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X-ray interpretation (CXRs and AXRs)

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Summary

In this interactive on-demand teaching session relevant to medical professionals, the speaker goes into what to look for when interpreting chest and abdominal x rays. The speaker will provide a pneumonic to help analyze an X Ray and then discuss how to present differentials based on the X Ray and clinical history. At the same time, attendees will also learn the five criteria: rotation, inspiratory effort, penetration, exposure and alignment, to accurately assess the adequacy of a film. This retreat provides an opportunity for medical personnel to improve their skills at X Ray interpretation.

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Description

This webinar will give you a useful format for data interpretation and how to spot common problems on an X-ray for ISCE

Learning objectives

Learning Objectives:

  1. Identify the types of chest X-rays and when they should be used
  2. Explain the principles of adequacy in chest X-ray interpretation
  3. Assess adequacy features in chest X-rays such as rotation, inspiratory effort, penetration and exposures
  4. Differentiate between normal and abnormal features in a chest X-ray
  5. Utilize appropriate clinical history and articulate a differential diagnosis and plan of action when interpreting chest X-rays.
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Computer generated transcript

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

Hello, everyone. Um, can everyone see? Um, see me and hear me. Just checking to make sure that people have been able to actually join. And it's working. Okay, Brilliant. OK, that's fine. And everyone can see me waiting on tenterhooks. Uh, brilliant. Thank you, Megan. Thank you, young. So, um, welcome, everyone. Good to have you back. Um, I hope you all had a nice rest over the Christmas break. And also, um, over the new year as well. Um, hope placements are kind of going okay since coming back. Uh, Wisma is joining me, or she had joined me, but I think there might be something wrong with the connection or something. I hope that she is still there. Um so today we're going to do a talk on X ray interpretation. Um, I was going to go through the, uh, to the easiest ones to kind of go through, which would be abdominal just X rays and abdominal X rays give you all kind of a format to follow and classic things to look for an X ray, and we wouldn't really have enough time to do M S K X rays, but that will be something as well that we definitely do for you guys. Um, the recording of this will be up online for you all to see, um, through our organization page. Um, And if you have any questions or just put them in the chat bar, I can't see it as I'm presenting. But towards the end, I'll answer all your questions and hopefully go through that. Uh, no. Prisma, you're not visible, but I can't see you. Unfortunately, um Oh, wait. Okay. So everyone can see you. That's fine. I can't see you. Um, no worries. OK, that's brilliant. Bismuth. Thank you for that. So let's get started, then. Love you all. Okay. Same imaging interpretation. So what we're going to go through is chest X ray and abdominal x ray interpretation. I'm not going to have time for M s K X for interpretation, but it's something that we will cover further down the line. So that's more just kind of give you a hint that we will be covering it later. Later on, um, in our series. Okay. So, to start off chest X ray, when you're interpreting it with any kind of station when you go in and you get given, um, a station where you're presented with an X ray. Okay. First thing to do is check the patient details. Make sure that the align with the patient that you took a history from, uh, then the things that you want to check. Kind of the details of the x ray. So the date of it review the type of chest X ray That can be quite important. So is this an AP film? Is it pa film? Uh, they should tell you. Yes. Uh, I can't see the screen. I don't know if other people can see your screen. Okay, can. Then we'll see the screen. No, no, I can't. Sorry. Um, it's not full screen, though, but yeah. Oh, it should be full screen. Okay, you have to bear bear with with those guys because it's the first time that we've started using the medal thing. It will be easier as we, uh oh, yeah. It will be easier as we kind of get into the swing of it. Um, let's see if I can fix this. Mhm. Mhm. Um, also just checking. Um, has everyone, uh, signed up to the new sign up link? Um uh, I I think I send it like over Christmas, because just make sure you do that because we're gonna change the mailing list. So if you're if you haven't signed up to the new sign up link, um, then we may miss you out. So just make sure you do that if you haven't yet. Can everyone see that screen? Yeah. OK, Brilliant. Right. So I'll start from the beginning again. So we'll be going through chest X rays and interpretation of Donald X ray Interpretation. M s K will be at a later date. Okay, so chest X rays as you go into your station. Um, most likely it will be, um, history you're taking. They'll ask you to present the patient all that jazz, and then at that point, they most likely present you with some kind of interpretation. Uh, could be something like an A B G. Some blood work, but a one which can commonly come up is an X ray that you need to interpret. And the the most likely ones that you'll get given is a chest X ray or even abdominal X ray M s K sometimes comes up, but those are a bit more difficult for a student to interpret. So chest X ray and abdominal X ray is the big one. So before you even get into kind of picking out all the nooks and crannies of any abnormalities that you see, you want to check details first. So check who the patient is and make sure it aligns with who it's meant to be. Check the date of the chest X ray. Check the type of the X ray that's been taken. So is it an A P or P, a film, usually in the corner of an X ray? It will tell you whether it's an a P O. P. A. A very easy way of also checking. If you're not, you're not given that information is looking at the size of the heart. If it's a PA film, the heart should look normal. The only times when it won't is if you have a cardiomegaly. But if it's a heart, which looks valuable, big rodent Um, I think the power point it keeps cutting out, which might be the other issue. Um, because I think it's swapping between your video and the part plane, and you can't see the power plant sometimes. Okay. Bad with us all. Shut your screen. Thanks. Guys were just testing out the platform today, So, um yeah, bear with us, please. Mm. Right. Everyone tell me whether it's cutting out or going back to me. We can see it now. You can see it now. Is it ever kind of cutting out? Um, not yet, but we'll let you know if it gets bad. Okay, that's fine. If we really run into issues, then we'll have to think of something else. Okay, so, um well, as I so chest X ray, make sure you assess which type of chest X ray it is. So a p or P A is the kind of first category, and the second would be Is it an erect, or is it a supine X ray? Difficult to actually tell just looking at an X ray. So that's more something that you kind of have to be told what it is. Um, there probably is nuances that you can check on a chest X ray, but