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Yeah. Mhm. Should we make a stop? Sure thing. So, um, hi, everybody. Um, my name is Izzy. I'm one of the FT S currently at Durham Hospital up in the northeast. Um, and I'm here this evening to have a little chat with you about radiology. Um, from what I understand, you're all final a medical students. Um, so I'm gonna try and aim this, um, a little bit higher. Um, and kind of assume that you have a little bit of knowledge already about some of the stuff I'm chatting about. But if you've got any questions, just put them in the chat, um, and I can answer them as I go along, there's an absolute bucket of stuff that I'm going to cover, um, this evening. So it's gonna be really fast paced. Um, so just prepare yourselves. Um, but, you know, if you, if it gets too much just, you know, take a step out. Um, and you can always come back and send some questions later on if you've got any, um, anything that's popped up. Um, so as I said, I'm Izzy, I work in Durham. Um, I've done jobs in respiratory. Um, Jerry's general surgery. I'm currently working in Gastro, so I see a lot of chest x rays, a lot of ABDO X rays, um and radiology is one of the areas that I'm really interested in. Um I love a good scan. Um And I think it's really important um kind of clinically to have a really good understanding of scans and actually like what constitutes them as opposed to just pattern recognition. Um So this presentation is going to be really picture heavy. Um And I apologize for that, hopefully, they're all good quality images that you can actually see. Um So let's get going. So these are kind of the aims and the things that I hope to cover this evening, I appreciate. There's a lot of stuff here. Um And I actually took this from last year's talk and the stuff that they covered last year um to get a bit of a framework for you. And this has come from the um radiology curriculum um from the Royal College of Radiologists from a couple of years back. Um And there's a lot of things there. My knowledge is mostly in the chest and Abdo stuff. I have thrown the neuro things in and I'll really briefly cover those just to, to pick up the big red flags in that area. Um But mainly Chest and Abdo. Um it would be really helpful if someone could put a little message in the chat and just tell me if you can see my cursor co this is gonna be a really bad presentation if you can't see the cursor. Um So someone just let me know. Um So I'm gonna structure it the same as the outcomes. Um So I'm gonna cover the chest up first, a little bit of an approach to chest X rays, colon presentations and some cases. Um And then we'll cover kind of abdo presentations and neuro presentations um as well. And then at the end, there's some time for questions and scatter through as well. Just feel free to drop um comments into the chat if you um if you want to. Um again, if there's any issues like audio, if you can't see the mouse and stuff on the screen, please, then let me know now and I can try and fix it. So chest X rays, um this was really basic things like, oh, you can't see the mouse. Oh, no. Ok. I might see if that's something I can fix um in a second. Then give me one sec. Let me see if I can do it through sharing a tab. Maybe let's see if that works well. It probably weren't like so bear with me one second. You guys still can't see the CSA, right? I see that you can't, that might be a bit of an issue. Why don't we? I'll give it a second and if it becomes a real problem, um I'll, I'll try and fix it in a sec, but for now, um chest x rays. So patient details, you'll all know this already. I'm just covering stuff that's, that's kind of basics, but you need to know the patient details. You need to look at um kind of the quality of the image. Apparently there's a um acronym for this now which is ripe. Um So you're looking at rotation looking to see if the collarbones are equidistant, looking to see if there's any um kind of obvious overlap with the ribs and things and kind of sometimes you can get some misplacement of the heart if patients are really rotated, um looking for inspiration, checking the number of ribs that you can see um and making sure that you've got a really good quality film you can see inside the lungs, um projection, whether it be AP or pa for a chest X ray and exposure, kind of the contrast of the image that you can see in front of you, then you can start to actually interpret the X ray. So here's another little acronym here um for how you can go about that, everyone does it differently. And I will admit, II don't use this approach personally, but this is um something that I see a lot and I think it's probably useful if you don't um see a lot of x-rays. So starting with a being a massive abnormality um and moving on to airway looking at your trachea. Um kind of the bronchi um and breathing, looking at the lungs, the lung markings, um looking for collapses, effusions, things like that. Cardiac being heart borders and the aortic knuckle, the size of the heart, depending on the projection of the film. Um Looking at the diaphragm for d so looking for raised hemidiaphragms, looking for pneumoperitoneum and things like that and then everything else, which I assume for this um would mean things like bones, um, artifact, stuff like that. So if we quickly go through some basic anatomy, it might be helpful if you um aren't particularly confident with chest X ray anatomy. So just take a picture of this now because I'm going to be referring back to this a lot. Um So the smaller picture is referring to the different zones. Um And the bigger picture is looking at um the basic anatomy, as I just said. So if you want to take a picture, take it now, um because I'm going to be assuming that, you know, this. So the most common presentation by far that I see on the chest X ray is L RTI S or pneumonias. Um So you can see the top left picture is a right base pneumonia. I think this is where I'm really gonna need to be able to um to see the, the do. So I wonder if I can do this, share my chrome T and share this. I'm not sure if this is gonna be very helpful for anyone. Let me see if I can work it out. I'm sorry, I know I'm far too young to be this rubbish, um, at technology, but on this page you should now be seeing a picture that doesn't say L RT is in pneumonia and hopefully you can see the mouse. I'm just gonna pop back to the chat and see if you can actually see that. Anybody. Can you see the cursor pretty please? Yay. Ok. Awesome. Fantastic. And can you still see it now? Please say yes, I'm gonna be really sad if you can't still see it. Oh, no. Ok. That's ok. I'll um I'll go back to here and hopefully you can still see it. So um someone speak up if you're not on the L RTI pneumonia page because I can't see the chat anymore. Ok. Um So L RTI S pneumonias, here's a right basal consolidation. Um Here's a left basal consolidation, here's another right basal consolidation. Um And with new areas, there is a little bit of kind of passing recognition and the more of them you see, the more you you'll get to seeing them. Hopefully the page has now changed to Air Broncho Grams. Please shout at me if, if it hasn't. Um So Air Bronchogram are really useful for determining if something's consolidation or fluid or some other kind of pathology. So you can kind of see here um where the kind of gray is remaining around the blue, um kind of inside the blue. That's where um there's areas of tissue that aren't infected and the air is still getting into them. And so they appear less dense to us on the X ray where black and gray is less dense and white is more dense. So air bronchogram are a good way of checking for consolidation, particularly from kind of infective changes. Um These are just more L RT S and pneumonias. So here's another kind of right middle zone pneumonia. Here's another right middle zone pneumonia just to kind of show you the difference between exposure and the patient's habitus. Um and how they can kind of present differently, but you're looking for the same features, kind of air bronchogram, a lack of defined edge and kind of normally asymmetry between the two lungs. And if you kind of lean back and squint, you can see that there's kind of they're not symmetrical and there's color differences on either side. Um On this one, you've got a bit of a left basal pneumonia. Um, you can still see kind of the, the diaphragm here just about. Um, and on this one, you've got a bit more of an interstitial pneumonia. So just to show you that although they do present kind of frequently looking the same, it can look a bit more diffuse like this. Um, and this is kind of more of like a right basal pneumonia with some kind of interstitial consolidation as well. Bronchiectasis is something that um to be honest, I don't see very often on chest X rays, but I think it's important to have a look at um to compare between consolidation um and like an L RTI and know the difference when you, when you're interpreting the films. So bronchiectasis to me looks a little bit like a spider's dropped itself in white ink and has just gone absolutely nuts over the X ray. Um kind of more dense in the center um and kind of more sparse as you move out. So if you look at and what I find really helpful um particularly when I'm looking at images is if I look at a CT scan that goes alongside that chest X ray. So again with um CT scans and the chest X rays black is less dense. So is air and white is more dense. So bone tissue or contrast depending on what type of CT scan you're doing. So, on the left hand side, we can see a bronchiectasis X ray and a bronchiectasis CT scan. And we can see the pathophysiology there of kind of the um thickening mucus walls, the thickening um airways and it kind of looks like honeycombing or something that I think from the number of reports I read is called honeycombing. We can see how these patients who have low saturations because of the sheer um size of the wall that the oxygen has to penetrate to be able to get