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X-Ray Rounds: Introduction

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Summary

This bi-weekly webinar provides an opportunity for medical trainees to hone their skills and gain valuable insight about chest X-rays from experienced Johns Hopkins physicians. Participants will be guided through real patient cases to help them develop the knowledge and familiarity they need to correctly read chest X-rays. This on-demand teaching session offers an effective way to gain additional experience that is essential for any medical professional, and is sure to provide invaluable understanding of chest X-rays.

Description

Introduction into how to read a Chest X-ray

Learning objectives

Learning Objectives: 1. Identify when to order a chest X-ray based on clinical suspicion or hypothesis. 2. Interpret chest X-ray imaging results and distinguish between normal and abnormal findings. 3. Explain the limitations of chest X-rays and why other forms of imaging may be more suitable in certain cases. 4. Effectively filter through data and information to make appropriate decisions. 5. Develop an understanding of how radiologists read X-rays and make efficiencies with the large number of X-rays they interpret.
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The following transcript was generated automatically from the content and has not been checked or corrected manually.

Awesome. Alright, fantastic. Okay. So here we are now, the purpose of these virtual clinical shadows shadowing is want to give you guys a skill. I mean it's reading a chest X ray. There's no reason it doesn't, it has to be exclusive to only when you become a physician or enter medical school, start learning this skill now. So when you shadow a doctor, you know, Austin is there, they're like, oh he's, he's premed Austin's like not gonna read this X ray and wow them, that's the goal, right? I want you guys to take these skills and start impressing people. Um If one of my students, Alex was here, maybe she is. Um there's a variety of names, apologists can't go through all of them. Um She'll tell you as a first year med student, she was wowing her attendings. So the goal of this is to learn that skill and feel comfortable with it. Um But the other part though that I'm hoping to give you guys some impression is understanding how we think as doctors, right? Cause that type of thinking takes a while to kick in through med school, but it really has to do with data gathering and data interpretation. And so the 1st 10 minutes, I really just kind of want to explore with you guys just open ended questions to give you an impression of how we think as physicians, right? In real time, we take on a lot of data and we use it. So for instance, where is David and lalit? You guys both shouted me in the oncology intensive care units this weekend, David, I'm going to call on you first, go ahead and a mute. How much data did you hear us talking about a patient? And then we make one decision based off of that a lot and things that I did not know what they were. I was just listening as well. So understood, understood. I know I'm putting you on the spot. You're like there's a lot of regrets and I even before we started walking down you to call the data for each patient to know the status of each one of them. Basically. Yeah. And then thank you David in the intensive care unit. Probably one patient. We probably throw out about 100 different data points. And then those that said, and we have to try to prioritize how to react. What's the move we're going to make to help this patient recover and stay stable. Um Others have shadowed me in the intensive care unit and, and Austin, I know you have as well and you get that you're like that's a, it's a lot of information, right? A lot to take in and then you make a decision based off of that chest X rays are one of those data points. And I say this because one thing I'm gonna open endedly plane to see to you guys is to understand what the intention is of. When you order a test, any test, an objective test, what do you intend to do with it? What is the goal of getting a test? Right? Cause we don't just test for any reason, right? We have a purpose and intentioned behind it. And as a physician, a lot of the testing has to do with just can it help confirm a suspicion of hypothesis that uh that we are leading with? Um David and Lil, it's, you guys came on Sunday, Saturday, one of the patient that we're most concerned about, you know, we just, you know, thinking if her, her bowels had perforated. So we got a chest X ray and you're like, well, why did you get a chest X ray? If you thought her bowels perforated, we'll go over that in the chest X ray reading. But if the bowels perf you can see air under the diaphragms that will give us an impression that, hey, here you go, there is a perforation there. So while we will have a lot of data gathering as clinicians, when we order objective tests, be it blood work or in this case chest x rays, they're really meant to help us confirm a suspicion. Right. Or to some extent, remove a suspicion. Right. Oh, I think this patient is a pneumonia. Get an X ray looks clean, I guess it's not a pneumonia. Right. So you move on from that. But you know, the intentions of these data points is to do just