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What were you saying? No, I was just wondering if the internet is gonna be ok all the time. If not, we can say hi and then hello, everyone. Welcome back to the fifth session of the Fy Survival Guide. Um We apologize for the delay. We've been working with some technical issues. Um But today, um today's session is on intro to CT, we have two speakers. Um Chan and Ed um one's a radiology ST and the other is a consultant. So we'll be having Chan um on first and he'll be doing the first part of the teaching series over to you, Chan. All right. OK. Hi, good evening everyone. So uh yeah, my name is Chan and with my colleague uh Pria, uh we both SST two at the uh at Newcastle. So Northern School of Radiology. So today we, so today, the, the aim of this, today's uh uh kind of presentation is to give everyone a flavor not just on CT but different, you know, imaging modalities that may be available that could even be more sensitive in certain, in looking for certain pathologies than CT. So, uh yeah, let's get on to it. So in terms of the key learning objectives before I move on any further, I just want to check with Lucas. You, you, you're hearing me clear and loud, isn't it? Yes. Yes, good. OK. So, um so I understand the title is Intro To CT, but we thought that um it would also be kind of be, be, be a nice thing to do to, you know, especially because I understand, you know, when we are starting as F I one junior doctors or, you know, as a medical student, we, we kind of don't, it's really hard to wrap our heads around, you know, what type of scan is actually better for the patient apart from CT, you know, so we thought we introduce uh you know, some of other imaging modalities and then, and then, and then see what are the indications, pros and cons and we have a few cases, these are the cases that we got from on calls. Um So just talk to share with everyone and then just so that everybody can have an idea, you know, next time when you're requesting scans, you know what to, what to look for. Uh and you, you know what, what is the main reason they're requesting it and then there's some take home messages at the end of it. OK. So yeah, imaging modalities um a donut there as a donut of truth as what many people may put CTS. But uh I would say most of the time, but not all the time. Ok. So um so um I'll just kind of just to kind of put a list out on uh you know, different type of modalities in the world of radiology um that, that we use. Ok. So as a kind of from a surgical foundation doctor point of view, uh you know, chest x-ray, abdo x-ray uh or x-ray of the kind of uh musculoskeletal system while you're doing an orthopedic job or doing an A ne job. So kind of these are kind of our kind of bread and butter. Uh When, when, when you, when you, when you're starting your job off as a foundation doctor, these are the most like the investigations that you're going to request or the team has kind of asked you to go and request. So, in terms of uh x-ray imaging, we call it radiograph. Um chest x-rays are good for looking at, you know, early uh sorry, kind of look for obvious changes like for example, very severe pneumonia or is there a rib fracture? Is there a pneumothorax or is a imaging mo modality that you need to have before moving on to do CTP A uh for reasons that will come about uh in a short while and then, and then just things like that abdominal x-ray in general, unless it's a very obvious volvulus that you could see, but most often than not, you will realize that it doesn't really add much of a diagnose like an immediate diagnostic value towards finding out abdominal pathology, uh even in the face of bowel obstruction. So it's not really sensitive. However, you do have a kind of fluoroscopy guided uh procedure known as a barren follow through which is both diagnostic and therapeutic purpose uh to look for, you know, small bowel or large bowel obstruction. And then there comes MS K, you look for fractures. I think this is uh kind of, it seems a bit, seems more rational to everyone including ourselves and then you can come to the ultrasound. So I think ultrasound is probably most, one of the most commonly requested investigation, you know, just after radiographs. So, uh in the world of surgery, you know, people will ask to look for cholecystitis, which is, uh which is good. And I as uh my understanding is that at the consultant radiologist will come up with uh imagings of cases later on. So I wouldn't go too deep in into that, but just kind of trying to give everybody a flavor of what ultrasounds good for. So like general acute pathology, ultrasound kub uh to look for any kind of post renal problems, any duplex to look for DVT. And then sometimes in certain hospitals like the hospital we're working right now, they ask us to perform a post transplant scan on both kidney and liver just to look at the blood supply and then to see any kind of very early signs of uh problems with the transplant organs. And then of course, then you have a CT scan, the thorax, abdomen, pelvis, CT P look for any blood