into the blood vessels. In contrast, we have something like a pneumonia on the right hand side. So again, we can see how these two things differ on a chest X ray just by putting them side by side. And we can see here a ct scan of a pneumonia and you can see how it's more diffuse, it's a bit more claggy. And you can see again how, how it differs from things like bronchiectasis. A caveat that this actually isn't a pneumonia. This is a COVID pneumonitis, but you know, similar things. Here's just more L RT S pneumonias. To be honest, I just trying to get you used to seeing them and getting used to kind of the pattern recognition a little bit of them. So here again, a nice right basal consolidation, another right, basal consolidation but not that bad. Here's a really nasty multilobe pneumonia. So you've got some right, lower, right middle zone touching into actually the right upper zone and some left lower um consolidation as well. So this is going to be a very unwell patient probably. Um I'd be very worried if I saw this chest X ray clinically at the bottom of the slide, I've given you um some kind of atypical pneumonias. So here's a fungal pneumonia. Um it still kind of very much fits the categories of the others. So it's got these diffuse edges and we can still just about see the diaphragm um There's, I think you could argue there's a good uh bronchogram here. I can trace the, the, the bronchi bronchus um kind of thrip. And then here's a pneumo pneumonia. So again, looking a bit more interstitial, a bit similar to this one actually. Um but again, we've got this kind of consolidation with these hazy edges and this one's an aspergillosis um infection. So really nasty, cloudy fluffy looking um infection. I wouldn't expect anyone to look at this X ray and say that's aspergillosis. Um even, you know, consultants and doctors wouldn't be able to do that, but I do need you to be able to look at it and say that's not right and it's probably something like an infection as opposed to fluid and things like that. So if we move on from um kind of chest X rays, the key messages with L RT S and bronchiectasis are looking for air bronchogram that will help you confirm that you've got tissue inflammation with airway sparing. Um kind of clinically, it's really, really vital to understand where this pneumonia has come from. Is it something that the patients attended with? In which case, it's a community acquired pneumonia. Have they developed it in the hospital? So for us, I think our guideline in Durham is got to be in the hospital five days and then develop the pneumonia for it to be hospital acquired pneumonia or is the patient aspirating depending on which one of those, um, pneumonias the patient has, you're going to treat them with different antibiotics and they're going to have different clinical presentations. You're going to have to manage an aspirating patient. Completely different to a cap patient. Um, because what you don't want them to do is to continue aspirating and eventually die even though they're on antibiotics. Um, you all have heard of curb 65 scores. I cannot hammer home how important they are in clinical practice trying to make sure that we're really specific and careful with the antibiotics that we're using. Again, things like micro guide and making sure that you're familiar before your exams with kind of the first line drugs for caps of different curb scores and ha of different curb score with different kind of um severities and looking at aspiration pneumonias and knowing kind of the first line treatments for those as well. Um I could see that being a very easy exam question thinking clinically about the option requirements of your patients. Do they need 100% O2? Do they need 88 to 92? What are their comorbidities? And that kind of pulls into things like concurrent diseases as well? So you need to think about patients. Um For example, if I showed you um say a 21 year old male patient with this lower right X ray, um I'd hope most of you would be a bit like, oh, that was not very good for a 21 year old to have a really severe aspergillosis infection. Is there something else going on here that's made them immunosuppressed? So, clinically think about how severe the picture in front of you is. And does it match up with the background of your patient? And as part of that to consider your atypicals? Um so things like legionella, I think clubs yellow is still an atypical and things. Um and that's kind of clinical practice. Um If your patient is not responding to the antibiotics, you might have the wrong book. Um So just think about that next is pneumothorax. So everyone's favorite. Um They're not very common if I'm honest, in clinical practice, maybe they just don't come to DG HSI, don't know. Um But this is a nice obvious pneumothorax here. I think the next slide or at least a couple of slides later I go through and I'll talk about how I can tell that's a pneumothorax. But first, if you have a quick chat about the different types, so there's traumatic, new authorities and spontaneous new authorities. A traumatic pneumothorax is where you have trauma. And surprisingly, so you've been hit by a bus, you've fallen off a bike, et cetera. The management pathway for these patients will be a full A three E or an ATLS depending on how you're trained. But basically, you need to look at making sure the patient is stable and they're not going to actively die before you even think about looking at the pneumothorax for spontaneous pneumothoraces. These are um they kind of just come on on their own. The general history for kind of a primary spontaneous pneumothorax is a young fit male who's really tall and lanky comes in short of breath after having a couple of cigarettes and that's a primary spontaneous pneumothorax. So, a patient with no comorbidity who just randomly gets a pneumothorax, um with no kind of precipitating factors. Secondary spontaneous pneumothoraces are um similar. So they happen without trauma, there's no precipitating factor, but generally, these patients will have underlying lung um problems or lung pathology. For example, emphysema COPD, um bullous lung disease and things like that. We manage them a little bit differently and I'll go on to that next. Any of these types of pneumothorax can become tension, pneumothorax, pneumothoraces. Um and they're obviously an absolute emergency. They need to be escalated. And the second, do you think someone's having one? So traumatic pneumothorax treatment is doing your full a to these patients will normally have other injuries. They will almost always require a chest strain or go on to have a chat about those in a second. And I thought this was interesting from teach me surgery. They said there's actually no role in needle decompression for these patients as long as they're non tensioning new authorities. So I guess you either drain it or you don't. There's no middle ground with primary spontaneous pneumothoraces um, there's two types basically or two categories. You've either got your tiny ones and the patient also has no symptoms with a tiny pneumothorax. So you still have to admit them to hospital, observe them for 24 hours, do their observations. Um, make sure their oxygen sats are ok and you can send them home without any intervention for large primary spontaneous new authorities. So, your 20 year old bloke who's come in with a pneumothorax for no reason, it's bigger than two centimeters or it's tiny, but they're just crying really short of breath and they can't breathe. Um They again need to be admitted. You have a really low threshold for pain in a needle and trying to decompress the pneumothorax and they sometimes require a chest strain, the secondary pneumothorax. So these are the patients who for example, have COPD and come in with a pneumothorax. They can be small, but we kind of have to treat them a little bit more carefully than we would with primaries. Uh primary spontaneous pneumothorax. So we need to admit them, we need to observe them, but we have quite a low threshold for um needle decompression in these patients. And if they're large and symptomatic, then we admit them and we almost always will put in a chest strain. So the logic behind that being, if you're a young fit person with no underlying lung problems and you have a pneumothorax, you're probably still able to compensate and you're still going to be able to oxygenate with the remaining lung if you're someone with bullous like emphysema or COPD, and you've already got really rubbishy lung function. And then we take a whopping big chunk of it away by giving you pneumothorax, you much more likely to die or become hypoxic. So we need to kind of treat them a little bit more aggressively. So here's some diagrams of how you do chest strains and how you do needle decompression. Um I'm sure this would make a very, very easy answer um in an exam like what is the final part of the triangle of safety? Um In fact, I'm pretty sure that's come up in at least one of my exams. So I would learn this, just learn it. You will almost, I can almost guarantee you'll never come into a situation where you actually have to do this yourself. Um Especially not as an F one, maybe as an F two if you've got kind of supervision. Um And it's not an emergence like an emergency procedure. Um But it's definitely worth knowing for exams. Here's another little diagram. Um So the red line here is where you need to put in your chest strains. And the blue line is where you do it, your needle decompressions. So here's that first picture again of the pneumothorax. So um I can tell this is a pneumothorax. It kind of from standing away from the picture and looking to see whether or not it's smmes sides aren't that different for you guys, but this side looks really dark and really black. So there's a lot more air on this side than there is on this side. Um I'm looking specifically for lung markings. So there's kind of a spider webby kind of like if you were to stretch out candy floss and that kind of speckle stuff