Coaching UKDI.pptx

8/9/2019 Coaching UKDI.pptx

1/176

OSCERADIOLOGY AND DIAGNOSTIC IMAGING


2/176

TABLE OF CONTENTRadiography conventiona o! "#$c#o$%eeta&

Radiography conventiona o! a'do"ina&

Radiography conventiona o! thora(&


3/176

OBJECTIVES

Review a systematic approach to interpreting x-rays

Review the language o !escription


4/176

M#$c#o$%eetaAde)#acy

*enetration+ correct e(po$#re&

Cover entire ength+ e$peciay ong 'one ,t-o

ad.acent .oint$/&

*ro.ection0Mini"#" 1 orthogona pro.ection+ #$#ay A* and

Latera perepndic#ar to each other ,23 degree$/&

4 or "ore pro.ection are re)#ired !or co"pe( 'one$tr#ct#re$+ $#ch a$ pevi$+ e'o-+ $ho#der+ -ri$t+ an%e&

5eathy6nor"a 'one radiograph !orco"pari$on+ e$peciay di chidren&


5/176

"BCs "##RO"C$"

"!e%uacy& "lignment

B Bones

C

Cartilage

S Sot Tissues

"pply "BCs approach to every orthope!ic ilm you

evaluate


6/176

A'I()*E)T"lignment+ "natomic relationship ,etween ,ones on x-

ray

)ormal x-rays shoul! have normal alignment

ractures an! !islocations may aect the alignment on the

x-ray


7/176

BO)ESExamine ,ones or racture lines or !istortions

Examine the entire length o ,one

ractures may ,e su,tle.


8/176


9/176

SOT TISS4ESSot tissues implies to loo5 or sot tissue swelling an!

/oint eusions

These can ,e signs o occult ractures


10/176

REVIE2+ "BCs"

"ssess adequacyo x-ray which inclu!es proper num,er o views

an! penetration

"ssess alignment o x-rays

B

Examine bonesthroughout their entire length or racture lines

an!3or !istortions

C Examine cartilages0/oint spaces1 or wi!ening

S

"ssesssoft tissues or swelling3eusions


11/176

E6"*#'E 7 89This x-ray !emonstrates a lateral el,ow x-ray:

There is swelling anteriorly which is !isplace! 5nown as

a pathologic anterior at pa! signThere is swelling posteriorly 5nown as a posterior at pa!

sign

Both o these are signs o an occult racture although

none are visuali;e! on this x-rayRemem,er&soft tissue swelling can ,e a sign o occult

racture.


12/176

E6"*#'E 7


13/176

E6"*#'E 7 ou will notice there are racture lines through the


14/176

'")(4"(E O R"CT4RESImportant or use to !escri,e x-rays in me!ical

terminology:

Improves communication with orthope!ic consultants


15/176

'")(4"(E O R"CT4RESThings you must !escri,e 0clinical an! x-ray1+

Open vs Close! racture

Complete vs incomplete

"natomic location o racture

racture line

Relationship o racture ragments

Special eatures 0impaction& !epression& compression1Special types 0a,normality stress or secon!ary pathologic

process1

)eurovascular status


16/176

O#E) VS C'OSEA*ust !escri,e to a consultant i racture is open or close!

Close! racture

Simple racture )o open woun!s o s5in near racture

Open racture

Compoun! racture

Cutaneous 0open woun!s1 o s5in near racture site: Bonemay protru!e rom s5in

Open ractures are open complete !isplace! an!3or

comminute!


17/176

")"TO*IC 'OC"TIO)Aescri,e the precise anatomic location o the racture

Inclu!e i it is let or right si!e! ,one

Inclu!e name o ,oneInclu!e location+

#roximal9*i!9Aistal

To ai! in this& !ivi!e ,one into 83?r!s


18/176

OR E6"*#'E::::2$ERE IS T$IS

'OC"TEA=


19/176

E6"*#'E9This is a close! ' !istal emur racture:

The main thing I want you to ta5e rom this example isthe !escription o location


20/176

")"TO*IC 'OC"TIO)Besi!es location& it is helpul to !escri,e i the location o

the racture involves the /oint spaceintra-articular


21/176

I)TR"-"RTIC4'"R R"CT4RE O

B"SE 8ST*ET"C"R#"'