they won't. You don't need to go into that much detail. Okay? Then you want to check the adequacy and I'll go into this abbreviation I have, right? Mangoes. Um, then you want to interpret the X ray, and I like to use the pneumonic A B C D e a And then you get to the end and you present your differential based off the X ray and your clinical history, possibly and how you would complete kind of your summary or even what, uh, the Examiner might ask you next is dependent on what kind of differential you present. So this is a normal chest X ray. Okay, this is kind of to act as a baseline for, um uh, what will kind of be going through in case there's any kind of differences and anything that I need to point out of what's normal and what's abnormal. Okay, this would be a PA film. You have the, uh when you're assessing the adequacy of the film, you want to use something called right mangos, which I go into. So there's five things to check an adequacy, the adequacy of a film. That's rotation. So this is basically seeing when they've taken the image of the patient. Have they been rotated slightly, or are they nicely aligned with the X ray machine. In effect, A good way to assess this is looking at the distance between your spine is processes and the clavicles. So if I go back, you'll see the clavicles kind of at the top coming down. And you can see this. Um, if people can see my arrow, just let me know if you can't. You can see this, um, spinous process here. So in fact, this patient does have a bit of rotation when they've taken the film that that's normal. It's just something to be aware of when you're looking for any abnormalities on the film. So you're not going to have the most perfect adequate film presented to you ever. There's always going to be some slight issue with it, Um, but it's important to vocalize these inadequacies because it can very much influence any abnormalities you pick up on. So, for an example, if this patient is rotated, let's say they're rotating much more, and the spine is processes very misaligned. You could mistake this for some being something like a deviation of the trachea, which is the nice central tube that you see in the center. The windpipe that could be something that's pathological. But if they're rotated, it's very difficult to assess that. So that's one example of why it's important to check adequacy. So you first want to assess rotation, then you want to look at inspiratory effort. So a good way to check this, uh, inspiratory effort is seeing Have they ventilated their lungs well enough so you can look at the seventh anterior rib and see whether it transect the diaphragm? So the posterior ribs are the ones that kind of, um, branch kind of into the body. I always, I always thought, and the things you see kind of coming from the outside and coming in. That's sort of downsloping, as I mentioned, are the anterior ribs. So what you do is you count the number of anterior ribs, you see, so 123456 and seven So that will be your seventh anterior river at the bottom, and you want to see whether it transect the diaphragm, which it does. So there's good inspiratory effort. Next, you want to check the penetration, so I always just thought of this, as is it to white or too dark. Don't spend too long on this, but something that's two white will mean that it's very blurry and you can't make out a lot of stuff on it. You won't be able to see all the kind of details in the lungs. And if it's two black, then you'll find that it's very difficult to make out anything on the image. So it's it's quite obvious you'll usually be able to just tell. Is the penetration okay? Or is it not? Then you want to check the exposure of the film, so exposure is just, um, knowing is basically seeing everything that you want to see on a chest X ray. So this would include your lung fields and the diaphragm as well, and that's up to the point where you have your costophrenic angle. So, in fact, this film wouldn't be good in terms of exposure, because yes, I can see all of the lung field okay, But as I as I go down the diaphragm, I can't see that tiny angle that you expect to see at the bottom on either side. So if there was like a small pleural effusion for instances, so a bit of liquid collecting in that space, I wouldn't be able to tell, so this wouldn't have as good exposures I would like. And this These are kind of things that you can mention in your conclusions at the end to say I would possibly like to have a P chest X ray to assess whether there is any blunting of the cost. A phrenic angles to assess for applause. Fusion possibly. And then finally, although they don't usually do this in the exam, but sometimes they can is on most X rays or films radiological films that you get in hospital, you get a marking that's actually put there by a radiographer, and it's usually a red mark. And it's to tell you that there is now an abnormality that they've spotted. So because it's an exam, I doubt that they would put that there. But it's normally in the top left corner that you'll see it, Um, and it's quite an easy way to say there's something that I need to spot that I can't miss her. Okay, so I hope that kind of explains how to assess adequacy for a chest X ray, and you'll find that it's a very traverse, a ble way to assess things like an abdominal X ray as well, although there are certain ones that you don't necessarily need to include in that. So interpreting the X ray actually looking at it. So before even going into assessing, uh, your A b c D. A. Before any of that, I always liked to take a step back and and look at the X ray in general and see if there's anything that really stands out to me. If there's a blatantly obvious pneumothorax and there's no cure deviation and it's a classic tension pneumothorax, and you don't even need to spend that long looking through all these extra details vocalize it. Okay, because it looks quite with that. You're not stating this absolutely obvious thing that's that's sticking out to you. But if there isn't anything that stands out to you on the X ray, when you look back at it, then go through it systematically and this is the systematic way. So first you want to do your A, which is for airway, so things to look for. Look at the trachea. The most important thing with the key is to see whether it's deviating anyway and think about it in terms of how the lung kind of exists in the body. Anatomically, if there is a gain of volume, it's going to push the Tokyo away. Okay, it's an increase in the volume, and the trachea doesn't like changes in this this volume. So it will move away from that extra, um uh, extra volume that's accumulating. So that's things like maybe account so that could be there. It could even be, um uh, or fluid that's collecting outside the lung that's pushing the lung and every other anatomical organ to the other side or the trachea could actually be moving towards the space where the pathology is. And that's when you have volume loss. So that could be a collapsed lung, for instance. Um and those are the real two things that caused procure deviation, volume loss or volume game. The next thing to look at is looking at the highland region. So I've actually pointed these out. You have a right Hyler point and you have a left hilar point and the hilar basically just the, um, uh it's kind of the anatomy that the radiologist basically talk about that the vast