that the other part though is you got to understand the limitations of these. A chest X ray is a utility that it is never going to go away in modern medicine. It's quick, it's easy to do. You can usually do it by the bedside if someone brings in a portable X ray, because especially once we get back into cat scans, you guys are like finally, why doesn't everyone just get a CT Scan of three dimensional X ray? They're great shows you a lot more of the lungs and subtle things that an X ray wouldn't pick up. But they're hard to get. They're really hard to get. And an X ray I can easily bring it into an intensive care unit where a patient struggling and their own, the most extreme interventions for life support that I cannot move that patient. So chest X rays aren't going anywhere. All right. So it's a skill that you should have. And I can tell you one of the reasons I love teaching this has a lot to do with my own education as a physician. I never had a no one. As far as I can tell, we don't really get formal trainings and chest x rays, which may sound crazy, but it's because everyone feels like everyone's getting it here and there a little bit in there and there, whether you're in psychiatry or whether you're in internal medicine, everyone kind of looks at chest x rays. So everyone just thinks everyone else is doing the teaching some extent or in reality, there's no formality in it. So this is my way of saying, let's do some formal teaching. Um But then even reading that uh data that will come up that interpretation. Some of you were with us last month when Dr Tony Chang, our radiologist joined and you've got to see how a radiologist read it and he made it clear we're going to come to the same conclusion were just reading it differently, doesn't make it right or wrong. This is just the art of medicine and you guys will all learn that right to get to one end point, you may find other convenient ways to get it. That makes sense for you where like the way Tony red is like, I don't think I'll read it like that because I got comfortable the way I read it cause it makes sense to me. But this is like studying like, you know Chelsea Aaron, who's saying you all may get 100% when the next test, but you may have realized you all studied very differently to do it right. It doesn't mean you're way was right or wrong. It just means, hey, there's different ways to get to the same answer. That's what I love about medicine. Like once you start getting into the data gathering to try to make a conclusion, you will realize how you filter this information to get to the conclusion that you need because medicine while it's great, it's a great sigh. Ins you learn a lot of the noise and that noise. Don't get me wrong. It's got its place and time, but you can't use all of that information all at once. You have to be really mindful of what you're picking and choosing for any of those. Uh you know, any of you who are musicians, it's like you, you can learn every note. You're not gonna play every note though, right? You're going to know what you need to play for that audience. Enough specific moment. That's it. Same thing with medicine. What date I'm not gonna gather to make the best decision to promote this person's health, to manage their disease and so forth. X rays are part of that. So what we will do moving forward as today's, let's read an X ray, that's it. I'm gonna do a lot of the reading. I'm gonna do it all. Probably at college. I'm not trying to steal your thunder. We will get you guys get your feet wet. I promise. But the goal of this is to get you guys comfortable with the intention of a data point to get you guys comfortable with understanding. When we order a test, it's meant to serve a purpose. So I will moving forward when I present you guys an X ray, I'll try to give you a normal one. Then I'll try to give you an abnormal one and give you an understanding of why we got it done. Last thing before I launch into this is one of my favorite things about Tony, a radiologist was he made it clear, like radiologist looks at hundreds. What would you say? Like 300 films in a day? 300? That's a lot. And you could easily spend quite a bit of time interpreting one chest X ray. The challenges with you when you have 300 x rays, you don't have that kind of affordability and luxury. So the way they are trained is one to miss things that are going to be life threatening. So regardless of why you got it, they will look for very specific things to not miss anything that could cause this patient harm. But to after that, their attention is going to be drawn to what your question was. So is your question rule out pneumonia. They will direct themselves ruling out of pneumonia. They want your guidance. What is the clinical reasoning? You're getting this test done so important, so vital to help our colleagues be efficient with how they're going to give you this data back. So, one of the things that I wanna hope I can do for you guys is when we move forward, regardless of what you think you want to do in medicine, you will always need a chest X. Right. Right. I teach how to read an X ray to or even our psychiatry interns because you know what in the inpatient unit for psychiatry, if they get a chest X ray, because someone can't breathe, they're gonna be the first ones to have to read it and