to hair is the heart borderline er sorry scrap. That is the heart borderline from there to here greater than 50% ok. However, I would still argue that the heart does look partially enlarged. So even on an AP film, I would comment, the heart does look enlarged, there could be a be a possible cardiomegaly. However, and this way you follow it up. However, it is difficult to comment on as this is an AP film right there. The examiner is kind of like they've made a really good evaluation and they've also said that they can't necessarily comment completely on that aspect because of the nature of the film shows that you're really good at, you know, going back to the basics of knowing what you can and can't comment on. So that's good. There is evidence of pulmonary edema, ok? And I'll say I'll explain why if you see increased whiteness so like specks all over, more so than you normally would if it just looks like there's, er, kind of increased opacification in aspects of the film like hair for. There's like, er, around these aspects that looks like increased opacification. Here, I can see there's more of a delineation of the upper lobe vessels. Here, I can say there's some, here, I can say there's some, this bit is your lung island but even here there is, it's extending further out all of these aspects. Uh showing me that there's extra er den, there's increased density in all these parts of the artery. There's very few things that can cause that. And if it's going on a context of there's a bit of cardiomegaly in the background, there's also bilateral pleural effusions which I can see here cos I can't see the costophrenic angle there and I can't see the costophrenic angle there. It makes my evaluation of this being pulmonary edema more likely. Ok. And the last thing that I'd like to comment on, you won't be able to see it that well. And this is where the examiners would have to give you better films. There were very little lines coming down here. The and yeah. Ok. Possibly that one's actually just part of the er, part of the vasculature. So I won't comment on that, but there is definitely a little tiny line going down there and down here and those have a very classic name to the, and I'm sure the name will stick out to all of you called curly bee lines. OK. And what curly bee lines are, are basically these um lines that have the term coined on a uh an X ray. But what they mean is you have fluid building up in between the space of your, of your um er lung lobes. OK. And that's fluid literally just building up in between. So it's fitting that kind of er criteria or the, the picture of a heart failure patient, if they've got all these other things like p edema, pleural effusions, a heart that's looking very big. And then they also have these small little lines coming off that, that's telling me that there's those curly bee lines. And the last thing that you'll occasionally hear some consultants talking about, which is, is something that I just wanted to discuss with you all is something called cation of um uh vessels. OK? And all this means when they say cephalisation, it sounds like a really complicated term. It's not when you're struggling to ventilate your lungs, your um body has this response where it, it, it diverts blood flow to the place where it's going to get oxygen best. OK? Your body's quite good at deciding, oh, this is going to be the best place to get it from. And so it decides to divert the blood up to the upper parts of the lungs and what it means from that is, it's diverting the cephalisation. It, it's diverting blood flow up to these vessels here. Ok. And it's going to go up to the top part of the lungs more so than you would get going down to the bottom. Ok. It still will go to the bottom but it decides, no, this is going to be the place where we get it better. And what that looks like is your blood vesser, your, your vessels on the picture will look more um er dense in the top part of the long hilum compared to the bottom in this film. That's not necessarily evident. I can't really say that, but in some films, you will see that you have lots of whiteness up here, more so than down here. You might see a bit of it here but it won't be as, as pronounced compared to here and there. You can comment, there's possibly this catheterization, but that's very er, kind of beyond the level of a an esky. And if you're simply in an esky, commenting on cardiomegaly, pleural of fusion, possible, um pulmonary edema are all features that I would say. Yeah, that students hit all the, the ticks that I would want them to. Ok. And then come to the conclusion of it's possibly like an acute heart failure or something or even just a, a chronic heart failure if you've compared it to a previous X ray film and this is already relatively known about. So, as we've said, uh, the 50% size, that's what you kind of go with, with heart size heart position again, kind of something that doesn't really happen all that much. But if there is a displacement of it and it, it's very pronounced, you can't comment on it. Heart borders very important when you're commenting on things like a, a pneumonia. Ok. If I can't see all the aspects of the heart border, like in this film, if I can't clearly delineate exactly where my heart, the heart border should be, if there's something obscuring it there, where I can't see that red line anymore and imagine that's the white line again, then that's some, that's something pathological. You don't get that on, on normal films. The aortic knob, OK? Is a particular anatomical structure that um you uh can sometimes comment on, it's very difficult to um properly kind of go into it in just the time that we have, but it can tell you things about whether there's an aortic dissection or um A AAA and sorry, not a AAA A. Um um Yeah, an aortic dissection as well as other features usually is just kind of like a dilatation aorta or something which is never good. Um And then something that er is, is very obvious if it, if it is apparent is something uh called like widening of the mediastinum, I'll have to see if um I can get a, a good image for you all for the next session. Cos I couldn't find one that was, did it real justice? Um in terms of er, mediastinal