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Awesome, welcome guys to our virtual shadowing for X ray rounds. Obviously, we're gonna uh stick with chest X rays. Um A couple of things before I introduce our guest today. Um Many of you have already been seeing that Lister go around, please. Um Make sure if you haven't gotten the link, drop me an email or drop me a chat box message because using that moving forward is how, I mean if you guys get through us through the heat uh court, great. If you get through us with uh future Congress leaders, great will still work with them. But moving forward, I want to be able to also communicate for those who have come to us through other means, you know, you, you know, you're in medical school in Pakistan and you're like, I'm joining because I want to do this. Great. So being part of the solicitor um will allow us every uh weeks. So the weeks that we don't have X ray rounds, you guys will get the recording and you can catch up and so forth. Um I do plan to also do a recording of just how to read a chest X ray the sim the simple, basic, simple principles of it. So for those of you who have just joined or like haven't joined before and this is your first time, you'll get that basic reading. So, no worries. So sign up for the Lister drop in the chat box, if you haven't signed up already, I believe many of you already have. Um Now let's go over the second thing. So I want to make this fun and exciting to you guys and I'm hoping many of you realize this counts as shadowing. So when you put this down for your medical school applications, put down virtual shadowing that you've done, we did this during the pandemic. Um Yes, Danny, if you're on great. If someone has the link drop, do you need the link? Yes, to drop it in the chat box for. Thank you, Danny. Sounds excellent. So, um for many of you during the pandemic, we created this to help students achieve those shadowing hours that you need and we're just gonna continue rolling with it. I think it's a lot of fun. And so please um make sure you recognize that for yourselves. Now taking off today, I promise I'll be bringing in Gest's galore and um oh, Danny, you dropped in the Zoom link. Did you mean to drop in the Lister? Blink? Oh Whoops. Um Yes, hold on, let me do that. No worries. So I'm going to try to bring in a lot of gest's and hopefully, Doctor Lin, who's here today is going to say, oh my gosh, I had so much fun teaching these amazing students. I'm going to keep coming. So uh I'll go between Doctor Lin and Tony. Um So he reads a lot of the x rays that we do. Great, 2nd, 3rd, 4th or just an official opinion. Um And I view him as a colleague in, as a friend and we'll probably be on some research projects together, hopefully, Tony with our Harvard colleagues if those grants kick in. Um But the way he looks at um x rays and interprets them, uh I just sit back, it's like watching Da Vinci paint, you know, it's just, it's mastery and art artistry. So today I'd like you guys to just sit back and relax and let Doctor Lin and I discuss the case. Is that okay with you guys? So you guys can kind of see in real time what we do and Tony, I'll pull up the X ray and um it's the one I sent on the slides and, you know, I'll walk you through the case and you know, we'll discuss it. Is that okay? Yeah, that sounds good. All right. And so uh if you hopefully can see it well, great and start my dad's in the background, giving me a pen. Thank you dad. All right. So let's go ahead and uh let me pull up the X rays. Tony, do you have any words of wisdom before, you know, these amazing students. You know, they're, uh, some of them are already residents and so forth. They're sitting back, they wanna become future doctors. Any words of wisdom on your end. Uh uh First of all, I'm, I'm Tony Lin. Thanks. Panic is for the, uh for the introduction. I'm uh I specialize in cardio thoracic imaging. So both chest and lung. Uh it's, he's paying me a lot of high praise, but that's probably because I'm like the only thoracic focused radiologist at Hopkins. Uh um So of course, um number one of one. but uh I think uh physicians like uh panic, these are, are the best uh partners to have in, in radiology because they just give us so, so much detail about the patient's that they know exactly what's going on clinically and what really helps the radiologist is clinical focus in the sense that if we don't, if we have the patient history, if we know what the imaging is being done for that, that takes us uh a long way. And most of radiology I feel is really just answering the clinical question. And um on another note, I would say if you're training to be a doctor, if you're thinking of medical school, uh or, or you're in, in medical school or whatever, um or in a medical profession, whoever is in front of you teaching you about radiology, about radiographs, about CT anything in radiology there, the expert. Okay. And I don't think there's necessarily like one singular optimal way to look at a chest X ray. And for that matter, any other imaging modality in radiology, everybody kind of has their own way of approaching a chest X ray. Uh I've, I found a few um algorithms that I found are, are easy to understand and, and so I stick with them when I teach chest X ray to the medical students to, to radiology residents. But there, there isn't just one way to learn. Okay. So whatever I tell you, uh it shouldn't uh conflict with whatever Doctor Gallus A does uh is teaching you guys. Oh Tony, I'm going to pause right there. I love that. You said