22/176

R"CT4RE 'I)ES)ext& it is imperative to !escri,e the type o racture line

There are several types o racture lines


23/176

R"CT4RE 'I)ES


24/176

R"CT4RE 'I)ES" is a transverse racture

B is an o,li%ue racture

C is a spiral racture

A is a comminute! racture

There is also an impacte! racture where racture en!s are

compresse! together


25/176

2$"T T>#E O R"CT4RE 'I)E IS

T$IS===


26/176

")S+ TR")SVERSE R"CT4RETransverse ractures occur perpen!icular to the long axis

o the ,one:

To ully !escri,e the racture& this is a close! mi!shat

transverse humerus racture:


27/176

")OT$ER E6"*#'E O

R"CT4RE 'I)E9


28/176

")S+ S#IR"' R"CT4RESpiral ractures occur in a spiral ashion along the long

axis o the ,one

They are usually cause! ,y a rotational orce

To ully !escri,e the racture& this is a close! !istal spiral

racture o the i,ula


29/176

O)E *ORE E6"*#'E9


30/176

")S+ CO**I)4TEA R"CT4REComminute! ractures are those with < or more ,one

ragments are present

Sometimes !iicult to appreciate on x-ray ,ut will clearly

show on CT scan

To ully !escri,e the racture& this is a close! Rcomminute! intertrochanteric racture


31/176

R"CT4RE R"(*E)TSTerms to ,e amiliar with when !escri,ing the

relationship o racture ragments

"lignment

"ngulation

"pposition

Aisplacement

Bayonette appositionAistraction

Aislocation


32/176

"'I()*E)T3")(4'"TIO)"lignment is the relationship in the longitu!inal axis o

one ,one to another

"ngulation is any !eviation rom normal alignment

"ngulation is !escri,e! in !egrees o angulation o the

!istal ragment in relation to the proximal ragmentto

measure angle !raw lines through normal axis o ,one an!

racture ragment


33/176


34/176

AESCRIBE R"CT4RE

R"(*E)TS


35/176

")S2ERThis is a close! mi!shat ti,ial racture9:But how !o we

!escri,e the ragments=

This is an example o partial appositionD note part o the

racture ragments are touching each other

"lternatively you can !escri,e this as !isplace! 83? the

thic5ness o the ,one

Remem,er aposition an! !isplacement areinterchangea,lewe ten! to !escri,e !isplacement

inal answer+ Close! mi!shat ti,ial racture with

mo!erate 0??1 !isplacement


36/176

")OT$ER O)E9


37/176

")S2ERThere are < ractures on this ilm

Close! !istal ra!ius racture with complete

!isplacement: "lso there is an ulnar styloi! racturewhich is also !isplace!

The !isplacement is especially prominent on the lateral

view highlighting the importance o multiple views:

There may ,e intra-articular involvement as /oint spaceis close ,y

Remem,er& remove all /ewelry rom extremity ractures


38/176

B">O)ETTE "##OSITIO)


39/176

AIS'OC"TIO)


40/176

AIS'OC"TIO))ote the !islocation on the previous sli!eD the articular

suraces o the 5nee no longer maintain their normal

relationship

Aislocations are name! ,y the positioin o the !istal

segemnt

This is an "nterior 5nee !islocation


41/176

)E4ROV"SC4'"R ST"T4Sinally when communicating a racture& you will want to

!escri,e i the patient has any neurovascular !eicits

This is !etermine! clinically


42/176

'")(4"4(E O R"CT4RESTo review& when seeing a patient with a racture an! the x-

ray& !escri,e the ollowing+

Open vs close! racture

"natomic location o racture 0!istal& mi!& proximal1 an! i

racture is intra-articular

racture line 0transverse& o,li%ue& spiral& comminute!1

Relationship o racture ragments 0angulation&

!isplacement& !islocation& etc1

)eurovascular status


43/176

AESCRIBE T$IS R *IAA'E

#$"'")6 R"CT4RE


44/176

")S2ERO,li%ue racture o mi!shat o R @thmi!!le phalanx with

minimal !isplacement an! no angulation

Remem,er to comment i open vs close! F neurovascular

status


45/176

AESCRIBE TO *E9


46/176

")S2ERThis one is a ,it more challenging.

R mi!shat ti,ia racture !isplace! G the thic5ness o the

,one without angulationD also there is ,ayonette

appositioning o the racture ragments

R mi!shat i,ular racture with complete !isplacement

an!