widening cos it's, it's a very easy thing to clearly spot. Um But that would be something that I can definitely show you guys in the next, next presentation. So this was another one which I just wanted to um kind of demonstrate what I was meaning before. This is a, a classic x-ray of again, acute heart failure. You can see your, your, the, the heart doesn't look good. You know, you've got all this uh increased opacification throughout all the lung zones. The heart looks enlarged. Um the the costophrenic angles look OK. So I wouldn't say there's any pleural effusions there. You have got curly bee lines that I can clearly see. Um And as well as that you also do have this cephalisation thing that I was talking about here. This is what I mean that's pointing up. You can clearly see that that's all going towards the top bit. And I can't really see that much going to the bottom, but like there's nothing there. And as you can see, there's all these features that I was telling you about. Oh, that's a different x-ray. Actually, I was going to say there is an apple of fusion on that one. Here, you actually have a pleura fusion in between the two lung lobes, the middle and the lower lung lobe on the, right, that's not the same, er, film. I just want to clarify that with everyone. So, uh they're, they're different but even in this one, it shows that there is some capitalization as they've, they've commented on um possibly in the mid zone, there's also quite a lot of increased classification there, but that's, that's expected with that. OK. So I have put uh a kind of quick thing about the Mediastinum here with the aortic knuckle and the what we call the aorto pulmonary window in effect if you lose this space in between it, it, it can be pathological. OK? Um Things that can cause that I put here medias style lymphadenopathy, but there's a lot of other things that can cause that and it's not something that you should necessarily say, you know, that's completely er you know, lymphadenopathy without thinking kind of your more serious things like if I lost that window and this mediastinum was looking wider, I would be thinking much more like an aortic dissection or aneurysm. OK. So sorry, we've gone through a which was for airway B for breathing C for your circulation, looking at your heart. D, we want to look at the diaphragm. So that's where you look at the um firstly, your costophrenic angles, make sure there's no blunting of them. If there is, it almost always means there's a pleural of fusion, you want to look for any flattening of the diaphragm. This is quite commonly associated with uh CO PD? Ok. Um What is happening there? Is your diaphragm is basically flattened, you'll see it very flat on the X ray. You won't see this nice concave shape to it. Ok. And it all it means is your lungs have got that hyper expansion to them, causing that diaphragm to be pushed out, flattening it. And that's what you see on the X ray. Yeah, you want to look for any air under the diaphragm, OK? If there's any air under the diaphragm, this can indicate one of two things OK? One is physiological and one is pathological. OK. When I say physiological, if it's on the, if it's on the right hand side that that's not normal, OK? You're always thinking mm. That could that likely is a pneumoperitoneum. OK? If it's on the left hand side, it can be one or two things, it can either be a gastric bubble. OK? Which all that means is when we image you, your stomach has a bit of gas in it. And as such, we can see that gas clearly on the thing, you know clearly on the film. OK? Or it can be a pneumoperitoneum. OK? And the way you tell the difference is one, you look at the thickness of the top white line. So this here is a pneumoperitoneum. OK. So you have a line here and you can see it, it's very, very fine. OK? And that fine line is the pa is the um er the peritoneum. OK. So it's, it's very easy to tell, but that's not the stomach cos the stomach has much more thickness to its line. That is more than like a thin, er th um a thin structure like a membranous structure. So, if I'm seeing air underneath there and that's the thickness of the line, I'm thinking that's more of a neop peritoneum. However, in this film, OK, we've got the same thing again. OK. We've got this air under the diaphragm. So, is it physiological? Is it pathological? Well, I would say that this actually looks a bit thicker. This is the thickness, it's a bit more chunkier. The other thing that uh kind of does indicate to me that it's likely more the stomach is usually, it looks more circular as well. Think of it as a bubble, a gastric bubble. OK? A pneumoperitoneum, you'll kind of just see it flattened like this up until the point. Whereas this has got more of a circular shape to it. So once you've gone through your D, which is for diaphragm, you then go for your e which is basically everything else. And normally this is just things that you're going to comment on. Like if there's anything very, very obvious that's sticking out on the x-ray. So this is like any chest, chest drains E CG leads, you can see pacemakers that are in, sometimes can see things like uh fractures on your, your ribs. Um And I'll go through um M sk x-rays and how to pick out a fracture. The, basically the way to do it quite easily. Um, but you can comment on rib fractures and then you can look at soft tissue stuff, but that's, you know, very unlikely to come up, I'd say in Uki, but it's good to always be prepared, I guess. Um, masses definitely could come up. You should be able to spot AAA mass on an X ray. But I'm more meaning things like your subcutaneous emphysema, that, that's quite a niche thing, but I've got an X ray here just to show you the classic sign of it. So if you have subcutaneous emphysema, what happens is your air, er a, a subcutaneous emphysema basically means you have air that's built up underneath your subcu fat. OK. And what that air does is it acts as a really good definer of features underneath it. So if you have muscle underneath, then it will show the really nice striations. Ok. Those lines that you see through muscle. If you remember anatomy, when you dissected anything, you have those nice er, defined like l um lines for a