clots. So to come on to the reason why we do a chest x-ray before CT P is that we try to identify problems that could be picked up early at the chest x-ray first, for example, like pneumothorax, which also can give you chest pain or like very severe consolidation infection of the lung, which means that if we, if we detect this early before we move on to the CT P, just to prevent us to doing a non diagnostic CT P. Because if there's too many lung pathology on the CT P that you are trying to do, it's actually not diagnostic uh in terms of ruling out pulmonary embolism. So, hence the reason why we are doing it. And of course, CTK, we look for kidney stones, CT angiograms, uh the the people in the vascular world. Uh we kind of know, know this uh this imaging modality. And obviously, you have MRI uh Mr CP, certain patients have it when they've done ultrasound, they couldn't find anything, the symptoms still there or when they have had the surgery, an endoscopic route is not viable because of the change in anatomy, post surgically. Uh Those are the reasons they, they usually request Mr RC P or it's just less invasive and patients able to tolerate better. And then in terms of people working in the spine or orthopedic world, you have MRI scan of the lumbar spine to the, the last thing that um I'll try to point out is that there's a, there's a website called I refer, uh which is something that came up by the uh Royal College of Radiologists. So this is just an example of the website. You can, you can try to look at different pathologists, you want to try to find out through the world of radiology and then you can search it up and then they will show you what's the most appropriate imaging mo these that you can use. Uh So, so it's a very good website. Uh If you have access, that's great. If you don't, you know, sometimes just make a phone call to the radiology department, you know, usually the on call registrar or the radiographers, they are really good at, you know, to kind of directing you to, which is the best imaging mo that you should get out of it. Uh And yeah, sometimes, you know what uh as registrar, we're not entirely sure all the time. So we're always happy to discuss, you know, who knows in the, in the, in the timing of discussion, we may find a better solution in terms of what's the best scans to perform. OK. Right. So now it start off with the cases. OK. Um Now I'll have, I'll hand this over to my colleague, Pria uh because uh we are using some of her cases so hand it out to you, Pria. Yep. Thanks John. Hi guys. I'm pre I one of the other ST twos. I'm just going to go over some of the cases. I was hoping we could use the chat function to make it a bit interactive. But I think there's some technical issues. I don't know if you guys can unmute and speak. Is that an option? Um, so the audience can't actually turn on the mic chat so I, I can read out the questions to you along the way or I can leave it to the end. Depends on what you prefer. Yeah, probably an interest of time since he started late. I'll go through the cases and if anybody has any questions, we can answer them towards the end. Is that ok guys? Sorry? Yeah. So the first case is we've got a 63 year old gentleman who is admitted post fall at home and they're complaining of chest pain, shortness of breath and they have a history of colorectal cancer and you're on F one and you're asked to see the patient in ed and their ECG is normal. Um So what investigations apart from the routine bloods that you normally do when you admit patients would you request? Um, so obviously patient, the main symptoms is chest pain and shortness of breath and they've had a fall. Uh, so the way you do your usual a assessment. Uh, you do your routine bloods and then the investigations wise, what you would start off with is, as chance said, uh, ideally you'd start off with a chest x-ray. Um, in patients with fall you want to look for, have they fractured any ribs? Um, have they had any you want to look at or, um, to see if they have any, obviously, if you have any rib fractures, you would have pneumothorax. So you want to look at all the lung fields to see if there is any um uh all the lung mars are going all the way to the edges. Um Obviously, if they had trauma, um sometimes look to see if you have any pleural effusions and in the context of tumor rather than pleural effusions, you do, it's more, more likely to be blood, isn't it? So you'd have um hemothorax or pneum uh hemothorax. Uh could be a question. Ok. Obviously, the patient has a history of colorectal cancer. So, given the history of cancer, you want to be thinking down the lines of dissipation to have something that actually led them to have um a single episode. Um you know, they could have been hypoxic for pe therefore, because of a pe and that's led them to have a fall. And so you want to think about down the lines of um doing a CT. So let me just put this here. So just to put on, I know one of the consultants is going over cases, but I just thought be nice to show you an example um of a pe so as you can see on the, the right you can