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I'm live. My whole screen needs to be on the presentation, so I won't be able to see the comments. Ok? No problem. Yeah. So it might be, or if there's anyone answering or if there's any questions you might need to pose them to, to, would you like me to interrupt you guys or just wait after you guys are finished for the, if there's any comments or questions or whatever works, we might bounce to you and just go off this. I guess we'll just say, is anyone any, any answers coming through? Yeah, we'll, we'll probably check in with you. Ok? I think quite a few few people have joined so we can just start now. Um So thanks for coming everyone. We'll have the session recorded. Uh It will be available after like on demand after the session. And if you stick to the end, there's also a feedback form and you'll get a certificate if you fill that out. So that would be great. I'll just hand it over to Doctor Burke and Doctor Anderson. Great. So I'll just get the slides up here. So good evening everyone. And thanks for giving up a bit. Of time of your evening. I know Usher was saying that the finals are coming up quite soon. So, hopefully this is a worthwhile session that you'll have a tinted this evening or, or we'll be watching back on demand. We're going to do a little bit about, I guess a little bit of radiology for finals. Hopefully some bits that will come up either in the AY or the knowledge test. Um, your guides for this evening are Olivia, uh Doctor Olivia Anderson who's in ST four, who you'll meet in just a moment and uh myself, uh Niall Burke who's in ST three. So we're, we're both kind of midway or coming towards the end of, of radiology training. So we were given the task of, of trying to cover a nice bit of radiology over the course of an hour. Um trying to at least hit on the, the key points that may come up and that's, that's not always going to be possible, I guess to hit on every bit of radiology that you'll see in your finals. But hopefully we'll, we'll hit on some of the more common areas that, that might come up for you. So we, we've broken it up into chest abdomen, M SK CT head and then we've got a, a few bonus bits at the end. Um We're really keen on interactions. So obviously there's a chat function there. So please do use the, the, the chat function if it's we don't, you know, if you don't know the final diagnosis, that's fair enough. But even some observations, if you have anything to say about the, the, the images that we're putting up, just, just kind of, you know, feel free to chat between yourselves or, you know, pop them up. We'll have myself and Olivia and usher, we'll be keeping an eye on the chat to uh pose questions and comments that you have to us. So with that, I'm going to pass over to Libby, who's going to take on the, the first part of the session type, which is the chest X ray session. Sure, thanks Nile. Um So yeah, so we're gonna do some chest X ray overview um type cases. Um We'll start initially with um just a little bit of how to approach looking at a chest X ray. It's kind of the bread and butter of radiology and what you'll be expected to, to know essentially. Um and approaching chest x-rays with a systematic approach will be the safest thing um coming into your ay and also coming onto the wards once you graduate. So by keeping a structured approach, you're less likely to miss something. So if you're in an exam situation, you'll be quite stressed if you get presented with a chest X ray and you don't know what's going on. The first response is to maybe panic a little bit, but by keeping a little bit of structure in your mind and sticking to each of these things, it forces you to look at different things and that will help you see um things that maybe you wouldn't have seen initially. So try and keep to a structure, you don't have to follow this structure. This is just a generic one as long as it's something that you're happy with. And I think most radiology registrars use a similar structure, but we all kind of have our own. Um So you don't have to use this. But basically, whenever you get shown a, a normal chest x-ray or an abnormal chest X ray, the first thing you want to do is assess this the quality of the film. So if it's a poor quality film, it's gonna be limited in terms of what you can actually tell from it. So just having an idea of what your setting is. So is the film rotated. Firstly, so are the medial clavicles equidistant? And are they, is the spinus process clearly seen in the center of the two clavicles and the body? Um if one's a little bit further away, then that kind of changes the projection of things and it might make the hi limb look a little bit funny and it might look, things look a little bigger than they should. So make sure that um the clavicles are nice and symmetrical. Second thing is um inspiration. So a standard chest X ray is taken on like maximal inspiration. So a good well inspired film. You'll be able to see about 5 to 6 anterior ribs or about 9 to 10 posterior ribs. And that's important because if it's um an expiratory film, so the patient has taken a deep breath out, their lung volumes will be smaller and all the lung markings will be closer together. And actually, it'll make things look a lot busier than you want them to look. So, just take keeping that in the back of your mind. Is it well inspired and then penetration? Can you see the vertebral bodies through the like through the cardiac silhouette? Can you see the vert bodies um the whole way down? That's a a marker of whether we've got good penetration. And it can be useful in that if there's, for example, some consolidation that's maybe in the left lower lobe. So behind the heart, if it's a really poorly penetrated film and you can't see the virtual bodies, everything's just gonna look white. So it's gonna be really hard to tell that apart. But if it's a well penetrated film, you'll be able to see the vert bodies and that consolidation behind the heart will be so much more obvious and then projections. So we have two main projections that we use for chest x-rays. The most the standard is your pa where the beam is being taken from the like going through the patient's back. So the the patient is facing the receptor and it's taken on maximal inspiration. That's your standard view. Um If we and it's usually labeled like that as well, but that's the standard if the patient has got AP film, basically that it's all flipped. So the patient has their back to the receptor and the camera is in front of them. This is usually for patients who are maybe bed bound, maybe a bit more sick or um more frail and they can't sit up. Um So things aren't gonna be the same. So because the camera is closer to the heart, the heart looks bigger and you can't quite interpret the heart size as well. Um And it can just make things look a bit more confusing. So keep a note of the projection, it's also an indication of whether the patient could be quite sick or if there's something wrong. Um as well. If it's an AP projection, you want to think in the back of your mind, why it's an AP projection and then going on to actually what your structure is. Um So firstly, ABCD, E as with anything in your AUS case, um this is just as a simple way to like approach your x-rays. So air A is the trachea central is in the middle, in front of the spinus processes if it's deviated in any way, is it because of rotation or is there something pushing it or pulling it that way? OK. So make sure it's nice and center and breathing So just look at the lungs. Um Is there any pneumothorax? Is there any obvious opacities that might indicate they have a mass or infection? Um Is there anything there that shouldn't be there? So, just looking at the lung markings of themselves or is there any um increased lung markings or pulmonary edema? Um that can look for that during your lungs and your structure and then going on to the circulation, looking at your heart and mediastinal contours is the heart big. So basically, is it more than 50% of the diameter of the chest? So if it's big or not, if there's any um cardiomegaly, um and if there's any lymph nodes or big lymph nodes in the mediastinum, so look at um see if there's any bulkiness at the hilar hilar markings. Um And uh then moving on to your diaphragms, are the diaphragms equal. Is there any air under the diaphragms that shouldn't be there? Um And are the diaphragms continuous and then everything else? So I think bones quite difficult to fit into structure cos you could put it into be, but it's not, it's not one of the first things I look at. It's usually the last thing I look at. So make sure you look at your bones, you can see lytic lesions, you can see sclerotic lesions, you can see fractures at the edge of your film. So make sure you look at all the bones um and looking to see if there's any like effusions or anything else in your soft tissues that maybe you haven't seen. And um I've linked to just a normal chest X ray from radio pia on the slide. But if we go to the next slide, this is just a spoiler alert. This is a normal chest X ray and I'm just gonna talk through it really quickly and superimpose the anatomy afterwards. Ok. So if we go through our technical quality, we can see that the medial clavicles are equidistant to the spinus process. It's not rotated. It's well inspired. I can see lots of anterior ribs. Um and the anterior ribs are the ones that are sweeping kind of going. Ok? And I'll show you those in a wee second as well. Um And looking at the penetration, I can see the vertical bodies through the cardiac shadow that's great and um projection, you can't really tell, it looks like it's an A APA film, but it doesn't say so. Yeah, but I think it looks like APA film, but you can't really tell that unless it's labeled essentially and then going on to our ABCD E which is nice and central. We can see both main bronchi great. Um The lung markings are nice and clear. I can see lung markings all the way to the edges of the film. There's no pneumothorax and there's no pleural effusions either and the lung markings look fine. There's no increased pulmonary vascularity to suggest that there might be pulmonary edema or something. And I can't see any opacities that might suggest that consolidation, fine, looking at our heart and mediastinal contours, the heart size is normal. It's less than 50% of the diameter of the chest. Also great and looking at our hilar markings. So, um, I don't know if you could see Nile's cursor if you move that can you see if you can just point out the right and left hilum for us. That's our left hilum there and then on the right side as well. So they all look, that's a normal hilum. And um, there's no obvious lymph nodes or anything there that we can see. So we're happy with those and then looking at our diaphragms, they are the right is higher than the left is, which is fairly normal. Um But there's no um, free air under the diaphragm and then looking at the bones, there's no bony lesions, there's no fractures, there's no sclerotic lesions, bones look, OK. And then everything else, just make sure you look at all your review areas. For me looking just behind the heart is something that seems quite obvious. Like just looking, you can see lung markings behind the heart. So if there's consolidation, those lung markings are gonna be obscured, so look behind the heart. Um, look at the edges of the film. If there's any like tumoral neck fractures, you can sometimes see those are there any gallstones, someone who's got central chest pain, they've got gallstones and there's no other cause of their chest pain. Could they just have cholecystitis? So that's a basic, quick overview of a normal chest x-. And if, now if you just sit next for me, um, to show just a bit of anatomy projected over this. So this is just, uh, just a very brief overview of the landmarks and a chest xi don't want to labor too much over it. But things that I wanted to point out are things called um the AP window if it's not labeled on this. But if n if you'd be so kind, so it's basically the we angle between the descending aorta and your left pulmonary artery coming out. This is one of the areas that if there's hilar, like if there's lymph nodes and big lymph nodes in like cancer TB sarcoid, you'll lose that sharp angle there and it'll be a convexity there. And then your right paratracheal stripe is another place where lymph nodes can lurk if there's a mass or something. So that's just at the top this white line um beside your tracheia and your right apex. Um But those are just two things