muscle, it would define all of those. So your pectoralis major and minor muscle on your chest X ray will be more highlighted and you get what we call the Ginkgo leaf sign. Basically the um coin from the, the Ginkgo leaf where you have all these lines that come up and it's like a, you know, it looks like a ginkgo leaf. Hey, you also have evidence of subcutaneous emphysema. It will look like. Um uh it would just look like almost sandy in a way where there's all these like whitish patches, but it's on the top part, it's not in the lungs. It's where all the, the skin would be. And the other thing is when you were examining these patients, if you examined them, and then you've done the X ray after you will find that their skin actually feels like what we would call bubble wrap. You'll, you'll feel it and you might even hear it crackling a bit and that's the air as you're, you're pressing on it basically, you know, making that noise underneath. Um So that's Js emphysema. Why is it important to comment on? Well, not necessarily for these, but it actually, no, I will, I will go with this if we put a chest drain in someone or we put any kind of um foreign instrument into a patient as part of an operation for whatever reason or they've had an operation on their, their thorax. OK. We've technically created an opening from inside to the outside environment. So all the air that's in the environment, it will go into the body. So all that air will basically sit there. So whenever you close that patient up, whatever you've done, whether you've put a chest drain in and you've sutured the skin back together or you've operated on them and you've stitched them together, all that air will still sit there. And so if you did an X ray, if they have any problems after, and you saw these features, likely it is this um, air that's, that's been left behind, your body eventually absorbs the air, but it takes a bit of time. So you might see the, this on an X ray and you can match it to the history, which is quite a cool thing that you, that you can do here. I just wanted to quickly show you um objects in kind of a heart context just so you know what these things look like when it, if it came to um A is they wanted a spot diagnosis. So this is what a loop recorder looks like, OK? This is what a permanent pacemaker looks like. OK? This is what an IC D looks like and this is what another type of IC D looks like. Loop recorder is quite easy to spot. And then there's always the difference between pacemaker and ICD. The way to quickly tell the difference between the two is if you see a white strip going all the way along pacemaker, OK? That's a pacemaker. If you see a single line very, very thin and you see a bit more like increased whiteness in one part. And then it's the thin line again, that's an ICD and that's the easy way to tell the difference between the two. Ok. Ok. This is, uh, I mean, when people initially see this they think, oh, what could this be? It looks a bit weird. It looks a bit fallen, match it with, uh, what you're seeing. I feel like I've j it's, it's cheated a bit for you cos it helps you out. Ok. I had one consultant before actually give me something like this where this, in this thing that you can see here was sitting right here in the lung and it just didn't look quiet, it looked foreign, but it looked artificial. Even with things like tumors, normally, you can see it relatively dark, demarcated, but at least there's like some discrepancy, it's got a nice linear shape to it. There's no divots, no change in the shape of it. And whenever you see something like that, it's normally artificial. It's normally something man made because stuff in your body doesn't come that way. So this is a defect pad. Ok. And you can see it's stuck on there. Um And the way it ha what helps is you also can see the attachment to the defib. Ok. So again, this can tell you quite a bit about the patient scenario cos you know that they might have actually needed something like CPR, if you know that the patient might need it, er, might have needed CPR, what kind of things are you wanting to look for, it's the one thing that we're going to be doing when we're giving them the CPR and you can put your, um, put what you, what you'll be looking for immediately and, and, er, Jack and ban can comment, but I'll come back to that, the one thing I want to say with all x-rays, which I didn't actually mention, um I'll just mention it here once you've gone through adequacy. Ok. So, so we'll just go back over just so we know what order. So patient details, date, type of x-ray, check the adequacy and then interpretation and your differential. OK. That follows, there's a bit here which I've, I guess I've missed out. But actually, it's the one thing that an examiner to be honest will probably want you to do, ok? If there's something very, very easy that they want you to immediately comment on so they can move you on in the station to get more marks and the only mark on that particular station is saying exactly what the problem is. Then why waste time going through all the interpretation that when you can get the thing, what they, that they want immediately. So this bit in the middle, I would say, is your go an opportunity to say, you know, after you've done the details and all of that looking at the film, the most obvious abnormality that I can see is and you can comment on it. So if they've got a massive tension pneumothorax, comment on it. Say it looking at the film, there appears to be a tension pneumothorax that I can see, but I would like to go through the slide er thoroughly by interpreting it, you know, systematically if they stop you. Ok. And say no, that's fine. I can move you on. Then the examiners heard exactly what they want to hear. OK. And you can save yourself some time if there's no obvious thing to comment on, then my next reverberation would be that I can't see anything obvious necessarily on the X ray to comment on. So I'm going to go through it systematic systematically and that's where you can go through it as, as we've gone through. So check the airway, check the, the B for breathing, check, C check D check A and if there's something which you like looks abnormal, but you don't