Computer generated transcript

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

Hi, everyone. Can everyone hear me? Ok. Yeah, just checking if someone can, if everyone can hear me, just pop a message in the chat. Uh Brilliant. Um ok. Hi, everyone. Welcome to the next teaching session for the is teaching series. Um I am very sorry that we had to push this teaching session back from the Monday. There was an emergency that um I needed to attend to. So, um, welcome everyone anyway to the part one of the imaging interpretation teaching session. Um just because we've got quite a lot of ground to cover, I'll kind of start straight away. Um, and if there's any stragglers, I people who are attending but are slightly late then they can join us a bit later on. Um. Ok. Right. Can everyone see the screen? I'll probably have to go back just to see the chat. Yeah, perfect. Ok. So I'll just go back. Ok, that's fine. So I'm uh Doctor Ray Fitzgerald. I'm one of the uh psych F two s working at Wrexham. However, I've worked previous jobs and surgery in respiratory medicine, um and anesthetics and it, uh, so chest x rays and abdominal x rays is what we're going to be covering today. Uh We're going to be doing chest x ray interpretation first and then be going on to abdominal x rays. This is kind of a teaching session to give you the basic principles of how to approach most x-rays and pick up the key obvious findings on each um abdominal x-rays. We don't do as much in clinical practice. Um chest x rays, we do all the time, but I'll give you a a bread and butter kind of teaching course on how to to interpret both. So by the end of the teaching session, I hope you'll to check the quality of the chest X ray and ABDO X ray film, know what a normal chest X ray looks like and pick up kind of key abnormalities in the chest X ray and know what a normal abnormal x-ray looks like and how to use a systematic approach for them as well. Ok. So to get started how to approach every chest X ray interpretation. So you've got a kind of a of how to approach it. So always, always, always with every uh kind of um investigation. The most important thing is checking patient details in your actual es you will get a mark just for checking those details. So don't forget it, checking the date of when the X ray film was done checking the type of chest X ray. And there's really only two types that we do in practice an AP film or APA film and I'll explain the difference between er, each then approaching kind of every x-ray, making sure the adequacy is ok. And I'll give you a rubric of how to approach that and then kind of going through your abnormalities. Now use an ABCD E approach as we all kind of use ABCD E anyway, in practice for lots of things such as approaching an emergency situation. And then when you've come to the end of interpretation, kind of giving a differential uh of what you most likely think the X ray is showing. I just wanted to check cos I've not got one of the faculty with me. Can everyone hear me? OK. Can everyone seeing the slides? OK. Just so I, I'll go back to the teaching session. Can everyone see the slides and can everyone hear me? OK? Can someone put a yes on the chart if you can hear me and see the lines? OK. OK. That's fine. So I'll just continue. OK. Right. So what's the difference between the two types of X ray film? So you have APA film and AP film, the way I remember these is er, part of my language but an AP film is a crap film. Er, the AP being the end of the CR AP, mainly because you can't interpret um the heart size on an AP film. So the way the projection works is if it's APA film, it's coming from the posterior side of the chest. So through the back and then out towards the front, as you can see in the top image on the top left, so the heart isn't going to be enlarged as much on that compared to the AP projection where it's coming through the anterior side of the chest and then coming out posteriorly through the back. And as you can see, because it's done that it kind of, it projects the heart slightly larger cos it's got more um uh more space to kind of project it and, and expand it on the image. So the way you can tell between whether it's a pa a film and an AP film, um the, the way that er I used to kind of pick that up is the clavicles, those are quite good at er telling the difference. So with an AP film, you'll see them in the apex of the lung. Whereas on the pa a film, you will still be able to discern part of the apex. So in the bottom, right, you can see on the pa a film on the left, you've still got a bit of apex of lung that you can see right at the top. So you can still see a bit of lung. Whereas on the AP film, the cla of course, are actually over overlapping that apex. So it's difficult to, to make up that apex. OK. So we've gone through the type of chest X rays. Now we're going to go through the approach that you take. So with every chest X ray, you should always check the adequacy of the X ray. And I like to use a rubric called ripe mangos. So each letter stands for something. So your R stands for your rotation, I for your inspiratory effort, P for penetration, E for exposure and M for the mangos being the markings, OK? The markings isn't as important cos with your exam, you're unlikely to get one which has a red mark. Um So really, I would just approach it as looking for your like. So rotation is seeing is the x-ray kind of er rotated at all in either direction, meaning that it's difficult to see one part of the lung or the other, your inspiratory effort er is kind of um explaining, can you see enough of the er lungs that they've taken enough inspiration that the lungs are expanded enough for you to see what you want to see your pee for penetration is how much of that uh um uh kind of imaging is, is uh translucent. So picked up and then your e for exposure is how much you can actually see of all the chest X ray that you'd want to. So right down to the diaphragm and all the way up to the apex, you want to see all of that long field. So I I'll go through exactly what you're looking for. So this is a, a normal one. OK. When I say normal, I mean, one which um doesn't have any pathology but is the adequacy normal. So going through your kind of your right mangoes, you are looking for rotation here, you're basically looking at the clavicles and the spinus process. OK. And II outline these. So if the distance from the spine's process is equal to the clavicle on either side, then the film isn't rotated. OK. It's, it's got normal rotation. But if it's slight, if the distance is slightly more on