"lso comment i the racture is open vs close! Fneurovascular status


47/176


48/176


49/176


50/176


51/176


52/176


53/176


54/176


55/176

The Abdominal X-RayThe abdominal x-ray (AXR) has a much more limited value in

diagnosis than a chest x-ray.

The radiation exposure of an AXR compared to a XR is also

considerably higher. !ne AXR is e"uivalent to #$ XRs.

The AXR is of most use in the patient %ith an acute abdomen.

&t may guide further imaging (!ther &maging 'odalities

ecture)

As %ith a XR an appreciation of normal structures is vital.


56/176

Abdominal X-Ray Projections:

*upine ++,rect

ateral decubitus.

no%ledge of the anatomy of the abdomenallo%s locali/ation of the abnormalities

observed on the AXR.

Assess the Film in Detail:


57/176


A simple guide to interpretation is sho%n belo%.

0or1ing through these headings one covers 2dar1 bits3

2%hite bits3 2grey bits3 and 2bright %hite bits3 in turn.

BLACK BT!"&ntra-luminal gas can be normal.

xtra-luminal gas is abnormal.

4o%ever intra-luminal gas can be abnormal ifit is in the %rong place or if too much is seen.



58/176

Assess the Film in Detail:BLACK BT!" #Contin$ed%- Intra-luminal gas:

The maximum normal diameter of the large bo%el is

$$mm.*mall bo%el should be no more than #$mm in

diameter.

The natural presence of gas %ithin the bo%el allo%s

assessment of caliber - although the amount varies

bet%een individuals.

The caecum is not said to be dilated unless %ider than

56mm.arge and small bo%el may be distinguished by

loo1ing at bo%el %all mar1ings as sho%n in the box

belo%.



59/176


The haustra of the large bo%el extend only a third of the

%ay across the bo%el from each side %hereas the valvulae

conniventes of the small bo%el tranverse the completedistance.

Intra-luminal gas (continued):&t is usual to see small volumes of gas throughout the

7& tract and the absence in one region may in itself

represent pathology.

8or example if gas is seen to the level of the splenic

flexure and nothing is seen beyond this a site of the

obstruction at this site 9 a 2cut off3 point is noted.



60/176

Assess the Film in Detail:Intra-luminal Gas:

Low Small Bowel

Obstruction

*mall :o%el obstruction.


61/176



62/176


Causes of Extra-luminal gas:

;ost Abdominal *urgery


63/176

Assess the Film in Detail:*+T, BT!" Calci.ication

Calci.ied str$ct$res(204&T :&T*3) are often seen on AXR.

The main "uestion is 9 does its presence have any importantimplications. alcification can be broadly divided into # types=

(>) alcium that is an abnormal structure - eg.gallstones and renal calculi

(?) alcium that is %ithin a normal structure but represents pathology -

eg.nephrocalcinosis

(#) alcium that is %ithin a normal structure but is harmless - eg.lymph

node calcification.

Bonesare normal 2%hite3 structures. !n the AXR they comprise

mainly those of the thoraco-lumbar spine and pelvis. 8indingsare largely incidental as direct bone pathology %ould be

investigated %ith specific vie%s.



64/176

;ancreatic alcification 7allstones



65/176


27R@ :&T*3 *oft Tissues

*oft tissues represent most of the contents of the

abdomen and feature heavily in the AXR. 4o%ever

these tissues are poorly seen %hen compared to other

imaging techni"ues such as ultrasound or T.

The 1idneys spleen liver and bladder (if filled) can be

seen in addition to psoas muscle shado%s and

abdominal fat. Rarely %ould action be ta1en on the

basis of this imaging alone.



66/176

*plenomegaly



67/176


2:R&74T 04&T :&T*3 8oreign :odies

8oreign :odies represent an interesting final

observation. !bBects that may be seen include

ingested and rectal foreign bodies items in the path of

the x-ray beam such as belt buc1les dress buttons andBe%elry. !ther obBects may have been deliberately

placed for example an aortic stent an inferior vena

cava filter or a suprapubic urinary catheter. *terili/ation

clips and an intra-uterine device are common findingsin %omen.



68/176

*terilisation and *urgical lips 8oreign body per rectum

Case /:


69/176

This CD year-old

%omen presented to

the surgical %ard %ith

a distended abdomen

and vomiting.