quite know how to comment on it, then just describe what you're seeing that's still right. OK. If you're commenting on this one, for instance, the consolidation one, OK? Or the increased opacification and you don't quite know how to say what looks, not quite right, then comment on it, just say looking at the X ray, I can see there's some increased whiteness. You don't even need to be too medical, you know, but you can make your life a bit easier if, if you're struggling on the day, I can see there's some increased whiteness in the right lower part of the lung. Ok. Um, and this could be related to, um, you know, as the person said before, it could be, um, pleural fluid, it could be pulmonary edema. And if you say what they're wanting to, which is pneumonia, this likely could be a chest infection, then they'll be like, ok, that's fine. They've said what it likely is. They've said a couple of other ones that were higher up, but they've said the one which we were looking for and if you don't see the one looking for, then regardless, you still commented on something that looks abnormal that you've picked it up, which is still good. It's still something to be like II, I'm OK. I picked up what was abnormal? Ok, Jack, what's everyone put for the um uh question I asked before. So bony fractures being number one. Yeah. Brilliant. Ok. So everyone's spot on. So you're getting into the rhythm of things. So when you have the history, try and match it to the X ray, what am I going to be looking for? Based off what I am already seeing. So if I'm seeing that there's a pleural effusion, then when I'm at eight, which is going to be looking for any foreign bodies, I'll be looking possibly for a chest drain. Or if I'm seeing that there's some subcutaneous emphysema, then it might tell me that they already had a chest drain and they've had it recently taken out and the pleural fluid has reaccumulated. So everything has a pattern, everything kind of has a history to it and it's figuring out that path, that journey. Ok. Good. You everyone's making some really good comments. I'm I'm very impressed actually. Ok. So going on to abdominal x rays. Ok. So we've done chest x rays, abdominal x rays now. So same thing again, patient details, comment on the type of a uh abdominal x-ray. So a standard abdominal x-ray is normally an AP projection. OK. So the patient's normally in a supine position. Ok. So they're lying down on their back. Yeah, you can get more specific projections, but these are very rare and they're very unlikely to give you one of these in the exam. Ok. So the ones that you normally have seen are all what we, what would be classed as your ap projection and the patients lying on their back. Again, you normally want to comment on the adequacy and I like to keep things as they are if it works. So, same thing again, using your right mangos one. It's slightly different the, the rest er to the x er chest X ray one. But you can still comment on the exact same things, er just according to an abdominal x-ray, same thing again, I've missed it out here in the middle if you see something very obvious s state it if not interpret systematically or you would anyway. And then I like to use an analogy called Bob. OK. And you'll see why I quite like the analogy Bob and then give you differentials. So a normal abdominal X ray looks like this. OK. Where they've commented on all of your like different structures anatomically. OK. You would have to be very good at abdominal x rays to pick up every single organ and be able to see it. OK? Sometimes you can't always see every organ and that's fine. Just comment on the ones you can see. And if you can't see some and you want to comment on them and state, I can't see for instance, the right kidney or the left kidney and you know, just move on. Yeah, but there are ones that you should relatively be able to see on abdominal x ray, at least part of your small bowel and part of your large bowel. Ok. And those are the ones you most likely to be commenting on in these situations and vary sometimes like you think you of them and of course, you can see all your bones and everything, which is things that you can comment on to. So again, going through adequacy, keep things as they are. So the only thing we're missing out is your eye because I and the original one was for inspiratory effort. There's no thing called inspiration for an abdominal x-ray. So we just keep it as this. So r for rotation, the best way to assess this is do the does the pelvis look symmetrical? So going back, does this pelvis look like it's situated roughly in the right spot? And another good way to sort of tell is using his spine as processes cos these always should be in the center cos it's his spine. If I were to draw a line going all the way down, does it transect the pubic synthesis? And in this case, it does, I'm just really poor at drawing lines. OK. Penetration. So making sure that it doesn't look too white or too dark, simple as that. And then exposure for exposure, you should be at L you should at least be able to see the joint, the hip joint. OK. And up to the liver. OK. The top past the liver. OK. That would be my assessment of a good film. However, they do recommend that it should be up to the diaphragms but sometimes it's not always the case. But II would actually argue that technically, it's up to the diaphragms and further because there have been cases where in abdominal x-rays, it's very important to comment on. Are there any effusions which can be related to things like liver disease and kidney problems, which, which can be related to things like your trans and exudative effusions, which I'm not going to be going through, but it it can have its importance. So Bob, this is why I like the analogy, Bob because it kind of matches with abdomen. Ok. So Bob, I always used to think he was like kind of a gastro patient who has like problems as jaundice and also, you know, had a bit of bloating as well. I always just thought that kind of fit the context of necessarily why you might be doing an abdominal X ray. Ok. Bloating particularly and if they have like, you know your abdominal pain and stuff. So Bob, the specific kind of um, uh letters standing for your B for