see. So I don't have a cursor to point, um you could see the um sad lambis within the um pulmonary trunk and the main pulmonary arteries and that's extending into the lobar uh vessels. Often the chest x-ray in patients with p would be more likely than not be normal. And sometimes if it's extensive, you could see, um, um, in pulmonary infarction, often the um, signs you'd see subtle, it could be wet, shaped, um, infarction, uh cause you can see on the right sort of basal area. Sorry, I can't point, I can't see a cursor and it's um, met shaped, peripheral, sorry, um, abnormalities again, in the context of patients, if they don't have a, a history of cancer, um, you'd also look for on a, on a chest x-ray. Do they have any, if they've had a fall in a long line, have they vomited? Have they thrown up? Have they aspirated any, if they vomit? Can you see any signs of any infection? Can you see any signs of any aspiration? But bearing in mind if they are aspirated, the signs of an aspiration, pneumonia might take, um, you know, 24 48 hours to show up on a chest x-ray. Ok. So let's go on to the second case. So we've got, um, 55 year olds. So, take them from that case, patient history of cancer or if they had, um, any, um, uh, recent surgery immobility, especially if you guys are working in surgical wards, uh, pregnant patients, um, long bone fractures. Um, you'd want to do a ddimer. Uh, but obviously if the ddimer is normal and it's a reasonably good candidate, exclude A P, but if it is positive, it could be raised for various other reasons. So good to take the phone and speak to the registrar and, and with the clinical picture to see what's the appropriate scan to do. Ok. So, and then just, uh, I would just like to add on, on, on pre uh, first case is that, um, important history when people putting up radiology request is, uh, you do have to tell us if there's a history of malignancy because that's very important that when we find something we don't, we don't flag up unnecessarily if it's something that's been known. So it's good that you tell us and then we could do it as part of the follow up as well to see whether things has progressed or changed. So, um, I'm only pointing this out because during our like on call experience is that most often they're not, uh, people don't, people when they request scans, they don't actually put like the, they, they write all the, they write, they write the stories which we get a good picture of, but there are very pertinent points we need to know is, is like history, trauma, any cancer. So these are the things that you, uh, as, as a clinician, when you're referring to do a scan, these are things you, you should include. Yeah. Yeah, especially if they had cancer and, uh, they're hypoxic, um, then need to think if did they have Mets or do they have like a malignant effusion? So, it does make an important point if you could have that. Uh, it saves us a lot of time to look through their previous histories as well. Uh That would be very useful to know. Uh It's a case of then, uh, we've got a 55 year old gentleman, uh, 10 days post whipple surgery and he's complaining of right side abdominal pain and with deranged LFs. So, what's the suitable imaging? Uh We would like to do? So, um, your Whipples is your partial pancreatic duodenal toy so often done for like head of pancreas cancers or duodenal cancers. So, what they do is they take of a part of the, uh, the pan, uh, the duodenum and the gallbladder and then they form a, uh Coco jejunostomy. So they join the bile ducts to the, uh, Jejunum. They join the rest of the pancreas, uh to the jejunum and they join the, uh, the rest of the stomach to a part of the Jeden as Well, so that's your gastrojejunostomy. Um So what you need to do is, again, main things you'd look for are what are the complications that these patients could have post surgery. Like most other surgeries. The common complications that we face are is in the acute phase after the surgery is, is the anastomosis intact. There any signs of any anastomotic leak, um especially because the pancreas is involved is if the juices are leaking, it could affect the surrounding tissues, vessels, et cetera. So you could have pseudoaneurysms, you could have um hemorrhage, the veins could be thrombosed. Uh So these are the sort of the main complications that you would want to be looking for um in these patients. So again, when you request these scans, um ideally, we would start off with a CT of the pelvis. But if you're telling us that the patient's um hemoglobin dropped, their BP is very low. Uh Then we might need to add on things like um an arterial phase to look at the vessels in more detail. So it all depends on the clinical picture. And um so it's really important that you include the pertinent um findings in there. Uh So here, as you can see on the left, you have a collection uh with the arrow pointing um with the, with the wall um in a patient after whipple's um procedure. So if their infection markers are raging, they Pyrex um post um Whipples or any surgery. Really. The main thing that you look for is