say, oh, I need to get them to a medicine floor or maybe an ICU. So there is a skill gravis of what medicine you maybe not pathology, but our pathologists are fine. Um But it will be a skill that you will need to learn and know how to do. And I think regardless of what you wanna do in medicine, you still learn the basis of understanding how to use the data point. So with that said, that's my little introduction for the last 10 minutes of a chest X ray. So without further a do, let's dive into this. And as I said today, sit back, relax for those of you who have been with me for quite some time. For those that are new. You're like, all right, I'm going to finally do this. Yeah, we're gonna do this. Let's do this together and have some fun with reading a chest X ray. So let me go ahead and share my screen. All right. So this is a lung X ray. Let me go ahead and hit share. So let me do this when I get an X ray. I'm, you know, here's Dr G. He's in clinic patient gives me an X ray. I jump in right the way I will read this. Let me sit back and just tell you guys how I do this and then I will explain what all of this means. So this pulls off. And so actually, I'm gonna time travel, gonna be the intern in the intern and my attending physician, the faculty member is like a intern. Hopefully you're talking about my name, read me this X ray. Love it like, all right, let's do this. So the way I do this is I sit back and go. Alright. I see the spinal process is they do not look like to be rotated. So there's no confounding of rotation in this imaging. Next, I'm going to look for the trachea as I go down, I find the Carino an anatomical landmark to look to see if the media steinem is gonna be shifted. The mediastinum is a space in between the lungs that the hard, the esophagus and other vital organs are placed into. And the shift of the mediastinum would it would exhibit some level pathology but it is not shifted here. Given to where the crime is located next. I'm going to evaluate surrogate anatomical markers of the pleural space. One being the costophrenic angles there are the base, both of them are, are very evident and I can see them well, implying no significant amount of plural fusion though, doesn't rule it out altogether. Next, I'll look at the A pcs of the lungs over there at the top to see if there's any free-floating air that would imply that there's a pneumothorax. I see lung markings all the way to the top through the clavicle through the clavicles. I do not suspect a pneumothorax. Next, I will look at the hilum, the intersection anatomically where the lymph nodes vascular and the airways all come out and look to see if the hilum is enlarged on the right side where you can see the entire set of the hilum, it looks normal and on the left side with a bit of a nub in that you can see outside of the heart, it looks normal as well. The hilum bilaterally do not seem to be enlarged. Next, I'll look at the heart and evaluate for cardiomegaly, which is the only thing you can really do when it says in the heart, the heart looks of normal size or it does not look enlarged both because of the fact that the left ventricle doesn't reach all the way to the uh chest and the fact that the left atrium does not look enlarged. Now, finally, I will go into reading the lung parenchyma. And while reading it here, I will evaluate to see if there's any infiltrates consolidation, Zorro pacification. And I'll go from top to bottom and evaluate how the lung markings are less prominent, the top, more prominent the basis and all of them tend to disappear by the time to get to the distal parts of the lungs where they will touch the chest wall. And as I'm going through them, there's a unified committee throughout the lungs. Uh both on the right from top to bottom, as well as the left, top to bottom and the top of the right and the top of the left bilaterally, all the way to the basis seem to be in uniformity altogether. So in this lung X ray reading, I don't find any significant pathologies with regards to the parenchyma of the lung and everything surrounding the lung looks to be normal as well. So this is a normal X ray. That's how I would read it. So all that, all that was not meant to fancy you guys. It's just what you can do after reading thousands upon thousands of x rays. So let's go over how I read that. So this slide deck will be available to you. But this is what I'm alluding to. This is look, this is one X ray, one X ray can have all these data points and I will tell you some of them are going to be noise. I don't have anything to do with them. I'm glad they're there, but it's not what I look at. So let's go over first things first that I've made a point of emphasizing and it has a lot to do with making sure that the X ray is not rotated. And you all who have been with me before know I'm a big stickler about this because it assures me that the patient is upright flat and a snap an X ray, a rotation implies exact what it means. Like say my right shoulder is coming out. You, you know, and not the left. That's all the way hit in the back. If your patient is rotated, the lung sizes are gonna be thrown off, right? You don't know like the heart may look too big, but it's just a misinterpretation because the patient's not properly placed spinal process. What I circled you all can feel