that's left, you can kind of see that all the way around the edge of the lung and it becomes more dense as we move in towards the highland. On this side, all of that's missing, there's no candy floss, there's no lung markings and we can see this kind of rough, weird shaped edge and that's actually the edge of the lung that's been pushed and collapsed in. So this to me looks probably like a tension with orx given the kind of severity of, of this. Here's a large phora just to kind of give you a visual. Um So this, you would be forgiven for thinking this was like a malignancy or a mass. But actually, if we look a little bit closer, we've got this kind of like candy floss speckling lung marking um on the right hand side of the film and on the left hand side, we're missing that we've got a lot of blackness, there's a lot of air um and the same down here as well. So this is actually what's remaining of the collapsed lung. Um, and this is a large pneumothorax patients, almost certainly symptomatic. Um I would be getting a reg to come and help me asap this one, I would probably miss this if I wasn't specifically looking for it. This is a small pneumothorax and on the, on this side of the side, you can see where they've drawn in a really helpful line to show you where the edge of the lung is. So we can see on the inside of this line, there's this candy floss there, it's lung markings. Um There's kind of spider webbing and then if we look outside of that line, it's just pure blackness and kind of a little bit hazier on the outside because of the density of the ribs Sola. Um But but this is a small pneumothorax. This patient may not be symptomatic. Um in which case, you know, depending on whether it's primary or secondary, you have different management pathways. These are some CT S and pneumothorax, pneumothoraces. Um This is just really to help you get to grips with interpreting CT scans and really hammering home black is air white is dense. Um because we can obviously see that what this pathology is. But the more you see it, the more your brain will start to pattern and recognize um kind of the different colors on a CT scan. Um and you'll get a little bit more of a feel for them. So this is spine, this is the back of the ribs. This is all of your um kind of back and neck muscles depending on how deep we are. This is the aortic knuckle. Um I can't even remember which vessels these are, I've had a very long day, so I apologize. Um These are um kind of heart and coronary vessels. This is normal lung tissue. Again, you kind of get this um spider webby approach um with kind of more dense white flex um kind of in the middle of the lung. And this is a pneumothorax where black is there? No pneumothorax and no no pneumothorax. So key clinical messages about pneumothoraces um would be to escalate them quickly if you think it's attention pneumothorax. Um it's probably a metal or whatever your equivalent of that would be in your hospital. And to also think about iatrogenic causes of um of a pneumothorax. So, patients who've had pleural aspirations or pleural taps um can develop pneumothorax, pneumothoraces. I'm going to get that wrong every time. I'm sorry, um can develop um this pathology. Um So it can be really helpful if you're a junior on the ward to say, oh, actually, this person is a really high risk having had a pleural aspiration. I'm going to order them a chest X ray after the procedure just in case to make sure we haven't caused any issues. And again, that could be a little bit of a high level thinking question on your exams. You know, a patient has a pleural aspiration, another short of breath. What do you think it could easily be a pneumothorax? So, lung cancers, they're in the list of things that the radiology undergrad people would expect you to recognize. Um, as long as you can recognize there's something wrong. I wouldn't expect anyone doctor or junior or anything, um, to, to be able to tell what kind of lung cancer or confirm for definite that it was a lung cancer on an X ray. Um But here's the same image again, just for some kind of overlay. So lung cancers tend to be really well demarcated. Um They tend to be in kind of unusual positions compared to consolidation. You don't get that kind of hazy edge that we were getting to um to the L RT S and pneumonias. There's a touch of an effusion down here. I would argue this could be um a consolidation um because it's a little bit um of an odd pattern for an effusion. But, you know, either way this is the lung cancer, that's what we need to spot is clearly abnormal um to kind of compare lung cancers and effusions, effusions, generally, um water kind of gets sucked down by gravity and normally at the bottom of the lungs. Um And if you've got a CT scan, they're normally at the back of the lungs because the patient lies flat. They normally have this meniscus which I'm sure you're all aware of. Um, a thing where water sucks up the edge of a glass. Um And you tend to get, um, they're a little bit dense um, compared to consolidations and you normally lose the edge of the diaphragm. Um They, they just look a bit thicker all the way through. They're not as cloudy, they're not as fluffy. Um So that's a effusion versus this, which is a cancer. Um In retrospectively, that image is really blurry. So I'm sorry if that's a bit n to look at these are something which is a pulmonary edema. So pulmonary edema is where the um kind of lung parenchyma gets filled with water. There's a couple of different causes. Um The number one thing that you'll be scared of as an F one is that you've given someone fluids and now they're overloaded and you've given them flash pulmonary edema. Um And it is something to watch out for. Um You definitely need to have your ear brain on in the middle of the night when you're being asked to prescribe fluids um for random patients, but this is what it looks like. So it's cloudy. It looks to me, it looks like cotton wall has kind of been overlaid over the picture. Um This is more interstitial pulmonary edema. Um Whereas this is really severe on the left hand side, really severe um pulmonary edema. And here's another image of pulmonary edema as well. This patients um you can kind of tell their body isn't quite as comfortably held as this one. And generally kind of the, the shape of the patient's body. If they're kind of really sump over on the X ray, I can already tell a lot about that patient's prognosis. Um kind of from that image alone if they can't even stand up for an X ray, you know, they're really symptomatic. So, you know, you can, you can draw a couple of conclusions from images without even seeing the patient. These are some pleural effusions. So this is a really horribly exposed picture. And here's a big old meniscus. And again, we've completely lost the diaphragm here and here is a really subtle pleural effusion. Actually, it's quite a nice little picture. So here's a nice subtle meniscus here. And again, we've lost the diaphragm um on both sides. So that's another effusion. So it can be small or large and, and you can clinically correlate that with the patient in front of you. Here's a bit of a comparison. Um because as a student, I was always confused, I was like, well pleural effusions where you get fluid in the lungs and pulmonary edema is where you get fluid in the lungs. So what, what's the difference? Um and actually looking at the imaging really shows me the difference. So the pleural effusions look dense and they sit in the pleura um instead of lung parenchyma, they've got a meniscus and the pulmonary edema looks cloudier, softer fluffier. Um, and it's more widespread, um, a pulmonary edema generally isn't bound by the rules of gravity the way that pleural effusions are. So a couple of cases and for this one, I'm gonna have to switch back and forth between, um, between this page and um the other page. I'm sorry if it takes me a second. But um case one, what's the diagnosis? So I'm gonna quickly talk through these. Um, I'm hoping that there will either be a poll or that you'll start to put some numbers in the chat, please as to what you think the answer is, um, please don't worry about being wrong. II, don't really get that. Um It's, it's half past seven on a Thursday. Um, and I'd rather that you just participated, please. Um, so if we were to go use our, um, kind of a to e approach and as I said, I do things slightly differently. So I'm sorry. Um, so to me the obvious abnormality is here and kind of in the right hilum, um, kind of right upper middle zone of the right lung. Um, and then from there, I would go down the trachea, I can see the trachea, I can see the bronchi on both sides. Um I'm kind of followed down the spine and I can't see any obvious problems. Um, no scoliosis or bone deformities. I then come down. Um, I can't see any blunting of the cost angles, I can't see any evidence of pneumoperitoneum. Then I work my way back up. Um The lung markings are present on both sides. Um The ribs look fine, right, the clavicles look fine on both sides. Um And the heart border looks fine. Um Given that I don't know what projection this film is for certain. Um So that's how I generally approach my x-rays. So if I come back in here, oh, I'm allowed to submit an answer as well. I'm going to submit that answer. Um So yeah, the majority of you said malignancy in the right high and that's perfectly correct. Good job. So, um, the way that I went through this was, I would look at the answers. So I would say malignancy in the right hilum fits. Um It's kind of in a weird place. It's quite well demarcated. It's quite dense. I think number one is a good possibility. A pneumothorax in the upper left lung. I can see lung markings. I don't think that's right. A pneumonia of the right lung. Yes, but it would be a bit of a weird one. Um And normally it would be zonal or lower. So that's a little bit of an odd, an odd one and we already know it's not a normal X ray. So, if I was in an exam, that's how I would approach that question. Um And the, the