I wanted to just kind of point out they're not really on many ANAs me things, but just for looking at chest x rays, I always think they're two things I didn't really know about before. And now I look at them every day. Um, but yeah, I'll maybe move on to cases next. Ok. So feel free to just type out your observations if you think, you know, the diagnosis, just feel free. I will not judge for any silly answers because I was definitely the person to give them. So, um, have a look, just fire them into the chat. Um, and we'll keep an eye and check back in a couple of seconds and we'll talk through it. Ok. So some answers coming in there, I've managed to get the chat on my phone here as well. Actually. So I think we've got quite a few for a right sided pneumothorax, which is correct. So, tension pneumothorax. So we've got one for tension pneumothorax and that's bang on. So we've got a tension pneumothorax here. First thing that we do in our structure is ABCD E so the A airway is not central, we can see the airway is deviated towards the left. Yeah, exactly. Some people are saying, but it's just heel deviation. So that's the first thing that you, you, obviously, it's not the most obvious thing on the film, but it is the thing that in your structure you want to make sure that you look at. Um and therefore that upgrades your pneumothorax to attention pneumothorax and therefore becomes a medical emergency. Ok. So just to talk, talk through a slight uh a bit more detail. So we have the, the tr is not in the center, it's pushed towards the right or the left. Sorry. Um And so is the Medius Dyn in here? So it's all shifted slightly towards the left hand side. We can see that there's a, an asymmetry in the two lung fields so that the right hemithorax is almost completely loosen. I can't see any lung markings. I can see this though, this kind of opacity there with a nice smooth contour and that's our collapsed lung. Um Thanks. I have been doing it on my screen for real. Um um So that, that's our collapsed lung on the right. Ok. So it's all collapsed. There's loads of air in that pleural space and it's pushing towards the left. So what would we do about this if we enter that into the chat, what you would want to do next? Um I'll give you a wee minute. This is one they always say that uh it should never have been taken in the first place. Yeah. So in clinical examination, that should might not be in the center if it's not in the center. Um And I've got a couple things like needle, needle decompressions and surgery. So, yeah, so this person needs urgent decompression. So your um second intercostal space, midclavicular line, just your the normal landmarks that you use and ultimately, they need a chest drain as well. But the important thing if you get presented with this in an AK is to say as soon as you say, it's attention, pneumothorax say I would do this, this and this. You need to act on this. You need to decompress, they need to let someone senior, you know about it. Um And they need a chest drain essentially. Um There's a couple of questions about the wee spots or E CG leads. Yeah, they're E CG leads. They're like little small rounded things. They're quite uniform and you can see the one on the, on the left chest wall that's kind of on the lateral aspect. It looks like a little clip. So those are little um E CG stickers well spotted. Um If you go to the next slides now. So yeah, just a few notes on this one. It's a large um right pneumothorax with a left sided tracheal deviation or me external shift. It's an emergency. So if you get this in osk, make sure you convey that, you know that it's an emergency. Um and always ask for senior help. I think that's the the bottom line in ay stations that you would ask for senior help. And it's something that I think everyone always forgets to do. Um So we go to the next case. Ok. So this is a 70 year old uh patients. They've come in with shortness of breath and a fever and a new cough that is productive of green sputum and they're quite unwell. What do you think is going on? Ok. So we got a couple of takers for a left side pleural effusion or an empyema. And both are good shots. You can't see that um left core angle at all. But yeah. So there's another another comment for pneumonia. So given the clinical history, they've got a fever, they're short of breath, productive cough. So, infection is your um first differential. And here we can see that yes, the core angle is blunted. They might have an effusion. But what's maybe more concerning is this really dense opacification that has almost like a convex border here and see these lucent thin lines running through it. Thank you. I keep, I keep using my own voice. So there's thin lucent horizontal lines running through this opacification. Those are called air bronchogram. If you hear about people talking about air bronchogram on um talking about x rays, that's what they mean. And that's pretty pathognomonic of pneumonia um or consolidation. So it's dense consolidation in the left hemithorax. Um There could be an effusion. We can't see that left costen angle at all, but there is a really dense opacification. And if you look to see, we can see that we can see the vertical bodies. It's, it's the penetration of this film is fine, but we can't see any vascular markings behind the heart. Like your your cardiac silhouette is gone on that left side. So it's really dense consolidation and in keeping with the clinical history, then this makes a pneumonia most likely things like an empyema. I can see why you thought that, that you can see the cost angle and they have a fever, not a bad shout. Um But in this case, because there's are bronchogram, it makes pneumonia more likely. Ok. Um If you go in the next slide, so they've got yeah, um dense left side of consolidation and just think of your clinical history um and your differential because if I change that to um a patient with a couple of months of significant weight loss and um shortness of breath and a dry cough, maybe some hemoptysis, your answer might be a little bit different. Ok. In terms of like thinking about malignancy and things, it's just dense consolidation, it could be a big mass. So just think of your clinical history and if we go to the next case, OK. So, oh dear, that's falling off. Um So this patient um had uh it's a 60 year old man. He had an, he had an M I about 10 years ago and he's acutely short of breath. What do we think is going on? Ok. OK. We've got a few votes for pulmonary edema and we've got a few for congestive heart failure. And yeah, I would agree. So there's cardiomegaly. Um and there's a couple of people are saying there's a few effusions on the right side. There's also an effusion on the left, this small blunting of the left costophrenic angle as well. And with this cardiomegaly, we can see that the carina are splayed quite markedly there that suggested that the left atrium is really big. Um And we can see that there's kind of increased classification at the hilum than what we would normally see. And there's a bit more going on there. Um And that's what we kind of would say is like bat, bat swings appearance. So there's this increased airspace pacification in the perihilar regions and the upper lobe venous diversion, we can see there's maybe more prominence of the vascular markings and upper zones and there's also interstitial um septal lines. So like your curly bee lines and I didn't really understand what the curly bee lines were really at all in medical school, like may maybe you do, but you'd be ahead of me. Um But they basically these really fine horizontal peripheral lines that you see mostly in the bases and this is just pooling of interstitial fluids um and the kind of the dependent regions of the lungs. And um that's indication that there is interstitial pulmonary edema. Ok. Um And yes, it's basically congestive cardiac failure and there are features here of an acute pulmonary edema, especially given the acute clinical history. So if we move to the next slide, I've got a few, we kind of pointers about pulmonary edema and a chest x-ray, the main signs I've, I've seen people do another ABCD E before feel free to use that if it helps your memory. Um But sometimes I find those slightly not very helpful in that they're not really a structured way to look at things. Um But basically the main features, cardiomegaly, pleural effusions, usually bilateral. Um but you can get unilateral effusions as well, upper lobe venous distension and intralobular septal lines and then the perihilar alveolar consolidation. So you can get pulmonary edema with alveolar kind of consolidation. A little patchy airspace like patchy round white dots around throughout the lungs. Um or you can just get purely interstitial edema. So I've tried to put a couple pointers about the differences between those cause. I find it quite confusing. Um But most of the features are interstitial, they're like in the pleural space and like in the interstitial spaces of the lungs. Um and alveolar edema, it's just in the airspaces itself. So it looks more like almost like consolidation and that's where your bat swings and your airspace capacities come from. And um you can of course, get noncardiogenic causes of pulmonary edema. So if the heart size is normal, but you see all these other features, think of your other causes of pulmonary, of pulmonary edema and then just the the distribution. Sometimes if you see some of these features that can be an indicator of infection or malignancy as well. So if it's bilateral interfuse with cardiomegaly, then pulmonary edema is probably your first thought. Ok. So we go next. Oh, I just wanted to point out, these are the airspace, the differences between um alveolar and interstitial edema. The white lines are your alveolar opacities that I was talking about. So, just like kind of dense little white circles throughout the lungs, that's your alveolar edema. And the black little um triangles are pointing to your curly bee lines just at the periphery and they're small, fine horizontal lines. Here we go next. OK. So this patient, um what are our thoughts? This patient um has had a stroke and they, they've had an NG tube put in by the um the ward and it's not aspirating. Yeah, this is the main question is why is the NG tube not aspirating? I OK. There we go. So it's kinked on itself at the top of the image, correct? So if n of you for a second, um So if we can follow, so where the m the cursor is? Now, this is the external port of the NG tubes. This is where your syringe will connect, it goes off the screen and then coming up to the top of the screen, we can see that there's a loop of tubing of a similar caliber to the external NG tubing. And we can't see any tube that goes vertically down the vertebrae and we can't see anything by section, the carina, we can't see anything below the diaphragm, partly due projection, but we would be able to see that through the trachea. It's quite lucent there. So we can't see the tube where it should be. And there is this spacious loop in the kind of level of the neck. So if we click next, now, this patient's NG tube was just coiled um in their throat. And when the clinical team looked in the back of the mouth, they could see the NG tube coiled inside. Um So just a cut another, we've got another case coming up next. Um If we click that, um what's wrong with this NG tube? It's in the right lung. Yeah, it is in the right lung. So we can see that the NG tube has come down the midline and it deviates towards the right, it goes down the right main bronchus, which is more vertical than our left main bronchus and it is kind of loop in the left lower lobe. So um yeah, RN G tube is not in the right place. Um And this is common enough like you would expect the patient to be coughing and spluttering, but sometimes it can be quite, they don't know until they get to the X ray and it, it's not where it needs to be and this just needs to be taken out immediately like they don't need um you don't need to hesitate on this one like you can just come out um and try again essentially. So if we go next, so just about NG tubes in general, we get asked questions. A lot about these. Um and it could potentially come up in an ACY um but basically the normal position, it needs to be in the midline. You need to see it dissecting the carina. So we want to see it below the bifurcation and we need to see it below the diaphragm as well. I mean, you just, we want to ideally to see it projected over the body of the stomach. It's good. If we can see the tip, sometimes we can't always see the tip of the NG