bowels. So you check your bowels, O for other organs and B for bones. OK. So b for the bowels, there's only two types of bowels. You can really comment on your small bowel and your large bowel. Ok? Small bowel is always in the center. Ok? Tummy. You have structures that we call valvulae convenes. OK? If you remember two anatomy, OK? Or just like kind of earlier middle school in general. Valvulae convenes are these lines that extend all the way across the, the tubing of that panel? Ok. So they might not show as well. No, no, they do, they do. So, here is the small bowel and you have a line that's going all the way along there, ok? And you can see another one that goes all the way along there, ok. So you see these lines coming all the way across and normally they're actually quite like close together. Ok? So that you can tell a small bowel, the other thing that helps me out is that it's roughly in the center, this kind of general vicinity is what your small bowel should, should be. Ok. So, and the other thing that they comment on is it should be less than three centimeters in diameter. Ok. You can't measure OK. In the actual exam. Yeah, because the X ray won't be the same size as what you get on the actual screen. Ok. So it's something that when we have these abdominal x rays, we can actually like draw a line using the, um, the computer, but you won't have access to that. So all I would say is when you're looking at them, if they're going to give you a small bowel obstruction or a large bowel obstruction, which is what would cause these diameters to be greater, then they're going to give you one, which is fairly obvious because they can't get you measuring. So instead they'll give you one which is definitely looking like a bowel obstruction. So whatever bowel it is will be looking very big compared to what it's normal is. So, commit to memory, this is what a roughly a small bowel should look like in size. And this is your large bowel, I'll go through why? That's what your large bowel should look roughly look in size of. So they didn't look too bad on this one. Ok. So your large bowel, ok, peripheral, as I said, so it's on the border OK, you have these structures called HAUSTRA. Ok. And the difference between these and the valve of entities, ok. The valve of entities were the ones that went all the way across your Haustra are the things that just stick out a bit. Ok. In a bowel. So if I was to draw what it would look like, there would just be these tiny lines that stick out like that. Ok. And in fact, er, it, it might be difficult to show you, there's one here, for instance that, that you can see so you can see that the bowel kind of it, it loops like this like that and you can see the divot there. So that divert that point here is going to be where one of these sticks out. Ok. And that's how you can tell whether it, it's large bowel or not in this case. Ok. And it's kind of one which sort of breaks the wall, but I can still say it's large bowel because it's on the periphery. So it's unlikely to be small. You've got a line that goes all the way across like that and that. Ok. So the wall isn't perfect. But, um, in most cases, you can tell whether these are, um, this large bowel or not, I would say this is still large bowel because I can actually see one here that just sticks out and it doesn't go all the way across. So that's how you can tell the difference between the two and then you have your diameters. So, diameters is what they love with. Um, abdominal x-rays, cos it tells you what shouldn't be the right, er, size. So, three centimeters, the cut off a small bowel, the large bowel, you only have two values, large bowel in general. Six centimeters. Ok. Cecum and sigmoid nine centimeters. Ok. So the cecum is the bit right at the start of the large bowel. OK. Which is where your ilium connects into, OK, which carries things up. OK. And your sigmoid colon is the bit that curls around. So, anatomically you have your cecum that sits, sits here, appendix. That's a divot here, ascending colon, transverse colon, descending colon, sigmoid colon here, rectum and anus. OK. And it's these two structures here that are the ones that you check to make sure the diagnosis is not over nine centimeters. Ok. So the 3691. So it's a good way to remember that you can look for gas in the bowel wall. Ok. Um, which can indicate ischemia. I'm just trying to reco it. So there's um, a picture that I did have from a year ago which did show it quite well, but I couldn't find it. So I will, I will see if I can find it for you guys, um, for the next session. Um, but it's one which I would actually like to have a bit more time to explain to you all because the rigorous sign and the gas in the bowel wall is often a really difficult one that people struggle to see. And I'd quite like to find a good one to show you, show you all. So you all know what it looks like. Ok. So those are the things that you'd be looking for about. So making sure that the size isn't greater than those, uh, amounts because that's the one thing that they're likely to throw at you guys because if it is, then you're looking at kind of your bowel obstruction, um, when you're looking for your bowel obstruction, the first thing is going to be, does the bowel look di dilated? Which if they're going to give you a bowel obstruction often will be and then the next part will be. Is there a specific point where a transition point we call it where it stops, um, where you can see things are stopping where the dilatation is happening. So, if I saw that the bowel was dilated all around here and then there was kind of like a, a part where it stopped because normally this builds up with feces which you can see or whatever it is, which builds up, that will be your transition point. Ok? If there is no transition point, there's one or two things, either you can't see it cos it's an abdominal X ray, ok? And you need act which these patients often do get. And that even sometimes can't pick up the transition point, but it's usually a bit better. The other thing it can be is an ileus, ok? Where there is no transition point, it's just the bowel has basically stopped working, it stopped moving things. And for that, your bowel will