correct answer is number one. So case number two. What's the diagnosis? So again, I'll talk you through my approach. Um And hopefully you guys will pop some answers into the chat. So, um if I work my way down, um first of all, clearly, there's a big odd abnormality again in the right lung. Um I can see the trachea, I can just about make out both of the bronchi, the spine and the spinus processes look. Ok. Um There's maybe a touch of a raised diaphragm, but it could be that the patients um kind of positioned a little bit abnormally. I can see both costophrenic angles and there's no evidence of pneumoperitoneum here. Um If I work my way up, there's maybe a touch of a loss of lung markings here. It does look quite dense, but I think there are lung markings there. Um And all the way up here and all the way up there, the bones look, ok. I can't see any obvious fractures. The heart could be a touch in large, but it's really hard to say given the film and I'd like to compare it to a previous film and this looks abnormal to me. So it looks cloudy and it's quite well decorated. Um It's a bit of an odd one. So what have you guys said? I'm gonna go for this one. What did you guys say? Yeah. So most of you got that one right? That is a right upper lobe pneumonia. Um So again, if I was to say a lung cancer. Um, it's a bit too cloudy for a lung cancer. Um, but, you know, it, it would be an easy thing to, to kind of get confused. But then it's also got this kind of straight line that's in keeping with the fissure of the lung. Um, which would make me think most cancers don't really pay attention to fissures. They'll just eat right through. So, I don't think that's very likely. The pneumothorax of the right lower lobe is a possibility. Um But there's lung markings. So we've ruled that out, unilateral upper lobe, pleural effusion, um pleural effusion sink gravity occurs. Um So I don't think that's right. Um And again, they're more dense. So that leaves us a bright upper lobe pneumonia and that's the diagnosis case number three. So one of the options here is normal chest X ray. So I'm not gonna give you any interpretation here, but pop your answers into the chat as to what you think is going on. Um Is it normal, is it higher lymphadenopathy, co PD or a right upper zone pneumothorax? I'm gonna have some coffee and give you a second to answer. OK. So there's a little bit of division here. The majority of you saying is CO PD. So if I was to interpret this, oh my um bronchus is fine, the bones look fine. Um postic angles are OK. The bones and the ribs are fine, the heart's fine. So no lung markings. Um, well, first of all, I'd say there's a lot of lung here. It looks quite hyperinflated to me if we switch to the previous slide compared to this slide that looks longer and the tops of the lungs are more blown out. Um, kind of off the bat. Um, is it a normal chest X ray? I don't think so. I think it's a touch hyperinflated. It's a higher lymphadenopathy. I don't think so. I think this is within normal rit, but I could see if you haven't seen enough chest X rays which hopefully you will see in this talk, I could see how you might think that that was high lymphadenopathy. Could it be COPD? Well, yeah, I've already said, I think it's hyperinflated and a right upper zone pneumothorax. There are still lung markings here just to touch, but I can see how it does look a little bit kind of more airy on this side. It's a little bit blacker, but there are still long markings. And if I was really concerned, it was a pneumothorax. I would be looking for that, you know, that tiny little line from that subtle pneumothorax. I'd be looking for that and I'd be seeing if I could find a point where the long markings stop kind of really, really strongly and I can't identify that line. So I would say this is CO PD and it is CO PD. It's almost like I wrote these slides, um, case number four. So, um, again, pop your answers in the chat. So if I went through it, I can see the airway, I can see the bronchi, the spine looks, ok. It's kind of difficult to tell given the exposure, but that looks all right. There's, um, some kind of, um, opacification here. Um I can still see the diaphragm though the bones from what I can see. Look, ok. Um There's obviously a consolidation here and the heart border looks a little bit enlarged to me, but it's um again, difficult to say given the projection and not seeing other X rays, but it looks um a touch big. Um So traumatic lobe collapse. I don't think so. I've got lung markings everywhere. If I have a lung collapse, I've got air and no lung. So I don't think that's happened. A pleural effusion. Um We, we'd be looking for a meniscus. We'd be looking for density. We'd be looking for loss of the costophrenic angles or not being able to see the diaphragm properly. Um You know, we can see the diaphragm. This is quite a cloudy consolidation, left, lower lobe pneumonia and right lobe collapse. Um Just no, if there was a collapse, there would be a loss of lung markings. So I know that's not true. So we're left with four. What did you guys say? Yay, a lot of you guys got it right. These aren't easy cases by the way. So I I've put these in on purpose to try and challenge you to really think about interpreting the picture in front of you as opposed to pattern recognition. Um and kind of going, you know, through the image and then matching up what you know clinically. So let you got that right. Good job. Um And if you guys are getting these wrong and you don't know why you're getting the wrong, feel free. I think there's a feedback side coming up later on my email is there um just drop me a line and we can go through it in a bit more detail, but this was a right middle and right lower pneumonia case number five, normal or abnormal x-ray. I'll give you 20 seconds big sip of coffee, normal or abnormal. Oh OK. There's a first spot here. So the majority of you are saying normal, this is a normal chest X ray. So I can see um the airway is absolutely fine. Heart is fine, bones are fine. It's not hyperinflated. There's no kind of increase of lung volume at the top compared to the bottom. Um I can see how someone might think this was high lymphadenopathy. It's not. Um I wish there was a way for me to tell you more obviously. Um Other than just looking at a lot of x rays that do have high lymphadenopathy and just comparing the two, the bones look fine, there's lung markings throughout So this is a normal chest X ray and they might throw these into your exam just to trick you. Case number six. What is the diagnosis? So, feel free to message in the chat. So does this patient have bilateral consolidations? Yes or no? What do we think is going on? Give you a couple of seconds to have a look at it? Oh, no one is answering. No one is telling me what they think it is. That's OK. This is a tricky one and again, it's thrown in there to try and trick you. Um Do we think that a patient would have bilateral random kind of outer middle, lower Z so zone consolidations? No. So this is actually a type of artifact. This is um circum breast implants. Um And I see these in patients surprisingly frequently. Um And it's something where if you hadn't got a clinical history, you might be looking at this and going, what on earth is that? Um Why is my patient so unwell. Um But actually going through and chatting to the patient, you probably would have found this out. Cool. So case number seven, I'm going to try and speed up. I know that we've got so much to get through in 20 minutes. So I'm going to talk even faster. I'm sorry. Um So case number seven, what's the diagnosis? So I'll chat oh I won't chat through because one of the things is a normal chest X ray, but you can have maybe 10 seconds. What do you think is the diagnosis in case seven? OK. Hopefully you can see a poll if you can't just check the numbers in the chat. Um I can count. Don't worry. No, perfect. So the majority of you get that's a normal chest X ray. So this is actually the chest X ray from case five repeated. But the point of this slide is um kind of to highlight how important it is to look at the image first before you read the question, go through, see what you think of the problems. Um see um kind of, you know, like the way I was chatting through each one, I chatted through each x-ray before I even looked at the question and looked at the answers. And that's really important to do in your imaging and questions because the second you look at those, you're going to start finding things that aren't there. Um So that's just a little bit of exam technique. Here's some interesting chest x-rays quickly. Here's why you need to look at bones. Um Here's some bony destruction secondary to a lung cancer that's infiltrated the right upper lobe. And here's a nasty cavitating mass which when you see it on CT looks absolutely gross. So you can see how um kind of these cancers and fungal things. I'm not sure if this was a fungal cancer like a cavitating fungal mass. Um I'm not sure what the actual diagnosis was, but I just thought it was a cool picture. So just to throw it in for some fun, here's some common artifacts. This is a pacemaker. Um I'm sorry that I'm not asking about is what you think it is. I'm just conscious that I've got 20 medical, literally the rest of medicine. Um Here's a pacemaker. You see these all the time, it's really important to be able to spot these, for example. So when patients pass away, um part of your job as the doctor is to do the cremation forms, one of the questions at least where I work on the cremation form is do they have a pacemaker? Because if you took that in a cremation furnace, it explodes and you'll kill the people working in the crematorium. So just look for them before you fill in the form. This is a bra patients should always have their bras removed unless they're incredibly unwell. And when they have x rays, because these can kind of cover up any abnormalities. And some people think it's surgical clips and things. Here's a central venous line which