pulmonary vasculature and also the bronch I that exists there. The right hilum is normally slightly lower than the left hilum. And that's quite a good thing to note because sometimes you can, um, in certain pathology, you can get moving in the right hilum up a bit, Um, as well as that. The Hailo are quite important because there are certain conditions that cause Hailo lymphadenopathy. And if it's bilateral high lymphadenopathy, there's very common pathologies that cause that, like sarcoidosis, um, lymphadenopathy or bilateral hilar lymphadenopathy will normally look, uh, like extra white, like sort of white collections kind of around that area. So if you see more um, uh, white accumulation around that area and it's on both sides, it could mean that you have some lymph lymphadenopathy going on. You could argue the case that in this picture that I show there is actual possible bilateral bilateral hilar lymphadenopathy. So it's important to vocalize it. If you think that it could be there. Okay, so next, so going on to be you want to assess breathing. So look at the lung fields. Even though your left lung and right lung, your left lung has two lobes and your right lung has three. Whenever you're talking about the lungs, kind of from an X ray perspective, you should talk about them in thirds. So even the left lung you have your upper lobe, middle lobe and lower lobe okay and same thing with your right lung. And that's just how you have to refer them to. And it's more, Um, when you're talking about, it's more based on what you see visually on the image rather than anatomy based. So the first thing that you want to do when you're looking at lung fields is trace around the actual lung markings themselves. If you see a roar fluid that's collecting on the outside, then you'll see that the lung fields don't don't kind of expand the entire way. Um, they'll they'll sort of miss the outside. So if I go back to the normal X ray that we had, you'll see. Obviously you have your highlight here, and then you'll have the tiny kind of airways, and what you want to do is you want to see do these airways go all the way to the outside, and if they don't, then it could mean that you have some air that's collecting on the outside. So although it's not the greatest image and they'll give you a better one on the day, and this is obviously using a computer screen, so it's not the best. Um, you will see that these airways do expand all the way to the outside, so you know that there's no there's no air that's collecting on the outside of the lung. Next thing you want to mention is that is there any white, white, like sort of spaces or consolidation that you can say consolidation means like it's usually referred to pneumonias. You don't talk about consolidation any other content context. If you see Oh, pacification that or increase to pacification as they say that that usually means that you have some, uh, kind of lesion in the space. And that can be something like a cancer. Other things that you can sort of mention as if there's like, uh, these kind of like black, um, lesion's So actual, uh, loss of this kind of these White Airways you have, like this almost cavity and effect. Those would be things like bully um, or cysts even. And they're basically just kind of, uh, spaces where air has collected inside, and they've been closed off by the body into these, like Saks. And then after you've looked for any kind of white, white kind of lesion's or consolidation any of the lung fields, you want to, um, look at the Plourde. So just see if there's any, like, klor thickening. Um, it's very difficult to to spot this and you can be. It's not something that I don't think they would. I don't think they would give you this on the day. But just for your own contacts, something to just check. You can see if you trace the ploy. You can see these kind of like white, um uh, lines coming down as well as a bit of like increased whitening on the outside. So the PLO Ryu shouldn't really see that in the lung. It's very, very faint. If I compare it to the other side, you don't really see these white lines coming down, and the actual, like Mem Member nous kind of like structure here. It's much thinner, whereas if I look at it here, it looks a bit thicker and it also kind of looks like it's got bits coming down off the sides so that that's what we would call pleural thickening. It's much more obvious when you see these kind of things coming down here. I hope everyone can sore. See that I make that out. If not, then then let me know. And I can try and find a better image. Uh, do you have a question? What is the difference between a bit of that pacification and consultation on the X ray? Okay, so, uh, voice, by the way, um, just going for the flu. If anything, I would whenever referring to, um, an X ray And you see, like these white like this whitening, um, or these white blobs on X ray. I would talk about it as being a pacification, and I wouldn't really refer to as consolidation unless your history supports it being something like a pneumonia or an infection. So if you've taken a full history, it sounds very much pneumonias like, and then you get given an X ray and you see this nice white collection somewhere on the lung field, then you're more than entitled to talk about it being possible consolidation. But I wouldn't really refer to it if the context is a patient who's come in. They're short of breath lying down, and this is like a classic acute heart failure. And they have some, um, por mony edema, for instance. I hope that that makes sense. But to be on the safe side, it's better to talk about it as being, uh, pacification in, in my opinion, because it's it's safe, and it's actually a much more descriptive radiological term. Okay, so moving on to see which is for circulation, um, the heart size that's important to assess. And as I said before, you have Pa films and the AP films, whenever you're assessing the heart and the size of it, you can only really comment on the size if you're using a P A film and you expect it to be less than 50% the diameter of the actual, like thoracic cavity. So if I go back to um kind of the normal chest X ray, what you would do is you can even sort of just take a step back and just say, Is that less than 50%? But if you were to do it, um, kind of properly you would use in kind of the equipment they give you in like a on a computer. You would literally draw a line that is horizontal all the way to the other side of the thoracic cavity on the same kind of level. And you would see what the the length is. And then you would basically go to where the like firmest point on the heart is on the right aspect and then basically transect it all the way to the other side where the heart is. And then you would compare the two and see Is it you know, 50% or less? If it's more than 50% then you've got a cardiomegaly. However, if you're dealing with an A P film, which they should tell you, then this you can't use for that. You can't really assess the heart in terms of size. Then you can assess other things. But the size is not one of them. The way I remember this is I think of a pea is being crap. So c r A. P uh, it's crap for this reason, and that's just a good way to kind of remember it. Um, moving on. You want to assess things like the heart position. So, um, as we talked about, um, with the trachea and seeing whether there's