that because that is such a, you said two very incredibly priceless things that I want to make sure I can emphasize for you guys. If you ever remember, we kind of dive into thinking a little bit of the diagnosis of what's going on with the patient that I make it clear when you wanna data point. You have to know why you're requesting it. Same thing with chest X rays, right? Your radiologist can give you, you know, literally can give you a text book of that reading, but you should direct him or her of what your clinical question is. So he can give you the clinical answer. That's the best utilization. I love that. You emphasize that Tony because that's the first thing that teach any intern. Why are you ordering it? What is your clinical question? You can give me a clinical question. Don't order it because then you don't know how to interpret the data. Good clinical question. Then the second part is exactly Tony said, reading an X rays, like writing a book or painting a portrait. Everyone's gonna have different techniques, everyone's gonna have different approaches. You know, the algorithm that I've taught and I'm teaching you guys, you're Tony's correct. Okay. That is not the only way to do it. So sit back and relax this doctor Lin, you know, um discuss this. It's so back to you too. And I just, I wanted to stop you those two points cause they're so important. You're so important in order to understand being a doctor wanting a data point means you have to know why you're asking that question. And then I love that you emphasize the art of medicine. We have different ways to approach it doesn't mean you're wrong or right. It's just my way. I mean, we'll still get the same answer as you. I just have a different way of doing it. I love that. Any other points you want to raise until we dive into the case. Well, I'll just, I'll just uh inject like a dose of reality and, and explain that if, if I'm like on a plain film shift, I go through about 200 of these x rays uh in a day and that's considered like, you know, average. And so what we're gonna do today, like really dissect the in's and out of a plain film, that's not necessarily what, you know, what you, you'll see us doing on a day to day basis and we'll uh an actual clinical practice will probably get a kind of just salt. Um And like, like we were talking about if, if we know what the clinical question is, for example, a lot of the intensive care unit films, they're done like every day, if not, like every um twice a day, we know that they're just looking for any change, looking for the and there take a tube. Uh And then we, and so we dictate them because we expect uh we can expect what the, the clinicians want to know about these daily follow up films as opposed to like these uh unknowns. We'll call it these, these cases. Where were we have time to be more thorough? Uh uh So if you ever have a chance to shadow a radiologist and they're just kind of flipping through multiple images at speed that seems hard to follow. Just understand that it's, it's not because we're not being cautious and looking at things that we should be looking. It's, it's that we, we know where to, to look and that were um our eyes can often process patterns um way faster than you can. Uh you can understand what, what is going on. And we sometimes call that like an Aunt Minnie, which is the principle that while you would never mistake your Aunt Minnie if you haven't at many, uh, for a stranger. Right? So when, when there is an imaging pattern that most radiologist would just recognize and not really have a differential, we will instantly know, uh, what to call that, that, that's an Aunt Minnie for us. Okay. Um And I think we, we, we can get started. Let's do it, let's do it. This is great. I love it. And, and you guys, if you ever have a chance to shadow radiologist that were recommended, the joke with them too is they see more patients than any other doctor in a day and that's 200 X rays on. Uh, it takes us like 30 minutes to get through one next right in the ICU because we're so much teaching anyway. All right, let's go over this case. I love it. Are you guys are in for a blast? So Tony, um let me pull it up. Let me confirm that you can see it and I'm gonna give you kind of the one liner of the patient. Is that okay? Yes, please go ahead. All right. And so in the chat box, I'm gonna tell you guys is Ben here, by the way, Ben who shouted me on Monday. I'll take from the silence that he is not. So on Monday. Um I in my clinic, I had um I see a lot of vascular malformation patient's meaning they usually just have some lymphatic issues or capillary issues. The capillary, the, where the artery and the veins meet the capillary just malformed. And this is the rare disease that it's rare. There's probably like 10 patient's in the whole east coast and I CMO um and I help manage them for some of the treatments. So this patient has Klippel Trenaunay Trenin syndrome. You guys can google it, interesting pictures. Um This is the patient has a vascular malformation genetic defect. She has 41 years of age, Tony. She presented to the emergency room with shortness of breath and so they snap the plain X ray. This is in the height of the COVID pandemic. So Tony, what I'm gonna pose to you is go ahead and you know, read as you see fit. Good, sir. And then I'm going to just point out a few things about the chronicity, some of the findings and if that changes some of the differential. So shortness of breath comes to the ed known COVID exposures, but it's the height of the pandemic