Present this 0-ray

1i(e a dia'nosis and

&otential ca$ses

Case /: Ans2er


70/176

Radiolo'y Re&ort:;lain abdominal radiograph.

'ultiple dilated loops of small bo%el %ithinthe central abdomen. 7as is not seen in

the large bo%el. Eo evidence of hernia or

gallstone to suggest potential cause of the

dilated loops.

These findings are in 1eep %ith a lo% smallbo%el obstruction.

& %ould li1e to 1no% if the patient has a

history of abdominal surgery as the

commonest cause is surgical admissions.

The three commonest causes of small bo%el obstruction are=

*urgical adhesions

4erniae

&ntraluminal mass eg small bo%el lymphoma or gallstone (in gallstone ileus)

Case 3:


71/176

This D> year-old

gentleman visits his 7;

complaining of blood inhis urine. 4e has had a

number of FT&3s in recent

years.

Present this 0-ray


&otential ca$ses

Case 3: Ans2er


72/176

Radiolo'y Re&ort:;lain abdominal radiograph.

T%o rounded radio-opacities measuringGcm %ithin the pelvis. :oth opacities are

smooth in outline laminated in nature

have the same density as bone and proBect

over the bladder. Eo other renal tract

calcification.

Hoes the patient have a history of

neurogenic bladderI

7iven the si/e of these stones and history

of FT&3s these are bladder calculi.

:ladder calculi are more common in those %ith a history of=

FT&3s

A neurogenic bladder

:ladder diverticulum

Case 4:


73/176

This patient %as

admitted %ith poor renal

function.

Present this 0-ray


&otential ca$ses

Case 4: Ans2er


74/176

Radiolo'y Re&ort:;lain abdominal radiograph

'ultiple areas of punctuate calcificationproBect over the renal outlines bilaterally.

The calcification is %ithin the medulla of

the renal parenchyma. The bones are

normal in appearance.

These findings are consistent %ithnephrocalcinosis

auses of Eephrocalcinosis include=

4yperparathyroidism

'edullary sponge 1idney


75/176


76/176


77/176


78/176

E$$entia$ Be!ore Getting StartedFor Thoracic I"aging

E(po$#reOvere(po$#re

7ndere(po$#re

Se( o! *atientMae

Fe"ae


79/176


80/176

E$$entia$ Be!ore Getting StartedBreath

In$piration

E(piration


81/176

Sy$te"atic Approach5eart and Media$tin#" ,inc#de trachea/5ia and L#ng Fied$

Diaphrag" and *e#ra Space$ ,$in#$e$/

Bony Fra"e-or% and So!t Ti$$#e$

A'do"en and Nec%


82/176

Sy$te"atic ApproachMedia$tin#" and

5eart5eart $i9e on *A

Right $ide In!erior vena cava Right atri#" A$cending aorta

S#perior vena cava


83/176

Sy$te"atic ApproachMedia$tin#" and

5eartLe!t $ide

Le!t ventrice Le!t atri#" *#"onary artery Aortic arch

S#'cavian arteryand vein


84/176

Sy$te"atic ApproachL#ng Fied$ and

5ia5i#"

*#"onary arterie$ *#"onary vein$

L#ng$ Linear and :ne

nod#ar $hado-$ o!

p#"onary ve$$e$Bood ve$$e$;3< o'$c#red 'y

other ti$$#e


85/176

Sy$te"atic ApproachDiaphrag" and

*e#ra S#r!ace$Diaphrag"

Do"e8$haped Co$tophrenic ange$

Nor"a pe#ra i$not vi$i'e

Intero'ar :$$#re$


86/176

Sy$te"atic ApproachBony Frag"ent$

Ri'$

Stern#"

Spine

Sho#der girde

Cavice$


87/176

Sy$te"atic ApproachSo!t Ti$$#e$

Brea$t $hado-$

S#pracavic#ararea$

A(iae

Ti$$#e$ aong $ideo! 'rea$t$


88/176

Sy$te"atic ApproachA'do"en and

Nec%A'do"en

Ga$tric '#''e Air #nder diaphrag"

Nec% So!t ti$$#e "a$$

Air 'ronchogra"