any, like, sorry, the, uh yeah, the trachea. If there was any deviation dependent on volume change in the thorax, the heart position is also a very telling, um, indicator as well. So if you have, um, uh, for instance, a lung, Uh, sorry. A pneumothorax, Which is a rare that collects on the outside the floor. Okay, quite often, you'll see that you have lost. This will be completely black because there will have collected on the outside your tricky will be deviating away, so it'll be moving away. So you kind of see it sticking out like this. Uh, so it'll be going out like that and then your heart, you loft, you'll often lose this. This border here on the left aspect, you'll see the right side sticking out really unusually here, and it will just show that everything is kind of being moved and deviated to the side. Um, So, um, that's another indicator. The heart position itself, and then other things you can sort of talk about or look at is the heart borders. That's important. If you're looking for any kind of consolidation, as I said or a pacification. So if you lose, you have some whitening that's cause loss of this border. The border should be quite nice and easy to transect. If you can't make it out on this side, then it usually means that there's something obscuring it. Um, so there's something in front of it. Um, another thing that you want to look at is the aortic knob, and also the mediastinum and the width of it. And I'll go into that. I've got the slides on that as well. So the mediastinum is this bitter, and it's basically your aorta as well as all the pollen Mona re kind of structures around that area as well. When you're assessing the mediastinum okay, the most important thing to look at is, is there any widening of it? And they mentioned this a lot with things like aortic dissections and stuff. What they mean by widening is normally you see this nice kind of like a divot that sticks out okay if it sticks out a bit more or it looks a bit wider, and it's that they have specific criteria where they measure these things. So if something looks bigger than what you've normally seen, I would vocalize it and just say there might be some widening. Um, even in this case, I would beg. The question is that to me looks slightly wider than ones I've seen. So I might say there's some I would say there's possible widening of the mediastinum. Um, so that's one thing to assess other things, to assesses your aortic knuckle, which is this bit here. Okay, and this window that you have here is the space that kind of sits in between so you can see the white bit here. And then there's another white but underneath, and it's kind of like a gap in between, which is the window. And if that's lost, there's two options. Either it's widening mediastinum, and most likely cause is something like a dissection or an aneurysm. The other option is lymphadenopathy. Lymph in the lymph nodes often exist in that space kind of there, as well as on the other side, but they they exist there as well, and you can lose this window if you have some kind of lymphadenopathy things. That's important to, uh, kind of mention moving on to D. You want to assess the diaphragm? So there's a couple of things that you can spot or look for? So flattening of the diaphragm if it's flattened and what I mean by that is normally diaphragm has a nice curve to it, including on the other side. If it looks like it's kind of just flattened out, so there's no nice kind of curve to it. It looks quite linear then. That's often hyper expansion, and usually it means that they have a background of COPD. Um, other reasons it could be is, actually, it could be that they have over, uh, inspiration. So we talked about when we were looking at adequacy of an X ray film. You want to look at the inspiratory effort when we go back to the right mangoes? That's the eye. Um, when patient's are taught to breathe in, sometimes they can over ventilate. And actually it can give us a film that looks like they possibly have some hyper expansion, but it's actually just a variant, a normal variant from how they've taken the film. But I wouldn't, uh, mention that unless you've got a history that doesn't 0.2 COPD at all. And there's no other factors that point to COPD, and they look like they have some slight flattening of the diaphragm. In that case, then it might be good to mention it. Okay, Another thing to note would be if there's any air under the diaphragm. So a pneumomediastinum, as they're called when you're assessing for pneumomediastinum and there's things that you don't want to confuse it with. And the most common one is a gastric bubble, which is basically your, uh, your actual stomach and the air that exists in that area. So the easiest way to kind of differentiate this is for one. A gastric bubble will be on the left side. Okay, where the stomach is. So if you have a rash that's collecting under the diaphragm on the right side, then it most likely means that that's a pneumomediastinum. Okay, as well as that you'll see for a gastric bubble, it will be unilateral. Whereas the new mo media start Uh, sorry. I keep on saying pneumomediastinum a pneumoperitoneum um, the air should be bilateral. Uh, so you'll see it both under the right diaphragm and also the left diaphragm. Sorry, f have confused people. A pneumoperitoneum is gas that's existing in the peritoneal space. It's normally when you've had a perforation of, uh, abdominal viscera. Viscera. Uh, pneumomediastinum is something completely different and not something that, uh, that I should mention or that you should worry about. Uh, sorry about that. After looking for any air under the diaphragm, the most important thing to kind of look at with the diaphragm is the cost of phrenic angles. And when you have blunting of the costophrenic angles, that always means that it's a pool of fusion that I say always. It almost certainly doesn't mean that you have applauded fusion. There might be some kind of weird reason. Um, other than that, but it's usually that what I mean by blunting. And it's, I would say, blunting in the exam, Okay, because it's just the kind of go to cloak. Well, way of saying, Paul fusion, when you're examining an X ray really is, you see this nice kind of like, um, dagger like appearance almost in the costophrenic angle. Okay. Where the diaphragm kind of like meets with the outside of the the thought ax when you have blunting it basically means that that nice, kind of like a dagger bit at the end is blunted. I almost think of it as a dagger, and it's kind of like lost its sharp edge at the end. And you'll actually see some, like, white bit collecting there that that means that there's fluid collecting in that kind of poor space. Um, and it's causing that our parents that you'll see and those are the kind of those the things to look for in diaphragm and then e I think of as everything else. So is there any medical apparatus that you can see on the chest X ray when you look at the bones, the other possibly any fractures? When you look at the soft tissue, is there any obvious abnormalities that stand out to you so masses or even something like emphysema? Okay, I know this is a lot to kind of like examine and look into, but I'll go back over. What are the things that I would say are most important is to be like, Yes, those are the things you should look for immediately bulbs. What I would say when you're