as well. And she has a background of this vascular malformation disease where she has known whole Maneri AVMs. So with that said, Tony, is that, is that enough to go off of, to go ahead and dive into the reading? Yeah, sure. Uh So let's, let's uh first kind of parse out what we're seeing here. So um just, just so we can ignore the labels on the top right of the image. If you see this backward L uh that L is to label the left side of the patient. And so if, if this isn't your first chest X ray lesson, then you probably know the left side of the patient is to the right side of the image. And so the patient is positioned as if your face to face with them. Okay. And under that L is also a number which is for the technologies to uh for Q A purposes if they need to know who took the skin. Uh These, these films are usually taken uh in the ED. If uh if they're in the ED, they're done affordably uh which means they put a plate under the patient and they have, they have them take a deep breath or if, if they can walk, they, they would come to our digital imaging sweet and that they, what they have the patient do is move there scapula out of the way. And so uh that they'll, they'll actually hug the, the X ray receive. Er and and that, that's called the Pee Post ero anterior film for a film that's taken with the X ray shooting from the back forward. Uh And I do see like the left scapula out of the way of the lung fields on this image. And So the approach that I would recommend for starting out um probably the A BCDE approach. So a stands for abdomen and it's not immediately intuitive why you would look at the abdomen when they wanted uh like a chest X ray, which presumably they care more about what's going on in the chest. But the idea is that if you are too fixated on what's in the chest and the lungs, you may leave out other things that may be pertinent. For example, if the patient has uh uh ruptured diverticulitis and has a lot of free air under the diaphragm, a lot of pneumoperitoneum or air in the peritoneal cavity, you, you may not get to it because you're, you're two fixed, um what's going on in the, in the chest. And so for a, we're gonna look under the diaphragm and where the cursor currently is, that's the right hemidiaphragm. Now, now you can see, yep, what the being drawn is the, the curved shape of the diaphragm and just want to make the point that the, the highest point of the diaphragm is not uniform um in the front and back. And so there are some lung behind that diaphragm and, and uh but that, that top part of the diaphragm would be where air accumulates if there's say pneumoperitoneum. And you can see that the, there's a, a gas bubble under the left hemming diver, which is normal anatomy, your stomach is in the left upper abdomen. If for some reason, the that gas bubble is on the right side, there's two possibilities. Either the p the film was flipped for whatever reason or the patient does have a situs abnormality that rarely does occur like less than 0.1% of patient's have uh cystitis abnormalities, which means that the organs are flipped in laterality. So the liver which is on the right side mostly will be on the left side. And then the gas gastric bubble or the stomach would be on the other side. Tony cannot calls you real quick because I want everyone to listen to this and pay attention because bringing you one and potentially uh the radiologists are more frequently. You, I love that you're, you're telling them how you think and how you review this and how you dive into this. Um I mean, you've been to enough of our own rotations and um X ray rounds where you realize a lot of us we dive into, there's a spinal process or not, you know, and I'm seeing this. So, you know, because they're not rotated. But I'm saying this because I love this. We all approach this uniquely and differently. And at the same day, it's meant to get us the same answers. And I love how you're explaining, we start in the abdomen. That way we don't miss things. That's such a key thing of being a good diagnostician and, you know, kind of sleuthing through this. So I just want to pause the praises. I love this. I'm like, yes, I want them to understand the diversity of how we think as physicians ultimately to try to get to the same answer. So, back to you, sir. Thank you. Thanks. Panic. Guess I thought you were gonna say that I was going too slow and too uh You're fine getting bored. No, no, no. All right. Well, uh I was kidding. Yeah. Um So next is b uh B stands for bone. And uh right now um on this film, we can see 12 ribs on each side, we can see the clavicles, you can see the scapula, the humor heads, these are the symmetrical structures. And so what you can do is to check both sides, make sure uh that their first of all, they, they look the same on both sides. And second, you should check if they're the same distance from the midline. So if the one clavicle is much further away from the midline than the other, that means the patient is rotated and that can introduce artifact. Okay. So, uh what that can cause particularly in a, a portable film is a difference in density even though like the, the same anatomy. For example, you if, if the X ray is not dead on the center of the patient, but to the to the patient's left, that means the left side is going to receive more X rays than the right side. And so it's gonna look more lucent because more X rays passing through and then on the right side it'll look more dense. And so you get this artificial gradient uh which can mimic pathology. All right. So