Radiology Dr John Curtis (08.12.22 - Term 2, 2022)



This medical on-demand teaching session for medical professionals covers the diagnosis of small bowel obstruction due to gallstone ileus, the presence of a lesion on the right side, and how to use CT and MRI scans to accurately diagnose the cause. During this interactive session, viewers learn about the Ridiculous Triad, how small bowel obstruction occurs with gallstone ileus and how to use contrast for brain imaging. Participants also discover how to identify a space occupying lesion with MRI scans.
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Radiology Dr John Curtis

Learning objectives

Learning Objectives: 1. Demonstrate understanding of the conditions of small bowel dilatation secondary to gallstone ileus related to small bowel obstruction. 2. Identify the characteristics of a gallstone ileus and the relevant radiographic signs. 3. Discuss the appropriate imaging techniques utilised when assessing gallstone ileus-related small bowel obstruction. 4. Interpret radiologic imaging reports and document results of patient assessment. 5. Demonstrate the ability to differentiate between central necrosis and a space-occupying mass lesion in the brain via the use of contrast studies.
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The following transcript was generated automatically from the content and has not been checked or corrected manually.

Okay. Good morning, everyone. Um, in the UK, it's extremely frosty and very cold, which is not unusual at this time of the year. I hope everyone's well over in Ukraine. And wherever you are watching this, I'm just going to continue on last week's zoom recording. Um, we, uh, looked at this on the first of December, and I think we got up to, um, number seven. Okay. It's not getting short goes, I think. Sorry. I think it was dislocating shoulders, uh, dislocating shoulders. Okay, that's fine. Um, let's have a look. Um, no, I think, um, that might have been the week before. Um, yeah, I think that was the week before. Um, let's go on to number seven. Okay. On this particular, um, link. Have you got the link? Has everyone got the link? Yeah. Yes, yes. Right. OK, so if we go on to number seven, open study and this is a patient who has got abdominal pain. So I'm just waiting for the some of the some of the films. Take a little bit longer to, uh, to fire up because of the internet. But you can see here We've got a patient with abdominal pain. What do you think about this? Uh, this bowel here gets smaller, large bowel. I think it's a large bowel. Why? Why do you think it's large Bowel it diameter? That's the only thing you don't think of. Larger than the diameter isn't Isn't that big? Actually, this is only about three centimeters better, and you can see the fold called the fall Feely convent highest. That's going right across the diameter of the small bell. Okay, so this is small bowel debilitation. Now, this is very, very subtle, but can you see a bit of gas going up and branching just here? Maybe not. That's fine. Um, but we'll come back to that. You can also notice that this patient's got osteoarthritis of the left hip joint space, narrowing osteophytes and few subchondral cysts. So this is typical osteoarthritis Gonna zoom up into the, uh, area over the liver and you can just see this branching. You'll be able to see it on your own screens if you open the case and you can see some branches here quite subtle. That's definitely small bowel, because the folds are going right the way across right the way across here. And so we, uh we then look at the, uh, CT, and we've got a CT with and without contrast. So I think the one with contrast, we look at first, I think this is a historical one. So this was a few years earlier, I think, from memory. What can you see here? So this is a This is about two years earlier than the the X ray pharmacist or a nap Cysts. Um, Well, um, if you look at what it's a stone in the gallbladder. Okay, there is the transverse colon. Remember, this is two years before the presentation of abdominal pain. So there's a stone in the gallbladder. And as we scroll through, just go through a bit of anatomy for you. There's the cord. Eight labor of the liver. There's the left lobe of the liver, which comprised two segments two and three. This is segment one, and all the other segments. 4 to 8. There's four, and then right down to here is statement eight. Okay, so that was the portal vein. There's the inferior vena cava. There's the aorta. There's the adrenal gland, which is like a little slip. And there's the other limb of the adrenal gland got kidneys on both sides. There's the left renal vein, which drains into the I B. C. And you know it's the left renal vein because you can track it back to the left kidney. Okay? And then we've got large bell here with feces. Then there's the transverse colon, which you're seeing here. Just that and there's the uterus. And then all of this is small bowel with gastrograph in and we give gastrograph in to outline the bowel on the CT scan. Okay, so anyway, let's go back to the abdominal film. So this patient has presented with abdominal pain. We've got delectation of small