looking for everything else is if there's something blatantly obvious, like a chest drain sitting sitting there and you can see on the X ray. It's important to mention it. Um, same thing if there's something like emphysema is important to mention it. So this is, um what emphysema looks like Emphasis. Subcutaneous emphysema basically means air that's collected in the subcutaneous tissue. Okay, so you have your, uh, layer on top of your skin, and then you have the sub cut tissue underneath, okay? The sort of fatty layer, and usually what causes these are there's some kind of opening on the top layer of skin that stayed open and air is basically kind of passing through is it's almost kind of like how a pneumothorax is kind of work. In a way, um, these can be quite, uh, easy to actually spot on the patient. Often you're, uh they'll actually be described. If you feel the surface of their skin and they have some subcutaneous emphysema, they'll actually say that it feels like bubble wrap or Velcro. When you're pressing down, it will sound like it as well. Um, very, very interesting. And very useful to, um, examine someone with it if you get the chance. Um, but because we're on X rays, I'll sort of talk about what the kind of things are to look for for it. So quite commonly, you can get this thing called the gingko sign. I I sort of put an image that had the gingko leaf, uh, as reference. What this is basically showing is it's actually a really highlighting the pec major muscle. Um, whenever we take X rays, air is what is, uh, kind of air is almost the thing that allows projections to stand out a bit more. That's why when you look at abdominal X rays, if they have air in their abdominal cavity, it can actually make things stand out. Which I'll go into, um so that what you're seeing there is actually there, Peck major muscle, and you can see the striations and the muscle quite clearly. And it looks like a gingko leaf. That's what they call it that other things that can stand out is you might see these, um, it will just look like this mesh of white and black, but it will be actually on the outside, and that can be quite that. That usually is emphysema. that. You see, you often see em POSTOP Patient's as they've been opened up as kind of leaked into the sub cut tissue. So if you see an X ray of a POSTOP patient, you might see some sub cut. And for eczema, particularly in M S K X rays, and it's it's good to mention it things to look for, um, in terms of medical apparatus that they might throw in that you can spot most common things to For chest X ray really would be a loop recorder. Okay, Um, I always imagine these is looking like a USB stick, okay? And it sits on the left side of the heart, and then you have all your like I CDs and pacemakers. So a single chamber pacemaker will look like this and you'll have a nice kind of same thickness line which passes kind of around. And then we'll go into, uh, the heart chamber, a single chamber I c. D. So an actual defib. Okay, we'll look like this, and then they'll have a nice thin line, and then they kind of get this thicker line to it, which is the coil, and then it will pass into the heart, and then you have biventricular ones, which look exactly the same. But they have two lines to them, and you can't see it as well. But you'll see you can sort of distinguish that there's one line there and then the thicker lines there. But you can sort of discern that there's two kind of lines that basically forming from the, uh, the I C d. Uh, and those are the only real ones that could maybe throw you off. But it would be quite a good thing, too. Uh, almost stand, make you stand out on the day if you know how to discern one of these and they throw that in. Okay, any questions on chest X for interpretation that people want me to go over or something that they want me to explain? All good. All good. All good. Brilliant. OK, so moving on to abdominal Uh, I did promise all of you that I would say, Well, what are kind of big things that I would say just to pick out on when you're doing it, because at the end of the day, you have a couple of minutes to go for a whole X ray, and that's a lot to go through. So what I would do is when I go to Airway, I would check the trachea, see whether there's any deviation. That's the most important thing. Have a quick look at the highland. If they look fine, move on. Looking at breathing. Sorry. Uh, sorry. Yeah. Uh, they're asked to explain the rotation again, please. Okay. Yeah, I can do that. So, rotation, um, you're assessing whether the patient as they took that X ray, the patient was slightly rotated. Okay. Which would actually mean that you you get less of a good image. It's not kind of like the person is not central. Okay, What we like to assess is the distance between the spinous process in the center and the clavicles on the outside. So I mean by this is I would pick this spine as process here. And your clavicles always sit like this. They always kind of come down like that and you can see the outline of them. And what you would do is you would measure the distance. So this is your left clavicle. You'd measure the distance from the spinous process in the center to the left, one on the outside. Okay. And then you would measure the distance of the spinous process from her to the right clavicle on the outside, and you would basically, uh, see whether they match or not. Now, you don't have a ruler in the exam, so you almost have to kind of go off your naked eye. Even looking at that, you can just sort of see if I've got these two clavicles sitting here kind of nicely does. My spine is process look like it's in the center. Or does it not? And it doesn't in this image, so this person would be are slightly rotated. Does that make sense? Yeah, she's easy. Yeah. What if it doesn't? Then just send a drop as a message and we can always go through it again. Okay, So moving on to abdominal X ray interpretation. Same thing. Kind of again. So check patient details, Check the date of the film, make sure that all matches. Fine. Then you want to go on to looking at the type of abdominal x ray. This isn't something that you can discern by looking at it. I mean, you can. There are ways, but they won't expect that level of knowledge. Okay, They'll even tell you, uh, that isn't a different film to what you're normally used to. Or you can just assume it's a standard abdominal X ray, which would be an a p projection. Okay, where the patient's lying supine. So they're lying. Um uh, they're lying on their back. Yeah, um, but that's all the technicality. Just recognize. Um, if they tell you that it's a different one, then you're dealing with a different abdominal X ray. When you're assessing the adequacy, you want to use the right mongers again. But there's ones that you don't need to kind of like, look at, uh, because it's an abdominal X ray. Then when you go on to interpretation, you can use the pneumonic bob. I like to use that, um, and then again come out of your differential and, uh, come over summary of what you would like to do. We'll answer the questions that examiner may have. So this is a normal abdominal X ray for all of you to see. So this is where it's important just to kind of have a basic understanding of your anatomy of the abdomen and kind of the organs inside it. Um, you'll have your large colon that kind of comes around the outside on the