it. David Little eat Sarah. You can feel if you take your hand, feel the back of your neck, those those pointy things that you're feeling coming off the spine, those are the spinal processes, right? And if they're coming right out, you straight at you, it looks just like this, it looks like an oval shaped product, right? Just looks like this almost like a teardrop. If they are rotated, they tend to look more like a two can a bird's beak, right? So you will see that our X ray technicians are really good and they make sure if they snap an X ray and you are rotated, they will snap it again. So in my practice of modern medicine, I think I've only seen a rotated film once or twice in the last 10 plus years. Our X ray technicians will retake it if they feel like it's rotated. But with that said, while you will trust them that they would have done it correctly. So trust but verify always to me, I always look at it. Now with that said, others will use other modalities. So look at the clavicles, whatever is easiest. I'm gonna train you guys the way I've learned by all means, you guys are welcome to take on other things. And I don't mean to say one way is better than the other. This is the art of medicine. Next. Before diving into the lungs, I look at every anatomical space before the lungs and one of them is the mediastinum. And as I said, the media steinem is the space in between the right and left lung. That space is where you're gonna have the esophagus is where you're gonna have the aorta is where you're gonna have the heart. Okay. And you want the mediastinum hopefully to not be diseased in some way, shape or form or abnormal. And the way I evaluate that is specifically through this anatomical landmark. This is your trachea and your trachea bifurcates at what is called the carina, the carina. All right, let's go to the imaging prior. So again, here's the trachea and right, right down there and we're bifurcates into right and left is known as the carina. The carina has the most concentration of cough receptors. When we do a bronchoscopy where I put a camera into someone's throat, into their lungs. I always stop at the Crimea and lidocaine it extensively because if I don't second my camera touches it, those patient's gonna cough and delay my procedure for another five minutes. That, but that's important, right? Because if something goes down your windpipe, your trachea, you're going to want your lungs to coffee back out. But the carina finding it is important because it's my anatomical landmark to make sure the mediastinum isn't shifted. So say I got an X ray where the media the carina is coming out all the way into the right lung. Well, what could cause that? Well, there could be a tumor in the Mediastinum pushing against it or maybe the right lung is so scarred up. It is dragging the trachea down, right? Nonetheless, that marker, the crying of being shifted tells me there's some pathology happening and it clues me in and either the mediastinum is the direct insult like a tumor growing in there or indirectly, the lungs are getting pushed and pulled, pulling the crying along with it. How can I tell if the crime now is shifted or not? I use the vertebrae of the spine, right. And if the corona can fall in between these two spaces, these two lines, I see the media sign it's not shifted. It's a reasonable anatomical surrogate. And if the mediastinum is not shifted, that implication is there isn't a pathology directly or indirectly impact in the carina. Next, we talked about the pleural space. Every mammal except elephants has a pleural space. It is a space covering the lungs lubricated with about three mL of fluid. So when your lungs taken in big breath inhale spanned, they slide nicely against the chest wall. The cost a phrenic angles are these angles at the basis that you'll see here that I'm circling. So why are they called costophrenic cost? Oh for bone, ribs, phrenic for the phrenic nerve and the diaphragm overall, the phrenic nerve uh uh innervates the diaphragm. So costophrenic implies it's where the ribs and the diaphragm come together. Now, the costophrenic angle I want to make clear is found when a two dimensional object, meaning when a CT Scan, I'm not going to see a cat scans or three dimensional representations. Remember a chest X ray is a two dimensional representation of a three dimensional being us. So it's like taking a three dimensional person as and squishing them right? So the costophrenic angles I'm going to see on an X ray, I won't see it on the CT Scan and what I'm looking for here. And I, you know, I will give you guys always some analogies, but I'm looking exactly for this, this kind of vampire like Fang. That's what I'm looking for. Just this is as normal as it gets if you can't see the fangs and I mean, not see it, not like, oh, I can kind of see it. It's hazy. If it's hazy just means there's probably breast tissue above it. If you can't see them, it's completely white it out, completely white it out. Right sir. Drawing that end, it means there's fluid in the pleural space, that fluid could go in there because of a cancer or because of heart failure, but fluid is in there and fluid shouldn't be in there. Now, if you heard me interpret this earlier, you said I don't think there's fluid in or um you know, I can't see a significant amount