bell, and we've got what looks like gas either in the biliary tree or the portal venous system. Now, because, um, it doesn't go out to peripherally. My hunch is that this is going to be biliary tract gas. And if we look on the, um, CT, this CT hasn't had intravenous contrast. So we've got gas in the biliary tree, I can no longer see the cool bladder, and the reason for that is probably because the gallbladder is now stuck down to the liver and whatever was in the gallbladder has emptied, and it's gone into the small bowel here. So this is all dilated. Small bowel. This is the colon. And can anyone tell me why the small bowel is dilated and the colon is collapsed? Uh huh. This is the colon here, and it's very much collapsed compared to small bell. So why might that be restriction? Important system? Yeah. Small bowel obstruction. Okay, now, the other thing that we need to do when we look at C. T as well as seeing dilated small bowel if we see an area of, uh, normal or collapse small bowel, we know that there must be a mechanical obstruction. Okay, So as we go further down, we can see that there is some normal small bowel here. Okay, this is a large bell which just collapsed. But this is small bell and I can stay. That's the Goldstone Goldstone, isn't it? Yeah. So this is very nicely shown on this Corona will CT. So I've just sectioned it at that corona level, and we've got gallstone causing obstruction. There's gas in the biliary tree. This is a gallstone. A lius. Okay. Now, as as a cause of small bowel obstruction. Do you think this is common or uncommon? That's the normal caliber about that is going away from the obstruction. Okay, so it's the normal caliber small bell. It goes away from the obstruction just here. And that's the point of obstruction. Well, it's not a very common condition, but as you get older, it becomes a much more common cause of small bowel obstruction. Okay, so this is gallstone Alias, and it's characterized by three things. An ectopic gallstone. So a gallstone not in the gallbladder, dilated small bell and gas in the biliary tree. And those three things are terms recliners, Triad. Just put it into the chat Ridiculous triad. And it means that you've got small bowel obstruction. Now, does anyone know how small bowel obstruction occurs with gallstone ileus? What's the first thing that happens? What's the first thing that happens? Anyone? Well, when you get, uh, inflammation of the gallbladder because you've got a stone in the other stone irritates the wall of the gallbladder, so you get wall thickening that gallbladder wall thickening then leads to a fistula between the gallbladder and the duodenum. And so whatever is in the gall platter just drops into the Judean. Um, and it travels around the small bowel until it gets to a narrowing in the small bowel. And it's a natural narrowing. The closer you get to the terminal ileum. And it caused an obstruction at that point. And that's what usually happens. Some stones can actually go through the ileocecal valve, and some stones can go directly into the colon. If you've got a fistula between the gallbladder and the opposite flexure. So there's the hepatic flexure of the colon, and the gallbladder lives very close to this area. And sometimes you can get officially going right into the colon. But the vast majority of gallstone Aaliyah's is where you've got a fistula between the gallbladder and the Judean. Um, and we've got this school stone. I'll ius. Is everyone clear on that? Yes, sir. Yes. OK, thank you. Um, let's have a look at number eight. Okay, so this patient has got parameter signs off on the right side. So any thoughts, these chemo? Oh, the yeah, changes. Uh, about is it due to a scheme yet or is it due to something else? Goodbye. Could be bleeding as Well, how much is it? Um, there's no hemorrhage. I don't think so. It looks like a central necrosis. Would that be, uh, lesion? Yeah. So what? What the radiologist has to do is they have to make up their mind whether this is due to an infarct or whether it's due to a mass lesion in the brain. Okay. Now, what do you think that would be? An s L l Yeah. Why? Why do you think it's an s o l good that we well, circumscribed boundary. So if it was an infarct, it tends to be wedge shaped. Okay, But here we've got if I can describe the outer aspect of this lesion, it's very irregular, isn't it? In fact, it conforms to the gray matter along the medial aspect and the gray matter along the lateral aspect. And so the grey matter is preserved. And this is white matter, Adama, and we call this visa genic Adama. So the edema goes up to but doesn't involve the cortex. And it looks irregular, isn't it? And just at the top of the sliced, just get the impression that there might be a lesion here. So what would the radiologists do in this situation? Patient's got right sided parameter signs. They've got weakness on the right. They've got, uh, increased reflexes. They've got stiffness, and we've got the CT brain. What would the radiologist do next? Patient still on the table to contrast. Study. Excellent. Well done. Yeah, that's right. Contrast. So the patient and then gets contrast. And I know the patient's been given contrast