would be really easy to miss and some ECG monitoring um heart monitoring needs. Here's also some metalwork from previous surgery. This looks like a quite unwell patient to me and this is a patient in ICU and just looking at the sheer volume of artifacts that those guys have to deal with when they're looking at um different chest x rays and how important it is to um kind of interpret them. Kind of first, I guess without any um kind of predetermined notions. Here's a quick bit on peas. I'm sorry, my tummy is rumbling. I'm really hungry. Um Here's some peas. So if we go back to the concept of black is air, white, is dense or white is contrast. So if you're worried a patient has a pe you can do a specific type of CT called Act PA or a CT pulmonary angiogram where contrast is given. And it's super clever. So the um radiographers know when they give the contrast, they have to wait like a specific number of seconds until that contrast is going to show up in the pulmonary circulation. So they put the patient in the CT scanner and then they'll perfectly time it every single time for the 100s of scans they do to show you exactly the view that you want. Um So there's a lot of skill in radiology. Um But here, the white is a contrast. So we can see there's areas inside the blood vessels here. Um knowing that the white is contrast, we know this must be blood vessels and not bronchus. So hopefully you're following the logic there. Um But we can see there's areas where there's no whiteness inside these um inside these vessels. So that's a sign that there's a blockage. Um There's something that's less dense than the contrast, that's a similar density to muscle, um and tissue, blood filled tissue. So that's how we can spot. Ap ei wouldn't expect you guys to be able to spot these. Um But if you had a patient who was critically unwell and you didn't have the time to wait for this to be reported, um I would hope you could spot these because these are massive peas. This is a normal um just to kind of show you the difference so we can kind of follow um and follow the blood vessels, ok? Here and this is a massive pe and here's another pe here as well. So a quick break um for you guys to have any feedback, I know it's a lot of information really fast. Um Again, if you've got any questions and you don't want to ask them in the chat, drop me a line. Um I really don't mind at all. Um I think the mind deplete people would be thrilled if you could complete the feedback as would I? Um So, so please do scan the QR code and take a second because we're about to go into abdo X rays. Would it be possible to put a link for feedback in the chat? Um Yeah, I think I can sort that out for you. Um I might have to do it at the end though. Sorry, just because I think it was in my emails. Um But I'm sure that's something we can sort out. Oh, don't worry. No, it's no bother at all. Um, cool. So, onto abdo things. So, sorry, deep breath. I'm doing a lot of talking. I'm sorry. It's, um, it's really content heavy but hopefully it's useful and if it's not, you know, put me on mute, um, I won't be offended but first piece of pathology, um, would be abdo x rays and obstructions. So, having worked in gen surgery, I've seen a lot of these and they're really, really common. Um, and in A&E as well in juries in elderly patients who, you know, um, it, it's just, they're really common. So, on this side is a small bowel obstruction. On this side is a large bowel obstruction. Um, kind of, the obvious difference is to me and I'm sorry, I know none of this is going to be professional terminology, but there's a lot more of this than there is of this. And you've got a lot more small bowel than you do. Large bowel. Small bowel has always looked like it's more, um, contrasty to me, it looks more like a worm that's been wiggled up. Um, you can see all of these, there's a special word for this on the next slide that I can't pronounce, but the white lines go all the way across. Whereas kind of in the large bowel you get kind of, um, firstly, it's wider, it's generally blacker. Um, and you don't get quite as much contrast in the image. So here's the posh words for all of those things. Um, here, small bowel with a nice little overlay of the Valvulae contes. Um All the wormy bits as I would call them. Um And here's a little bit of the, um, kind of the large bowel as well and kind of looking at, um, the dilatation. They generally, to me, um, look kind of more airfilled than the small bowel does. Here's another set of comparisons for you. So, here again, is a small bowel. There's more of it. They're generally more central. Um, whereas a large bowel kind of follows that nice. Here's the ascending colon, here's the transverse colon, here's the descending colon. Um So you can kind of see the anatomy of the large bowel better. Um, and small bowel again, it's just smaller. So you've got the valvulae con Aventis again. Um, you've got, um, this kind of big loopy sausage bit of bowel here as well. So those are the key differences. Um I know it's not professional terminology, but hopefully you're all understanding what I mean in kind of layman's terms, here's a ct scanner of an obstruction. So here's a normal CT scanner bowel where kind of the white is mucosal membrane or the whiter bits of gray as a mucosal membrane. And again, here is the stomach. Here is the mucosa, um, black, is air and gray and gray bubbles is either food contents or fecal matter. So, this is just a bowel. Here is a bowel that's obstructed. So, um, here we have something called a fluid level. So when the patient is lying back and their bowels obstructed, they're not getting rid of anything. Generally, a lot of the fecal matter gets a little bit watery, a little bit loose. Um, and you end up getting this fluid level where the gas rises to the top through, um, kind of the liquid fecal content. Um, and that's what we're seeing here. Here's a obstruction. This is a large bowel obstruction, that's a small bowel obstruction. Um, so you can see the sheer extent of the dilatation of the bowel loops is absolutely insane and this will probably, um, you get your like toxic megacolons as well, but this looks more like a, an extreme dilatation and we're still seeing the fluid level. So, although it looks like the patient in this image is standing up, they're still lying down, but we're just getting the gastritis to the top. So these patients are, um, generally Tympanic, they're very uncomfortable. Um, they've got a lot of pain, they look about 100 months pregnant. Um, it's, it's quite an unpleasant thing for the patients to go through. So, clinical messages about bowel obstructions, think about the cause. So for bowel obstructions, you either have to have a loss of peristalsis, um, or a blockage basically. Um, so the blockages can be caused by things like surgical adhesions. Um, but they can also be things like cancers, um, especially in older patients, if you've got a patient who is obstructive with an iron deficiency anemia, you probably need to be thinking about, um, colonic malignancies. And then the common thing that I see in gen surge is kind of POSTOP Ilias and this is something that was never taught to me in medical school, maybe it's different now. Um, but after you have surgery and as the surgeons like to say, um, your bowel gets a bit shocked and it takes a bit of time to get back to working again. It goes on holiday. Um, and normally after you've had surgery in a fair handful of patients, um, you'll get what looks like an obstruction where the bowel just isn't squeezing, you're not getting peristalsis and nothing's moving through. Um, these patients get really unwell really fast, their tummies blow up, they don't pass wind or, or feces and eventually the pressure gets so big that they just start vomiting. Um, copious amounts of just really nasty, stinky vomit and bile and gunk. Um, so for those patients, you'll always get called to them in the middle of the night. Um, they need an NG tube which will help decompress the pressure. It goes through the nose down through the esophagus and into the stomach. Um, and it helps kind of the gas and the, um, bile come out, there's a couple of key bits of terminology regarding NG tubes. So you'll hear the phrase spigotting. Um Spigotting is just a fancy word for putting a bung on the end of it. Um So if you spigot an NG tube, you put a bung on the end, you stop um kind of the decompression and you kind of give the patient time to see if their bowels start working again. Um Whereas if you uns spig it or unb um the NG tube, um you're letting kind of all the pressure come out. So you might get to like day four of a patient with POSTOP I who's got an NG and the consultant will say, oh, put the bag on like a spigot and see how they do. Um And that's what they mean. The other thing to think about um is these patients can perforate and to keep an eye out for perforations. Hopefully, I've got a slide about that. Next I do go me. Um So these are CT scans of perforations. Um You can use chest x rays to look for pneumoperitoneum. Um But generally, um I've just seen CT scans used. Um So here again, back is air. Um and you can use the different windows in CT scan um to look for air. So, um here's a lung window really good at looking at air. Um And you can use it on an ABDO CT scan to kind of show you little um spaces where there shouldn't be air inside the peritoneal cavity and this big black um blob of air at the top as well. So the air floats to the surface. Um, you generally shouldn't have a big pocket of air in front of your liver and that's what this is, this is liver. Um So, yeah, perforations. Um I was always taught to treat them as an emergency, but in clinical practice, the surgeons don't seem quite as fussed um as, as kind of what we learn to be. Um, but if your patients are perforating and bleeding into their perforation and they're going to become hemodynamically unstable and that's an emergency. And so to be aware of that risk factors for perforation are kind of