of fluid said not a significant amount of fluid. If you suspect there's fluid in there, a cat skin will tell you definitively yes or no for a chest X ray. Just find fluid obliterating the cost of phrenic angles. You need at least about 300 millimeters which may sound like a lot, but it's really not, it's hard to even tap that and remove it. But so that's why I would say no significant amount of fluid. Now why is fluid at the base? Why is fluid at the base because of gravity? Fluids are heavy compared to air. Air tends to rise. So if I think there's a rare in the pleural space, I'm going to look at the top, I'm gonna go ahead and look at the A P C's. So going back to this, the apex, the apex of the lungs are all the way up here. Actually, David, oh, there's two Davids. This is great. David, Koshi Chelsea. David, you can feel, well, you can't really feel, but you're, you're a pisces are right up here right above the clavicle bone. So say, goodness forbid you're in a life or death match how I don't know why they teach you this in Mexico and I don't know why it sticks with me, but stabbing a person up here gets into their lungs very nicely. Don't do this. This is not meant to be violent, but actually let me put it to more of a reason for medical purposes if I have to put a central line in a patient and um, a long catheter into their neck. So with a long needle about eight inches long. One of the reasons we get an X rays because knowing we're working in this area, I got to make sure my needle didn't by accident, slip and puncture the lung. So sometimes, sometimes with an internal jugular through um um central access, but definitely through a subclavian. Um, if I'm trying to enter the subclavian veins. Nonetheless, if I want to see if there's a rare that got into that space. And if you're wondering how does air get in there? There's fluid, you could probably think about it. Right. I already told you there's fluid in there to begin with about three mL. There's a lymphatic system that puts fluid in there. So if something blocks that, for instance, a lot more fluid will come in. But also infections can put fluid in there. Right? Anything that causes inflammation gets fluid around it. If you ever ever cut yourself like a nice paper cut, you know, your skin gets a little bit red and raised, right? That's inflammation fluid comes there because it's bringing healing cells to help fight it off or help heal. So same concept, the bad pneumonia may get you some fluid in the portal space. But how does air get there? Air will imply that somewhere the lungs got injured, punctured where the air you breathed in, escaped out and ended up in the pleural space, ended up in the pleural space is a dead end. There's nowhere for that air to go nowhere. So that air with each breath keeps accumulating, accumulating. It actually pushes down, down, down, down down the lung until the lung can't breathe. You get short of breath and you need my medical attention for me to put in a chest tube in the back in your back in order to let that air escape, allowing the lungs to reinflate. So where I look for air is carol rise is an apex. That's it. And you feel like, well, how do you do that? Uh Hannah G's, how do you do that? Dr G all I look for is a scene if there are obvious lung markings that are coming up all the way to pass the clavicle. So look at these lung markings right here. There's still lung markings going up ear in the apex. We'll create a pitch black, pitch black like this black right here where I'm circling. Look, look all the way in the lower left hand corner. That level blackness versus in the lungs, the lungs will have greatness to great. You're gonna be great because there's gas exchange actively happening. Pitch black just means there's air just sitting there, nothing's happening to it, right? No blood supply is going there. So I would expect some level of blackness to be happening to the apex. And depending on how big the pneumothorax is, the lungs can get really squished. Lungs can actually go all the way down to here, squished away, made them into a nice little kidney beans. So I look to make sure the pleural space is normal. Looking to see if I can see the costophrenic angles and if I can see the apices of the lungs. Great. Next, I go into the high one, the hilum for many of you. I've actually, I've always done the readings, but I'm going to start making you guys do it the right hilum. You can see very nicely. The left one you can just see the top because then the heart obscures it. This is a normal right. Hilum looks like a kidney bean and the left just looks like, well, the top of the kidney bean, a pathological hilum, it means it's enlarged. It's not too small. Right. Some, a lot of these things when X rays it's not a small or big or normal, it's just normal or too big. A too big hilum loses that concave nous, right, loses his indentation pumps out. That's what you're looking for. The hilum is where your lift nodes, your, your lymphatic system, your blood supply your airways all there together and start branching out. Okay. And let me go. You guys can see it somewhat. Um in this X ray reading, receive the right hilum and the left hilum here, a lot of noise. Again, this X ray has a lot of information. So I look to see in the highland will be enlarged often times because