one side, then you know the film has rotated slightly. OK. So I'll just show you what I mean. So I outlined the first half on the right here and then I outlined the clavicle on the left and then I basically circled around the spinus process. So you can see that the distance to the right clavicle is slightly less than the distance to the left clavicle. So, you know, this film is slightly rotated. OK. So that's something that you would comment on on the exam. OK. Then going onto your eye, which is inspiratory effort. You're basically counting the number of anterior ribs to see. Is there good inspiratory effort? So how you count them is you go right from the top. So you've got your first rib here coming round, then you've got your second rib, then your 3rd, 4th, 5th, 6th and seventh. So there's seven anterior ribs, which means there's good inspiratory effort. So the minimum, if I go back is six, OK, six is an all right. Number seven is perfect, but six is the bare minimum. OK. Then going on to penetration. OK. This basically just means can you see uh the image clearly enough? And the way you can tell is when you look at the spinus process is the spinus process visible. OK. And this kind of ties in when you're looking at rotation, if you can't find a spinus process, you know that the penetration is probably quite poor on the film. OK. So this is an example of very poor penetration on chest X ray. OK. A film being either under exposed on the right or a film being over exposed. And this just er is basically um explaining that when those um er kind of radiographic waves pass through the um er pass through the chest, the film is either too much exposed or too little exposed. So it's just how much um is being projected really onto the film and then exposure. So this is the end of your a of of ripe. So exposure just means can I see everything I want to on the chest X ray? So the best way to look er for this is can I see the costophrenic angles on the chest X ray which are the little er divots right at the bottom of the lung fields on either side? And can I see the apexes now, I can see the apexes quite clearly, but I can't see the costophrenic angles that well. So I know that the exposure isn't adequate for this film. OK. So, although there is no pathology on this chest X ray, I wouldn't say that the film is adequate. Ok. Right. So we've gone through checking adequacy on a chest X ray film. Now we're gonna go on to actually interpreting the chest X rays. So, looking for pathology. So I like to use the ABCD E Mnemonic. Ok. So my A is for airway, B for breathing, C for circulation. OK. And then this is where it slightly deviates from your er, kind of acutely unwell management of a patient, your ABC kind of stays the same D is for diaphragm and A I kind of stand for everything else. And what I mean by that is you're looking for anything like any um wires or ICD in the person, like kind of foreign objects on the film or anything related to bones or soft tissue that you can see. So broken ribs or um uh kind of subcutaneous emphysema you can sometimes see. So, so those kind of things really for. So we now know what a normal chest X ray looks like. Ok. But going through it using like ABCD A, I would look at the airway make sure that it's central and it's not deviated because we've already established that the film is slightly rotated. Ok. That I it's, you know, it's difficult to, to comment on, but I wouldn't say that ea is moving to one side or the other. It appears quite central. Um So that's your a then looking at your b I'd kind of look for any increased um, uh whitening in any of the lung fields, which to be fair. I can't see any opacification. So that means increased whiteness. Um Looking at sea, I'd say the heart size appears normal. You can measure it if you wanted to. But uh grossly looking at it now, I don't see any abnormalities and the heart borders appear quite nice. So I would kind of trace around the heart to make sure there's nothing obscure in the heart border on either side then looking at the diaphragms. Well, I can't actually look at the diaphragms here because as we said, the exposure isn't, isn't adequate. So it's difficult for me to say whether there's any sign of like a pleural or fusion. OK. And then e looking at everything else, I can't see any foreign objects on the X ray and I can't see any um broken ribs. OK. And I would basically just look around the bones to see if there's any like break um in like the cortex of the bone. And that tells me whether there's any um uh any broken ribs at all. OK. But we'll go through kind of how you go through your a to a, so a is for your airway. So the first thing I would look for is uh is there any deviation in the volume loss? So I if there's anything causing the volume loss, the tria will be drawn towards it. And then if there's anything actually causing the volume gain, like either a mass or um a tension pneumothorax where there's a build up of air, pushing everything to one side, then that will cause the tria to deviate away. Um then moving on from your trachea in A, I would also look at the hilar regions as that's kind of considered part of the er a and that's basically looking at the pulmonal your vasculature and the major bronchi. So you have your right hilar region and your left hilar region, your right is normally always um slightly lower than your left. Um And normally they're kind of the same size. So if there's any asymmetry or there's more um volume on one hilar region than the other, then it, it could indicate some kind of pathology. So here, um this is a, a good example of deviation of the tika. So from this film, you can actually see that I'm kind of skipping the point, but if I looked at bay which is for breathing, I would be kind of looking in the lung fields. And as you can see on the left in the left lung, you can see that there's quite a bit of um like volume loss in the the lung region and it appears like there's air surrounding the lung. So there there's a pneumothorax on the the left side. And because the tr is actually being moved to the right, and you can also see the heart as well as being moved to the right. Then you know that this is a pneumothorax causing um movement of of all of the uh the kind of chest structures to the right. So this would be a likely tension pneumothorax and a tension pneumothorax is often um you have to kind of link it alongside. Is there any hemodynamic instability um with, with that kind of uh examination finding as well as chest X ray finding. So you can see that that's where the lung field