collections, abscesses, um, wound infections, um, et cetera. And on the right, you can see a splenic artery, um, pseudoaneurysm. Ok. Do you want anything to add on Jan? Um, nothing other. No, that I'm very happy. Cool. Uh, case three, then we've got a 45 year old, uh, lady with a history of gallstones, um, and has developed two days of severe upper abdominal pain. Their amylase is uh very raised and their lactate is also raised. So what's the most appropriate uh next steps in this patient, as you all know, um when your amylase is raised and they have epigastric or right upper quadrant pain, the patients clinically uh will be treated as pancreatitis and the common causes for this is, you know, gallstones, alcohol, et cetera. But from the history and the race lactate, you can see that the patient is quite unwell. So the first step is obviously do your a assessment, fluid resuscitate the patient, uh et cetera. Um in terms of imaging, then in the acute phase, often the changes might take some time to be seen on CT. So here you could see the pancreas in the middle. Sorry, I can't point again. Um But if you see just underneath the skin, you can see how the fat is nice and a nice, darkish gray. Ok. Um Lucas just I apologies just because I want to use the curso to show people. What what pre is talking about? Yeah, that's completely fine. Yeah. So as you can see the uh this is the normal fat which is like a nice, darkish blackish gray. Um sorry if I can enlarge the picture. So see that's your normal fat. That's how it's meant to look around here. But because it's all this is the pancreas, this is your spleen and that's your liver. Ok. This is the splenic vessels running just posterior to the, the uh posterior to the pancreas. So you can see how the fat here. Uh here is all quite dirty. It is, there's a lot of fat fat stranding we call it um which is all signs of inflammation. Um And this is what you see if there's appendicitis is a sort of the stranding that you'll see around the appendix depending on where the inflammation is. Um So that is acute appendicitis. You just do that for slight stuff stuff. Yeah. Oh, you mean for the next case? Uh no, to just enlarge the slides. Um So yeah, so ideally when you request the scans in a when when this patient presents to ed, uh surgeons often would not take the patients unless they have had a CT scan. So they do end up having the scan in the acute face. Um Usually it would be your portal venous face that it would be done. But if you, if you're worried about any uh complications of pancreatitis, like they could have walled of collections, they could have part of the pancreas, could be necrotic. Uh And as you can see, the pancreas is quite close to a lot of the vessels. So you could have clots in the vessels. Uh you could have pseudoaneurysms and in, for example, the splenic um Archey et cetera. So if any of these is a concern, they might have, we might need to do different faces of the scan. So as much history, you give us, we could protocol the appropriate scans for the patient. Um Yeah, I think that's the third case. Do you want to do the rest of the case? I suppose the the take home point uh is that when, when the, when the team is asking um asking us to request a certain scan, it would be nice to just kind of ask, ask your senior consultants or the register site. Oh, what are we actually looking for? Uh not, not, not in a very, you know, straightforward way but saying that this is good for my learning as well and then just try to pick up from them, you know what they are actually trying to find. Uh then, then, then you can put it down as a request and then we protocol the scans better. So that, you know that I think the last thing you want to happen is that yes, the scan was done, but we not doing in protocol that is going to help the team to look for what they want to look for and then patient come back for a rescan. So it's just like logistically it's not benefiting everybody. Patients get unnecessary radiations. Uh It, it's just things like that we're hoping try to reduce, you know, or even avoid it altogether if possible. Yeah. Ok. So, um I'm gonna enlarge the slides again. 23 year old Amita pain associated diarrhea and vomiting. So, what's the most appropriate next step? Um So if uh if, if anybody realizes that uh the way we stem these cases in a very kind of open ended way because it's like anything is possible. Uh because that's the main aim of our presentation. We think that, you know, we should, we should let um everyone feel that, you know that there's, there's a lot more things that we need to take care of and know what to do. Uh apart from just requesting, you know, scans or certain types of scans only because uh I think clinically uh there are a lot, there are a lot of things that as a clinician, we should, we all we should be, you know, looking out for to, to prevent ourselves fall into this pitfall of using scan to lead us. Um you know, in a very, in a certain direction. I'm not, I'm not saying a scan is not useful, but I think it the best way to do it is in a combination of both your clinical