the lymphatic system is reacting. Neither it's congested because of heart failure or it's in congested because of cancers or it's sending a lot of the white blood cells to attack some level of the pneumonia. They'll be nice and plump. Next, I go to the second most important organ in the chest, the heart. So in the heart, I'm looking just to see, is it too big? That's it to measure out in a large heart and this is a bit of a bias, but I will drop a little bit of a hint over. Not a hint. I will drop a little bit more of a teaching. The heart is honestly to organs in one, the right side and the left side really behave differently. They just happen to be together. The right side of the heart sends blood to a very low pressure system, right? The circulation of the lungs is a low pressure system. Like think about the BP you go and maybe someone took on your arm. The top number is 100 and 20. The bottom number is 80 millimeters of mercury. Well, in the lungs, it's 20 or for 10, 20 millimeters of mercury over 10 millimeters of mercury, it's a low pressure system. So the right side of the heart is right here and right side of the heart to look just like this a little pumping out because of the right side. But, you know, forming a nice little angle down here. That's it. So I do look at the right side of the heart to see if it's enlarged or not. And we'll keep driving this point home a little nubbin that comes out and comes together nicely uh in an angle. Then my and why would the right side be enlarged? Usually because of something escalating the pressures in the lungs. The majority of times it's usually a blood clot in the lungs, something called a pulmonary embolism, the heart struggling to send blood forward right side of the heart blossoms. We'll talk more about other pathologies as we go forward next, the left side of the heart. This is where honestly, where I'm looking because look a big right side of the heart doesn't necessarily mean there's something happening in the lungs. It could, you know, the pulmonary embolism, pulmonary hypertension, but usually means it's something that's congesting it before even gets into the lungs or into the lung tissues. Not all the time, not all the time. The left side freaks me out because if the left side of the heart is not working well, that blood is supposed to send forward, ends up going back into the lungs and back into the lungs and back into the lungs. So let's look at the left side of the heart, the left ventricle, by the way, darn cardiologist, the tip of the left ventricle is also known as the apex. So when I say apex in our lectures, I'm always implying the top of the lungs, the apex on the heart is the distal end of the left ventricle. Left ventricle should have some space between it and the chest wall. If it does normal sized heart so far, life is good. The left ventricle is where the blood last goes before it exits, goes to the body. A big part one that extends all the way to the chest wall, often times not all the times, every, nothing in medicine is 100% but often times the left side being big gets big because usually of some Quran Isett E of fighting high pressures, I think of your muscles, right. You know, you can get bigger muscles with more tension on them, right? More weight. So if I dial up the pressure in your body and you're living with now, with BP, like at 1 80 constantly, well, that heart's gonna work harder. So it will adapt by making it more muscular. That is not a good thing. I promise you there's more muscle in the heart means it needs to get more blood supply. And that often times may not be the case, it may not get to it. Plus a lot of those blood vessels of the heart gets stiff in etcetera, ultimately leading to a myocardial infarction, a heart attack. So the left ventricle, if it's big usually tells me in my mind, whatever is happening has been happening for some time and maybe across a threshold to create symptoms, maybe not yet, but something chronically is happening. The other part that I pay attention to is if the heart top chamber has these two slopes here, once of going down and then another slope coming out, the salt going down is the left atrium. If this to slope system is lost and all you get is kind of just one slope entering the left ventricle. It means the left atrium has a lot of high pressure in it. Why that's important is because if I see a normal left ventricle, but a big left atrium majority of the time something just happened, something immediately just happened. Maybe the patient just had a heart attack. And that's why you're seeing a lot of high pressure in the left atrium is the left ventricle just can't squeeze and send blood forward. It's backing up, backing up. So left atrium big without the left ventricle being big, usually clues me into potentially something immediate happening versus a chronic issue that's just taken place. So there you go. Right left ventricle as it is here and you see the left atrium stuff happening here as well. And we already talked about the right side of the heart, right atrium predominantly. Is that convex shape that you're uh that we were talking about earlier? So that is the heart. Next. Let's dive in to the actual lungs when you guys all want to be like, come on, doctor G have been eager to get into the lungs. But, but by the way, one