because the basilar artery has just lit up. The venous Sinuses are just lit up. There's the middle cerebral artery, middle cerebral artery. So I know that this patient has, um, had contrast. Given when I see all of these, creature's here and here. And if I just compare it to the UN enhanced, uh, superior sagittal Sinus has enhanced on giving the IV contrast. Okay, So as we go a bit further up, I can see, But there is something going on here now. I'm still not entirely sure what, but I know that it's not an infarct. I get the impression that there's a figure of eight mass lesion. Can you see that? So what does the radiologist do next and do NGO? Uh, you could do an angio, but We've already done a CT. With contrast once I have a question. Um, I actually taught contracts for brainy. It's not, uh, used and for bleeding rather on my road. Uh, if punk masters not used when you've had a bleed. Yeah. Yes, and no. Uh, under normal circumstances, if it's an interest cerebral hematoma, you wouldn't give contrast. But if you were looking for an aneurysm that caused the bleed in the first place, then you would do a CT angiogram. Okay, But this patient, um, we've already identified that there might be a space occupying lesion, but we haven't seen quite so well. So what else can the radiologist do? The clue is on the left hand side. There be, uh, yeah, so we'll do an MRI, so I'll just show you that. Okay. And does that give you a better insight as to what's going on? This is the T two weighted image. This is the T one weighted image. Can you see that now? Yes. And can you see that? It's much easier to see on MRI than it is on CT. And then, just like we gave contrast on MRI, we can actually do that on CT as well. So what I'm going to do is I'm going to do this. This is t one with gadolinium, so you can see there's a ring enhancing structure here, which is much bigger than is suggested on CT. Okay, now we've got this low signal around it, which, when we look on the t two causing all this too Dema And can you see that the edema goes up to but doesn't involve the gray matter? Yeah. Can everyone see that? So the grey matter is not involved in the edema, and that means it's vasogenic edema. Okay. And vasogenic edema occurs when you've got a space occupying lesion. So we've got an enhancing space occupying lesion, which is multifocal in the left posterior parietal lobe. And the radiologist issues a report saying that the patient is likely to have a brain tumor. Okay, but then the clinician is a bit concerned because not only is the patient got right sided weakness, but they've also got a fever. So what else could be the diagnosis? Be an infection. Yeah, such as assist. Uh, what would what would you call an infected cyst? Did system? What about an abscess. Yes. Terrible business. Now, why is it important to think about a cerebral abscess where it's coming from? Be a primary. It's a completely different treatment to a brain tumor. So, uh, seeing, uh, an enhancing lesion in the brain in someone who's got fever. Both the radiologist and the clinician need to think, Could this be an abscess? Now, when I was a medical student a long time ago, um, what happened was that patient's just used to get treatment with antibiotics, and the hope was that it went away, okay? And if it didn't go away, it was probably a tumor, or it was an abscess that was not going to go away unless it was drained. Okay. But nowadays, what we can do is we can do diffusion weighted imaging, and I'm going to show you something, which is very clever. Uh, and it means that the patient doesn't have to have an unnecessary operation. So, on the diffusion weighted images, uh, that's just put plastic there. So here's our lesion here, and I'm just gonna go through now. They appear at different parts of the brain. It only appears different because during this sequence, the angle of cut is slightly different, but it's in the same position. Okay, so we've got this. Lots of edema. We've got all this gray matter here, and this is like an inverse of this sequence. And like all in verses, it shows you the opposite. So it's black on the inverse ts, and it's white on the real study now very, very complicated. And I don't want you to, uh, look into this in any great detail, but I'm just trying to show you what MRI can do for your patient. So if I keep on going and what we're going to do is, we're going to do what's called a diffusion waiting. And again, it's too complicated to describe the physics behind it. But this tells me as restricted diffusion, okay, and this multi labor, multi focal lesion that's producing all this edema and this one sequence along with this in verse sequence tells me that the patient has got cerebral abscess, and I think that is great, because if we didn't have this sequence, we would have to end up doing a craniotomy make because it looks like a tumor. Otherwise so, it's just a great method of picking up a cerebral abscess. Now, the next thing for the radiologist to do is to work out where the infection is coming from. Okay? And the infection could come from the middle ear. Okay, Um, this is just the Corona all so it's a very, very multifocal abscess. Um, it could come from