untreated bowel obstructions, um, medically managed bowel obstructions in elderly patients and things like that. Um, trauma complex surgeries, repeated surgeries, um, stuff like that. Volvulus comes next. Um, so you'll hopefully by now have heard of the concern. I'm just going to quickly check the chat. Yeah, that's fine. I'll, I'll put the feedback link in, in, in a sec. I just need to find it in my email. Sorry. It'll take me a minute to find it. Um, and there'll be other opportunities for the feedback link as well. I'll put it in another couple of times. So hopefully you've all heard of the coffee bean sign. This here is a big old coffee bean. Um, and this is kind of the center of rotation. Um, and evolvulus is effectively where, um, the bowel should be looping around and just doing its own thing. But instead a section gets twisted and the rest of the bowel wraps around and you end up with this coffee bean sign, which is kind of my two arms wrapping around each other. Risk factors for volvulus or volu are having previous abdominal surgery and having had a volvulus before are actually the two biggest risk factors as far as I'm aware from the teaching I had from the surgeons last week. Um, so that's something to watch out for. There's a really gross picture coming up. So if you don't like gross pictures look away now, but this is what it looks like intraoperatively. Um, when a patient has a volvulus, so you can see how it would be really easy for the tissue to become ischemic. Um, necrotic, how easy it would be to perforate. Um You can see how incredibly painful that must be for the patient as well. Having these massive massive loops of bowel inside the inside the tummy. I'm pretty sure these are kind of extremes. I hope they're extremes. Um, I've never looked at, um, been in the natural vol surgery, um, but it looks pretty grim. So gross pictures have gone away. You can look back if you're squeamish, um, colitis. So colitis is inflammation of the mucosa of the colon like colonitis. Um, there's a couple of different things and these are buzzwords. So I'm not going to teach you how to read an Abdo CT. Um, I couldn't even in a couple of hours, teach you how to read a CT S, but I can teach you the buzzwords that might come up in SBS for each type of pathology. So increased wall thickness, we can see here, um, that if it up here, sorry is the stomach. So you can see like a nice thin wall of stomach and then kind of food matter up here. Whereas down here, we can see that this is the colon and the walls are much, much thicker. So you've got increased wall thickness from the itis bit of the colitis mucosal enhancement where um kind of this one doesn't show it actually where this one just has like a relatively smooth wall. This one looks um I don't even know, it looks a bit like um someone's kind of scribbled in sand, doesn't it like that kind of weird pattern? Um of kind of darkness in the middle where you get kind of um enhancement of the kind of mucosal enhancement. I don't know how else to word it. Um Hopefully you look at that and you understand what I'm trying to say. Um But yeah, you get this kind of mucosal enhancement buzzword and you get this thing called fluid or fat stranding and this is a real buzz word in clinical practice. Um So for example, if something said fluid and fat stranding around the pancreas, that's a really key sign that it's probably something like pancreatitis. Similarly fluid and fat stranding around the colon is probably colitis. Um When you tell us it's fluid and fat stranding because it looks like strands, um it's more dense than um kind of um fluid inside the peritoneum, which is what this kind of gray stuff is. Um And it's kind of linked somewhere between kind of the omentum and the fluid and um the coon, there's no real explanation um anatomically for what that stuff is. Appendicitis. Again, here's um a dilated appendix, here's um uh appendicitis. So, dilation of the appendix probably appendicitis, um periappendiceal inflammation. So, um here we can see kind of this darkness is fluid and um tissue swelling. Um And there's actually this stuff around here. It looks like fat stranding as well and um fluid stranding and an appendicolith. I have no idea what that is. My best guess is um something to do with like gallstones and how they like the word coli being like stone and stuff. Um But again, if you were to see that that would buzz word in my head, appendicitis. Um So you don't need to know how to interpret um scan, you just need to know the buzz words. I apologize if there's any background noise. My cats trying to break into the room. So sorry if I keep glancing over there, pancreatitis. So, here's your pancreas and this is a patient on day one, pancreatitis. Um We can see some kind of fat stranding here, um some kind of inflammation of the um pancreas again, keywords, pancreatitis, fat stranding necrosis, stuff like that. Um And this is day three. and this patient actually died from, from the case study of this image. It was a young gentleman who'd attended um with an acute pancreatitis who ended up dying of um basically respiratory distress syndrome. Um So, pancreatitis as boring and mundane as it may seem um does and can lead to deaths. Um So if you haven't watched it already, there's a fantastic video by um I think it's Ninja Nerd on youtube. Um I'm not sure if I'm allowed to openly promote it, but it's really good. Um It goes into some really good detail about the um kind of pathophysiology of pancreatitis and kind of the other um uh pathologies that can come alongside it. Um And why they're so important and I have seen patients die from pancreatitis. Um and, and the kind of complications from it. So definitely read up on those um easy marks and they're really important clinically to be able to recognize cholecystitis is inflammation of the gallbladder. Oh and back to pancreatitis. Um Golan, the acronym I get smashed or whatever it is that you use nowadays we used, I get smashed. Um That would be a really easy one. If like a pancreatitis history came up in a ACY to be able to say, oh, do you keep pet scorpions? Probably get you some really good points. So, just learn it. It's rote learning. Um, but yeah, cholecystitis is inflammation of the gallbladder. Um, so here I'm pointing at it with a pen which completely pointless for you guys. Um, so here's your gallbladder, um, in a couple of different, um, views. So this is a massively inflamed gallbladder. It's filled with fluid, it has a thin wall. And so you'll normally see, um, a thin walled fluid filled dilated gallbladder will be what normally, um, comes up on the report. Um, the gold standard for um, gallstones compared to cholecystitis is actually ultrasounds. So, a key part of um, abdominal imaging is actually know in the gold standard for the pathology you're looking for. Um, for example, in cholecystitis, um, and stones, we would want an ERCP, sorry, an M RCP prior to being able to do the procedure to get rid of the gallstones, which would be an ERCP. So at least in my trust, you need an M RCP prior to the ERCP and making sure that you order those. The second you think that that's what the patient's got really does save them a lot of time and it can speed up the amount of time it takes for them in the hospital. Um, liver cirrhosis, I don't know why it wants you to spot this. This is his t of different types of liver pathology. His normal liver. Um you'll see a normal liver with normal reflectivity um and normal paran smooth surface is normally what the report says this is fatty liver. So it's um less dense. So hypodensity comes up and then this kind of jagged edge to cirrhosis. The gold standard for um looking at liver cirrhosis is ultrasound, um specifically something called a fibro scan. Um So this is normal liver. And again, we can see in cirrhosis it's um just nasty jagged damaged tissue, liver cancer. I'm not expecting you to know anything about liver cancer, but I do expect you to be able to look at these and go that's not normal. Um So hopefully you're all looking at that and saying that's not normal. Um So yeah, that, that's the key bit of learning there. But um basically you're looking for um Hepatomegaly. So here we can see, um kind of the liver is coming quite far around. It looks quite enlarged. Um My guess is I'm not an expert with um Abts, but this looks like stomach toy. Um And it seems like it's not quite in the right place. Um It should probably be over here. So something's happening here to move the anatomy around a little bit. Um Here's like a, a big old obvious lesion and this just doesn't look right does it, it's not all one clear cut density. Um It's kind of got an odd surface to it. So these are um liver cancers. So the key clinical message is fat stranding, fat stranding will tell you um where the problem is. Um And you need to make sure that you know the modalities of imaging. So um loads of questions and I don't know if it's the same um in other people's BS but for my ba S and in my finals, it was very much like a patient comes in and it sounds like they've got this. What's the next test? Um So yeah, um learning those getting um getting really comfortable with knowing which test to, to use um is helpful. So here's another feedback slide. Um Let me um send across the link to you guys. Let me see. Just give me one second. I know I'm far too young to be this bad with technology, but unfortunately, here we are. Um I'll get this sent across to you in just a sec. So again, have you guys got any questions? Oh, awesome. Thank you. Um That's fantastic. That's so much better than me trying to find it. Um Can we have the slides? I don't know if you're allowed the slides. Um That's something that the mind, the bleed people will have to, to say. Um But you know, if there's anything specific you wanted to know, Samira, um just pop me an email. Um and I can send you little chunks if I'm not allowed to share the whole presentation. Um That's absolutely fine. I know we're running over. Um, so