tube. But if it's in the stomach and um beyond the gastroesophageal junction, um then that's good. Ok. So just if you're showing an NG tube, um x-ray and your os, just make sure to mention it's in the midline bisect of carina and it's seen below the diaphragm projected over the body of the stomach. And all the protocols will vary. So if an NG tube is not aspirating, um most places will just have a chest X ray as the next port of call. Um but it will vary from um hospital to hospital. And if you're not sure where the tip of the tube is, um either in an O or on the wards, ask for help. So you can ask your just whoever your most senior person or the next senior person is that you're working with, just ask for help. And if no one's available, help your friendly neighborhood radiologist. Ok. So if you go next. Ok. So I think this is maybe one of my last cases. So what is wrong with this chest X ray? The patient came in with um oh, sorry, just back on the NG tube topic. So even if the NG tube aspirates you to do an X ray anyway, to confirm placement, usually I think most places you will but it again check your lo local protocol. Anyway. Um most places if they have an N tube in, they will have to check it in the first instance, it's part of the protocol. So just as long as you kind of stick to your local guidelines, that's fine. Um uh So the answer is essentially yes, but um potentially not always if he goes to another hospital. Ok. So if we go to, let's see what? Welcome. Um So this patient has come in um with acute kind of central uh lower chest epigastric pain. What's wrong with them? And their amylase is raised? Yeah. So we've got free air under the diaphragm, pneumopar and the best place to look for this is beneath the right hemidiaphragm. You shouldn't really have anything gassy there. It should just be your liver. Um Sometimes people can get a loop of cool on there, but most people should not have any gas beneath their right hemidiaphragm. And if they do, it's a sign that there could be free gas or like a a per or perforated viscous in the abdomen, you can see it also under the left hemidiaphragm here, but you do have gas there. So sometimes that can be quite, um, that could be, that can be quite deceiving sometimes. But if it's under the right he of diaphragm, then you know that it's not meant to be there. So this is pneumoperitoneum. Um, and basically they need a surgical referral and ABCD resuscitation, um, if needed. So that's the kind of end of the chest x-ray talk. Um I've put together a few other chest x-rays, including some of the cases that we've shown here. They're all from radio pia. Um And I've put them on this um playlist. So you sh if you just search that on radio pia, you should get all the cases. And so a few extras that were maybe we were in the list that um OSHA send us um that we haven't been able to cover as well. So I think that's the chest X ray section done. So I'll hand it back to them. Grant will progress to level two, which this is not done in any sort of level of difficulty at all, but we're just going to progress through levels because of the, the, the theme here of the presentation itself. Um So we're going to do abdomen. Now, next. Um I should also say in my cases have been taken from radio as well. I don't have a playlist, but at the bottom of all my cases as we'll see in a, in a few moments, uh There's a little raped ID. So if anyone wants to look into a case in more detail, you can literally just type that number into the search box and raped and the case will come up. Um So similarly to the chest X ray, it's useful to have a systematic approach to abdominal X ray as well or an abdominal radiograph. Um I think to, to be fair, the use of abdominal radiographs has, has really gone out of fashion in a way that the chest X ray hasn't in the last, you know, 2030 40 years. But it, it, it is still one of these things that can come up in uh in ACY. Um but there are a fairly limited selection of things that they could show you really because you can't really see that much on, on an abdominal radiograph. So the assessment that's recommended or one of the, one of the ones that's recommended is this idea of looking at air initially on your, on your radiograph, both the air that's supposed to be there in the bowel, for example, and the air that maybe isn't supposed to be there. Olivia has just shown a case of newer peritoneum and an erect chest X ray is a much more sensitive test for looking for newer peritoneum than an abdominal X ray. But you there are some features that you'll be able to pick up so that you know, you just want to kind of be mindful of that when you look at a, particularly a, a patient with surgical type symptoms or a surgical abdomen, abdominal pain, make sure you're not missing any newer peritoneum on, on an abdominal film, which can be a little bit difficult. Then you're going to look at the bowel specifically itself. So you've got small, small bowel, large bowel, they're going to be the, the headlines of, of an abdominal radiograph really. Um So you're going to want to kind of assess that and we'll come to that in a moment and how you, how you do that of small bowel is much more likely to be central within the abdomen. And then it's almost kind of picture framed by the large bowel around that d structures is next, that's the D and ABDO X. Um, and the things you're going to be particularly looking at here are calcifications. And again, at this point, it's probably no harm to have a look at bones. Um, you know, rare do you pick up, you know, is it, it, it may not be related to the patient's presentations? But yes, there is the potential of picking up uh lesions in the bones or being able to comment on, you know, bad degenerative changes in the hip joints and, and things like that as well. Organs and soft tissues. As I said, it's, it's quite a limited test for looking at these things but sometimes you can get really nice uh contrast, you can see the outline of the kidneys or um uh you know, the actual soft tissues that you can sometimes see the so muscles in that as well. But it's just kind of paying attention to those things to see if there's any gross abnormalities. But you would not be expected to pick up any, you know, small or subtle pathology on those things. And then there's the X which is uh a put in external uh for external objects and artifacts. I think myself uh when I'm approaching any of these, any radiograph, it's, it's, it's quite difficult initially to, if there's something really obvious, like if there's a big, you know, machete in the, in the middle of the, the radiograph, it's quite difficult to just move on with the standard assessment and just be like, well, I'm pretending I'm not seeing that and I'll come around to it at the end. It sometimes is better whether it be a line or a tube or a foreign body to just state it initially when you're going through, it, just get it out of the way, address the elephant in the room. And then once you've kind of said that and you've got it out of your system, you might be better able to then move forward with the, your kind of structure again. So mention it and then kind of move on with your assessment and then maybe come back to it again, at the end would be my approach. We're going to do some cases now just to kind of demonstrate some of the things that might come up in acies. Um, so this is a 60 year old female who's come in with a distended abdomen and vomiting. So, again, similar to what we did with Olivia, if anyone has any ideas about what might be going on here, can you give some comments into the chat and we'll give it, yeah, 15 or 20 seconds to see if anyone has any ideas and then we'll go through it. So we've got a, a comment in there nice and fast with SBO. So a couple of comments, uh, so small bowel obstruction. So we've got multiple dilated bowel loops of bowel here which are predominantly in the center of the abdomen as I'm chatting through this. Yeah. And somebody has said the bowel that they convenes, which is this idea that we've got dilated bowel loops, they're quite central and you've got these lines that go all the way across the, the whole, um, d diameter of, of the bowel here itself. So it would be making us think that we've got, uh, a small bowel obstruction here. Does anyone have any ideas as to what would be the underlying cause here or anything else that they want to comment on or anything else that you would remark upon? So you're talking initially about. So, the a looking for air. So we've got a good bit of air within the bowel itself. It doesn't look like there's any, uh, pneumoperitoneum. But again, as I said, not the most sensitive test for this, the bowel, we've had a chat about, it looks like small bowel valva convenes and then dense structures. So there's, there's quite a few, a few bits around here. Um, you've got some kind of circular densities in the, the right abdomen and a few clips here on this side. Um, so they're worth mentioning and may come back into, uh, maybe important again in a moment. But, um, the, the finding essentially is small bowel obstruction and we'll, we'll have a chat about the cause of that in a moment. So the features of small bowel of bowel obstruction more generally, um, is, is bowel dilatation and there's this 369 rule which you've, you've probably heard about in the small bowel can be, you know, is, can be dilated up to three centimeters and be normal. But above that, you'd be thinking, is it obstructed large bowel up to six centimeters and then the cecum, um, can dilate a little bit more up to nine centimeters. But beyond that, you'd also expect, uh, some obstruction to be going on small and large bowel, we've hit on a few of these things already. So, distinguishing between the two, sometimes it's useful to look for those bowels like kind of kind of entities and the hof are the, the markings on the, the large bowel, which obviously don't, they, they won't come in and meet in the middle of, of the bowel itself. Um, if you have dilated bowel loops that are dilated by over six centimeters, then you're thinking that it's likely going to be large bowel as well because although the small bowel can dilate up over three centimeters, it's rare for it to go above six centimeters without some sort of a perforation happening. So we're just going to ask a question now here. So if people could have a look at this question and just think about what is the most common cause of bowel obstruction in the UK population. Again, this is a a worthwhile kind of bit of knowledge to have in the background, particularly if something like this did come up in, in an ac and people are jumping in on sea for adhesions, which is correct. Um Well done everybody. Um So adhesions, surgical adhesions are the most common cause of small bowel obstruction, definitely in the UK population and kind of in uh in in the western world, I guess. Um other causes. We've mentioned a few of them here, hernia. So, abdominal hernia are also a common, a common cause. And actually, it is worth when you're looking at an abdominal film where you see small bowel obstruction to have a look down um at the inferior margin of the, the abdominal X ray to see if you can see a bowel loop kind of down around the, the obturator for and, or anywhere down around there that might make you suspicious that there's a, a hernia. Um, other causes malignancy can cause, uh, bowel obstruction, small bowel obstruction, but it's actually, uh, a rarer cause in the small bowel, uh, inflammatory bowel disease. So, Crohn's disease is a potential cause you can get inflammatory strictures. Um, and yeah, we've touched on the, the femoral hernias there as well. Uh, volvulus, we're gonna possibly come back to that again in a little while, but essentially most parts of the gi tract apart from the esophagus have the potential to evolve and turn on its mesentary. Um, but it's, yeah, usually in, uh, ii wouldn't be expecting you to be given a small bowel ovulist in, uh, in your finals. To be honest. Case two. So we've got a 30 year old female who's come into A&E with abdominal pain. Quite nondescript. Uh, and her bowels have an opening for, have an open for three days, query obstruction. So, what do we think? I guess the two questions are, is there bowel obstruction and what is the cause of her abdominal pain likely? And just think about that kind of systemic assessment. So, think about the air. We've got some scattered, uh, bits of air which look Luminal. So, within the large bowel there, er, there's no obvious free gas that I can see er, look at the bowel itself, probably got