the middle ear. It could come from, uh, the nasal area or the Sinuses. And so it's very important that the radiologist looks at these areas to make sure that there's no infection there and that they need a clinical e n T examination. Okay, any questions about that? Yeah, episode something you said the, uh, dilation is restricted to the right. Right matter? Is that what you said? Yeah. So it's caused white matter edema. Um, but not, um it doesn't encroach on the gray matter. So here's the gray matter. This gray stuff, and then the black stuff is the white matter. It's the grey matter is here. And then there's lots of white matter edema because on t to a Dema looks white. Okay. And it's gone right up to but not involved in the cortex. If it was an infarct, the outer border of this lesion would be straight, and it would involve the cortex. Okay, so it's just a bit of a tip for you. Now, you could get a clue clinically that this wasn't an infarct by the speed of onset, because in Fox tend to occur very quickly. And tumor's and cerebral abscesses tend to occur over a short period of time. Yeah, so? So the clinical history is just as important to a radiologist as it is to any of the doctor. Yeah. So it's very important to to link this to the clinical history. I'm going to show you number nine. And this is just a very nice demonstration of the silhouette sign. No, this patient has got pneumonia. So where is the pneumonia? On the left hand side. Well, we'll consider the right in a second, but just look at the left hand side. Where is the pneumonia? Lower low. Correct. Well done. I think that was a sad who said dust. Well done. So why is it in the lower lobe that's of its position and the shadow just showing up. So can you see the diaphragm? Yes or no? The diverticulum. Uh, yeah. That's the diverticulum angle. Now, can you see? Can you see the diaphragm? Yes or no? It's not easy on the left side, too. You can get by squinting it, but it's not easy to make up, so you can't see at all on the left that is blunting out the left costophrenic angle. Correct. And there's always shadowing. Can you see them? You can see the left heart border. Yes. Oh, no. Yes, yes. No. Which lobe contacts? The left part border. Which lobe is in contact with the left heart border? I think it's the part of a middle lobe is one. It's the lingula segment of the upper lobe. Okay. And so because the lingula segment of the upper lobe is aerated and it's in contact with the left heart border, you can see the left heart border. But the diaphragm is in contact with the under surface of the left lower lobe. And because I can't see it, it implies that the consolidation must be in the left lower lobe. Agreed? Yeah. Can you all understand how it worked it out? I can see the left heart border. Therefore, the lingula segment of the left upper lobe is okay, but I can't see the diaphragm. And I know that the lower lobe sits on the diaphragm. Therefore, we've got a lower lobe pneumonia. Now, if that patient, uh, comes from the community into the hospital with a low bar pneumonia, what's the most likely organism? Script? Icals streptococcus pneumoniae I or pneumococcus, as we call it. Yeah, And this is a patient who's got a low bar Pneumonia due to pneumococcal pneumonia. Now, we've also got an area of fluffy spherical shadowing in the right mid zone. And this also turned out to be pneumonia. But you can see the dilemma for the radiologist. This looks a bit like Thomas Lesion, doesn't it? And there's a bit of blunting of the medial aspect of the diaphragm here. So there's some consolidation here as well in the lower lobe consolidation here in the lower zone. Now, I'm certain this is in the lower lobe. Why? Of the position and the you can't see the lower part of the lower border of the heart. You can't see the diaphragm. Okay. You can't see the diaphragm. Therefore, this shadowing must be in the lower lobe. Can you see the right heart border. Yes, Yes, yes, yes, yes, yes, yes, yes. Okay. Therefore, this shadowing is not in the middle lobe. It's in the lower lobe. So this is lower lobe consolidation. Also, it's a bit more problematic with this shadowing because it could be in the middle or the lower lobe because they get superimposed on the frontal projection. Anyway, it doesn't really matter for the purposes of treating the patient, because we've established that we've got multi focal consolidation. And so this patient's got a pneumonia, and they need treating with antibiotics. But can you see how the silhouette sign helps me to work out the exact position of the consolidation? Yeah. Lower lobe, lower lobe, Right. Mid site. Okay, let's have a look at number 10. It just takes a little while to open. Okay. What is going on here? Multi focal consolidation. Somebody just asked the question. Is consolidation in more than one place? That's all it means. So it's in the lower lobe on the left lower lobe on the right, and somewhere else in the right lung, Possibly in the right mid zone, saying like lung collapse. Yeah. And why is the left lung collapsed. That's intubated on the right. Excellent. Well done. So here is the ET tube, and it's gone too far down. There's the Carina. It's