rotation is one thing. Um you want to look at penetration of the X rays. So that center line that was uh visible just the second ago, that is overline the vertebral column. So the vertebrae's are very dense and not, not only are they dense structures because they are bony, they, they have lots of calcium. Uh you're, you're not just seeing a vertebral body, you're also seeing the pedicles and the uh uh spine is process. And all of these densities are superimposed. And then you also have the cardiac silhouette and the criteria for adequate penetration, which means that you have enough X rays to pass through all the uh structures of interest is that you're able to see through the vertebral column. And on some films, you're not able to see through the vertebral column, you're not able to make out the different structures that make up that vertebrae. Uh But on this film, it does look pretty good. And another criteria is being able to see through the heart. So the contour that panic is through on the left, that's showing you the contour of the left heart. And, and so there are lung that lung markings that are just, I guess to the left of that border left by our, um, our perspective and your, since you were able to see lung markings past that heart, uh I would say this is a pretty good quality study and let me, let me pause. You hear Tony guys, like what I like Deborah to Ariana. Like what I appreciate as you guys listen to Tony, right? You know, he, you know, being a radiologist, you want to make sure you got the right film, you want to make sure nothing's going to muddy the waters of how you're gonna interpret. We we put stock in like the rotation of the film. But listening to my radiology colleagues like Dr Lynn, I love this because the penetration is important because that can fool you if it's not. If it's poorly predatored, overly penetrated, it can present murky results and conclusions. So the fact that Tony Doctor Lin, you are sitting back really thoroughly letting us know like this is what we look for too short. It's a quality film that no confounder is there's not gonna be nothing that's going to muddy my interpretation of this film. I love that. I love that. Thank you. Good sir. Back to you. Yeah, Tony. Tony is fine. I'm off the clock right now. I understood that upon Aggies is final my end too then. Huh? So, so speaking of cardiac border that that's see, that's cardio mediastinal which is cardi the the heart, cardiac and the mediastinum or you can make it cardiovascular. I I think either is fine because the mediastinal structures because they share similar densities. And when I say density I, I'm referring to like the physical property of these organs such that this the X rays that passed through are going to meet the same amount of resistance uh through these structures. And that, that's actually called like a linear attenuation gradient. And so the concept is that soft tissue is going to look the same. And so you're, you can't distinguish different soft tissue structures, even if like the there are right on top of each other. They're just going to look like one big blog and similarly, um fatty structures are gonna look similar next to each other. You won't be able to make out say a lipoma within the skin and Tony if my outlines don't help to say panic is get rid of that. But I'm just trying to outline the tricky and the carina, which they know the corona that keeps looking for it. And then the cardiac civil let's to meet into the aortic arch and so forth. But if that helps um for you, that's great, that's great. So the bottom portion of the mediastinum, the curved portion, that's the heart, that's the, the right heart border usually sticks out a little bit to the right of the vertebral column, whereas the left heart border sticks out a lot more. And so most that means most of your heart is in the left side of your chest, which is normal. Whereas if, if the heart, if this cardiac silhouette is enlarged uh in the setting of like a dilated cardiomyopathy, for example, or some congenital heart disease, uh we should be able to detect that very easily on a chest radiograph. If the hardest shifted to the right. While we were just talking, we're just talking about situs abnormalities earlier. But this is a normal person normally positioned heart, normal size and then the upper contour that panicky is true uh to the left and right of the trachea, that is the vascular contour. So you have a aortic arch, which means that as that the aorta comes up from your left ventricle and it kind of bulges to the right. So that right, uh that arrow overline the right lung that's pointing to the a sending irrita. Then you have an arch that connects to the descending irrita, which uh is that other arrow that panic is too. And so you, you wanna make sure that there's no mediastinal widening. So that means steinem. If it's widened, it can indicate pathology such as an aortic dissection or an uh aortic aneurysm. All right. So we covered see nexus D which stands for diaphragm. And so next, we're gonna look again at the diaphragm, but this time, look at the angle that it forms with the, the lateral rib cage and this acute angle that it makes is normal because the way that the, the diaphragms are attached to the ribs, um and it at simultaneously it's being pushed upward by the abdominal organs that, that, that's what gives it this dome shape. And so if that, if you lose that angle for any reason, if it looks blunted or you have like uh some density that's sitting on top of that uh lateral cost of finicking. Go