periphery, and then your small intestine will kind of exist in the center. Um, your rectum will be at the bottom. Uh, and then all your abdominal organs, like the liver, will sit. Uh, sit up here spleen on the other side. And your kidney is kind of, uh, bilaterally underneath those two organs. So when assessing adequacy the film when we did it for chest X ray, we use ripe. So R I p. A. You'll notice that the only thing I've taken out is the I. Because I stood for inspiratory effort. So it's not. We don't need to do that for an abdominal X ray. So the only ones you need to look for, uh, rotation, so the same thing again. Rather than using your clavicles, you can use the pelvis. That's usually a really good way of assessing symmetry. It's going back to this when we're looking at rotation. We're almost seeing kind of does this body look symmetrical or does it not? And if it doesn't look symmetrical, often one of these pelvises will appear bigger than the other. In this case. Yeah, you could argue that one of the one on the right may look slightly bigger, Okay, but it's not significant enough. Uh, kind of say that it's too discernible a difference that it's not a good X ray. So this is all right in terms of rotation, I would say, then you want to look at the penetration. So again, this is the not too white or not too dark. If you can make out kind of the general pelvis, okay, and you can also see a bit of the intestines, then it usually means that the penetration is okay. The only time when it's important, kind of discern. Is this pathology or is this how they've just taken? The film is if they've got an air, if they've got air leaking into the abdominal cavity, so a pneumoperitoneum, then the film will look like it's got some over penetration. You'll see that there's a lot like all of the intestines will kind of be outlined really nicely, and that's where it's up to you to kind of say, Is this pathology or is this just a variant of how they've taken the film. So is the adequacy that good? So once you've assessed penetration, you then want to move on to exposure. So exposure should just be Can you see up to the diaphragms? In this case, you can't. So the exposure is not great. Um, and then also, you want to be able to see the pelvic joints bilaterally. So where the actual femur is uncertain, which you can in this image. So it's an all white film kind of down below, but you can't make out the diaphragm. So the exposures, uh, not as good as it could be. And then again, look for a marking. But in the exam, they might not well give you this. And then you get onto interpretation, which I like to use. Bob and I always like the Bob Pneumonic. Just because I think of Bob as being kind of yellow, and it could be some kind of like jaundice, and it looks also a bit bloated, so it makes me think of abdominal problems. Um, so first B stands for bowels Oh, other organs, and then your final B is for your bones. So I'll go into all of these. So your first B, which is for bowels. You want to look at your small bowel? Okay. Normally, this is, uh, central. Okay? It's in the center, and you should see these things called valve. Really? Con of entities. Okay. Valvula convent ease. Okay, this is where it's important to kind of know your anatomy as well as, uh, like the colon anatomy. But value the con of entities are basically these lines that look like they extend across the whole colon. You can't see it that well in this image. Um, I probably should have put an image and to show it better. Um, but it will. It will basically look like a tube. Okay. And lines that extend the whole way across the diameter of that tube. And they'll be like this all the way along this tube. And that's what the small intestine kind of looks like. This is different too. Large bow intestine, where you have this tube. And but you have these things called House Tre. And rather than these kind of lines extending all the way across the tube, they'll sort of just kind of come out a bit but they won't go the whole way, and you'll see them kind of either side coming out a tiny bit. But they won't go the whole way across. So it's, um so you'll see that the other important thing is your large bowel will be on the peripheral aspect of the abdominal abdomen. So that's another way of distinguishing Is the small bowel? Is this large bowel? It's fine if you can see small bowel or large bowel. What you want to spot is. Is there any dilation or is there, uh, is there any signs of this possibly being an obstruction where the diameter would be more than what the, uh, normal diameter is for the bowel? So for the small bowel, normal diameter is less than three centimeters. Okay, large bowel is six centimeters or less, and then the cecum or or sigmoid colon is less than nine centimeters, and it's you remember, it's in the 369 rule. Obviously, you don't have a ruler in the exam or a tape measure. So the way to basically spot this is knowing what your normal abdomen abdomen looks like in terms of, uh, colon and what looks abnormal So this is what normal? Uh, kind of colon diameter. Looks like. Okay, so, yes, you You see this segment, which is a large, Um, sorry. That's that's, um Yeah, that's the large intestine. Um, you'll see that It kind of, uh is on the periphery, but it doesn't look too dilated, so that's normal. Whereas if I move on to this one, you can see that the I mean, this is your verse to go here. Okay, This would be what I debilitation. Looks like where the colon looks very. It looks massive. Basically, um, and this is normally, like an obstruction or something that's causing this. Um, So you want to look at, uh, for small bowel, the large bowel? Um, look, if there's any dilation which could be explained by some kind of obstruction, um, other things that you can look for with gas and the bowel wall. So what this will basically look like if I move forward is if I use, um this one is an example. Okay, you can see that There's the bowel wall there. Okay. You may see this, like, black stuff in between. It was kind of like transect this white this nice white line. Uh, and that can be a possible sign that you've got some, uh, that's collecting there, which is a sign of a ski. Me A. That's occurring to the bow. Um, and what? This, uh, this gas is basically being produced by the bacteria that exist in the in the gut. Basically, And then other things you can look forward, something which we call vigorous sign and wiggle. A sign tells you that there's, um, gas or air that's existing in the bow, possibly due to a perforation. Um, if I move forward to here, Rigorous sign, basically, is where you see two different. Um, where you see the bow on bow Okay, both sides of the bowel wall. Um, it's very difficult to explain it, and I would recommend that you go away and kind of read up on it about like through, like Radio Pedia and those kind of sites. But rather than discerning whether there's regular sign or whether there's not regular sign, the most important thing to kind of identify if there is a perforation is can I see the whole outline of the bowel basically, So all of the intestines and the large intestine. So that's one. And then, uh, the abdominal organs like the liver, the kidneys possibly outlined as well. If you're seeing a lot of outlining and it looks like there's a present I penetrate, it looks like it's over penetrated almost in terms of the exposure. Then