89/176

S#""ary o! Den$ityAir

=ater

BoneTi$$#e

Ti$$#e


90/176


91/176

L#ng Anato"yTrachea

Carina

Right and Le!t

*#"onary BronchiSecondary Bronchi

Tertiary Bronchi

Bronchioe$

Aveoar D#ct

Aveoi


92/176

L#ng Anato"yRight L#ng

S#perior o'e

Midde o'e

In!erior o'e

Le!t L#ngS#perior o'e

In!erior o'e

L#ng Anato"y on Che$t


93/176

L#ng Anato"y on Che$t>8ray*A ?ie-0

E(ten$ive overap

Lo-er o'e$ e(tend

high

Latera ?ie-0E(tent o! o-er

o'e$



94/176

L#ng Anato"y on Che$t>8rayThe right #pper o'e

,R7L/ occ#pie$ the#pper @64 o! the right

#ng&*o$teriory+ the R7L

i$ ad.acent to the :r$tthree to :ve ri'$&

Anteriory+ the R7Le(tend$ in!eriory a$!ar a$ the ;th rightanterior ri'



95/176

L#ng Anato"y on Che$t>8rayThe right "idde

o'e i$ typicaythe $"ae$t o! the

three+ andappear$ triang#arin $hape+ 'eing

narro-e$t nearthe hi#"



96/176

L#ng Anato"y on Che$t>8rayThe right o-er o'e i$ the

arge$t o! a three o'e$+$eparated !ro" the other$'y the "a.or :$$#re&

*o$teriory+ the RLL e(tenda$ !ar $#periory a$ the ththoracic verte'ra 'ody+and e(tend$ in!eriory tothe diaphrag"&

Revie- o! the atera pain:" $#rpri$ingy $ho-$ the$#perior e(tent o! the RLL&



97/176

L#ng Anato"y on Che$t>8ray

The$e o'e$ can 'e$eparated !ro" one another'y t-o :$$#re$&

The "inor :$$#re $eparate$

the R7L !ro" the RML+ andth#$ repre$ent$ the vi$cerape#ra $#r!ace$ o! 'oth o!the$e o'e$&

Oriented o'i)#ey+ the"a.or :$$#re e(tend$po$teriory and $#perioryappro(i"atey to the eveo! the !o#rth verte'ra 'ody&



98/176

L#ng Anato"y on Che$t>8rayThe o'ar

architect#re o! thee!t #ng i$ $ighty

dierent than theright&

Beca#$e there i$ node:ned e!t "inor

:$$#re+ there areony t-o o'e$ on thee!t the e!t #pper


99/176



100/176

L#ng Anato"y on Che$t>8rayThe$e t-o o'e$ are

$eparated 'y a "a.or:$$#re+ identica tothat $een on the right$ide+ atho#gh o!ten$ighty "ore in!eriorin ocation&

The portion o! the e!t

#ng that corre$pond$anato"icay to theright "idde o'e i$incorporated into thee!t #pper o'e&


101/176


102/176

The Nor"a Che$t >8ray Latera ?ie-0

@& O'i)#e :$$#re

1& 5ori9onta :$$#re

4& Thoracic $pineand retrocardiac$pace

;& Retro$terna

$pace


103/176

The Siho#ette SignAn intra8thoracic

radio8opacity+ i! inanato"ic contact

-ith a 'order o! heartor aorta+ -i o'$c#rethat 'order& An intra8thoracic e$ion notanato"icaycontig#o#$ -ith a'order or a nor"a$tr#ct#re -i noto'iterate that

'order&


104/176

*#tting It A Together


105/176

7 d di * h i


106/176

7nder$tanding *athoogica

Change$Mo$t di$ea$e $tate$ repace air -ith a

pathoogica proce$$

Each ti$$#e react$ to in.#ry in a predicta'e

!a$hionL#ng in.#ry or pathoogica $tate$ can 'e

either a generai9ed or ocai9ed proce$$


107/176

Li)#id Den$ityLiquid density Increased air density

Generalized Localized

Di#$eaveoarDi#$e

inter$titiaMi(ed?a$c#ar

In:trateCon$oidation

CavitationMa$$Conge$tionAteecta$i$

Locai9ed air-ayo'$tr#ctionDi#$e air-ay

o'$tr#ctionE"phy$e"aB#a


108/176

Con$oidationLo'ar con$oidation0

Aveoar $pace :ed-ith ina""atorye(#date

Inter$titi#" andarchitect#re re"ainintact

The air-ay i$ patentRadioogicay0

A den$ity corre$ponding toa $eg"ent or o'e

Air'ronchogra"+ and No $igni:cant o$$ o! #ng

vo#"e


109/176

Ateecta$i$Lo$$ o! airO'$tr#ctive

ateecta$i$0No ventiation to the

o'e 'eyondo'$tr#ction

Radioogicay0

Den$ity corre$pondingto a $eg"ent or o'e Signi:cant o$$ o!