that, that is plural effusion and uh Tony, I've uh the group here as well. And um they, they love that vocabulary costophrenic angle. I think back in medical school, someone's like if they look like vampire fangs, they're, they're good. I love that you're much more scientific, like it's an acute angle, etcetera, but that vampire fang uh imagery has never left me. That's how I tend to describe it. And then I still with fangs and like if it looks like looks like tusks of the Walrus, that's an abnormality. So if it's blunted. So anyway, but I, I love that you the, you know, discussion of it and so forth. Thank you. Good, sir. So, in radiology where no stranger to like, eh Penans? Well, not is it f in, in or, or like using other more uh accessible image res to as labels for signs? Like we, we talk about Apple, Apple Core sign, the linguini sign, the military or like Millet seeds sign and it, I, I think it's no coincidence that we um So some of these signs that people come up with our, you know, our food or things that evoke emotions in the case of maybe it was Halloween when they came up with, they could have been. But ever since then that's like stuck in my mind. So nice. Okay. So uh so d diaphragm is also important because we want to tell if this is a good inspiration. Uh I mentioned like I see you films, those you are usually patient's who are not able to take a deep breath, which is what we normally instruct patient's to do on these X rays. And, and so for those patients', their diaphragm would be way up high and um we would not be able to see through the heart uh to see through the lungs as well. But I don't know if panicky has gone through like uh how many rids you should be able to see. Generally we have not, we have not uh dive into it. By the way, Tony, I want to pause here as well to the students the way we've gone through our algorithm, you know, while it's taken a different path, there's a huge similarity here. We don't, we have like Tony the way, you know, I do it as well as spinal processes. I look at the mediastinum, costophrenic angles, apex, cardiac sweat Tyle. Um But what I'm alluding to with all of that is we don't dive into the lungs into the last thing we want to make sure the film, you know, there's a look for Confounder is, but then we don't wanna make sure we miss anything else. And I love, like, that's how you approach it to. Like you're like, hey, I'm looking for everything so I don't miss before diving into the meat of it. So I, I, you know, that's a huge point to make as a physician that, you know, we get what we want to look at, but we don't want to miss anything else too. Yeah, absolutely. Back to you, sir. Yes. Rib county, let's do it right. So, um you can count the Horace, the more horizontal ribs which are the posterior ribs or the more angulated ribs, which are the anti ribs. And the thing about the anti ribs is that you don't see the media portions of these ribs because their card, they're made of cartilage uh when they're attached to the cern. Um and so, uh you should be able to see about 78 anterior ribs. So um I don't think I can entity, but so here you can see the annotations that panicky see destroy. Um So the highest blue line that's the third rib. So let's start counting through 3rd, 4th, 5th, 7th, 8th, 9th, 10th. So I said 7 to 8 anterior ribs, but you should be able to see 9 to 10 posterior ribs. So these are posterior ribs. Um and because they usually are higher and your anterior ribs, they, they are angulated downward. Uh You can see more posterior rib and that, that indicates that the patient has six, adequately taken a deep breath and that this is a good quality inspiration. Okay. So, yeah, that line that was more angulated, that panic ease through earlier. That that is an example of an anteroom. All right. So we did the A BCDE is everything else which includes the lung. And like panicky says, we should uh save the most pertinent thing for last just because we don't want to forget anything. And because there is a pitfall called the satisfaction of search pitfall where we get uh too fixated on the immediate thing that jumps out that we miss other important findings. Okay. So the finding that we see in the lung and what I generally do is I, I checked for asymmetry as a just a little and, and so we can see immediately that the right lung is more dense. Uh You can, you can say dense or you can say it's, it's more oh pacified or that it looks um more white uh in layman term. And that the first question is going to be, is this an artifact? Is this truly in the lung? Is this a problem occurring within the lung or outside? So, things that could potentially do this um uh quick things that can potentially mimic a right lung pathology is, for example, if you have absence of your pectoral muscles on the left side, right, if, if you have a mastectomy on the, on the other side, that can make that, that lung look more lucent compared to the contralateral lung, the lung on the other side, uh That's not what's going on here. You can see uh two breasts. Uh I'll be at the left breast looks larger than the right side. So that, that's not absence of the pectoral is it's called Poland Syndrome or they one lung could be hyperlucent. So, is this pathology where the left side is completely emphysematous and the right side, relatively speaking, is more normal and it just looks more dense because it has normal lung tissue compared to the other side, which is all air. I don't think that's what's going on either because the left lung by, it's by the lung