basically ends. So you know that anything outside of that is basically a and that's where the trachea is. So it's deviated slightly to the right. OK. So here is it's a bit difficult to spot this but going from ra the key is central. But then when we look at the hilar regions, the high low regions appear quite enlarged. Ok. There's a some people would think the this is like a pacification. So you could think maybe it this is infection or what have you. But because both hilar regions just look slightly more enlarged than normal, this would be what we call bilateral hilar lymphadenopathy because it's b it's both sides and this is likely related to the lymph nodes being enlarged and some kind of pathology related. So that's that the enlarged Hyalo regions, you could just say there's bilateral hyalo enlargement and that also would be equally valid. So you can actually compare the difference between what normal hilar regions look like and what abnormal hilar regions look like. So on the right, you can see that you, you can partially make out some of the vasculature and and airways on the right and on the left. But in the, on the right image, the BHL, you can see that they're, they're very, very enlarged. So BBS for breathing. So this is why you're looking at your lung fields, I would always split them in or I not just me, but good practice is you split them into your thirds and either describe it uh on your right or your left. OK. And whenever we're kind of talking from a chest X ray perspective, if we don't have any clinical context, consolidation is often referring to infection, whereas opacification just means whitening. So you're better placed to say that there's opacification on an X ray rather than consolidation because consolidation, you're jumping to the conclusion that it is infection. So better to just say there's opacification and that indicates to the examiner that you've, you've identified that there's just increased whitening on the X ray. So this is where you would split your chest X ray up into your FBS. So you have your upper middle and lower and you have your right lung region, your left lung region. OK. So, from this chest X ray, I'll just quickly um, let everyone have a look and then people just drop their, er, er, ideas in the chat. What do you think this is? And remember what I've said? Don't, don't jump to the conclusion of something I've not given you any clinical context. So, just describe what you say, I'll just stop sharing really quickly. I just have a look what people are saying in the chart. Yes. Very good. So I would agree that this is right, lower lobe and quite correct is this is opacification. OK. You're not jumping to the conclusion of consolidation. So I would also say there's some middle uh if if you split this into thirds, you could say that the middle um right, middle lung zone is also affected. So I would say that there's right, lower lung zone opacification with possible middle, right, middle uh lung zone opacification. And then also uh when you get to your differentials at the end, you can say this uh likely could indicate a chest infection. However, this also could be fluid in the lung. This could be so a pleural effusion um whenever you're kind of giving differentials in the exam, you say you're most likely. But then it's always good practice just to say, could it be something else? You never know there could be a pleural of fusion underlying this as whitening that obscures anything underneath. Same thing goes, there could actually be a mass underlying this um opacification. That's why whenever someone has a, a chest X ray and they've got a chest infection, we always do a follow up chest X, chest X ray in a couple of months because it allows us to see once that chest infection has resolved. Is there anything like a um a lung cancer underlying it? Um which, which you wouldn't be able to see from the initial chest X ray? So that's where all your pacification is, all that line there. OK. What do you think? This is? Everyone just popped their ideas in the chat. What do you think even better is if you can like go right from the start. So going for your A and going to your B this one's a bit harder to describe but um see see how you, how you can sort of explain this if you were in an exam situation. A R DS. OK. Yeah, I, I'd et cetera. What? Um so that's kind of like a differential. So that's what you're thinking it could be. So DS is acute respiratory distress syndrome and it's often um it's a because it's a syndrome, it kind of um it describes more of the collection of chest X ray findings, but also um kind of uh hemodynamics and how well the patient is. So A DS, if you have the time, actually, I do recommend you read up about it in your own background. But one of the things that it will often describe is the chest X ray and it's this bilateral haziness. So a lot of people have put this generalized bilateral patchy OFAC, OK? And someone's also put bilateral pa patch ofac all lung zones. Yes, good. So I would agree that when you're describing it, but just go back when you're describing it, I would describe this as bilateral, patchy is the perfect way to describe this. It's, it's just all over, there's spots all the way throughout the lung zones that are being affected with this opacification. Now, if you see a chest X ray like this, yes. A RT S can be something you're thinking about an A DS more describes the pathology of what's happening. But in this case, because you're seeing all this white whitening across the whole lung zone, this is fluid. So this, this would likely be something like a pulmonary edema um where fluid has basically uh leaked out of the blood vessels into the, the airway or into the RV O LSAC. Um And this can be related to heart failure DS um which is often a uh a reaction to something. Um but with this kind of chest X ray, the best way to describe it would be it's bilateral, it's involving all the lung zone and it's just patch pacification and then the air, if you were to comment on the a your airway, I can't, the t from what I can't make out it's central, the higher regions. I would actually say in the exam, I can't really discern where the higher regions are because of this oac oac opacification. Yeah. Another description you can make is initial opacification. Uh which just means um I II would disagree with that. Actually, I would say patchy is probably a better way to describe this, to be honest, but I've, I've heard students say interstitial opacification or just widespread opacification, all of them are valid, I would say as an examiner. OK. So