look distended. Ok? But you won't see any point where the bowels stopped working as such, like causing a blockage. It will be that the bowels just stopped working. Ok. So o is for your other organs. So you just look at your liver, your spleen, your kidneys, gallbladder, your cac muscle and your pancreas. Ok? The only one which I'd say is probably your, your, your three most important ones in this is your liver. Ok? Your kidney and your pancreas. Ok. So I'll just see whether I can actually find a good image of a chronic pancreatitis. Ok. So here we are. OK. So with chronic pancreatitis, OK? On an abdominal X ray, the one thing that you're basically trying to pick out is what we call these increased calcifications. So these white spots that you can see. And in fact, this one shows it really nicely because it's, it's going in the direction of the whole anatomy of the pancreas itself. It won't always appear like this. So this one's very nice. Ok. Often than not, it might be more subtle. So you might only see a couple of these spots. Ok. Increased white spots in the upper part of the abdominal X ray. Ok. It's up to you to, to make sure to look for them. So you don't forget to look, you have a good look and see. Is there any of them here? Ok. This one's probably a better one to show that. So, ignoring the, the one on the right hand side, cos that one actually is more clear even on that left hand side of the abdominal X ray, OK. Where there's, there's small spots that you can see that the, the arrow is pointing to very fine, but you actually can see them if you look hard enough. So that's what I would want to be looking for for chronic pancreatitis. Ok? For your acute pancreatitis, you don't get these calcifications, OK? That's a feature of chronic pancreatitis. Ok? Acute pancreatitis. You might see features of complications of it, but we normally go for act for acute pancreatitis. Um But your complications of pancreatitis can be things like a pseudocyst or um you can develop um necrosis, but that won't necessarily show on an X ray. But with pancreatitis, you can get things like fluid extravasation into your peritoneal space. And as such, you might see fluid accumulating in different spots of the abdomen. Um But again, CT has got done in those kind of patients because it's a lot better for picking that up your liver. Your uh the things that you're most likely to be spotting is um masses or cysts and those. Again, those will just look like fixed um uh demarcated er, lesions. Ok. They'll be fairly easy to spot. Ok. And then the last thing is your kidney. Ok. When I say kidney, the one thing that you can pick up fairly well on an abdominal X ray if it fits the criteria of it, because again, I I'm not going to go into detail with it, but it, it, it depends on the type of, of, of it is kidney stones. So if a kidney stone is one that's um uh radiolucent on an abdominal, on an X ray, then you'll see it. Ok. But that very much depends on what type of kidney stone it is because you can get ones that are calcium phosphate, uh related to calcium oxalate a lot of different ones. Um things like uh strew struvite stones as well. And all of these either have radiolucence or radio opacity on an X ray. So either they show or they don't show, sorry, II said radiolucent before radio opacity. Um if they show up on the X ray and for those, they will look like a stone. So you'll look for the parts where the, the kidney would be and the ureter would be coming down. So if I uh just show you now don't X ray kidney stone, I'm hoping that it'll er, show me a fairly good one. See again, the CT shows it a lot better. It, it's showed it very well cos it's a white whitish there. That's fine with me. Here we are. So that shows a very nice slave. So you can see a little, little white spot right there. And that is exactly where you're thinking, oh, they have a stone there. It is actually fairly common and I have seen it before where you will actually see something like that on your abdominal X ray. Ok? And you will think that they have a kidney stone but they are not symptomatic. Ok. That isn't, that doesn't mean that we necessarily um, uh, worry as such about that because it can be that you're just a patient who has a kidney stone. Um, and you're passing it, but you're not symptomatic with it. People can actually pass them and not even be aware and they can have them and they're not even aware. So it's not always something that they actually are symptomatic with. They usually are. And, um, that's just, but it's something that kind of just to quickly look at. So look where your uterus is likely to be, which is just next to your vertebral bodies. Um, and work your way down to where your bladder would be. And in general, that's where your stones normally get trapped. And it is actually in that classic position that we expect, which is where the ureter um uh it, it um passes under. Um, oh, I can't remember the anatomy. I'm, I'm sorry about that. But it's in the classic position where we see kidney stones often get trapped because it's a point of passage where they often do get trapped because of the anatomy of the ureter at that point. So those would be the things that kind of you look at. So when I would be going through this, I would look at the liver, see if you can see the spleen, often you can't look at the kidneys and the often you can't even see the kidneys, but look to see if there's anything sticking out where they would naturally be and look at the ureters as well, where they would naturally be. Is there any abnormalities there gallbladder where you'd also be looking at your liver? So shadow if you want is normally something that you can't look at that well, on abdominal x vein and your pancreas look for any chron chronic pancreatitis. Oh I'm sorry about that. So then for B for bones, OK. So you'll look at your hips. So your hips are a really good place to actually check the um uh structure of your bone, your bone kind of structure in general. Um You can look for things like Paget's disease, any Mets. So lytic and sclerotic, OK. Lytic meaning they were eroding the bone sclerotic, meaning that increasing the density on the film. So the increasing density at that place