a little bit of small bowel, uh, with some gas in it there as well, er, more centrally but nothing really dilated or anything that's really making me worried about anything there at all then dense structures. So, is there anything kind of around dense structures and bone that are making you think about a potential cause for the patients symptoms? I was talking about being able to see different parts of the the organs here. It's not often you can, but you can see the inferior part of the right lobe of the liver here. Um And there is something here. I don't know if anyone wants to talk about what this might be. Um And yeah, this is probably one where you could comment that there's some mild to moderate background, osteoarthritis of the hips as well. So any any thoughts on on this patient, obviously, we, we're, we're lacking a lot of information here in terms of bloods and a and a proper abdominal examination. Yeah, so we've got some, some answers coming in. Um So gallstones is the one I was going for here. Um I think again, there's quite no, there's no real specific findings I think on this that would be making you think about um pancreatic uh cancer or any sort of pancreatic pathology going on. But again, if you were given a history with some amylase raised or some kind of central um epigastric pain radiating to the back, they'd be the things that are making you go down that line. So this this case is essentially there is no obstruction. The only pertinent finding here is the fact that the patient has a gallbladder full of gallstones. And this was mainly just to kind of reinforce the point that I was saying earlier on that uh abdominal radiographs, they commonly fail to actually add much to the clinical picture. And CT is being used a lot more in the assessment of, of the surgical abdomen. Now, it is useful in cases where you know the the question is query obstruction and you know, clearly the question there, query obstruction. I think it's quite easy to say that that there is no bowel obstruction there. Um And then, so this, this idea, you may see some reports like there are reports for abdominal films very commonly are just normal bowel gas patterns are unremarkable, bowel gas patterns. There's quite a quite a variety of appearances in the large and small bowel that are fairly unremarkable from our perspective. And it's just whether if they're dilated up or uh to that kind of 369 type threshold that we'd be thinking about, um you know, raising the potential of obstruction. And yeah, just go through that the d the D part of the D structures and bones make sure you actually do spend some time looking for calcifications, foreign bodies. Uh the bones there So next one case three. So we've got an 80 year old male. So kind of a, an more elderly patient who's come in with increasing abdominal distension and bowels are opening for three days. Um Anyone want to give me, hopefully this should be a what we would call an aunt mi, you see something like this in it? Yeah, somebody's jumped on it straight away. So a sigmoid volvulus. Um, so we've got grossly dilated large bowel and it's kind of got this a host pattern. It's, they say. So a lot of as you can see, even it's difficult to see any Hatra here at all. And the, it seems to be kind of focusing down to the, the deep pelvis. Uh the thing that it's, it's usually referred to this kind of a coffee bean sign. Um So the, the one, I guess it's, it's far more common to get a sigmoid um vivalis than a cecal volvulus. But the, some of the, the ways of kind of pulling them apart a little bit is on this radiograph. You can actually see the ascending colon and possibly this the, the, the cecum down here. You can see a little bit of kind of scattered fecal material in it. So it's still, it's, it's not involved in this kind of evolving process and the whole idea of evolve. I'm, I'm sure you've kind of seen this on your surgical rotations is that it's just twisted upon its mesentery. So the, the sigmoid colon as the descending colon comes down and kind of dives and becomes a little bit squiggly into the, the deep pelvis on that mesentery, it gives that it allows that potential to sometimes twist. This is something that's far more common in elderly patients. So if you're given a, a clinical history of AAA patient in their eighties or nineties who's come in with abdominal pain and symptoms of large bowel obstruction. So, you know, abdominal distension, absolute constipation, uh nausea, vomiting. And if you're hopefully given either the the description of a coffee bean or um a radiograph like this, you need to be thinking about sigmoid, er sigmoid volvulus, the management of these. Um I guess the the the main major complications are that when it turns it cuts off the blood supply to the bowels so they can end up getting ischemia, which is is not very good for them at all. Um, or perforation is is obviously the the other main thing. So usually they're decompressed endoscopically. Um A lot of patients will return over and over again with, with kind of revolving of of their sigmoid and sometimes they need to actually kind of do a like a sigmoid ca pexy where they kind of pin it in place so that it the potential for it to evolve kind of stops. So the few learning points that I wanted to take away from this were the causes of large bowel obstruction. Um, and the, in terms of the major causes of that, we need to be thinking about malignancy as number one. malignancy is by far the more common cause of, of large bowel obstruction. Um, we talked about, um, adhesional obstruction and hernia being quite common in small bowel, but it's malignancy more so, uh, colorectal carcinoma. Number one and also pelvic tumors can start to kind of invade into the, the large bowel, particularly kind of the the sigmoid colon, um and cause a kind of an obstruction from from there. Other causes, diverticulitis is quite common in the population. So people who have had diverticulitis and end up kind of getting a lot of inflammation when that calms down, it can all get scarred and strictured and cause obstruction that way. And volvulus is the example we've just chatted about there. So sigmoid volvulus know the appearance know that's that coffee bean sign. It's definitely more common in the patient population who are more elderly and decompression. Um, usually endo endoscopically is, is kind of the mainstay of of management. Um Hoping that you're getting in there before they develop complications such as uh ischemia and perforation. We've, I've kind of mentioned earlier on that volvulus is this this idea that, you know, structures in the gi tract turning on their mesentery. So you can get cecal midgut gastric volvulus as well. But I think to be honest with you, that's a little bit beyond what you'd be expected to know for finals. Next case. Have a quick look at this one. So I've got a 25 year old male with abdominal pain. If anyone wants to jump on and let me know what they think of this. And from Olivia and uh Austra side, the connection is still OK. From, from your side. Yeah. Yeah. Grand. I feel like I've been talking to myself for a while so I just want to make sure lead pipe b so that's a good one. Someone has gone for lead pipe ball and that it's kind of fairly featureless the, the, the, the bowel that's dilated there. Um Yeah, and that's uh this, this is the kind of way you need to be thinking about things as well as the, you're, you're likely to be given quite classic demographics and presentations of these. So I would say, first of all, I probably up to about six centimeters. I'm not convinced that this is beyond six centimeters and it is very, very central. So I think it would be quite unusual for this to be large bowel. So I think it is going to be, it's going to be small bowel. Um I mentioned the fact that like it's very rare for a small bowel to dilate beyond six centimeters. I'd say we're probably on the threshold here, but we're probably at a point where something has there's been a complication of uh the small bowel obstruction Um And this, as I said, is quite a difficult thing to, to pick out, but particularly on these margins here kind of laterally. The bowel wall is really sharply defined. It's, it's, it's more difficult where there's loads of overlapping bowel loops, but definitely over here, it's just quite abnormal and I guess it, it, it, it lends itself to, as somebody said that idea that it looks fairly like like a lead pipe. Um, I know that's more of an inflammatory bowel disease type, uh, finding. But the idea here is that this is actually newer peritoneum. So we've got a small bowel obstruction. We've got dilated multiple loops of small bowel in the middle of the abdomen. But we've also got peritoneal free gas as well. So gas outside of the small bowel and that kind of tension from inside and out is actually causing these bowel wall, the, the, the small bowel wall to be really well defined. Um, and the other point is it's quite, quite a difficult one to pick up, but there's actually little bits of triangular type gas, which if you see triangular gas, um, on an abdominal film, essentially, it's, it's a, a fairly, uh sure fire one that there's going to be free gas. Cos essentially, there's, there's no structure that's triangle that should be holding gas in the, in the abdomen naturally. So you can kind of see the little bit of a triangular bits of gas here and bits up just under the liver. There's a bit of pneumoperitoneum here. So this is, um, somebody did tap into it fairly well. So it's pneumoperitoneum. It's, it can be difficult with abdominal radiographs. And hopefully, in this case, they would have also done an erect chest X ray, which would have made it very clear. So that, that idea of the well kind of the sharply defined uh bowel wall or the idea of kind of seeing both sides of the bowel wall, which you don't normally see because you've got gas on either side is a regular signs named after an American radiologist. And those kind of triangle areas of gas are the other thing. So we've got multiple dilated central, uh, located small bowel loops and the bit that was held back here is that this patient had a known history of, of Cro Crohn's disease. So, actually, this was secondary to an inflammatory bowel disease type stricture. Um, so that was that one, this one, I won't spend too long at this because I know we're running a little bit over. But this is a 7070 year old female who's got a distended abdomen, absolute constipation for 24 hours. We've hit on this a little bit before, but hopefully, you'll recognize that these are, this is there are multiple dilated loops of large bowel. Um, I know it does obviously come into the middle here a little bit, but it's, uh, wanders slightly So we've got the, the transverse colon, the scin and colon and then the, the sigmoid kind of goes on a little bit of a journey for itself here. But you can see down here deep, definitely in the deep pelvis, you see these haustra coming across. Um and we've talked about causes of large bowel obstruction. And this, when the patient went on to have a CT scan, ended up having a, a quite a, a low um sigmoid or rectal um tumor. That was the cause for, for the obstruction. Few things to point out in case you in case they do come up, it's always quite impressive if students mention these things like Olivia had with the ECG dots, if you can, if you can just say what they are and just, you know, um disregard them for there on, from there on out, got a, a right sided total hip replacement and also a vaginal pessary here as well. Um So just sometimes you'll spot these things on, on radiographs and the final abdominal radiograph case if somebody can put this together for me. Nice and swiftly, it's a very rare um one but sometimes I guess it's, it's ones that the, the surgeons do like to, to ask about. So it's a 60 year old female with a distended abdomen and vomiting anyone else have anything. So just think about it from the, that kind of a uh systematic p approach, perforated small bowel obstruction So the last one that we had there, the, the kind of all those dilated central loops with the triangle bits of gas that was a, a perforated small bowel obstruction. So I haven't done that again. For some reason, this, this radiograph was done erect. It's quite rare to do an erect chest radiograph. So people who are talking about free uh free fluid in the abdomen, there may well be, but it's not very sensitive. You can see some fluid levels in the bowel itself, which aren't necessarily that abnormal to have some fluid levels. Um particularly if you have a