last thing and I never really mentioned use and not that you have to even be aware to do this when we read X rays. Tony. Does this, the radiologists do because you don't want to miss anything but radiologists will also this is the diaphragm, they will also pay attention. Let me make sure that I can draw this a little bit better and there's a reason behind making sure it's a little bit better. The radiologist will all look under the diagram. I, I will look if I know why I want to look, but my eyes do go there. What they're looking to see is if there's any air under the diaphragm and it will look, it will be right up against the diaphragm will be a sliver of air right up against it. Not, not like this here, right here, this air with good thickness before the dive room, that's just Aaron your stomach, that's fine, that's expected. Um But what they're looking to make sure there's no air floating in the stomach, they will always do that reflexively. I do that, but I really don't call it out because it's rare that I'll be, you know, finding that. But nonetheless, you guys got another data point. There you go. Now, let's finally go into the lungs. So the way I look at lungs, honestly, the way my eyes go through lungs is a zigzag back and forth, back and forth, back and forth, back and forth, back and forth, back and forth, then to go to the other side, back and forth, back and forth, back and forth, back and forth, back and forth and back and forth. And what I try to find is some love assurance that the way the top looks is the way the middle of the right lung looks is the way the base of the lung looks and sorry, they're not just drawn all the way out. And same thing with the left lung, left lung top tends to match somewhat match the bottom. And then these two tend to match together. There's no middle lobe in the left lung, but the basis tend to match together. That's it a level of uniformity overall. So how my eyes do that and what is considered normal and abnormal. Let's go over that. So one thing I want you guys to be aware of me drawl again is that the blood vessels of the lungs will be somewhat more evident, the closer they are to the hilum. Okay. Right. Look at this, you got the hilum so congested and the blood vessels start coming out out and actually look at the apex. The blood vessels get so faint, so faint, so faint versus the bottom. So when I said the top should match the bottom with a caveat, the bottom blood vessels are going to look much more prominent, much more prominent. The answer for that is the same reason fluid floats to the bottom and not to the top gravity denser things are more blood, it's denser, more blood will be more prominent at the base. So the apex of the lungs will not have the blood supply there. It's fine, it's fine, it does its job, but the blood vessels are not going to be as prominent. I mean, look at these blood vessels here, look how prominent, look how much they stand out. It's gravity, man, gravity's pulling all these blood vessels down. But the other part is that the blood vessels really should not be present up until the chest, the edge of the chest that you really shouldn't see them. They should fadeout because the blood vessels are going to get smaller and smaller in diameter, right? Because ultimately, they need to get to a battle of millimeter in diameter where the blood vessels can safely and securely get oxygen in into the hemoglobin and get CO2 out of the blood or. So you shouldn't see these lung markings all the way to the edge of the chest. And if you're seeing them all the over there, then you can make the case, maybe there's some pulmonary vascular congestion brought on usually by heart failure, the heart networking. So I'm looking when I'm zigzagging at the markings, all the lung markings, making sure they're following that flow top to bottom, more prominent at the bottom than they are at the top, more prominent, the closer they are to the highland. Next, I'm also making sure that there's no infiltrates. What is an infiltrate kind of very anatomically sound marking that's going through the lungs and infiltrate could imply that there's some fluid or I mean, the differential is always going to be the same fluid inflammation, infection or blood. Next, I'm looking to see if there's any opacities, opacities will be somewhat cloudy little markings, think of clouds taking and putting them into the lungs. And again, those could be the beginnings of a pneumonia that can also be blood. Plus, let's say, plus I'm thinking of just inflammation that's not caused by an infection. So it would be like an autoimmune process potentially happening there. And then finally, consolidation, consolidation is when there's something completely whiting it out. This is not a consolidation, but this is a type of color and consolidation will take, it will be completely whited out. That's usually a mass. Uh It could be cancer still be infection maybe or it could be an autoimmune process, but you would call it a consolidation. Now, by the way, if you guys were looking at this, you're like, oh doctor G, you didn't. What's this little thing here? Just blood vessels got to remember these blood vessels are coming. Maybe they're going side to side, but some of them are just coming also straight at you, straight out you where they'll just look