vo#"e Co"pen$atory

hyperination o!

nor"a #ng$

St ! E ti


110/176

Stage$ o! Eva#ating an

A'nor"aity@& Identi:cation o! a'nor"a $hado-$1& Locai9ation o! e$ion

4& Identi:cation o! pathoogica proce$$

;& Identi:cation o! etioogy

& Con:r"ation o! cinica $#$pen$ion Co"pe( pro'e"$

Introd#ction o! contra$t "edi#" CT che$t MRI $can


111/176

*#tting It Into *ractice


112/176

Ca$e @


113/176


114/176

A $inge+ 4c" reativey thin8-aed cavity i$ noted inthe e!t "id#ng& Thi$ :nding i$ "o$t typica o!$)#a"o#$ ce carcino"a ,SCC/& One8third o! SCC

"a$$e$ $ho- cavitation


115/176

Ca$e 1


116/176


117/176

L7L Ateecta$i$0 Lo$$ o! heart 'order$6$iho#etting&Notice over ination on #naected #ng


118/176

Ca$e 4


119/176


120/176

Right Midde and Le!t 7pper Lo'e *ne#"onia


121/176

Ca$e ;


122/176


123/176

Cavitation0cy$tic change$ in the area o! con$oidation

d#e to the 'acteria de$tr#ction o! #ng ti$$#e& Notice


124/176

Cavitation


125/176

Ca$e


126/176


127/176

T#'erc#o$i$


128/176

Ca$e


129/176


130/176

CO*D0 increa$e in heart dia"eter+ attening o! thediaphrag"+ and increa$e in the $i9e o! theretro$terna air $pace& In addition the #pper o'e$ -i

'eco"e hyper#cent d#e to de$tr#ction o! the #ng


131/176

Chronic e"phy$e"a eect on the #ng$


132/176

Ca$e


133/176


134/176


135/176

Ca$e


136/176


137/176

*ne#"onia0a arge pne#"onia con$oidation in theright o-er o'e& Hno-edge o! o'ar and $eg"enta

anato"y i$ i"portant in identi!ying the ocation o!


138/176

Ca$e 2


139/176


140/176

C5F0a great dea o! accent#ated inter$titia"ar%ing$+ C#ry ine$+ and an enargedheart& Nor"ay indi$tinct #pper o'eve$$e$ are pro"inent '#t are a$o "a$%ed

'y inter$titia ede"a


141/176

1; ho#r$ a!ter di#retic therapy


142/176

Ca$e @3


143/176


144/176


145/176

Ca$e @@


146/176


147/176

*e#ra e#$ion0 Note o$$ o! e!t he"idiaphrag"&F#id drained via thoracente$i$

C @1


148/176

Ca$e @1


149/176


150/176

L#ng Ma$$

C @4


151/176

Ca$e @4


152/176


153/176

C @


154/176

Ca$e @


155/176


156/176

Right Midde Lo'e *ne#"othora(0 co"pete o'ar coap$


157/176

*o$t che$t t#'e in$ertion and re8e(pan$ion

C @


158/176

Ca$e @


159/176


160/176

Meta$tatic L#ng Cancer0 "#tipe nod#e$ $een


161/176


162/176


163/176

Right #pper o-er o'e p#"onary nod#e

Ca$e @


164/176

Ca$e @


165/176


166/176

T#'erc#o$i$

Ca$e @2


167/176

Ca$e @2


168/176


169/176

*erihiar "a$$0 5odg%in$ di$ea$e

Ca$e 13


170/176

Ca$e 13


171/176


172/176

Ca$e 1@


173/176

Ca$e 1@


174/176


175/176

*#"onary artery $teno$i$ -ithcardio"egay i%ey $econdary to $teno$i$&

J#e$tion$K


176/176

J#e$tion$K

Documents

Coaching UKDI.pptx