markings, by the volume of the lung, by the shape of the diaphragm that it looks pretty unremarkable aside from a few nodular opacities, which we'll talk about soon. So there's increased airspace, opacity in the right lung. And I use the term airspace opacity. I know that some physicians will still use the term infiltrate. I would just preface uh this the following by saying, I don't care if you use infiltrate and not directing. I'm not directing this, that anyone in particular kind just kind of uh every, every pulmonologist like, oh, we like that word infiltrate. That's, it's like stuck in a vocabulary but understood Tony's. Yeah. And, and because it's stuck in people's vocabulary, it's become sort of an all encompassing term where people are not exactly sure how to define infiltrate but airspace. Opacity in comparison is very intuitive. That opacity as panic is put stated in the chat, that's it's increased um increase whiteness or increased uh density. And, and, and so let's go through the differential for what can cause diffuse whiteness or diffuse airspace opacities through one side of a lung. Now, I, I think there are some differentials that you can memorize but I, I usually just think of this as what, what can fill the lungs, what can cause um the long to become consolidated uh or, or increase in density like like this. Uh So uh one thing that's very common is pus, so if, if there are, is an infection, if there is say Pneumocystis, if there is a bacterial pneumonia that tends to be unilateral or some, often it, it just involves a lobe or a, a segment of lung. Uh bacterial pneumonia generally wouldn't give you such homogeneous uh opacity, uh which I think would be unusual, but Pneumocystis uh also tends to be more bilateral. So don't like that as well. Uh Just a type of infection that Tony's implying. But you're right, like the uniformity here, like, you know, a good bacterial infection shouldn't, it's too pretty for that way, too pretty. Right. Right. So, so what I'm trying to illustrate here is that besides knowing what can cause these densities, these opacities, radiologists should also be familiar with the patterns or, or more specifically the distribution of disease. And, and so in this case, the latter unilateral itty of abnormality is a tip off for us that we should be thinking of disease processes that can affect one lung and not the other, right. Okay. Okay. So, uh so similarly viral infection uh previously, we see a lot of influenza, but these days COVID uh is pretty common as well. That, that tends to be bilateral as well. Okay. So an infectious process seems less likely given the appearance this hazy vale like capacity. Um it could be fluid, so the fluid could be in the lungs. And so if, if this is pulmonary edema, uh one reason to get a unilateral pulmonary edema is if the patient has collapsed that lung and then you re expand it very quickly, you can cause what's called the re expansion pulmonary edema where the, the blood quickly flows into the lungs and then the, the it leaks uh into the interstitial in. And that would be uh a calls for one side of the lung to, to demonstrate these opacities. I don't think that's what's going on here either because there's no pneumothorax, there's no chest tube, uh the fluid could also be in the pleural space. So what I'm talking about is if the fluid is layering behind the like posterior to the patient behind the lung. And the reason we're not seeing the blunting of the diaphragm that we expect to see when there's plural fusion is because if the patient is laying on her back, the fluid is not accumulating uh inferior early, but it's accumulating all, all along the right lung. Uh because that's what gravity does to fluid in a space that allows fluid to move around. Yeah. So fluid being dense will always go to the, you know, if you're especially sitting upright, Tony, um the unilateral unilateral wral itty of sometimes infections, I mean, you you brought up viral before, but during the COVID height, especially earlier in, did you ever see this type of uniformity at all with COVID or not really? Like to me, I felt like I'd usually just see pockets here and there but nothing, nothing this well distributed. And that's saying this is COVID, I'm just asking, right. And so when COVID give you this diffuse abnormality through the lung, it tends to be bilateral. And those patient's are usually our sickest because those opacities represent diffuse alveolar damage, which is like a very acute phase, a very severe form of inflammation in the lung. Whereas if there are um uh we've also seen like these more nodular looking opacities developing patient with COVID infection, COVID pneumonia. Uh and those tend to be bilateral as well. And so, so, yeah, I agree with you this, this is not a great look for COVID but all right. And, and so we, we talked about fluid, uh there's also cells. So cells refers to malignancy. So you, you, you can theoretically have a large tumor. That's, that's so one example as needle feel yoma, which is this plural malignancy. So, any uh any but boundary of that lung that you can see is lined by flora, flora. And so if you have a tumor that grows along the pleura, uh and I understand like there's a lot of Klor a anterior as well as posterior to the lung, then you can, you can develop increasing densities because uh because of tumor that way. Uh Again, I don't think that's what this is because yeah, what was gonna say what I appreciate the way you're, you're describing it to the students and I love this, right? You're