it means that there's a perforation, and that's just the most important thing to kind of identify. If you want to look up kind of about regular sign, then please do, Um, but most important thing is just discerning. Does it look like there's a perforation going on or not? After you've looked at the bowels, you then want to go on to know which is your other organs. It's very difficult to kind of identify any abnormalities really in the abdominal organs based off an X ray. Okay, but just for um, showing the Examiner that you're kind of checking to make sure there's nothing that's blatantly obvious standing out to you, you just want to vocalize that you're assessing the liver. Assessing the spleen, kidneys, gall bladder. Um, and the pancreas is kind of the most important one. The pancreas, um, can produce a very classic sign on X ray, and it's the only one really way. You can actually properly see something if it does exist, which is chronic pancreatitis. With this, you're basically start seeing these like white calcifications where the pancreas would be. Um, so if I use the normal X ray as an example, what you would basically see is these white spots kind of on the top, and it would. It would almost outline the whole anatomy of the pancreas. So if your liver exists here, your pancreas kind of sits on the same level kind of across where the vertebral would be, and so you'll see white spots and, like white dots across the whole way, all the way kind of to the other side. And that's quite a classic sign of chronic pancreatitis. And then, once you've assessed that, you can then move onto bones. Um, so for this one, it's It's not as important because obviously, it's an abdominal X ray. The most important things to kind of assess for an abdominal X ray is like, Have you got any perforation or any bowel dilation? But if you're assessing bones, just check the spine in the pelvis and, uh, make sure that there's no obvious signs of these kind of conditions. So the biggest one, which kind of stands out, is there Are there Mets possible possibly present on the spine? Or is there any signs of osteoarthritis? Uh, usually, you can see that where the femoral head inserts into the pelvis, which are going to So the classic pneumonic for osteoarthritis kind of expert, uh, it's loss. So elf A Yeah. Say, um, it almost off of the bone. They kind of They just look abnormal when you see them. Um, and then the other things to look for a sub condor sclerosis, which is basically when you have the the joint which the bone sits in and that joint looks like it's getting some whitening to it. So normally you shouldn't see um, this increase like, oh, pacification on that aspect. But in this case, you can actually steer, particularly the top where the femur inserts just where the kind of bit sticks out from the pelvis hair. You can see this white bit, which is closest. So it's like, uh, increased, um oh, pacification there and then last things to look for the Symbicort Subchondral cysts, which assisted. It almost looks like this black kind of space occupying the bone. So you can You could possibly say that on the femur. Here on the femoral head, there could possibly be a sub condor cyst just there. Um, and those the kind of classic signs of osteoarthritis. These are better examples of cysts. Really? So, um, you can see them up here that's very clear. And then you can even see one just existing hair where it's, like a kind of black space and even one there. And then these are osteo fights. So, as I said, they look like kind of divots that's sticking out, which just look at normal. You can see one sticking out there, one there and one which is really obvious there. And this is the kind of sclerosis I was talking about. So just the increased whiteness, Um, where the the joint joint exists. This is quite classic. Um, it's a It's quite classic kind of PT thing that we get tested on. I'm sure you're aware of it, but quite classic thing that they could give you on the day is it's almost like a spot kind of diagnosis. You have sigmoid volvulus may and seek Evolve Really, And a volvulus is basically whether, uh, mesentery almost twists on itself. I won't go into into much detail, but this can either occur where you have your sigmoid colon, which is like the end bit of the large colon or your sequel volvulus where your cecum is, Um, and they produce this very classic kind of sign. So for sigmoid volvulus, you get this coffee bean sign and you can even see the coffee being here where you have, uh, this large based on the top large bit on the bottom. And then this white bit that kind of transact sit and then for sequel volvulus, you get this classic fetal apparent sign, and it actually looks like a fetus where this would be the head. That's the kind of, uh, the arm. And that would be like the tail here. And these are kind of the, uh, classic like associations. So a sequel volvulus. It's less common, but you get it in younger patient's, um, you can even look at the end of the colon and see whether there's any kind of, um, or basically pure feces that's collecting there. If it looks empty and it looks like it's not dilated, then, um, it kind of supports the diagnosis of sequel for this further further, Um, where's the sigmoid volvulus? It's more common than a sequel. You get an order, patient's and quite classic associations and things like the neurological disorders like Parkinson's, M s or even schizophrenia. You'll hear this term band aid a lot, Which the toxic megacolon Okay, it's not something that is a radiological diagnosis. A lot of people confuse that. It's almost, uh, an amalgamation of different things that before it becomes a toxic megacolon. So for one, you even need to have like, uh, inflammatory bowel disease. Or it needs to be an infectious colitis. And then the other thing would be Is that evidence of Clonic dilatations? And then the third thing is, are they systemically unwell? Okay, so if it was a tumor that's obstructing the, uh, colon, and that's causing dilatation of the bowel and the systemically and well, that wouldn't be a toxic megacolon because it's the tumor that's obstructing it. But if they have a gastroenteritis and they get this and they're systemically unwell, then that would be a toxic megacolon Are you going to a lot. So are there any questions? I've gone through that quite quickly, but I hate that was helpful. There we go. I've also tried sending the feedback form on the chat now. Okay, that's fine. Thank you. Asthma. I'm very sorry that there weren't more pictures, the radio, radiological images. I will. I was intending to put more in, but I was rushed for time for this pier and chest x ray. How increased basket would look like. Uh, please, can you show Manchester X right? How increased vascular markings would look like Are you talking about with, uh, like, uh, heart failure? Yeah, I would, I would think. Yeah. Okay, that's fine. Um, if I share again, can you just repeat the part about toxic mega colon cancer? Yeah, that's fine. So, um, I will answer your question, Towler. I'll just answer this one quickly while I'm here. So, to us, uh, with a toxic megacolon, it's basically you kind of have criteria for it. But it's something that people get confused with in order to have a toxic megacolon. For one, it needs to be either resultant from them having inflammatory bowel disease or they have an infection like