this is something that I would say likely resembles pulmonary edema, linking this further to something like heart failure, you have like specific findings uh for heart failure. So there's the pneumonic abcd. So we, you, you see this one come up a lot. Um It is a, a fan favorite by a lot of people. Um But these are kind of your key findings for congestive heart failure, congestive meaning things are backing up uh often into the into the lung like like the blood and the fluid. Um and these are kind of your specific things that you see. So a is your alveolar edema er and you get like this classic ba swing appearance, that's more around the hilar lung regions. Um You get these things called curly bee lines, which it would be difficult to show, show you all that I'll see if I can, um, find a good, uh, see if I can enlarge this at all for you and just draw on it. Your curly bee lines, they'll, they'll be like little strands here. It's very difficult to actually see them on this X ray. But you basically see like these white lines, very discernible white lines coming down, um, from the periphery of the lung zones coming inwards, almost like the, er, how the ribs do. And this is basically fluid in between the um actual like lungs themselves, uh kind of like a pleural fusion almost, but the fluids actually accumulated in between the uh the lungs themselves. Um and that's your interstitial edema. Um I, I'll see if I can actually find a better picture for you all to actually see that cos it's, it's quite a um good finding to be able to spa and then you see is your cardiomegaly. So this is an enlarged heart. So your heart rate, your cardiothoracic ratio is something that we use. And that, that's basically just a measurement on the um the widest diameter of the heart. So you basically will go from the uh right from the outside all the way to the um edge of the heart border if you like. And then if that heart size, the cardiothoracic ratio is greater than naught 0.5. So your thoracic ratio is basically from the edge of your thorax right to the bottom to the other side, your cardiac ratio is from the widest part of one cardiac border all the way to the other cardiac border. If that ratio is greater than naught 0.5 that you can see on the chest X ray here, then you know that um the cardio ratio is larger than naught 0.5. It's very difficult to actually comment on that if you're dealing with a AP film cos as we said before, an AP film enlarges the heart already. So you can't really comment on that and then d is looking for your dilated pulmonary vessels. Um You can actually see on this X ray, you um the vessels coming upwards, it's very abnormal to see that. So that's likely those upper lobe vessels being dilated and then e for an effusion. And that's if you see any blunting of the cost angles at the, at the bottom, which I'll show you later. So see, for circulation, this is where you're looking at the er heart size, the heart position. So as we saw in the previous tension, pneumo thought we actually saw that the heart was actually positioned more to one side, you're looking at the heart borders. So if you see any obscuring them of the heart border, you know that there could be some kind of opacification obscuring that then looking at a very specific area called the aortic knob and the mediastinum, that's really important for picking up things like dissections. So this this area is your mediastinum here. And if you see any widening of this mediastinum, then this can indicate like an aortic dissection or um uh an aortic aneurysm more likely. So you have your knuckle, which is th so this is your aorta coming down here and this is the knuckle, which it, it looks, it looks like a knuckle. That's why they describe it as such. And you've got this little gap in between called the UL window. Now, if you see any loss of that window, then that can indicate uh kind of mediastinal lymphadenopathy. Um but also if you see that loss of that window and you see um widening of that mediastinum no, and a reduction of that defined board of the knuckle. And that can also indicate something like an aortic aneurysm. So this is a perfect example. If I saw this, I would be very worried because you can clearly see that that's where your media, that's where the mediastinum has, has eventually finished. So you can see that that mediastinum is significantly widened. So that would be a a worrying sign of something like an aortic aneurysm there. And you could also argue that um because this is the pa a film, if I was to measure that cardiothoracic ratio, the heart does look enlarged to me. So II would also say that there's maybe some signs of cardiomegaly on the er the film as well. Um The costophrenic angles don't appear very discernible. So maybe there's some evidence of bilateral pleural effusions. Um So, and then also on the right side, you can the right and the left, you can see those upper lobe vessels coming up uh here and here. So you may also say that there's some di dilated upper lobe um uh vessels as well. So this could be an indicative x-ray of heart failure as well. So, um um uh as we said before, congestive heart failure, which could be linked to the aortic aneurysm, then moving on to your D so D for your diaphragm. Um This is where you look to see, can you see a really er discernible um costophrenic angle. So normally they should be quite jagged. So if you see those being blunted, that's the description we often use and that can indicate like a pleural or fusion. Now, II men, I didn't mention this but it is on the slide, you can have flattening of the diaphragm um or, and this also this indicates like a hyper expansion of the lungs. So if you can, if you look at this X ray, you can see that the diaphragm appears flat. It's not got that nice um er sort of round like rounded appearance. II think convex would be the convex would be the right word to describe that. Um And then as well, if we were to go back to checking adequacy of a chest X ray, you would often be counting like the number of anterior you say for this, I'd probably say there's, there's 1234567 eight. So it does appear like there's quite a lot of lung feel that I can see. It's, it's got a hyper expanded appearance. Um And, and this would be indicative of like AC O PD in like a picture on X ray. So the, the way you would, the way some people would describe this is you've got in the right lower lung zone, there's this increased opacification. OK. And the difficult thing here for people as well is this opacification related to like a chest infection or is this something