findings and then you correlate with the scan findings, then uh you know, patient will receive better treatment from that. Yeah. So essentially the point, the point of the of this case is that uh left iliac fossa pain, it could be general surgical cost, it could be gynecology cause it could be urological cost, it could be other cost like MS K causes. So, so I suppose, but then in just to kind of bring back some memories is that 23 year old child bearing age lady, when they first come in, things that they should have is a urinary pregnancy test. And also ask about the uh you know, the where they their period cycle and then you will then decide whether an ultrasound of the abdomen. Usually you can do a transabdominal ultrasound first. And then if you don't find any proper explanation of what the direct cost of the patient's pain, they may need to consider trans vagina ultrasound if it's appropriate to look for gynecological cause. Uh you know, sometimes things like uh when an implant uh has not been in a position where it should be in the uterus that could cause some discomfort or in the case of left i fossa pain, it could well be um you know, ovarian torsion. It could well be a kidney stones. It could well be a P nephritis. It could well be a um an appendix which is not sighted in the right I fossa, you know, it could uh it could be just in the center side towards the left, then patient could get left I fossa pain as well. Or it could be a case of uh diverticulitis, you know, just, just many things you could think about. So, but then the, so hence uh the reason why uh with the, that I put up this case just to make everyone to have a think about before going straight into CT, there's actually a lot of things that we could do in the meantime. And then, and then this is all these are ct findings of the uh appendicitis. So I'm gonna, I'm gonna come out from the presentation, just use my curso. So as you can see this is an appendix. So on CT scan, we know is an appendix blocks like we try to follow it when we are reading the scans, it's like a blind and a blind ended small so small tube, you know, uh at the edge of the cecum. So usually we find the little valve and then you try to scroll down 4 to 5 slices. This is where you should normally see the appendix. So obviously, they, they come in different, you know, sizes, position and shapes. But um the things that we look out for is there any fat trending, as you can see, as pre I mentioned earlier, you know, clean fat should look like this. This is stranding surrounding the organ. And then, um, you could see there's a bit dilatation of the appendix. It, it should, a normal, a normal appendix should look like small blinded tube than the and the wall is kind of like paper thin. But if it's dilated it freely contents that it's probably something is going on. Uh, as you can see, it's more obvious on this second picture. And then the third picture is just to show that uh uh how appendicolith looks like, uh on CT scan. Yeah, uh just talking about appendicitis. Um Some of you might be interested in like peak surgery so often peet patients and occurring appendicitis or generally peats patients, you tend to do ultrasound because you don't want to expose them to radiation. Um So yeah, just, I'll add that. Yeah. Yeah, that's very true. Um And then, and then skillful, you know, uh like radiographers, they could actually, uh ultrasound may, may just be the things that they need to find out what's wrong with the patient. Um So bearing in mind, one of downside ultrasound is that it could be user dependent as well, especially, you know, like a young registrar like us, we are not, we are not that skillful yet. So, but we hope we could get there. Yeah. And then, uh this is the last case that I, I put up is something that I, I've, I've encountered myself during the on call. So 66 year old gentleman right sided fem, femoral and below the artery bypass one day ago, has developed sudden onset of severe limb pain. So, because it is like a surgical theme kind of presentation, um I thought just to bring back the memories of acute limb ischemia. So when you're seeing the patients, remember to look for the six piece um on the, on the, on the referral and true phone call discussion with the vascular registrar. This patient does um that presented with the six piece day one post surgery and then the most appropriate imaging or choice as everybody would guess is ct angiogram of the lower limb. So um it, it's uh i it's a very good test to look at uh you know, any evidence of, of um kind of abrupt feeling defect of the contrast. So I thought, I thought I could show you and if you ever in doubt, you can use radio pedia as well, it's very helpful. So as you can see, OK, is better. So this is a kind of uh angiogram uh with contrast. So let's first start off with the kind of common iliac comma, eye comma I external I lock and then you see your bifurcations and then, and then this is how like a a normal angiogram she look like. OK. So it, it's just, it's just that straightforward, this patient's got a bit of lower limb diseases, but