a gastroenteritis. Um, so an infection that is related to the colon. So gastroenteritis, for instance. They also have evidence of dilatations. So the X ray is kind of classic, really, um, of showing that. But CT could also support it. For instance, then the final thing would be Are they systemically unwell? And those are kind of your three big factors that or go go in hand. Really? If a person has cancer, uh, colon cancer and that's leading to obstruction and let's say that systemically unwell. Also, they haven't met all three criteria. They don't have an infection and they don't have inflammatory bowel disease, so that wouldn't be a toxic megacolon. Occasionally I've heard before the some people have said toxic megacolon and there's no evidence of an infection or it being inflammatory bowel disease. So it's important just to discern. I guess those quite areas specifically and systemically unwell would be, you know, is there BP? Um, is the BP down? Are they take a Codec? Um, you know all your like Are the obs unstable? That's why I would kind of think for that. And then in regards to your question till, uh, I'll just show my screen again now. Okay. Can you see that? True. I presume what you're referring to is the, uh, kind of the bat wings classic a sign that you get with acute heart failure, for instance, um, so for acute heart failure, you get the, um In fact, they use the exact same demonic, which is a B C d. A. So a you get this alveolar edema. Um, which how it basically it looks as your you'll see, like, this kind of white, like there's increased whitening in the spaces here. It'll just look like there's a bit of, um, stuff collecting in the actual lungs themselves. So that would be your alveolar edema. You're a your B would be, um these things called curly be lines. Okay. And this is, uh, curly be lines is a fancy radiological kind of sign that, uh, basically indicates that you're getting fluid collecting in the interstitial in to the space. Uh, this has taken me back to my histology or whatever. The insicion the space kind of in between yourselves, whatever. And what it will classic look like as you'll see these kind of white lines that's all stick out here. You can't see them on this image, but you can. They're very difficult to spot, but, um, they'll be like these white thin lines that stick out from the signs. So there's your curly be lines. Your c is cardiomegaly. So does the heart look over lodged Your d is um Oh, gosh, this is challenging me visit to help me out here. D I'm pretty sure is the Yeah, yeah, so as I explain it, So in fact, you can see it well on this image. Okay, You have your hilar here, and it looks like the vasculature if you look at it points down. Okay, so you have this nice white thin line pointing down here If I looked at this one, you know, it looks like the white lines kind of come out here, and then they go down like that. In fact, you can see the pulmonary veins sticking out and a bit of it branches up, but most of the veins come down. Yeah, and the same with this one. It looks like a lot of the stuff is coming down when you have upper lobe diversion. What? That means it is. It'll look like all these white lines of almost shifted, and they'll start going up and you'll see less of this less of them down here and more of them up here. That that's all they mean by upload. Diversion. Um, I wish I had I'll have to trying to figure out how to work out using, you know, drawing on these things and people to see and stuff. But, um, I I hope that helps. And that sort of explains it. Oh, stuff. I know that. Yeah, that's fine. Brilliant. Are there any more questions and thank you all for bearing with us? Uh, this is the first time that we've kind of used medal for the site. Um, can you go over the key points that you present and Yeah, sorry. I was meant to go over that. Okay. In fact, I'll do them now because I don't really need the size of this. So for one when I would be looking at a I would look at does the trick here look deviated or not? Okay, then going on to be as I'm looking at the lung fields, the most important things I'm looking for are, is there any white things that stand out to me So any oh, pacification anywhere? And then if I trace around my lungs, do I see any? Does it look like they extend all the way? Or is there the case that it could possibly be that there's a, uh, pneumothorax air collecting on the outside? Okay, so that's your B. See, I would look at the heart if it's a PA film and say, Does the heart look large or not? Then I would trace the border of the heart. I would say, Does this heart border look nice and uniform, or does it look like something kind of just obscures on the way? And then I would also look at the mediastinum and say, Does that mediastinum look normal? Or does that look like there could be some widening D? I would look at the diaphragm and say, Does it look like there's any blunting at those angles? And is there any air that's collecting under the diaphragm? And then e. I would just kind of take a step back and say, Does it just look like I've missed some kind of tube going in and the at the side, Or is there any air on the outside of the body? Um, and anything else that stands out to me. I talked about kind of looking funny. Bone fractures and or rib fractures and those kind of things. That's very be difficult to spot an X ray. And in fact, you only look for it. If you have a history that supports that someone has fallen out of a 10 story building, Okay, you're definitely going to be looking for rib fractures, but someone who comes in with some chest pain, you know, you're not doing it on every x ray. Um, so those would be the things that I kind of would just think if I want to go through this X ray quickly. That's what I'm looking for. Um, the other things were kind of So you have those in the back of your mind if something just stands out to you like you're looking at the lungs, you know, like those hilar look much bigger than they normally would. Then you know what that kind of would be called or what it refers to. And in terms of presenting sorry. Um, uh, if I was presenting an X ray, I would I would actually speak out loud What I'm seeing as I'm going through the x ray because it's verbalizing that I'm checking all these things. But then at the end, I should have some kind of differential of what's going on. They're not gonna They might give you a normal X ray, which you know, on occasions they have done that in the past. Um, which in that case, then it's important not to kind of second guess yourself. If it's if you think it's normal, then say I think this is normal, but I would like a senior to, um to review this just to check. Um, but really, when you're presenting, it should be based off the x ray that I've seen, uh, based off X Y and zed that I've seen on the X ray film. I think the different the diagnosis is this, um and then either they'll they'll stop you and ask you some questions. Or the other things I would say is what kind of other things I would like to just check or confirm. So I'd like a seniors to check over the X ray. I'd like to get these investigations and often they'll stop you if you're kind of going off on a tangent. But it just means that you're kind of showing your train of thought and what you're wanting to do. No worries all. If you have any more questions, then please drop us a message. Mhm.