osteoarthritis, you get an abbreviation, it's the abbreviation of the X ray features er called loss and I'll quickly go through that and then you can look at things like vertebral fractures if you want as well. But again, very difficult to evaluate it on an abdominal X ray. So for osteoarthritis, you can look for loss. So l for being loss of joint space, o for osteophytes, which are like bony prominences sticking out from the bone. Ok. It's, it's bony outgrowths and effect subchondral sclerosis. And what subchondral sclerosis means is uh at least on the abdominal X ray. What it, what it looks like is you get increased opacification, this increased whiteness at the rim of where the uh the hip joint is. Ok. That's what it looks like. So you can see here, that's your subchondral sclerosis, OK? Where it looks, there's that increased whiteness, ok? That it doesn't look quite, quite right? And then you also can look for subchondral cysts which are cysts um uh in, in the um er at the joint at the joint. So here you can't see uh kind of uh I mean, you can argue that there may be a subchondral cyst here. Um and maybe here, but there's no uh very, very obvious ones. There's, there's a lot nicer ones that, that II can show here. So here you can clearly see two well, easily defined cysts. So that, well demarcated, there's a loss of density in the center, OK? And they're next to the joint. OK? And then here you have your osteophytes. So, these are your bony outgrowths that stick out from the, uh, the bone here. Again, you've got the marked sclerosis, ok. Um, that increased whiteness that I was talking about. This was one which I wanted to, um, kind of quickly go through with you guys. Cos it's a really easy spot diagnosis, one they can give you, so tell them the difference between er, the two types of valvular that you can have in patients. So a sigmoid volvulus is involving your sigmoid colon and a volvulus is where it basically twists on itself. Ok. And why these are dangerous is it obviously can cause an obstruction where things are backing up, but it also can make the bowel very ischemic. So these have to be treated fairly quickly. Ok? So your sigmoid volvulus, you get this plastic sign called the coffee bean sign and you can clearly see it looks like a coffee bean, OK? They call it that for a reason and you'll see called volvulus is what we call the fetal appearance sign. So it basically looks like a, a fetus and embryo. OK. So you can see in effect, this is what would be the head, OK? The arm, OK. And then the body, OK. And that's why they call it that fetal appearance sign. OK. So these are kind of the features of your sequel and, and sigmoid volvulus, OK? Your sigmoid is more common, OK? And often it's associated with particular conditions. OK. The associations that like your Parkinson's MS schizophrenia. So basically any neurological or psychiatric conditions normally get associated with sigmoid ovular. The evidence behind that. Ok. And I won't go into it in too much detail, is basically due to the dopamine uh dopaminergic effect of these conditions. And that will have an intern effect on your bowel because your bowel is dependent on dopamine receptors to be moving things along. That's why you give you avoid things like metoclopramide in your bowel obstruction because it's a, it works on your dopamine receptors and it can make a bowel obstruction worse. Um, but I won't go into that in too much detail just, just because of uh shortness of time. Here, we have a toxic echo. I can actually see that I've included my er vigor site and vigorous trial site. I'm glad I actually er ha had it. So that's fine. I'll go through that. So the toxic megacolon, ok? Is something that a lot of people confuse or use without understanding what it actually means. The definition. So toxic megacolon. Ok? Is if you have an inflammatory bowel disease or an infectious element and you have evidence of colonic dilatation and systemic toxicity. Ok. So you have to have all those features for it to be a toxic mega colon. Ok. So if they come in and you're thinking it's infectious related or Crohn's background, ulcerative background, any of those, you have an abdominal X ray showing palliation. And I would say this is a validation and II don't even need to measure, I can say, without a shadow of a doubt that is over six centimeters. It, it looks dilatated on top of that because the bowel is so dilatated, it's actually wrapped o it's, it's caused pressure effects, meaning it's shifting into these abnormal anatomical positions. It normally doesn't like to hold because the pressure is so great, it's like twisting in a way it doesn't like. Um So you have evidence of chronic dilatation. And that also can be if the uh patient is um has bowel distension and peritonitic, all these features because that indicates it's bowel obstruction likely and they have systemic toxicity. Ok? And when we say systemic to toxicity, that is any element of BP change, heart rate change temperature. Anything that basically means that uh looking like a sepsis picture. Ok. But in the context of this, OK. Um Because this is what is making them, well, they have a inflammatory or infectious uh element to their bowel obstruction that is causing them to be very unwell. OK. And likely these patients are septic on top of it, which causes them to have that systemic toxicity. Ok? And lastly, we'll just quickly go over A R sign and I won't go over a Rigler triad because it's not something you really see in abdominal x rays at CT S that you pick it up with. Um But you can have a look to see the definition if you're interested. So, Rigler sign, OK? Is basically where you see bowel on bowel. OK. What that's what it's referring to. OK. And what is happening is if you have a, a perforation, OK. So a an organ that's perforated in your tummy and that's allowing air to seep out into the tummy. You will have firstly a pneumoperitoneum, OK? And the dome sign shows that you have air which is building up under that diaphragm that you can clearly see. And as I said earlier, you can have the, the right part of the diaphragm where you can see air and that's almost always abnormal. If you see it under the left, you have a bit more of a decision, but