thinking in your mind what causes this and then you, you go down like, could this be what's here or not? Like, I love that like, and that's how we all think to some extent, like you're going through in your mind who creates these typical patterns? And then you're trying to convince yourself is that what's happening or that's not what's happening here and like that kind of back and forth of, you know, how you're doing it. I love and you know, the fact that, you know, the students are listening in real time like, oh, this is how doctors staying constantly, they're they're trying to, you guys are trying to find a pattern and the one that makes sense for this patient. So I'm back to your tone. I just want to make sure the students understand like this is gold like listening to talk about these patterns. This is how we think in real time. So thank you, sir. Back to you. Sorry, I'm only cutting you off because the way we think I think is great for the students to understand. It's not an immediate, I see this. I know the answer. It's like no, let me go through my mind. Thousands of pieces of data to try to see which pattern makes no sense to tell someone back to you, sir. No, I appreciate that. So um so right. The the way radiologists report things is that we, we tend to give our top few differentials and, and often that differential diagnosis is based on our experience as well as what we see on the films, right? Or maybe the other way around. Um And what that means is that we, we are often thinking of the common things which are infection. Uh at Elect Icis is another one. I don't know if you've talked about an electric cyst. It's uh we've had two lectures on it. Yeah. Okay. Okay. So uh airspace opacities could be from uh us at Elect Icis Fluid. These are common and then uncommon things would be like uh protein Avila prognosis. Or a fat lipoid pneumonia or cells, uh which includes, you know, any mesothelioma, lung cancer, uh lymphangitic carcinomatosis, uh lymphoma, etcetera, um and hemorrhage. So if, if the patient has vasculitis, if there's a bleeding death, this is if the patient has bronchiectases, uh these are all conditions that can raise the risk of bleeding in, in the lungs. So that being said, I, I think there are additional interesting abnormalities on the film and which panic ease, alluded to the in a patient with vascular malformations, malformations, you should be looking as well for any nodular or psa pigeon iss looking lesion's in the chest. So where uh what, what's being contoured right now? That is what we would call a nodule. So it looks ovoid and on plain film or radiograph, it's impossible to completely characterized nodules. So we can, cannot tell you if this is benign or malignant. We cannot tell you if this has any um internal fat or, or if this is communicating with airway, if it, if this is community canning with vessel. Uh But given that this patient has history of Klippel Finale Trine Nominee Weber. I would wager I guess that this, it is a vascular malformation and on CT, we would be able to see a connection to this night iss this nodular opacity, I think on the right side. Sorry. Oh, no. And you're, you're spotting. I mean, so what I, you know, one other thing um Yeah, we're not doing here at the moment. But one of your thing you said earlier though is you tend to pull up a lot of films, especially older one. So you can compare, right? So you're like, I can give you 1000 differentials here. What's it? This could be acute, this could be chronic. And if you have a older x rays, if you can time travel and like, oh, this has been there. So something that's been there chronically over years, something I got a smaller differential and it helps me, you know, that way you don't tell the patient this could be cancer or this could be benign, right? The chronicity of it is, is huge. And so yeah, this has been, this lesion has been in this patient, you know, going back to 2014. Um So it's been there for some time. So, but, you know, you made that point earlier as a radiologist, you're pulling up tons of imaging, you're looking at them pretty quickly for patterns, but you know, one of them is what's been there before and what's new. Yeah, you were gonna say something about the right side Tony. So if you can highlight the right mid lung, there's, there's another nodular opacity there. Uh So those to stand out. But uh I think there are more possibly so at the right lung base, uh a little bit more laterally that looks like a nodular opacities. I don't think that's a nipple shadow. And, uh, those are the ones that I can make actually, if you go to the top, right, um, that it's more, not very nodular but it's more like a patchy, a patch of a pass itty. Just, just slightly too. Um, the, uh, the higher of the left sided circles that you've annotated, just go a bit high. We'll go down, um, you're right about here, uh, go down another rib and then draw a circle laterally and downward. Yeah, that, that, that looks like another patch of something. I think it's, um, uh, it would be, I'm not sure what, um, that is but it's probably falls within one of the, one of the differential that we talked about. Well, one of the things that I appreciate what you're doing right here, Tony and what I'll do, let me stop sharing and we'll bring it to it and this patient ended up being diagnosed, um, with bronchitis, all her viral panels were negative and so forth. But all these findings that you're bringing up these are chronic, her X rays really don't look that much different, but I thought it