like a pleural effusion? And when you're looking at these, the way you can tell the difference is looking for something called, which we call the meniscus. So the meniscus is like a nice well defined line uh basically showing like the fluid level. OK. So with this, you can actually see, I've tried to draw it on the best I can. This is this is the uh line that best sort of discerns that fluid level, which would basically be the meniscus if this was like a chest infection and you had a pacification, you would see much more patchiness to it. Whereas this one, it's got quite a nice discernible point where you have lung field and then you have this opacification. So that's how you can tell the difference looking at the diaphragm as well. Uh sometimes you'll see x ray, chest, x rays where they have uh air under the diaphragm. The most important thing is discerning is this like a pneumoperitoneum. So, um this with uh pneumoperitoneum being where you've basically got air, that's, that's in the actual um abdomen. And this can be related to like a perforated viscous, um, like a perforated bowel obstruction for instance. Um And how do you differentiate this from a gastric bubble? Which is when you've got air in the stomach, which is perfect, which can be normal. So a gastric bubble you'll often see on the left. Ok. Whereas on the right, that's where you'll normally see a pneumoperitoneum because you, your stomach is always on the left unless you have like some anatomical ABN um, a abnormality. Um The other way I can tell this is the gastric bubble is, it's much more circular. Whereas with the pneumoperitoneum, you can see that it, it's got like quite a defined line where that fluid where that air level um is ba that air is basically accumulating that you can see on the right and then finally moving on to a, so this is your everything else. So this is where you'd look for any like medical operators. So like ECG leads chest drains, pacemakers, bones, look for any rib fractures and then s for your soft tissue. So, um, II would look for any kind of like masses or uh something called subcutaneous emphysema, which I'll show you what that looks like. So subcut sema basically means air within the subcutaneous tissue. This can be if you have um uh a break in the skin and then air has basically got underneath. So lots of patients who go for surgeries, you've opened them up and then if you have a sub or even if you do like a chest strain, which has opened up their skin to put something in doing, that means air can get, get in. And when that air gets in, what it does is like how chest x rays and abdominal x-rays and all x-rays work, it, it outlines what you're seeing and so that air which has accumulated in the tissue starts outlining structures that you wouldn't normally see. So on the, on the left, you can see one which actually is outlining the, the muscle, the pectoralis muscle. And that's what, and that's why it looks like a Ginkgo leaf cos those are your muscle fibers that are being outlined by it, which is quite cool on the right. That's basically showing another sign of that emphysema, which is like this patchiness, which you may, which, which you may initially think could this be opacification in the lung zone. But again, this is outside of the lung. So it's, it's, it wouldn't be something like a, a calcification related to like a chest infection or something cos it's outside the lungs. These are kind of your um I just wanted to show all of you what these like look like. So if you ever did see one in a um exam, you know what they look like. So a, a loop recorder, this, this records like heart rhythms and we put this in if you've had like arrhythmias that cause them are always suspecting someone's having an arrhythmia that's caused them to have like syncopal events. So the best way to describe this is, it looks like a USB stick. Um And it's, it is quite easy to spot. Then you've got like your P pacemakers and your ICD S. So a pacemaker will kind of have this appearance where you've got this lead, but it's this lead that's coming out. It's got like the same, same kind of um thickness to it, same kind of whiteness. So is, is quite easy to differentiate that from an ICD coil where you've only, you've got like this really thin strand coming up and then you've got the ICD coil which is much thicker and then you've got like the strand bit again and then an ICD, you have like two. So you can have a single chamber, one where you've only got one lead and then you can have a, a biventricular ICD which has two leads to it. I wouldn't worry about differentiating the two. Just know what a pacemaker looks like and what an ICD looks like on a chest X ray and that's pretty good going. OK? Does anyone have any questions before we move on to abdominal x-rays, we've already covered quite a lot from chest x rays and I know I'm going quite quick. But, um, does anyone want me to go over any of the slides again or um, explain anything that, that didn't quite make sense? I'll just give people a bit of time to, uh, put any questions in the chat. So making good timing anyway. Ok, I'll move on. But if there's any questions that, that I don't catch, I'll, I'll um go back to them. Ok, bye. So, moving on to your abdominal X rays. Now, we don't see that many of these in practice. The only time that we do ever request like an abdominal X ray is if requiring something like a bowel obstruction for a patient. Um Usually we go for things like CT Abdo pelvis is now in practice. But if you want something quicker and you want to rule out a bowel obstruction, we normally will go for like an abdominal X ray sometimes. So you have different types of abdominal X ray. You're only really going to get in the exam. A standard abdominal x-ray, which is an ap projection. Um However, you can get others like pa prone and lateral decubitus upright A PS. But II won't go through those as those that you're unlikely to be getting. Same thing goes. II like to keep the rubrics the same if I can so ripe mangoes, I still use, it's just you don't, you don't really look for inspiratory effort on abdominal X ray because you're not looking for um ribs, there's no inspiratory effort needed for abdominal X ray. So you only really need to worry about your R pa and they still stand for the same thing. And then I use another mnemonic called Bob and I'll show you why I use that mnemonic and then lastly always finish off with your differential. So how you'd complete your, um, move rather than how you'd complete your summary, what your main differential is. And, um, why you think