that because it's on both sides and it, it, it, it doesn't look right. You can tell that it's, it's a perforation, it's a fairly obvious one, ok. The rig sign, this bowel on bowel is basically where you see the bowel wall of one of the, the parts of the bowel. And then you see the bowel wall coming over on the other side. Ok. So it's like they're crossing over, they're transecting each other. So here is a good example. OK. So I will draw the line of one bowel. OK? So that's one. OK? So there's your bowel there of 11 part and then you have some bowel coming over here and over here for instance, you have some bowel going over that. Oh, and then you have some bowel coming over here. So, in all, in all you have bowel that's crossing over on each other. Ok. So that's your vig sign. What they also refer to is often you sometimes see, er, like this, like two layer structure, it looks too thick and that's like the bowel almost crossing over on each other. Ok. And the, the air is delineating all the bowel on, er, inside the tummy. And as such, you're seeing all of it kind of crossing over on each other and that's your vigorous sign, the other, um, one which I commented on and II might actually be able to comment it on this one, your rig sign, but also your, um, I'll just go back to, to show you all, um, just so, you know, the, the bowel wall, the ischemia, the gas in the bowel wall. Ok. So this is the other thing that you can look for, ok, if you're looking at the border of the bowel. Ok. So I'll use this one for an example or actually, let's see if we can find a better one. I might actually be able to use her. OK? You might not all be able to see this, ok. And it's probably easier if you're able to actually see the X ray. But if you can, then, then that, that's good. OK? Is if you see any black spots kind of in between the layers of the bowel wall, then it's likely an indication of ischemia. Ok. Where in effect the bowel wall is basically becoming necrotic and when it becomes necrotic, the, the organisms that live inside the bowel, they produce gasses. Ok. Um, er, because of the, the response and in effect, that air basically will accumulate in the bowel and it will also accumulate in the wall itself. And it's often where you can see the white line of the bowel. But then you sometimes can see these like black spots in between it and it's never really a good sign. This, this might be a better one to show you here. Oh, let me just draw that again. Hit it if I actually don't draw it as well. This bit here the, where you see first a bit of a white line and then you see some, a dark spot there and then you see a white line again, this might actually be the stomach. Ok. But it's, it's hard to say with the kind of bowel causing this bowel on bowel appearance. But if this is bowel wall, then you can see there is some, uh there is an in er, a decreased density in that wall which could indicate that there's some gas in between the bowel. All these features are features that if you can spot on an abdominal x-ray, that's brilliant. If you can't see an abdominal X ray, that's why it was, that's why CT S were made cos they're far easier to see these features, but they're things that you can look for. So that's kind of your chest x rays and abdominal x-rays as an examiner, what they would hope for you to do. OK. Is, can you systematically uh can you first do the basics? Say the patient details, say the Tyer um say that you would compared to a previous film. Can you, you know, spot us? It's an A you or APA if you can't, you can't say that the adequacy looks at all, even if you just comment on it and say, I think the adequacy is fine looking at the rotation, penetration exposure, they all look adequate. Can you spot a, a clear cut diagnosis right off the bat? If you can't, then can you at least show a systematic approach to what you're doing? And if you can do that, then you'll be fairly, you'll be doing very well. OK, on that particular part of the station because then you're being systematic and you're trying to make sure that you don't miss anything. OK. So even in abdominal X ray, if I was looking at the battle, so the first B I would be looking at the all the different quadrants of your bowel. OK. So even as you like, examine someone, if I just go up, I would go by, you know, looking at your right upper quadrant, top part left part, middle, middle, middle, lower, middle, lower and looking at the bowels and these, OK. And then looking at your organs and saying, I can't see the liver so well. So I can't comment on it. I can't see the spleen so well. So I can't comment on that. Looking to see if there's any increased cal like any calcification in, in um indicating chronic pancreatitis. There's no evidence of that. I can't see the kidneys so well. So I can't comment there and even if you're saying that you can't comment, at least you're saying that you're looking for them. You're looking, I mean, I can actually see that the left kidney is there. Um So I can see the left kidney partially but not too well. So it's difficult to comment on. Um If you're doing all that, then it's showing that you're being systematic, which is, is you're, you're very unlikely to miss something doing it that way. Ok. But um does anyone have any questions at all or anything that you wanted me to go over again? Thanks for coming guys. I've just bought the feedback form on the chart. If you could fill it in, that would be great. Um And we'll be, uh we'll be doing E CG interpretation next week. Um Same time and following that, we'll continue with the um ex um yeah. X interpretations. Was there a question? What is the left lower black space above the diaphragm? I do. Um I'll just quickly go back. I think that was, I think that was solved. Oh, did, have they gone through that? Sorry guys, I can't, I don't see the comments what I'm presenting. So there's no questions. Ok? If there's any kind of questions outside of what's been answered, that you want me to go over, just pop them in the chat and I'll go over anyone, any questions, right? If no one, if no one has any more questions, we'll stop, uh, live broad. Um, we're gonna stop the live broadcast. Yeah. Thanks for coming. See you next week.