there's no kind of sudden abrupt feeling defect that make you think it's like a acute limb ischemia. Um The the message for this case is that in general, I think the vascular colleagues, they are very good. They are actually some, I think most of are actually better than us because they know what, what exact procedures the patient has underwent. Um so that they, they know what to look for. The the the job of the radiologist is that of course, we need to look for the same uh kind of clinical pertinent findings. But I think the job of radiologist is also as a supplement to look at other things that are not related to the kind of the vascular territory of stuff, like any kind of collections, any type of other injuries or any type of things that, you know, they could point the the clinician towards other direction, which is necessary. But uh the, the point, what I'm trying to say is uh vascular surgeons. So registrar, they are, they are good at, they're good at reading the CT angiograms and and yeah, yeah, keep doing what they do. So the this is almost the end of our presentation. So just a few take home messages, clinical examinations are very, are very important. Um I know, I know nowadays it's difficult pressure uh and everything keep up with the load, uh you know, staff shortages but, but do spend time examine the patients um before you n because at least, at least you can guide us to what to look at. Because the last thing that we want is that we, we get, we get a scans where both parties doesn't exactly know what we are looking for. And then, you know, we, we are not, we are not doing our job as a radiologist from that point of view. But obviously, we try our best as, as always to try to try to look for things that could explain what's going on with the patient. Um As uh I always reiterate histories are important with filling up the forms and then you have to know what and why you are looking for. CT is useful most of the time, but not all the time. Other things to consider is like CT uh sorry, it's like ultrasound, a radiograph or MRI. But again, you know, this would be, should be a discussion between uh the radiology team and the clinical team and then they will decide what's the best for the patient. And last, but not least we hope this is helpful for people starting off with a surgical jobs. It's going to be a stressful one. But I, I hope everybody can learn at least a very nice job to do and I hope everybody will learn something from it and that's the end of our presentation. So thank you everyone for your time. I'll hand it over to you Lucas. Yeah. Thanks guys. Makes up the swipes think we can hear you Claire. Hello. Right. I'm Claire. Can you hear me? Great. Uh We can't hear you at the moment. Could you try turning your mic on and off? Can you hear us Lucas? Yeah. Yeah. Yeah. Ok. Does anyone have any questions? Yeah, if, if you guys have any questions just pop them in? Um So, ok, so it seems like Claire's having some issues with her Mike, so I'll just take over. Um, so this was just the first part of this session. We do have a second part um in just a bit. Um Unfortunately, the second speaker who's a consultant was not able to join um on med. So what we've done is that we've created a teams link for you guys to join and the consultant will be pretty much adding on to what Chan and Priya has already done and going more in depth into ct interpretation. So I will just pop the link into the chat just now and we'd be very grateful if you could all join on teams. We do appreciate that. Um It's a bit of a hassle to go on to two different platforms. Um But yeah, we will see you on teams in just a sec and please don't forget to fill out our feedback forms um as well if you guys have any questions uh chan and for you will stay on for a bit. Um and they will be happy to answer your questions, but otherwise please pop over to the team's chat. Yeah, I think it's just joint, isn't it? It's just a cut. I just, maybe we should check just to make sure they don't have any questions on the metal. Metal is still open, don't worry. Yeah, no questions. But, you know, they, they, they did type out what they are so good to have interactive session. Yeah. Yeah. The, oh, yes. Yes. I'll be working with G I, mm mm. Yeah, I know. I know. I, that's Yeah, thanks trying to. Right. Sure. OK. Uh uh you can do it. That's this one. Yeah. Yeah. Fine. Ok. Mhm. She depression. Are you doing any like articles research? Right. Yeah. Anybody could just speak to what I wanna do. No, no, but I, what, what the procedure as well? Is there anything that I can speak to you? What this? Yeah. What special TV? You rest and yeah, you prefer to speak to me out of here do at work. Yeah. Well, I, I'm not. Yeah, I, I thank you. Yeah. Um OK. Right. There's no iron, there's no iron after. Yeah, I don't wanna go any time. Yeah. Yeah. Got you. Oh, the constant form is in me. Definitely. Series. What, what? OK. That's why, that's why I do usually do cause III I, I can't, it, I'm not good. I'm not, I'm, I felt in my first language so I don't feel very good at that. Yeah. OK. That