I'm happy to keep going if people want me to keep going into the neuro stuff. It is really brief. Neuro is not, um, my kind of specialty. Um, but I'll kind of keep an eye on the chat. If anyone says that they want me to be quiet, that's fine. Um, otherwise I would just carry on. Yay. No one's telling me to be quiet. That's nice. Ok. Awesome. Ok. Last little bit. So neuro, um and again, I'm going to carry out this with, um, I'm not in any way, um, experienced with kind of neuroimage. My approach to neuro is um, spot the problem basically as long as I can spot that there's something wrong. Um, that, that's all I need to know. Um, and again, kind of with BS and exams and things, it was very much spot the key word that linked to the diagnosis. Um, because in clinical practice, um, if you think there's something wrong with the CT head, either you've got a patient who's in front of you who's dying from the extent of the, the kind of brain injury or, um, you're waiting for the report to come through because it's not something you're going to play guessing games with um, in clinical practice. So, neuro stuff, um, the first one is going to be stroke. So, um, I'm going to carry out this with, I've never done a stroke job. Um, it's absolutely not something I see in day to day I work in a specialist stroke hospital. So um they don't come to my ward, they go somewhere else. I don't see them. But um we all know that there's a couple of different types of stroke, there's bleeding strokes and there's ischemic strokes, um which is how I remember them. Um So we can see here, hopefully, the key messages for neuroimaging are, is it symmetrical? Um And that's kind of it. So if we look down the midline here, we can see there's an area of more blackness on this side. Um This isn't symmetrical and this is like an area of kind of infarcted tissue. If we go back to what we remember before with black is air and white is density um or contrast, it would make sense that um kind of an area of blackness is maybe an area that's not getting contrast or it's not getting blood or it's more dense. So it's clearly an abnormality here. And here we can see that this is where the infarct is. They're also showing us here that there's an area um of vascularization that's denser. So it's getting more blood and more contrast that's not being able to be distributed. Um So that's a dense MC here. So this is um kind of an infarct stroke and here is a hemorrhagic stroke. So, seeing the same thing here where there's lots and lots of blood. Um but instead it's being dispersed intracranially. So this is a hemorrhagic stroke. Um, yeah, that's all I'm going to say about strokes. Um, otherwise we'd be here for about four days going into all the different types and things. Um, I'm pretty sure that geeky medics do a really good, um, kind of summary strokes. Um, but again, II could be here all day so we're gonna quickly move on to bleeds. So here's a basic bit of anatomy, um which I'll admit I have forgotten um a little bit before doing this talk, but the different layers of um kind of the cranium. So you've got your scalp where your hair is attached, your skull, which is the bone, um the periosteal um gator, which is under the skull, the meningeal ator, the arachnoid mater, the subarachnoid space, the p and the cerebral cortex. Um I'm sure you guys know this and if you don't know this, take a picture, learn it. Um This will be again, super easy. Um SB if your uni focus is more on like academic stuff. Um But you know, you can read um and you can read this as well. I would say take a big picture of this. Um This looks really useful for exams and things. I'm not going to read it to you. You're all, you're all big enough to read. Um This is from Gy medics. Um This is not me at all. So if there's any mistakes, um I blame them, but it all looks pretty much um spot on and I've run all this by consultants and things as well. So, um no one's pointing out any issues. So take a picture of that or just go to geeky medics yourself. But this looks really useful. I'd have loved to have seen this before my exams. So if we work outwards, inwards with bleeds, you can have extra dural hemorrhages. Um These patients present um pain also mental status, reduced gcs, they might have cranial nerve deficits. Um So the cranial nerve exams actually do come in handy um when you're a doctor, um which is a little bit of an odd one. I thought they never would, but they do. Um these patients might have motor sensory deficits. It's difficult to predict um if they're going to have kind of um issues with their reflexes that can be hyperreflexive or particularly um increased spasticity, they'll have upgoing planters if they've got um you know, kind of any um abnormal reflexes. And there's apparently a thing called Cushing's triad, which I had to go away and look, look up, but it sounds like a nice high level answer that could get you some extra points if um if you're aware of it. So, um Cushing's triad is where you because of the CP of having this um basically enormous pressure inside your head from all of this blood. Um You end up with cardia and hypertension and you end up with a very abnormal breathing pattern. The green boxes here are how you treat it. So, I guess, um, thinking has this patient had a fall? Um, you know, are they on anticoagulants? And if they are, have we stopped them, do they have an underlying coagulopathy, which we haven't diagnosed? So, do you want to do um, like a coag panel? Um, maybe an inr if they're on Warfarin. Um You'd want to have a chat with the hematology department. See if you've got reversal agents available. Um You would want to think about things like antibiotics for patients who for example, maybe have been kicked in the head by a horse and they've got a big old hole in their head. Um which is what you can see on this bottom scan. This is a traumatic extradural hemorrhage and there's a big old skull fracture and kind of an external hematoma as well. So we can see the hematoma is the same density as the brain tissue in the infarct. So that's how we know it's not like a big bony lump or a mass, it's just blood. Um And all these patients actually have big old lumps on the sides of their heads plus them. Um Here, we can see a bit of midline shift um as well. So it should be a nice straight line and it should be symmetrical. Remember, um this isn't symmetrical here, the ventricles aren't symmetrical. This one's actually the most symmetrical of all of them, but then they've got a big old lump and a skull fracture. So when some, you lose some um in terms of other treatments, these patients might need anticonvulsants. Um Their seizure threshold will be massively lowered due to the raised CP and kind of just general stress response. Um You might want to lower that intracranial pressure as well. This is not something you will ever be doing. Um Trust me, this is itu 100% or at least the Ed Reg consultant would consider things like Mannitol or barbiturates um to try and lower that. Ip there's a couple of different treatment pathways for these patients. Um So for example, if you've got 100 and one year old Greta who's fallen out of her bed at the care home and she's got a DNA R and she said she's had enough. Um you might manage it conservatively um by trying some kind of um correcting coagulation, um kind of making the patient comfortable and monitoring them. Um Kind of younger more fit patients might have things like bur holes, trauma, craniotomies, and hemi craniectomies. Um Again, the s for the kind of ins and outs of those um because not something I'm familiar with subdural hemorrhages. So we're working our way in um similar again, and you're going to get a lot of kind of vague neurology here. So, limb weakness, sensory disturbances, cranial nerve abnormalities, again, learn those cranial nerve exams. Um they're really, really useful in clinical practice and it'd be such an easy Os station. Um Just practice on yourself, practice on your friends, practice on your cat. Um Do what makes you happy. They could get facial weaknesses and visual field defects depending on where the infarct is or kind of the extent of the infarct. Um They may have ataxia, abnormal gaits and seizures again from that low threshold from the raised ICP and they'll normally have a reduced G CS or just an abnormal G CS as well. Again, the treatment is to correct the curies if they've got them. So first line would be, I'd like to do um like a coag screen if you were in your oscopies throwing my pen around. Um again, think about conservative management versus surgical management. Um And again, with the kind of surgical stuff, um looking at trauma, craniotomies and hemicraniectomy. Um and apparently the hemicraniectomy are particularly indicated in large bleeds. Um If I'm honest, I think these would be quite mean questions for an SB but they're probably quite high level answers. And if you're here at quarter past eight on a Thursday night, you're probably the high level students. So, um it might be worth you guys kind of noting bur holes, whereas previously in extradural hemorrhages, they were kind of a first line treatment or first line surgical option and they're actually more chronic, used for more chronic subdural hematomas. So here we can see there's kind of two different scans here. Um It's difficult to say whether it's like an Mr with contrast or kind of what the image is. But you can see um it's not symmetrical, there's a bit of midline shift, the ventricles don't look symmetrical here. There's obviously an abnormality which has been beautifully highlighted for us here and again, um this is not symmetrical, the ventricles have shifted um whether this is one ventricle or two that's smushed. It's really hard to say there's an obvious abnormality here. I wouldn't expect you to look at these and say, oh, that's clearly a subdural hemorrhage. I would expect you to look at it and go oh my goodness. I need to really quickly um get some help for this patient. I liked this picture