patient standing up, which I'm not really sure what the the merit of this was. So this one is uh another kind of hopefully, once you've seen it tonight, if you ever see it again, you'll, you'll be able to pick it right out. Um And I think again, malrotation is obviously something great to know about, but hopefully they wouldn't be asking you that particularly in an X ray or in an osc on an X ray in an oscopy. So we've got some dilated loops here. Again, I think I'll convince convince you that there are small bowel loops in the right abdomen. Um So we're looking at the a part. So air, is there any other air? We've got a gas gastric bubble here which is normal. I don't know if it, it projects very well, but there's some linear gas here. That's um in the right upper quadrant. That, that, that is something that is probably worth picking up. Um, and then moving on to the dim structures. We've got this circular, er, structure down in the deep pelvis. Um, I don't know if it's, if it's coming out, if anyone is figuring it out just yet. Um, and then in terms of organs and soft tissues, not really an awful lot to see. I guess you could kind of come back to this a little bit again. This is the liver likely in the right upper quadrant. And you've got this gas here, possibly in the liver. Um, no one's, this is a very tough case. I think I would have struggled this as a medical student. Hey, it's, I think, I think it's it. Yeah. Yeah. So it's a gallstone. Is somebody, somebody got in there in the end? Excellent. So, again, it is, it is a very difficult case. But the idea here being that there's been a, a big gallstone in the gallbladder for a long period of time, it's been quite closely related to a loop of small bowel. So much so that they fist, they've kind of become inflammatory and fistulated together. The big gallstone has been made its way into the small bowel got fairly far down, usually it gets close enough to the ileocecal junction and then causes a bowel obstruction. So the findings are, uh, again, just going through the assessment, even if you can't get to the bottom of the, you know, the actual core of the answer. Just kind of speak about what you can see. There's a small bowel obstruction, there's some sort of a calcific density in the deep pelvis. I don't really know what it is and maybe you might have seen that the pneumobilia, the gas in the bilary system, um, the rigs triad of abdominal X ray findings are pneumobilia, small bowel obstruction and a calcified gallstone down in the, in the abdomen somewhere. And that's Leo Rigler, uh, the American radiologist who had both the r sign of pneumoperitoneum and the wrigglers triad. So we're going to move over to Olivia. Now we're coming up to eight o'clock. So Olivia is going to do her bit on M SK and then we'll bop back for a little bit of CT head and hopefully be able to wrap it up close enough to half past. But obviously, as we go through, there was a quick question, actually there about, um, six centimeters roughly being the vertical width. That's not something I've ever used myself. Uh, and to be fair, whenever I'm measuring kind of, er, measuring bowel, I'll always kind of use the, the tools on the, the workstation itself. I think it's, I think it's probably a better rule of thumb to look at the location of the bowel. So if it's more central, it's likely to be small bowel and if it's more peripheral, it's going to be large bowel and, um, the hofstra and valvula conven, I think they are the things that will help you differentiate rather than thinking too, getting too bogged down in, in the vertical. II don't know if you've ever used. Um, yeah, I think in terms of the specific measurements, they are really a guide. So basically the dilated loops of bile are your impression. So if there's essentially dilated loops of bile, you know, they're dilated. And if there's peripheral loops of dilated bile, you know, they're dilated, the 369 ra is useful when you can't quite decide. So if things are kind of distended but not overtly dilated, that's kind of where I would maybe use measurements, but I'm not sure. I think six centimeters is the width of her body seems very big, very good. I don't have a ruler in front of me, but it seems quite big. Um So I'd say if it's bigger than our whole body, um I don't know the specific width of a virtual body. Um but I don't know if six centimeters seems quite large for a viral body. So potentially not, not, not a, not a rule of thumb that either of us use. OK. So I'll hand over to Olivia. Um So I appreciate we're kind of running a bit short in time. So I've just put together M SK is a huge topic. There's so many joints in the body and because there's so many different joints, there's lots of different anatomy and a lot, it's much harder to have your definitive structure. Um But basically, um we'll look at a few trauma x-rays and we'll kind of talk through how we'd approach them. Um But basically, you're looking at your kind of if there's any fractures, any breaks in the cortex, if there's any dislocation and like if the joint is in alignment or not, essentially and looking at your soft tissue swelling. So those are kind of three things that we're kind of be focusing on. So if we go to our first case, I've just chosen a case for like each joint in the body as a kind of fairly cl like classical presentation. This is a 70 year old woman who's fallen on her outstretched hand. What do we think has wrong with this wrist? X-ray, let's give you a couple more seconds. Ok. So we've got a couple of votes for a Collies fracture and that is what this case is. So it's, we'll point it out what the findings are. Um So a Collie's fracture, I'll point out the features on this film is that once we kind of know our anatomy. So we've got our distal radius, it's a, it's a wrist. So we've got a distal radius where now pointer is there, that's your articular surface and he's going down the middle or the side of the cortex of the radius. And we can see that actually the actual joint alignment is is fine at the end at the articular surface. But actually a bit more proximately, we can see that there's this dense kind of sclerotic line and a little bit of a defect in the cortex that seems to overlap where the cursor is. No, and that's your fracture. So that's your extra articular transverse fracture. And the line is because there's a bit of impaction. Um so it's impacted as well. And then we look to our lateral x-ray. So the basic principle for M SK plain film is that one view is two view, you need both. Um So you always need two projections for any joint. Um On this one, we can see that the thumb is lying kind of, I would say anteriorly, but it's a volar um side. OK. And we can see that's the thumb. So we know that that's where the palm is and we can see that this fracture. So whilst the joint is in alignment, we could be with the um with the carpal bones, we can see that that's fine. But actually, when you go a bit approximately where that fracture line was, there's a sharp angulation there and there's a definite break in the cortex and a fragment coming to the volar aspect. So basically a collie fracture is a distal radial fracture. It's extraarticular, there's impaction and there's dorsal angulation. Um So if we go on to the next slide, I've given this basic overview of the different types of fractures. Um And you can also get a ulnar styloid fracture associated, but it's commonly by falling on an outstretched hand is your classical history. It's usually uh like people with osteoporosis. Um and it's extraarticular. Ok. And there's a few different fracture patterns. So there's collie fractures is the most common and it, if it doesn't have all of these features, you can call it a Collie type fracture if you're not sure. So that's maybe a good, a good cough out if you're not sure. Um But yeah, so extra articular distal radial fracture with dorsal angulation, um Collies fracture and then you can have a look at this kind of Smith and Barton reverse Barton fractures as well if you like. But I think Collie fracture is the most common and the one that examiners like to talk about um because it has all these very specific features. Ok. Next, this is another um wrist hand x-ray. So just type into the um chat what you think is going on. Yeah, scaphoid fracture, good. Um So this isn't a specific dedicated scaphoid series film. First, we can do if someone has um if they've also the the mechanism for a scaphoid fracture is usually fallen outstretched hand and if um it's usually in a younger demographic. Um So that's kind of the the differentiator in your clinical history. So if it's a younger patient who's fallen out outstretched hand and they've got tenderness over their anatomical snuffbox. So, just like in this area here, um you're suspicious for a scaphoid fracture. So you can do a scaphoid series of views, which is just different angles um rather than your normal wrist kind of ap and lateral film. This is an A ap and lateral film helpful, but you can see that um in your carpal bones, the one that's just above your, your distal radius um is your scaphoid and there's a very thin black line traveling through that. And that's a scaphoid waist fracture and it's a bit harder to see on the um lateral view, but it is definitely there. Yeah, thank you. Um So we'll move on to the next slide. Just a few more facts about scaphoid fractures. Um Just a, a kind of quick uh overview of the anatomy and the lateral wrist joint. Um So your distal radius and you have your lunate and then your scaphoid sitting kind of overlap with your lunate and your capitate all in the same line. So you kind of call it um what is it cup? And I actually, you know, I can't remember what it's called an apple, apple in a cup and a s yeah, apple and cup and sauer in a very, very helpful um way to remember it. So they, they stack on top of each other and if there's anything under the line that's something to look for in your lateral X ray. So sometimes your lunate can dislocate or you can get a per lunate dislocation and your um saucer at the bottom is off. Um So it's just a little kind of demographic of what the anatomy is in a lateral film. But sid fractures again, sorry, younger patients who fall in the right stretched hand. Um and they've got pain in the anatomical stuff box. Why we're so paranoid about scho fractures is the risk of avascular necrosis because the blood supply of the sca forward comes distally. So like from the top of your hand down, um it means that there, if there's a proximal pole fracture, it's at risk of not healing and nonunion and that can have um quite significant consequences down the line if it's not picked up. So basically, um if we're concerned about skip void fracture, we do dedicated skiway films and if you're not sure even after that x-ray follow them up in a few weeks. Um just to make sure that um we haven't missed one. OK, we can move on. This is an elderly patient who has fallen. What do we think is going on? Right. I don't know if this one's projected quite so well. Actually, it's quite tricky. OK. If you can see it on the plain X ray, then that's enough to call it. Yeah. OK. OK. So we've got a couple for P ramus fracture. So any other comments? Yeah, a fracture? OK. So I'll, does anyone see anything else? I think it is, it is quite subtle. I'm struggling myself. I think it's perhaps the projection and then obviously, OK, we'll go on to the next one. So it is a neck, a feur fracture. So just so we can move. Yeah, so this one is really subtle. Um And the lateral film makes it really much easier to see. OK. So you can see that on the lateral film. This is why two views is really helpful. Um Yeah, so it's a, it's a right neck of femur fracture and it's not, it, it's not the space, it's slightly kind of, I wouldn't say there's market displacement, but there is a little bit of angulation there. Um So where miles cursor is, that's quite a sharp angle and on your lateral film, it should look. So if you um the femoral head should sit right on top of your femoral neck, on the lateral film, like a lollypop. Like if you think of those like ch ch lollypops, the femoral head should, should, should sit right at the top of that first. This one, we can see that it's angulated back. Um It's like off center. So that's why your lateral films are so helpful because actually it ha firstly, it hasn't projected terribly well on this and I do apologize. Um But there is a very subtle cortical break on the AP film on the right kind of um femur, you can kind of just about see it past that um superimposed film, but just there, there