was a good X ray to show the way you even just discussed. The last part. Something's there. You know, one of the things that I try to, uh where we've discussed here over and over again is you got to know what normal is. You got to have a good understanding that what normal is and there's 1000 variations of normal because the second something pops up like you just did like something's off there. You may not know what it is but something's off there, right? But you know that tingling sensation cause you've seen 1000 you see millions probably of x rays and you know what normal is. So if something's catching you something maybe very obvious but then something maybe that subtle cause that's subtle nece. I didn't pick up until you direct and I was like, oh, shoot there it is. So I love that. Like, I mean, like that's that um do you mind in 30 seconds just saying like that can only come from years of doing this? Especially when you know what normal is? Yeah, I think uh that that's one of the first things that I teach my radiology resident is it's just focus on normal anatomy, particularly as you get into cross sectional anatomy and you start seeing all the little different uh structures that you can find in a human body. Um It's very important not to get lost in the weeds and start describing uh uh first of all, all these um uh stable benign findings. So like Kennedy says that the prior X ray is probably like the second most important film to, to look at besides the ones you're looking at today. I love it. So Dr Lynn Tony, you're off the clock, we'll bring it to an end. But this, this has been amazing. Like what this is why when did you hear men? Like, seriously you guys, this is like watching, I mean, it, it is like watching Da Vinci and like the way you tease it out, you teach us lung doctors. Uh Well, I, I feel like I always learned something new with you, my friend. And the way you set the stage is so important, guys, you're going to learn how to read x rays. 1000 different ways from amazing attendings and physicians throughout your training. But at the end of the day, there is a pattern that we all do the same thing. Hey, we don't want to miss anything. So usually we will train ourselves to not dive in, like look at everything else like surrounded, make sure there's nothing muddying the waters, make sure there's, you know, we see everything else before we go to where we want to be directed. The other part is you're listening to the physician on the opposite end of the X ray. Like, why did this person in order it? And so the, you know, when Tony finally got into the weeds of the lungs or got into the lungs, he's like that. No, that's, that's what my colleague is directed me to their here short of breath. So let me really be succinct of what's going on there and the fact that we are emphasizing what's new versus what could be old means. Yeah. We're gonna also time travel when we can. And finally the pattern recognitions. I love that you're like looking for things to set me off to kind of like what is normal or, hey, something's, you know, something I'm finding something that's telling me, direct my attention here and whether it's physical exam or radiographic films, you guys have to really know what normal is that way. When there's an abnormality, you will be very quick, even if you can't explain it even you can't understand it immediately, but you'll know it's there and that's going to help you to the next step for the diagnosis. So this was a Tony man. You rock, you always always get excited then whenever I have you want um any less closing comments to the students. Well, um but thank you, panic is for giving me a chance to, to share my expertise. I uh there is a reason. So E stands for everything else which includes the lungs, right? Um So there, there is a reason why radiology is a four year uh residency. Oh, so a is adamant be, is bone, C is cardiac slash cardio mediastinal silhouette, uh D is diaphragm and E is everything else. Um So I, I just want to reiterate that there, there is no really wrong way to uh approach as chest X ray. All the experts that you're gonna here are correct in there in correct in different ways. And that uh I truly enjoy radiology because, because I enjoy solving a puzzle that I treat every study as a puzzle where I have to get to the bottom of what's causing this, this patient, the symptoms that the clinicians are telling me about. And so I really enjoyed that aspect, the problem solving the uh playing a detective in a, in a way. Uh I hope you that you guys get a taste of what makes radiology so enjoyable to us. This is great, Tony. We're going to have you on again, my friend. I promise you. And, uh, maybe I'll even have one of the students read the X ray with you so they can try to wow you a little bit too. Um, so we'll go ahead and end here. Thank you, Tony guys. Round of applause for Tony. And, um, if you celebrate one of the abrahamic religions, Happy Passover Tonight, Happy Lenten season, that's, it's coming to end to some extent. And, uh, for those of you who will, um endure Ramadan celebrations not ended for the time, but break fast tonight from Ramadan. Um, hopefully, uh, last week in Atlanta, someone gave me three dates and some water and told me that's how the prophet would end his evenings in Ramadan. I appreciated that. So, however, you celebrate or whether it's a spring break, go out and celebrate. Thank you all so much, Tony Iraq. Thank you. Good, sir. Yeah. Thank you. Panic this and take care everyone All right guys, take care. Bye now.