because it had fruit on it. Um And it's actually been really helpful for me to tell the difference between the two types of bleeds. So here's a nice little diagram of where the different bleeds are most likely to occur. And here's a nice diagram of telling the difference between extradural hematomas and subdural hematomas. And so subdural look like bananas and extra drawers look like lemons. I think that's really cute. Um And it really helps me remember it, subarachnoid hemorrhages. There's a lot of me reading here. I know you guys can read too. Um But again, reduced G CS um and sometimes reduced G CS purely because of the raised ICP as well, um, as opposed to kind of, um, areas of the brain being damaged, it's more just to do with overall pressure. Um, patients can get kind of neck stiffness, which might kind of mirror something like meningitis and it is because they're getting meningitis, but it's because of irritation from blood and kind of the meninges getting pressure as opposed to infection. Um, Koenig sign, which is when patients can't extend their knee out because they end up getting too much pain. Um, and the way that you test for things like subarachnoid hemorrhages are, um, you can do an LP about 12 hours after the patients start getting the symptoms, which are generally, um, go back to this page. Um Does this even tell you your symptoms? No. Oh, yeah, it does. Thank goodness. Um, you kind of start to develop headaches. Um So yeah, your thunderclap headaches, um, about 12 hours after the onset, you can start doing LPS and look for Xanthochromia, um, which is like a yellow pigmentation that you get um, in the subarachnoid from the kind of blood breakdown products that end up in the CSF these patients if they're young and if they've got um, kind of a good chance of being viable for surgery, you would refer to neurosurgery, I mean, you're going to refer everyone every way anyway. But if again, you've got 100 and one year old Greta and she's just come in with a sub, they're not going to go and cut her head open or kind of give her crazy management. So kind of looking at the pictures but also looking at the patient in front of you, which sounds a bit wishy washy. But you know, if you think a patient's got something like this wrong with them and they're 100 and five and they've got a DNA R and you know, think about the implications of, of bringing them into hospital and investigating and things in clinical practice. So, subarachnoid hemorrhages, um specifically um a little bit dustier, a little bit softer, they tend to lie around um areas where you've got a lot of vasculature inside the brain. So they clearly look different um to the kind of extra dural um lemons and the subdural bananas that we saw earlier. Intracranial hemorrhages can present in lots of different ways. Um Lots of different severities. Um I've seen intracranial hemorrhages in little old ladies where they literally you are just unresponsive and they lose the majority of their brain mass and they just die. Um And then I've seen intracranial hemorrhages. Um like, I think one of these ones was actually a completely asymptomatic patient who'd come in um because they'd had like a little bit of vision change or something. And then they found out they'd actually had a, a hemorrhage like this and it turned out they'd had a coagulopathy. So, depending on the patient in front of you, you need to kind of prioritize different tests. And that would be a really good one kind of thinking about whether you need an a to e or a neuro exam or a cranial nerve exam or a cardiac arrest call, you, they're all going to be different presentations. But again, the key messages are, is it symmetrical? Obviously not? So something's gone wrong. I need to call for help. Um and that's basically it with intracranial hemorrhages. They want you to know about brain mets. I think this is a bit nuts. Um Here's four different types of brain mets. Um They'll look different depending on the primary. Um and you'll get different symptoms as well depending on where um where the cancer is. So generally, um the patients I see with brain mets um are at toxic, have vision changes. Um Specifically things like nystagmus, abnormal eye movements, generally, oculomotor stuff is what I've seen um in brain Mets. They normally, well, hopefully patients with history of malignancy um frequently it's um like lung malignancies, liver malignancies, breast malignancies, they love to metastasize to the brain. These patients get um confused, they have behavior changes. Um And it's really sad to see um one of the treatment options for these patients is dexamethasone, it can help shrink the brain mets um and kind of help alleviate the symptoms, but it obviously doesn't cure the cancer. Um So here's a couple of different um interesting Mr S and I think one ct um of different brain mets. Um But again, if you can recognize that something's wrong, um and you can escalate that that's all you need to be able to do. I would guess you don't always get so much midline shift from brain mets because they tend to be slow growing compared to these intracranial bleeds, which are fast and hard. And you see um generally kind of hear loss of the ventricle, hear complete midline shift, complete midline shift. And so keeping an eye out for those features might help you tell the difference. But if you're not escalating this to someone more senior, you're probably doing something wrong brain abscesses again, really random thing for them to expect you to know. Um But we can tell it's an abscess um because we end up with like a ring with a gap in the middle, basically um where black is either fluid or air. So here's probably infected fluid or um kind of a cyst um type of picture. Um We can tell the difference between those in the brain mets because of the difference in density brain mets have nice dense tissue, not nice dense tissue um on the inside. Whereas um kind of abscesses um don't have that same density and apparently there's a thing called ring enhancement as well. Um Again, those words um for, for brain abscesses, that's really high level stuff. I don't think most doctors would get that if I'm honest. Um raised ICP was just completely out of my remit of stuff to look up. But here's a beautiful summary of what you would find on CT and Mr from the National Institute Institute of Health regarding raised ICP, so enlarged ventricles, which would I suppose make sense your kind of herniation and mass effect. Um, but you know, it's one of those things, the clinical signs of raised ICP are, are kind of easy to spot. So headaches and nausea. First thing in the morning are quite common. Um especially in young people who have raised CP and you'll get things like idiopathic raised ICP in um overweight, young females is quite a common presentation as well. You get this um kind of nausea, really severe headaches with no other calls and that's raised ICP. Um So we kind of discussed, I think for extra dural hemorrhages, you can give things like man and barbiturates to manage this acutely and things like stents can be used in idiopathic raised ICP as well to basically shunt the fluid down into the spinal tract and try and reduce the raised ICP in those patients. Here's some spinal compression. Again, I would not expect any of you guys or even me if I'm honest to be able to read an MRI spine, but we can kind of see here. Um This is spinal cord um and kind of the different um mater of the spine. And here's an obvious abnormality where the nerves are getting crushed. Um, so I would hope that you would spot that and say, hm, that doesn't look quite right. We can also look through all these bones, bones, bones, bones, black with, um, kind of gray with black edges, gray with black edges, gray with black edges, uh, kind of whiteish with gray and black edges. So that doesn't look quite right, does it? So, even though we don't know what we're looking at, we can tell there's probably an abnormality here based on the pattern recognition of what the other um other tissues look like. And this was a young, a young guy, I think who'd got some kind of bone cancer with a femur as a primary who'd gone on to have basically destructive bony lesions. So, oh my goodness, that was a lot of stuff to cover um, in just over an hour. I'm sorry for keeping you 20 minutes late. Um There's another, um I think they all linked to the same thing if you guys have got any questions, feel free to put them in the chat or um, just pop me an email. That's absolutely fine. Hopefully that was useful. Um Sorry that it was a bit of a whistle stop tour. Um I'll give you, that's ok. No worries. Hopefully it was actually useful for you guys. Um, and not a waste of your Thursday evening. Um Yeah, feel free to drop, um Drop me a line if you've got anything you want me to cover? Cool. Crazy. I'm please fill in the feedback form guys. Um It, it is really helpful for us for our portfolios and things. Um It'd be really, really helpful for you guys to do that and hopefully I'm gonna butcher your names and see what answer. Um Hopefully um just let us know if um if there's anything you need me to do before I sign out of the call. Um But otherwise I think that's us done. Sorry, it wasn't reconnect. Yeah. No, that's all good. Perfect. Thank you so much for that. That was a really, really good talk. No worries. Hopefully, II know it's so much stuff to cover in an hour. I think I've just blowing my own mind, let alone you guys. But hopefully that was helpful. Yeah, it's, it's recorded and it we on demand so they can go back and watch, watch it back. But there were some really, really good and I think it was really comprehensive of what you cover. So um I definitely would go back and watch this as, as a revision. Actually, I think it's very comprehensive. Nice. Well, I'm glad that um that you enjoyed it. Um Am I OK to just sign off and Yeah, absolutely. I'll end the call here and thank you so much for your help as well. No problem. You're a see you later. Thank you. Bye bye.