is that subtle, very subtle um abnormality, but it's just to kind of emphasize how important it is to look at two views. So that was a sneaky one. So if we move on next um neck or fever fractures really, really common. I see them every day and there's different types and it's important to kind of identify what type of necro feur fracture. It is because it impacts the management of it. Um So basically, if it's an intra capsular fracture, we're worried about the blood supply to the femoral head and the risk of avascular necrosis. Um So it needs to be identified. So, um basically, they're kind of um the cut off, basically, if it's subcapital. So like the bottom of the top of the femoral head um and transvaal. So across the neck, those are considered within the capsule and any um like um other fractures. So like the intratrochanteric fractures or subtrochanteric fractures, they're all considered extracapsular and they get managed differently by the orthopedics. So if we go to the next case, so what's wrong with this one? Ok. So we got a few options for distal fibular fracture and someone's even gone for the Weber classification. So, really good. So this is your distal fibula um that is fractured. So it's the the smaller bone in the ankle. Um and someone's even gone for tar shift that's a really good call and I would agree. Um But basically, um this is a um distal fibular fracture which has um you can see it on the ap you can also see it on the lateral Nile if you don't mind pointing it out in the lateral for everyone. Um So it's like an oblique line that you can see through the tibia. Um and there's a bit of soft tissue swelling, there's a bit um of til shift. Like we said, that kind of space between the, the medial malleolus and the talus um is widened. We only want that to be a couple of centimeters, but it's not symmetric to the other side where the fibula is. Um And basically, this is a distal fibular fracture. We can classify the in terms of Weber A B or C. Um And basically, it's all in relation to where the syndesmosis is. So like just the ligaments of the ankle that keep it um stable. And basically the Weber classification is to help classify whether it's a stable or unstable ankle fracture. So this is we Weber be fracture is at the level of the syndesmosis, it could be stable or it could be unstable, they can go either way. But if we click the next Nile, if um this should be, yeah, this is just where syndesmosis is. And then it's the next slide. I've got a bit more information about the types of um Weber fractures So Weber A is below the level of synesis. So it's just the tip of the lateral malleolus or the distal fibula. Um And you can see it's a very transverse lucent line through the distal fib fibula. Um just the tip and there's a bit overlying soft tissue swelling that's Weber A that's stable. The one in the middle is the one that we had in the previous slide. That's your Weber B and then the one on the right side of the screen is your Webber C So it's above level syndesmosis. It's unstable and there's a lot more tailor shift on that one if you can see in contrast to the ones before. OK. So that's our ankle once and this one, it's not a fracture. I'll, I'll, I'll, I'll give that to you now. But are there any features in this x-ray that you think um are not normal? So someone has said about the thumb being dislocated and the thumb, it's not dislocated, but it is abnormal. Six, gotta vote for a uh I've got subluxation and Z um So those are correct. So we've got, what do we associate AZ shaped thumb with? And we've got lots of joint space around the MCP and T IP joints. So, yeah. OK. So the MCP joints I agree with, with the D IP joints. Uh I think there still is a bit of joint space. You can still see a nice thin black line between um the interphalangeal joints and the distal joint and someone has summarized it for us and said, rheumatoid arthritis. So, ra and so the Z tip thumb that somebody has pointed out, we can see that the thumb is not a normal alignment, it's subluxed. This is your Z shaped thumb. We've got some joint space narrowing and some erosions at your um MCP joints. So your metacarpal pharyngeal joints. Um and there's also this periarticular osteopenia and these are all features of rheumatoid arthritis. And I can see a situation in an oscopy where you could be asked to examine somebody's hands and be shown a film and you just talk through the features of rheumatoid arthritis and it's what really CS it here is the distribution. So it's symmetrical small joints, um inflammatory arthropathy and it mostly affects your MCP joints and then kind of um also come with carpal bones as well. Um And he can give you some subluxations so you can get um you can get some ulnar variants. So the wrist can kind of tilt like this. You can get your Z shaped thumb or you can get the swan neck deformity as well. Ok. Um osteoarthritis mostly affects your distal joints. So like your small joints of the fingers and the base of your thumb and if you go the next slide. So, yeah, this is basically just the distribution that you'd see in rheumatoid arthritis, small joints, other features we didn't talk about, we talked briefly about erosions, but marginal erosions are pretty classical. And if you get given other joints, um effusions are very common and you can get soft tissue nodules as well. So I think you always get someone um who has their, their hands out for a hand exam and you have to make sure you, you examine up to the elbow cause they'll have a nodule on their elbow. Um It's a classical oy scenario. Um But yeah, so that those are just some features of rheumatoid arthritis to be aware of. I think that might have been my last case. Um uh Yeah, so basically, just to summarize, trace all the bones, make sure that the cortex is intact, make sure the alignment is intact and look at your soft tissues, things that we haven't covered and that were on the list that we were given. So, osteoarthritis, um avas necrosis and other types of wrist fractures, um and forearm fractures. So your Monte galii fractures um haven't been covered. Um I'll try to add more. I've put up together another playlist for the M SK cases. I'll try and add some of those things onto that playlist. So you see some examples. Um But yeah, I'll hand back to Nile to just finish this off. Great. Thank you very much Libby. Um So we're at just about quarter past now. So I appreciate, obviously, there's a lot of radiology for one evening even though it is the best specialty and everyone will want to do it after this session. But, uh, I know obviously people do want to eat as well. So we'll try and whip through these cases fairly swiftly. So bear with me and try and get the answers in nice and swiftly. Uh, and we'll get this session wrapped up. Ok. So the idea behind this part of the session is not necessarily to make you in any way competent or expert level at, at looking at CT or MRI. I'm going to focus on CT and, and no one would expect you to be that for medical school finals. Um Any abnormalities that you're shown should be very obvious. And similarly to the other cases that I've shown you earlier on, you should be given a fairly classic history as well. And the, the imaging should just kind of tip you over the line um to, you know, give it kind of make the diagnosis. The first things that I would say is that having a full on like how to approach a CT head, like in the same way as as we've done for the chest and ABDO, uh it's probably not applicable. I think the, the way that we myself and Olivia look at CT heads again on a daily basis, uh involves using a lot of kind of different windowing approaches. So we look at different structures with, with different levels of contrast and um you know, change the gray levels quite a bit and look at, look at specific things in different um different axis. So coronal sagittal and axial, which you know, again, that's not going to be something you're going to be doing in, in a, in a, in an OS. So it's just about being able to really look at an axial image or an axial slice in particular with obvious pathology. And there's only a few obvious pathologies you should be given. Um The first thing just to note is obviously looking at a CT, it's quite impressive if you're able to say what's left and right and what's anterior and posterior. So you always have to imagine that you're looking at a patient as if their head is, if we're all looking at a computer screen. Now, the patient's head is behind the computer screen and their legs are pretty much sitting on your shoulders or however you want to think about it, but they're, they're lying on their back and their head is behind behind the computer screen, their legs are coming out of the screen. So that's the way you're looking. So it's always going to be opposite. Kind of your right, your anatomical right is going to be kind of um the, the radiological left and vice versa. Uh So just have a, a little bit of a think of that. A lot of the scans will be labeled anyway with right and left, but just uh bear that in mind. And the main thing would be the the benefit of a CT head is that there's a lot of symmetry. So right and left should look very similar. So if there's an abnormality, there should be a level of asymmetry. So looking for a difference in density, so kind of big areas of of white or dark in in the the brain itself or or within the skull. Um So looking at the brain parenchyma, the the ventricular system, so the lateral ventricles in particular, and the skull margin and mass effect. So if there is anything in there, is it pushing things in a certain direction? Um Looking for that kind of midline shift, the main things I guess is always think, am I being shown a stroke, a bleed or some sort of a space occupying lesion like a tumor or an abscess or something? They're really beyond that. I can't imagine you being asked anything else. So, here's some cases, I've got a 50 year old male with right sided weakness and slurred speech. Um We've got a few pictures from the same case. So, um if somebody could tell me what they think is going on, I guess the, the history sounds like they've, I guess first of all, don't tell me what's going on. The history sounds like they're having a stroke. There are a few signs that we see on ct of hyperacute kind of uh stroke or kind of early ischemic change on CT. Does anyone want to tell me what this one is? Yeah, anyone come across this before again looking at kind of symmetry. Um And I also think whenever you're getting a clinical history of a stroke, knowing what side the symptoms are on is really helpful. Um because we also know that if a patient has dense right sided weakness and slurred speech, then we're thinking that the lesion might be on the other side. Remember? And yeah, we've got a few. Yeah, great. So as Olivia was saying, we've got right sided symptoms. So focusing on that left uh air left kind of uh hemisphere and focusing in on the MC. So we do have a, a hyperdense vessel sign here. The, the, the left MCA looks a lot more dense than the other side. So that's the first one, same patient. Um Again, these, I think if you kind of can bear at least these three findings in mind, I don't think there would be anything else on this. Again. Just have a quick look a little bit more subtle. I think this finding. Um if anyone wants to, again, we're looking at the left side in particular because the, the they've got right-sided symptoms, we'll see if anyone jumps in, in 10 seconds again, slightly slightly advanced, um for, for med school. But I think it's, it's probably, you know, worth worth having a um idea there is, I think happy to get any sort of observations that you're getting here, this chio plexus calcification. But that is something that we will see quite normally in patients. Um The finding here is this um insular cortex, so we can see it over on the, on the, on the normal right side. Uh the patient's right side, it's quite, quite well defined here. Um We've got early signs of, of stroke going on here. So there's a, a bit of edema and loss of, of that kind of definition there. So it becomes a little bit darker. You can see this insular cortex is slightly darker relative to the other side. And then because you, you get that edema, so there's some kind of early fluid uh kind of um uh cytotoxic edema going on here. So the the kind of cells are filling with fluid, you lose that definition of the insula, that's the loss of the insular rhythm sign is the, the second one that I was just going to show you there. And the third one then down similar lines here. This