gone too far down. And so what happens is as you a rate the right lung. You are depriving the left lung of any oration, and soon it undergoes a complete collapse. Okay, And that's what you're saying there. If you saw that on the chest X ray, what would you do? Pull the tube out, pull the tube back. Not as put back about arena. And you don't know whether it's hit the Carina. So you're going to have to have the rough idea. And if you pull that back about four centimeters, you will be about here, which is perfect. Okay, so before you pull it back, you just need to make sure that you're not pulling it back too much. And the other thing about pulling it back is that you have to be very careful if there's a balloon inflation and the best thing to do is to ask an anesthetist to do it for you, Okay, because what you don't want to do is to traumatize the trachea. If it if it's balloon inflated. Okay, so call for an anesthetist. But if you're on your own and it's desperate, pull it back by four centimeters, and then this left lung will re expand. Now you can see some little clips here, and you can see an energy tube with a big gas bubble here, which was very spherical. So what's going on? Is that a gastric buckle? It's not the gastric bubble. Um, it's the stomach. Uh, sorry. No, it's not the gastric bubble, but it's in the stomach. It's a balloon, and the balloon is around this tube here, which is in the esophagus and then in the in the stomach. If there is a balloon, that means it's not an N. G tube is, um so Well, it's a kind of nasogastric tube, but it's got a stick, and it must be a sense taken tube saying stark and tube. And in fact, this patient presented with viruses. They have the same stark and tube in, and these are clips from previous um, ligation of the of The virus is okay, and it just was so unfortunate that the intubation resulted in complete left lung collapse. Okay, everyone clear about why this X ray looks the way it does great stuff. OK, let's go on to case number 11. Now we've got two films again. Sorry, guys. It takes a little while to load. Um, I hope it's loading for you. Now this is exactly the same exposure. We just use a technique called edge enhancement to see tubes a lot easier. So if I just go into adjusting the windows, not particularly great great film, really person. Even if that was the best I could do in terms of altering the windows, I still can't see the tip of the tube very well. And so what we do is we with the same exposure. There's another plate behind this plate where we can manipulate the film. To see tubes and media style structure is much easier, and that's what we're doing. So there's a nasogastric tube and, well, what do you think it is? It's gone through the left main bronchus is to the left lung, possibly possibly, although, um, the left main bronchus is here, but I agree it went into esophagitis. It's still in the esophagus, but it's coiling back up, or is it perforated? through the esophagus. Um, well, that's that's possible. That is certainly possible. Is there enough information? Would it be higher? Two Solenni in? Yeah, nations got to celonia. So if you saw that X ray, what would you do? I would go back to the radiologist and lost them to enhance it. Uh, yeah, you could certainly do that. You always get help, get or get a city. Yeah, CT. You can always ask a radiologist. Okay? And if they've got a pack system, they can see the film at the same time as you can see the film, and they could say, Yes, it's in a height. Antonia, pull it back. And so what you would do is you would pull it back and then try and advance it forward again. Now, the problem is, as you pull it back and then advance it further forward, you might run into the same problem. And if it's really, really important that you feed that patient, you could, uh, into a conversation with an interventional radiologist, and they can actually pass the tube under screening guidance. Somebody has asked what is a packed system? It's actually called a packs system. Um I'll just spell it packs. Um, and it's a picture archive and communication system. OK, picture archiving communication system. Okay, So this this patient, um, has got a nasogastric tube in a hiatus hernia. And I think, uh, when the patient had this removed and then reapplied, it's still cooled up in the higher to Tonia. And so an interventional radiologist had to help to forget this into the intra abdominal stomach. Because, of course, some of the stomach is in the abdomen and some of it's in the chest, but we can't have it in the chest. Why? What happens if you feed this patient even though it's in the stomach? What? One preach to the stomach because of the heights? Yeah, because the height of attorney of the sphincter is now and vomiting vomiting might occur very weak, and you'll get aspiration. So the tube has to be in the abdomen. Uh, or at least in the internet abdominal portion of the stomach. Okay, so that's, uh, fairly straightforward, I hope. Uh, number 12. Okay, I'm going to open up these two films here. Okay, so we've got a patient who has jumped from a height and can you tell me what's going on here? Is that, uh, the L2? Uh, it for helpful? Helpful? I I