it's that? Ok. So this is what a normal abdominal looks like. Ok. Um, often than not, it's very difficult to see any of the abdominal organs like the liver, the spleen, the kidneys. Um, but the most important things you're looking for the bowel, ok. And you have your large bowel and you have your small bowel. And the most important thing is first finding out the bowel that you're looking at? Which type of bowel is it? Does it look normal? Um, and is there anything kind of abnormal that, that you can spot often than not all the other abdominal organs? They're very difficult to see any pathology with. Um, and if you are investigating those, you'd likely be doing like a ct of the pelvis. Ok. So, starting from the, er, the start because that's where we want to go from checking the adequacy of the film. So same thing again, looking at rotation, but there's a different way to look at rotation on an Abdo x-ray. So you'd basically be looking rather than at the clavicles, you're looking at the pelvis and then you're still using that spine as process as your defining central point. Mainly because your, your spine is always central. It's quite a nice landmark. And so your spine as process is directly in the center. So you know that if there's any asymmetry to that, then the film probably is rotated or something's going on, we go past eye cos I doesn't stand funny thing on our Abdo x-ray. Oh So your penetration. So making sure it's not too white or not too dark, your e for your exposure. So can you see everything you'd want seen on Abdo X ray and then empty mangos markings? But you're unlikely to get one which puts a red dot on. And just so you know what the, where the red dot normally is. What, what I mean by that is certain, certain times when um a radiographer wants to kind of highlight something to the clinician when they've requested an X ray and there's something abnormal, they'll put a little red.in the corner and that's a way of them basically saying there's something abnormal on this X ray that you need to be aware of. Often the reports come with them. So that will tell you what's abnormal. But again on the film itself, they'll often put that mark as well. So this is a normal abdominal X ray. We're gonna use this as our um er defining one to go through the adequacy of the film. So first checking rotation, you're gonna mark around the pelvis and your spine is processed to see. Is there any asymmetry or difference in distance? That's meaning that it's rotated one way or the other. So this is the the first kind of line that you're drawing around the pelvis. So that's on the, on the right and then on your left. So you can just see where I'm drawing around. So you know how to and then you've got your spinal sclerosis. So grossly looking at this, the distance looks roughly the same. So I wouldn't say the film is rotated at all. It look, it looks OK. Then looking at the penetration, I'd say that I can see the spinus processes clearly and that's the best way to tell. So I'd say there's no over exposure or under exposure of the film. Yeah. So I can see that one clearly. So I know that the film looks OK. And then lastly looking at the exposure, now I can see the femoral joint bilaterally, which is good. So I know the bottom part of the film is OK. But when I'm wanting to see the diaphragm, because I want to see all the way up to the diaphragm on an abdo x-ray cos that tells me anything going on with the liver and above the liver, like a pneumoperitoneum, for instance, which I'd still want to be seeing on an Abdo x-ray. I can't see that on this film. So I can see the femur joints really well. I can't the femoral joints really well, but I can't see those diaphragms. So the exposure is inadequate. Ok. So that's adequacy then moving on to interpretation. I like to use the mnemonic. Bob. Why did I choose Bob? Uh as the mnemonic? Well, I always thought Bob, the minion looked quite jaundice and bloated. So he's kind of like your abdominal pa your abdo patient that comes in with like hep uh hepatology and, and those kind of things. So, uh I just always thought that it was quite a good way of remembering it. So your B stands for your bowels, that's the first thing you're looking at then your o for your other organs, which we've already kind of uh, gone through that. It's difficult really to evaluate. So if you can't see them, that's no worry. And then lastly, B for bones and bones, you can also include bones and anything else. Yeah. Cos that's always something that you just want to pick up on. Uh, any x-ray. Ok. So first your first B, which is LS. Ok. You've only got two bowel, you've got your small bowel and your large bowel. Ok. How do you tell the difference? Well, small bowel, it's often in the center if you have to X ray because it's all your small bowel always sticks in the center. You often have these things called valvulae convenes on them, which I'll show you what those look like. And this is something that you should remember because it's kind of the most important thing with ABDO X rays. That is this rule called 369 rule. And it basically describes the maximum normal diameter of that bowel. And if it's over that, then it's likely indicating that you've got some kind of obstruction and it's causing that bowel to be dilated. So 369 basically describes and it, it's quite useful cos it goes and stages. So it's, it's moving up. So you start your small bowel, that's three centimeters is your max diameter for that, then you move on to your large bowel, which is six centimeters. So anything over that would mean that you've got a large bowel dilatation. And then your nine is basically describing your caecum that also describes your sigmoid as well. So those are the maximum er normal diameters of those particular parts of the bowel. So your large bowel in general is six centimeters. But your caecum and your sigmoid of your large bowel are nine centimeters. Ok. So just commit that to memory. So, moving on small bowel, central position, valvular kind of entities, less than three centimeters. Ok. Large bowel, it's on the periphery so on the outside. Ok. To the small bowel, you have these Haustra, ok, which have a specific look to them on an ab xray and they're normally less than six centimeters excluding your si your sigmoid, which is nine centimeters. Ok. Things that you're looking for on bee. So, of course, if there's dilatation of the bowel, that's your most important thing, any gas in the bowel wall, which I'll show you what that looks like. And if there's any specific findings and one which you sometimes see comes