is where. So we've got the gray white matter differentiation. This is what I was saying about the way that we look at at, at CT scans. So you can see that with, from the first picture to the last one, we've slightly changed the way that the, the gray, the gray levels are are kind of operating to help us kind of spot more subtle pathology. Um So on this side here. This is where your basal ganglia would be. So your Lior nucleus caudate head and you can just, I think again, you might, you might agree with me that this is darker than on the other side and you're kind of losing that gray white matter differentiation. So this is the the basal ganglia kind of loss of, of your basal ganglia disappearing basal ganglia signs. They're the, the three just to bear in mind. If you are shown a CT head in the context of a possible stroke, there'd be things to, to to be aware of. So the main thing to say is that if a patient comes in with a stroke, it's quite normal for us to see an absolutely normal CT head. And that's actually one of the important things that we need to do in those in those situations, which is to rule out there being a hemorrhage so that we can kind of at least rule that out as a hemorrhage being a contraindication to thrombolysis if they need to thromb the patient. Um hopefully, you will have had some chats through medical school about thrombectomy as well and stroke thrombectomy. Um and obviously a 50 year old patient like this patient with a DMCA, that would be a large vessel occlusion. So, you know, if you ever did get a case like this in an OS and were able to say that there's a large vessel occlusion that might be suitable for thrombectomy. That would be a very impressive way to wrap up the case the imaging features of of early ischemia hyper vessel, the hyperdense vessel sign, as we said, loss of gray white matter differentiation and that kind of insular er rhythm, that kind of uh cortical hypodensity, so low density in that area and swelling um as opposed to established infra so old strokes will look like low density areas um and will not be giving mass effects. So we've seen those areas that were lower density because of edema are kind of causing a little bit of swelling in the area. Whereas old infarct won't do that a quick question for everyone there. So, a 63 year old man with acute onset facial droop and right sided weakness has CT head demonstrated an asymmetrical linear hyperdensity at the expected location of the left middle cerebral artery. Sounds quite familiar here. What is the most likely underlying process? Is it an intracerebral hemorrhage, deep venous thrombosis, cardiac arrhythmia or a fat embolism? People still with me, hopefully got a few answers for c popping in. So, yeah, er cardiac arrhythmia, the one I'm referring to is atrial fibrillation, um which is uh one of the more common causes of a cardioembolic stroke. Um I guess would, would be quite a common cause. So often these patients will come in with symptoms of a stroke and only on their presentation and diagnosis with a stroke. Will it will they realize that they have atrial fibrillation in the background and then will be started on treatment for that as well. Um Deep venous thrombosis is a very rare cause of stroke because if you have a patent form in a valley, you can get a paradoxical embolism, fat embolism, um very rare cause, but that would actually cause uh it wouldn't be a dense MCA. It would be a, a low what? Uh because obviously fat on CT is, is low density. Um It would give a different app appear and intracerebral hemorrhage is what we want to exclude with the CT. So that would be different. So, um a quick one here, I think I might rush over this one because I think the, the bleeds are possibly a little bit more useful. So we've got a 70 year old female who's got left sided weakness, query stroke. So again, unfortunately, this is something we come across a little bit. Um So we can look at this head and look for symmetry initially. So we've got all this kind of less dense area in the, the left hemisphere. There's also something here that doesn't look like a, a rounded Hypoattenuating area here as well. I'm not really sure what this is and I think if you go down a slice, you can possibly say that there's uh another kind of rounded lesion here and this one is coming into view as we go down a little bit they may give some contrast and you get this kind of peripheral contrast enhancement of the lesion. You've got all this darker stuff beside it, which is edema. So there's a lot of fluid in the tissues beside it. And um I don't know if anyone is, is jumping at what they think this is. But um we've got multiple lesions in the, in the brain and we've got, got to think that there's potentially um metastases here, which are the the more common cause. So again, these, these are mimics of stroke. So, again, not, not uncommon. Do we scan patients query stroke to rule out a bleed and actually end up finding um space occupying lesions such as metastases. So space occupying lesions kind of will will take in they're kind of an umbrella term for metastases, pri primary brain tumors and abscesses. Um metastases being the most common uh space occupying lesion and can come from a variety of areas such as lung, uh renal cell, carcinoma, breast me melanoma. Um they can mimic strokes, as we said and multiple as we just saw in that last case will increase the likelihood that it's metastases. But actually, we can, even if there's only a solitary one, it's, it's quite likely that that will still be a metastases rather than a primary brain tumor. Just obviously given the incidence of both. Uh we've talked about the peritumoral edema, all that kind of dark tissue around it. The hypodense or low density area around it. Sometimes you can get bleeding into the tumor and that ring enhancement. So it's essentially just these tumors have outgrown their own blood supply. So all the central bits are just dead necrotic tissue and you've got enhancement on the outside. So quick, run through a few bleeds, which are, I guess a more likely thing that might come up for you all. Um, so we've got a 40 year old male with a RTA and a head injury. If people could tell me what type of a bleed that they think this is and we'll do the same for three others. And that will be the, the neuro part, hopefully almost done. Somebody's jumped in an extra jel on this one. So things that would be making you think that obviously are the, this kind of um bicon uh convex shaped looks like it's kind of uh held within the, the, the the sutures itself. It's causing quite a bit of mass effect. I've just put a, a Coronal um picture on here as well. So you can see this midline shift and early uncle uh uh herniation as well. So we've got a high density biconvex collection. This patient had a temporal skull fracture and bleeding from the middle meningeal artery, which is the most common reason that this would happen. So I think again, if you've got a younger patient with a history of trauma, um this idea of a lo interval so that they're, they're ok initially um after the injury, but then deteriorate, think even before you see the picture that it's likely going to be an extra dural. Next case, that is not the correct history actually. So this should be a an 80 year old female with increasing confusion and somebody's jumped in with the subdural there very fast. So we've got this cresentic type uh collection um subdural. Exactly. Um And that again is causing mass effect. We've got some blood here kind of coming immediately. So it does track along the tentorium and the fact a little bit as well, but that's still all subdural blood. Um And again, this isn't helpful because I've not put in the correct clinical information, but these patients will likely be older patients as we'll come to here. So got this high density crescentric collection over the cerebral hemisphere and it's due to venous bleeding. So there's these kind of uh tearing of the, of the bridging veins and it's often in the context of volume loss of these older patients who've got kind of their brains have atrophied through the years and just kind of minor trauma, um sometimes can be concealed trauma. You might even know these patients have, have a clear history of trauma, but they've got increase in confusion. Um And yeah, often older, that's, you know, if you've got an older patient with increased confusion, possibly a history of a a fall, then you you've got to be thinking of a, of a, a sub juror even again before they show you the image. Next one, we've got a 55 year old female with sudden onset headache and collapse. Um We'll get a quick one on this one as well. So we've got quite diffuse hyperattenuating material here down at the basal cisterns. It is the fourth ventricle, subarachnoid people are jumping in on that straight away. That's great. So again, history here is classic sudden onset headache, think about thunder clap, think about, you know, the collapse, that whole idea. So we've got high density material in the CSF space is cer and sulci. So you can see it actually um quite well here just even within the, the sulci here um down with kind of the uh anterior cranial fossa, as I said in the, the fourth ventricle. Um So these are classically due to aneurysm rupture, you can get traumatic subarachnoid. But I think realistically, if you're given one, think about just see these patients, you know, you have to rule out that there's a, there's an underlying aneurysm, classic headache, meningism and younger patients are the likely demographics. And this one, we've got an 80 year old female with expressive dysphasia and a loss of consciousness. So kind of stroke like symptoms and she's got a history of hypertension and Af on Apixaban. And what is this one? This is a little bit more difficult, but hopefully, even with the history and notably the hypertension, we might be able to figure out what's going on. It's also a horrible off axis slice of a of act head. So I apologize for that. But again, it's a radio pia case. Yeah. So I guess it's the last one we had left there to cover which is an intra uh intraparenchymal intracerebral hemorrhage. So either either one intracerebral or intraparenchymal hemorrhage. This is focused if you'll believe me on the basal ganglia. So a basal ganglia intracerebral hemorrhage is is very likely to be related to hypertensive hypertension. So a hypertensive type bleed, but there is extension of this bleed into the ventricles, which is not some, you know, it's it's not unusual to see that as well. So there's a big bleed in the tissues that you don't see over here, but there's also some blood in the ventricles. So a high density focus in the brain tissue itself, think intra parenchymal. So, hypertensive bleeds or bleeding into a tumor. Um as we said, with the metastases and primary brain tumors, they can, you can get bleeding into them and that can be a trigger for presentation as well. But I think more likely it will be a middle aged, older person with stroke symptoms um with a headache, loss of consciousness and they might have a past medical history of high BP. So these are the ones we again scan these relatively often um because they come in and they're like, oh, query thrombolysis and it ends up being that they've had a, a hemorrhagic stroke or intraparenchymal. Um, so this is my last case. I think that I'm going to cover. So it's a 35 year old male with, uh P ea arrest neurological deterioration and unequal pupils. And I'm not going to spend too long at this, but hopefully you can appreciate that this, the things we've seen kind of with the CT heads we've seen so far, there's been much better differentiation between the, the cortical gray matter and the white matter in the middle. And this is just all um lost differentiation there. And we've got this high density at the bases. This is called a pseudo subarachnoid sign. And it's just because there's so much edema here that the contrast changes with uh at the bases here and it looks like the subarachnoid blood. But it's just because it's so oedematous the the brain. So actually, this is a hypoxic ischemic encephalopathy. So, and um quite a, quite a, a complex one. But if you've got a patient who's got a, you know, an ex a an acute event such as a near drowning or cardiac respiratory arrest and has had extensive resuscitation efforts. This kind of just a global insult to the to the brain is, is something that, that can be seen again, less likely than the bleeds we've talked about for you to see. But I just said I'd pop it in. That's my neuro stuff done. We're now at 25 to 