saw it on the right right side. Okay, so l 41234. There's L5, and there's a little bit of depression here. I can't see the superior endplate here. When you look on the lateral, you can see that the endplate is fractured and we've got most of going out more anteriorly. And if it's going up more anteriorly, What does that mean? Posteriorly slip. Well, if you've got a fracture of this financial, uh, and you've got a fragment going anteriorly. And it's an actual loading force. What does the nation of Post Asian of this? So you've got a fragment going into really? And it's a an actual loading force. Could it be that you've got a fragment going posteriorly as well? Okay. And we call that a burst fracture because if you apply a pressure onto the vertebra from the top, you can get this burst vertebral fracture. Okay? And I'll show you what I mean. So So we get these cts there. So there's L3. There's l full. There's L5 Can you see that a fragment has gone anteriorly. So if we draw a line from there to there, that fragment has gone entity really got lots of fractures here and here. And we've got a fragment that's compulsorily into the spinal canal. So what's happened to the spinal canal diameter? Here, shorten the Lumen. Yeah, so? So what's that going to do to your cord? Require? Er, squeeze it or luxury. Come out. Yeah. It's going to be compressed, isn't it? So the cord require gets compressed, and as we go down, you can see how narrow the spinal canal is at that point. And this is called a burst fracture. Because if you squashed an orange by stamping your fist from the top, the orange goes in all directions, doesn't it? Yes. Don't Don't try it because you might upset your your colleagues, but, um, put your hand over an orange, smash it from the top, and it splatters everywhere. Well, in the same way, if you've got an actual loading force on a vertebra, it goes in all directions. So it goes that way that way, that way, that way it goes in all directions, and it's called a burst fracture. So the normal spinal canal diameter it's here. There's the fecal sac, which you can see very nicely. That's at the L3 level. We go down to L4 and we've got a very compromised spinal canal because we've got a burst fracture and this is going to cause a cord require a compression. And how might that present in the patient, uh, numbness. And because And no, uh, palaces of the lowland? Yes. So they can get muscle weakness of the lower limbs that can get sensory problems. And, most importantly, they can get bladder and bowel incontinence. Incontinence. That's a very potent sign that you may have a problem with the spine. If the patient can't hold onto the urine, it may be that they've got damage to the nerves that supply the urine. Okay, that's by the urinary bladder. Okay, just a bit of anatomy for you. What joint is that? Sacred Sacred number? Sacred. There's the steak Riley out joint. The, uh, that's called the Facet joint. Sit there for set joint. It's like rows of tiles on the roof. There's one tile overlapping another tile. Well, that's the first step joint get a bit higher. There's the facet joint, uh, the the level. Okay, you can see it's a bit widened, and it's hardly surprising because we've got a fracture here. So there's been, um, some disruption of the ligament and flavor. Okay, And then, as we go a bit higher back into a normal for sec joint again. So these. These are your first step joints, and you may have heard of patient's who've got for set joint pathology. And they can easily have injections into the facet joints, uh, of steroids, just to calm down some inflammatory change. So that's called a burst fracture. And it's a It's an acute emergency. It's a neurosurgical emergency because of its effect on the court trick. Whiner. What is it called? The cord require because of the appearance, Like a horse tail. Yeah, and it comes from the Latin, uh, Corder, which is tail the choir in ER of a horse tail of a horse. And you can see why all of those, um, patient, all of those patient's will have trouble with the nerves that supply the legs, the blood of the bells, etcetera. Okay, we've got up to number 12. So the next time I do it, we're going to go from 13 to 21 because I think the next time I do it is the last time, uh, before the Christmas break. So do you have a look at this? Um, uh, set up on pack spin and all. Pac spin is it is a, uh, method of showing you, uh, films that you would see in the workplace, But on the web, Uh, and this is, um it's a It's a great useful. So hoping you found that useful. Uh, if anyone's got any questions that I didn't answer. Uh, please. Feedback to your moderator. Uh, I'd be very, very happy to answer them. Uh, but I hope that was useful. So what we did was we did Gallstone. Earliest did cerebral abscess. We did a multi focal consolidation, which is just consolidation or pneumonia in more than one place. We did, uh, e t tube in the wrong place. Intubating the right man Broncos. We then did a, um, nasogastric tube in a hiatus hernia. And then this one is a burst fracture. So thank you very much for your attention. And I will see you next week. Thank you very much. Thank you. Thank you very much. Doctor. Pleasure