up in the textbook is this Rigler sign, which basically is this bowel on bowel appearance. So one bowel wall is basically crossing over another bowel wall. Ok. So this is a normal abdominal X ray. Ok. On the white, uh, with the white hose, it's showing your a large bowel. Ok. So going through how you, um, kind of differentiate the two, it's on the periphery. Ok? You can see these Haustra, ok. And the HAUSTRA are these like very thick white streaks going into the bowel. Now, they look a bit like val convenes, but val convenes have, they're more bunched up and they're thinner in their parents. They're, they're thinner strands. Ok? This one doesn't show it as well, but I'll show you an image that is a bit easy to see. But I know this is large bowel anyway, because it's on the periphery in the center where the black arrow is, that's showing a small bowel and the best way to tell this is small bowel is, well, it's in the center is your large bowel is unlikely to be coming over to her. Ok. So this is, this is what Haustra looked like. Ok. They're these white little divots going into the bowel, but they don't completely cross over. They're very thick and they're kind of almost like streaking into the bowel. Ok. Now, here, ok, this is showing an actual dilatation of the bowel. OK. So I know how I said initially, the bowel normally is on the periphery, but in this case, the bowel is completely dilated. And you can tell that this is large bowel, even though it's in the center because I'll just show you on the image just so you can see these here are your house strap cos they're not going all the way over. They're little, they're thick little strands, almost like thumbprints. OK? Going into the bowel. OK. And I can tell, uh, obviously we would measure this to, to know for certain, OK. But we don't, but we don't have the kind of tools to, to do that on this. Uh Mainly because this isn't, um, kind of a, a radiographic app that allows me to measure, but even just looking at this, I can tell that this large bowel here is dilated cos this doesn't, this isn't normal size for large bowel. OK. And I've drawn an, I've kind of put a cross there to show that you can see that this large bowel is completely dilated all the way along. Ok. If I just draw the, the path that goes around here all the way through here comes over and then all of a sudden you see it stop, you don't see any more large bowel down here. Ok. And that's basically showing the transition point that this is where the, the obstruction is occurring, that's causing that backlog that's allowing that bowel to become dilated. OK. It just came back. OK. So how do I know this is large bowel, most of it is on the periphery. It has the Haustra that clearly show that this is large b and also commenting on this being the transition point. OK. With the th would be the things that I would comment on. OK. So this is showing your uh small bowel. OK. Again, this appears too large for a normal small bowel. OK. Small bowel is meant to be less than three centimeters. This definitely is not three centimeters. OK. I can clearly see what we call the bowel with the kind of entities and on the, so the left is what the no, the Abdo x-ray would actually look like. The right is basically lightening up the features on it. OK. And it's showing those val kind of entities which are those thin strands that cross over the small bowel and they're kind of continuous all the way along. OK. This is something that sometimes people get a bit stuck on. Ok, whether you've got like this patchiness, ok, where the bowel is and they're like, what is this? Ok. This mottled appearance is basically feces. Ok. This is what feces looks like on an Abdo x-ray. Ok. So you can see it circled there, you can see it circled there and even in the top left, you can see that there's some mottled appearance which, which also could be feces as well. OK. This is kind of a classic sign that um, it would be like one of those spot diagnoses that examiners just want you to uh to immediately spot, OK, which is a volvulus. So a volvulus is when um, the bowel basically twists on its own mesentery, OK? And that causes an obstruction. And so you get these like classic er, findings or classic um, Abdo x-rays from them. So the sigmoid vvs is where the sigmoid colon basically twists on itself. And you get this classic look, which is called a coffee bean sign. And in fact, when you look at the Abdo xray, you can actually see the coffee bean, OK? And on the right, you have what we call a sequel Volvulus and it has this appearance called a fetal appearance kind of looking like what the fetus looks like in its early stages and um, um, embryological development, OK. This is just a kind of a quick tease of what the difference between a cecal varus and sigmoid vus is in terms of which demographic effects, which bowel effects and uh and so on. OK. So that there all the slides are uploaded by the way onto meal. So if you want to read these and, and learn about these, I've got, there's some extra like things that you can look, look up. OK. Um So another thing that I just want you guys to sort of know about is in inflammatory bowel disease and features to look for on an Abdo x-ray. OK? So the first one is something called thumb printing. OK? So you saw what normal haustra looked like, OK? But when you get this thickening of the mucosa, OK? Which you get in IBD, thi this is because of the like edema that you get and the kind of inflammation that happens, you get like these thumbprints that project into the lumen and I'll show you what this looks like on. And after X ray, you also get, you also can get a feature called lead piping. OK? And this basically just describes a colon which has lost all its features really and it just looks like a, a pipe almost. OK? And then sometimes something that you'll hear is something called a toxic megacolon. OK? This is basically a, a condition where you get this colonic dilatation on an A X ray, OK? But there's no obstruction and you have some kind of colitis going on. OK. So this is what printing looks like. So to say this isn't what normal house looked like. The house that you saw earlier still looked a bit thick, but they, they didn't look as thick as this. OK? And you can see, I've kind of got these thumbs sticking in which, which shows what the thumb printing basically is. Ok. Hi. So this is um uh kind of an Abdo x-ray that I got, which was IC megacolon. OK. But it had a really good finding to it, which was this featureless colon. So that's your lead piping. So a featureless colon. Um, and this was