9, there was a few other cases that we could have covered which we can, can come back to in a moment if we, if we want to. But uh maybe we should just see if anyone has any particular questions to start with. Um and go from there, feel free to drop them in the chat. There's II, I've got like two or three questions kind of more structured around the knowledge test to go through and just have a quick chat through which we'll probably be able to do in five minutes if people want that or if people want to ask questions. Um just, just let us know and hopefully everything that's been covered so far has been useful if you were to be shown a CT head and oy, I wouldn't expect them to ask you too much in detail. Um Like, II think it would be an extradural hemorrhage where it's like a, a very clear history of trauma, a young patient with a lucid interval and that big lens of bloods um or like a subdural or a very obvious sub. I don't think they'd give you anything more complex than that. Um In the intention definitely not to scare people into going off learning about CT heads. I think it's the, you should, you should be able to answer those questions. I think even without seeing the imaging but I think it's just to get a, that it should be so clear from the history that that's what they're trying to get you to go and that should just be the clincher is a very obvious ct head kind of picture. Ok. But we appreciate that was a very, a lot of information in quite a short period of time. So, um, uh, yeah, we do apologize for that. Why if, if anyone has a quick question that they're thinking about an asking in the next five minutes, uh just kind of get it typed into the box. I'll go in and have a quicker look at this presentation again for AAA moment or two. Just kind of go through a question or two that I've taken from the sample papers from the Medical Schools Council. And at least we've kind of covered it from that perspective as well. I think a lot of what we've done today, hopefully there will be bits that will be useful for the knowledge test, but a lot of it will hopefully be useful for your upcoming Acies. And these next couple of questions that I do should be hopefully useful then for the knowledge test as well. So I'll just do that fast. Olivia if that's OK and we'll, we'll wrap it up then. Um And I think for, if you're shown a plain film in an osk, um what we've said about like keeping a structure like that is really helpful. But what Niall said was actually really important that if there's something really obvious that you know the answer, say that first and then go like your structure is like something you fall back on after that to make sure you don't miss anything else. Um And the structure is really helpful if you don't know what the answer is. So if you know what it is, say it and use the structure to complete your answer. But if you don't know what it is, stick to the structure. And, and this is just kind of highlighting what we were saying already is that um this, this is a 36 year old man, I'll come back to that in a second. Uh with head injury, fall was unconscious for a minute, recovered, seemed fully alert and orientated and then becomes drowsy and confused. You should know the answer to this question without seeing a picture. So it's essentially going to be an external hemorrhage. Ok. Um This one, a 52 year old woman has had uh four episodes of severe colicky epigastric pain associated with vomiting over the past three months. So it's quite a protracted history here. The episodes occurred after eating and lasted about one hour before complete resolution. She has type two diabetes and takes Metformin abdominal examination is normal and she's got a slightly raised or raised BMI what is the most likely uh investigation to confirm the diagnosis? Great and somebody's gone for see there. So this is describing bilary colic. Um And yeah, essentially, even though we, we have shown that you can see gallstones on a radiograph, ultrasound of the abdomen is, is the, the, the test of choice here to demonstrate that that there is gallstones in there. Um, thankfully, at this point, it doesn't sound like an acute presentation of cholecystitis. Um, but I just said I'd pop in a quick picture of what that does look like an ultrasound. Again. That's this again, just unlikely to come up. But I think it's, it's worth just having a quick idea in your, in your mind. So this is the gallbladder, this is the inferior part of the right lobe of the liver and these are the gallstones also got some mixed density stuff in here. So likely some sludge as well. And this gallbladder wall is thickened. There's a bit of fluid in there as well. So it's quite edematous and thickened and this is what it would look like then on, um, on M RCP. So again, gallstones similar to the ones that we saw on that abdominal radiograph. And this is, again, you'd be obviously able to scroll through this in real life. But there is a stone there quite close to the, the cystic duct which is causing this. There's a bit of fluid and thickening of the gallbladder wall here as well. Um Final 1, 64 year old woman is seen same day emergency care department with chest pain and shortness of breath. Past medical history includes COPD hypertension and type two diabetes. She's limping as she's recently twisted her knee on a family hike. Uh, her heart rate is 105 oxygen saturation is 96. Chest X ray is clear. Um, she's on 2 L of, of oxygen there as well. What's the most appropriate diagnostic investigation? Yeah, I think that's fair enough. I didn't really want to cause a, any sort of argument uh with the last question, but uh I think most people are going for CT PA here. Anyway. Um, this is more, it's less about radiology knowledge and more about kind of your knowledge of the wells score, I guess. Um, this patient, I guess it is that kind of the, the number one headline is that it sounds like it's, it's um let it's unlikely to be another diagnosis. So there therefore, uh they'll get a score of three to start with anyway. Um And then you've got a few other things like the tachycardia, she's got a knee injury that might have had her immobilized for a little period of time. Um So I think we can probably say that her well is over for and go straight to a C TPA without going for the D Dier. Um But if the wells was under four, then we might consider doing the ddimer first. Oh, yeah, this was uh another one that we actually we were discussing this before and we thought this was actually quite an unfair one to put on the, the medical because obviously the Medical Students Council had me a, a mock paper as I'm sure you've seen. So a 43 year old man is involved in a low speed RTA. Following this, he develops pain in his lower back that still troublesome several, several months later. So again, it's, it's a protracted type history. The pain is worse after activity and is relieved by rest. He has an exaggerated lumbar lordosis with a palpable depression above L5. The range of movement of the spine is grossly normal. Neurological examination of his lower limbs is also normal. Um see the MRI image. So the MRI image that they gave was something like this. Um again, not that you would need to know, but it was at one image which doesn't really give a great view of the CSF and the, the vertical canal itself. Um And all usually you get a nice bit of contrast between the CSF and the discs. So you'd be able to see a big disc bulge. You don't see it that well on at one. But the, the finding really was that. So this is the end to part of the vertical body of L5 and this is S one. So you've got what looks like slippage here of, of that on, on, on those two. So the, the answer of those So we've said you can't really see the in intervertebral discs very well called equina syndrome. It doesn't really fit because the um the neurology sounds quite normal and it's more of a tract, of course, compression fracture. I think the one thing you can probably say on this is that there is no evidence of a compression fracture of the lumbar vertebrae that you see, but you've got that slippage. So I think the, I think it's a classic thing that always uh confuses medical studentss and even even junior doctors is this distinction between spondylosis, spondylolysis and spondylolisthesis. So I think we won't go into it this evening but just have a bit of an idea. But the lis theis part is the slippage. Um And yeah, so that's, that's what essentially that one is showing. So essentially that's all the bits that we wanted to go through. Um So I'll bring down my presentation again. Um There was a question that came through, I think at the start there, it's not a no daft questions at all, James to start with. Uh is X ray or CT regarded as first line in small bowel obstruction? It comes up in practice questions with very varying answers. And I think that's because there, there probably is varying practice as well. Um Particularly if there's a low um index of suspicion. I think it's, it's fair enough to do an X ray first off because if you don't have, you know, clearly dilated bowel loops. You can, you know, at an early point, consider an alternative diagnosis. Whereas obviously if they're dilated, they'll end up likely having a CT anyways afterwards. But a lot of patients who come through Ed and I'm sure you'll find this if, you know, if you've already spent time and when you do spend time in, um, CT is, is, is fast becoming the, the first line assessment tool for, for anyone coming in with any sort of surgical abdomen type picture. So I think is that that fair enough? Olivia? Yeah, I think it, it is difficult for you guys because practice in real life varies quite a bit. Um because whilst it can be really helpful if you have like gaseous distended, looks a small bowel in the abdomen. Remember that your small bowel normally is full of fluid. So your small bowel can be distended with fluid just as easily as it can with gas. And if you've got fluid filled, distended, looks a small bowel, you won't see that very well in an abdominal X ray. So it is really tricky x-ray can be useful. If you can see kind of normal boil gas pattern, you can see bits of gas and small, like bits of small boil that can be really helpful. So I think abdominal film can be useful. And I think if it was an exam, I think it could be the easiest way to get an answer. As to what's going on with the patient and you can see hernial orifices as well. So you can see if they've got an obstructed hernia and a plain film sometimes as well. Um So I appreciate that's, that's actually a really good question and it's actually really difficult to answer because practice varies so much. And as, as, as James is saying, I think even in the mock questions that they do, you get variable answers. So it may well be an unfair question to even ask because practice does vary. Yeah. And I think both are actually valid. Great. I think that's us. Unless anyone has any more questions, we'll hand it back to you. Er Yeah, thanks very much. That was very helpful and I appreciate that was a lot to go through in 1.5 hours. Um I've just sent the feedback form into the chat. So if you guys could complete it, you'll get a certificate form and it would be great for us to know um how the session went. Thank you. Great. Have a good night and obviously best of luck to everybody in their, their finals as well. And feedback is also useful for us. So it, it's good for us to get a bit of feedback as well on, on our teach if, if that's OK. Um Sorry to interrupt, I've just noticed one final question. If there is hemodynamic instability, would it be X ray first for speed? I personally would say that a see if someone is critically unwell. A CT scan is going to give you a more definitive answer quicker. And if someone is really unwell at the point where they're in extremist or they might need surgery urgently or it support, then act is gonna give you the most information for that patient. Yeah, I think we, we also live in a, in a, we work at an age where people are, will very rarely take a patient to theater based on an abdominal X ray. They'll, even if it's a barn door sigmoid volvulus, they'll still want act of it to plan their, their operation. Yeah. Great. And, yeah, I get the whole, the presentation will be available on, on med all anyway, afterwards. And I guess Olivia, once we, we might be able to comment on that and give, uh, the links to the playlist that you've linked to anyway as well. Yeah. Thanks everyone. Sorry. So, if we've gone, we've gone over a little bit. So sorry to keep you. Good luck. Yeah. Good luck, everybody.