an Abdo X ray of um, er, a toxic megacolon, mainly from how the patient presented. They didn't have er, any obstruction, which they could see, I think on the CT or the Abdo x-ray. Um, and they had a background of infectious colitis and this colon was dilated. So all in all that encompassed a diagnosis of toxic coma and that, that's your lead piping. I've showing that this is a sign that you sometimes see, I wouldn't worry about it too much, but it's something that you can be aware of. So, um, Rigler sign. OK. That's the only one which I really want you guys to know about is this kind of crossing over of bow. OK. And you, you've got these different arrows basically showing it, but the one which I want you guys to, to really look at which, which shows it best is you've got the one right on the far left. Then you've got the one which is kind of second left. Ok. Just, just left to the V sign. Ok. That one shows a bit of, uh, bowel. Ok. Coming up here, I don't know whether II can enlarge this and then, and then draw it on for you all. So you can see, I'll just draw under it. You can see there's the line going up here, ok? And it crosses over like that and then you've got this line coming up and it crosses over here. So you've got this bowel on bowel appearance, OK? And what this basically indicates is when you have a PF um, like a pneumoperitoneum. OK? And as we know, air likes to show everything, OK? You wouldn't normally see, it starts showing up all the bowel, OK? And that's when you start getting this bowel on bowel appearance where things are crossing over because that air is basically showing up everything that you wouldn't normally see. OK. So moving on from b so we've covered quite a lot in bowel this I don't really want, but o is looking at your other organs, the only thing you can very easily see in a spot diagnosis for an ABDO x-ray is chronic pancreatitis, OK? If there's calcification, OK? And I'll show you what this looks like. So this is what this calcification looks like. So it's very easy to see it it's like patchy increased calcification where the pancreas would be. So, you know that that's likely pancreatic calcification indicating chronic pancreatitis. Ok. So you don't see this in acute pancreatitis. Ok. So if you did want to look at other organs, OK. Going back to our um normal uh our x-ray here, OK. You can see some of the all abdominal organs. So this is where they would all be, but again, very difficult to really kind of exa like examine any of them or, or make any conclusive uh diagnoses as they're very difficult to see. So I would only really look, see, is there any pancreatic calcification, maybe look at the kidneys and see that there's no like kidney stones and these would just look like very um kind of uh if, if it's a, a kidney stone that shows up where it's got that um white appearance on, on an Abdo x-ray, which not all of them do, but you would see like a stone. So a very small circle that's lighting up and then lastly to finish off your b is for your bones. So, um these are kind of, so this is looking at like your spine, your pelvis, your femoral joint, um mainly just look at them to see. Is there any increased whitening? This could indicate METS and also look for any signs of like osteoarthritis. And if there's any like fractures and a fracture would basically just look like a break in the cortex, not easy to see on an ABDO X ray, but just look at the bones and make sure there's nothing really obvious that's standing out. Ok. So there's a good mnemonic for osteoarthritis. Um II won't go through all of this because um we're II don't know how well we are for time, but the signs are on here and you should be able to see all of these. So loss is your mnemonic that we use. So loss of joint space, osteophytes. Subchondral sclerosis and subchondral cysts, I'll show you what all of these look like. So subchondral cysts, they cysts. So you kind of have like this loss of opacification that looks like a um uh kind of a collection almost. That's the cyst subchondral mean its next to the joint osteophytes. These are what like. So you've got like these increased outgrowths from the bone. Ok. This is uh an X ray showing marked sclerosis, sclerosis, meaning hardening of the bone. Um And you can see it probably better on the right that it's really white in that specific area. Ok. Right. So that's everything. So I'm more than happy to go over any of the sides again, but you should now be able to go through a chest X ray and after X ray with some with a bit more confidence and be able to pick up certain things that, that um are important and are kind of your main things that they'll probably ask you in the Cardiff if I give you. Ok, cos you remember they only, they have to give you something that when you're rushed for time you'll be able to pick up quickly. So remember that, OK, so chest X ray go through your first but every x-ray obviously patient details, date of film, all of that jazz then go through your quality. So right Mangos, normal chest x-ray ABCD E and then your most kind of obvious differential A X rays, same mnemonic just without the eye bob for interpretation. And then your main differential, these are the um places that I've got my sources. So any questions we have covered a lot. So um I know it, it's a very, very quick whistle stop tour. But um I'm hoping that we at our kind of later sessions, we actually can do a bit of 1 to 1 quizzing on certain and x rays, sorry and chest x-rays. I Yeah, nice. Has anyone seen any X rays or um kind of want to know what's at least kind of want to know what certain x-rays I've shown you were showing um that you think that you've spotted that, that I haven't gone through or um it seems I've stunned everyone into silence, but if there's no questions then um thank you all for listening and coming to the, the talk. Um That's all I have for all of you. Um So the next in person session will be um, hopefully, uh, not this Monday coming up the next Monday. Um, we still need to confirm a few of the details. But, um, yeah, we'll definitely be letting you all know when that's going to be ok. But if no one has any questions, then thank you all for, for attending. And, um, uh, yeah, enjoy the rest of your, your evenings and your weekend. I'll hang around a bit more for a couple of minutes if anyone has any questions. Oh, brilliant. Thank you. Every, everyone for attending. Um, and I'll, I'll finish the session now. If anyone wants to email me or, or drop me a message or anything, uh, with any questions, then please do. All right. Take care everyone.