nice and circular. That's it. Nothing abnormal here. I promise you this. It's how you read a chest X ray over the next eight weeks with me. Not every week, I'm going to try to do it every week. I actually said to Doctor Urban, we're gonna do it every week and then realized next week I'm going to be away at um one of our research meetings um that's taken place in Maine um for one of our phase one trial. So I apologize. Um But I'll be back the following week and we'll take it from there. But this is what we'll do whenever we're together. I'm gonna have you guys listening to the clinical story and then read the X ray with me. You will let me know the spinal process is present. I can see that the patient does not look rotated. You'll let me know where the carina is. And if it's uh and if using that as an anatomical marker, the mediastinum is shifted or not. And you will see that I found the carina, the mediastinum does not appear to be shifted. You will tell me if you see the costophrenic angles implying there's no significant fluid in there. By the way, any type time there are, there's fluid in excess where there shouldn't be any fluid. It's called an infusion. I'm saying that because you may have had a bad injury to your knee and someone's like, oh you have a knee infusion, right? Collection of fluid, too much, too excessive in an anatomical space that there shouldn't be, this would be called a pleural effusion. Next, we'll find me the apex bilaterally letting me know if there's any air in there. And if there's Aaron there, it implies there's a new Mo most Latin for air actually script for air to thorax, thorax implying it's in the thoracic cavity not inside the lungs. Now it's out of it. And if there's no air in that, uh, above the apices, then there's no pneumothorax. Then you'll read me the hilum. Let him, you know if it's abnormal size or enlarged, you'll go into the heart. How does the right atrium look? Has a left ventricle, look, has the left atrium, look, reading all of that next after that. Finally, you'll dive into the lungs and you'll let me know if the pattern of the lung is normal. In regards to you, see the lung markings more prominent at the basis and you are at the top. And with that in mind, it's following the normal distribution of blood supply, given the force of grabbing. And then you'll let me know if there's any infiltrates opacities or consolidations and then you're done. That's how we read a chest X ray. So let me stop sharing. Let me take any questions that you guys may have, by the way, for those of you that may be new. And if you're throwing, throwing things into the chat box, I try like not to, I may not get to it. So I apologize. All right, perfect. Oh, you guys are like answering your questions. This is amazing, Deborah, you've been on here and I feel like I comment when you a lot, my friend, but tell me any, you've been with me for a while. What are your thoughts about these X ray rounds? Until unless someone has questions. Oh, they are super good. Uh We have, I have been here for a year and yeah, I really like it. I try not to miss it one any week. So yeah, I like I was gonna ask you like the last part that you said that the lung we can see in future in fruit states, consolidation and opacities if you can give for us one example of disease that we can see that patrons. Uh So all of them are part of that. So anything that can the four differentials is it puss? Is it inflammation? Is it blood, is it fluid or is it um infection? I can tell you fluid from heart failure, pulmonary edema here. Um That's really going to cause more infiltrates. Your vasculature actually is gonna look rather congested. Um Occasionally they'll cause some level of opacities. Yes, just depending on how bad the heart failure is. But opacities can also be caused by blood can be caused by infection. So those four things really the differential is wide open. That's why like if I, if I got Tony in here and he saw opacities is like, tell me more about this patient like I don't know this could be blood, maybe the pattern doesn't look like it, but I can't rule it out. So, Deborah, that's why you got to know the patient and what's going on. Oh, hold on one quick second. As my five year old walked in hold on, sellable vaccine normal is still on and uh oh then in a speedy oh he then in a speedy to support the family Polyp Maddaloni. Yes, that's fine. Yes. All right. Sorry about that. Alright. But thank you. Um and Yasmin. Yes, grand. But the only challenge I will say though about ground glass opacity. So opacities just means kind of like a cloud nous. The ground glass tends to be more reserved for cat scans. That's how the terminology came out. So I try not to loosely use it. And again, there's nothing wrong. I've heard plenty people say, oh, this is Grand glass, but the term really came out of cat scans, but opacity just implies that cloud nous, that fluffiness does that make sense? But very nicely said with regards to and the cell could be a could be a malignancy, could also be autoimmune as well. Can't forget our autoimmune, right? This is what I love about being a lung doctor at the end of the day. Actually, pulmonary medicine is not, I'm a I will tell you pulmonary lung doctors do just as good cardiology exams that are cardiologists cause I got to make sure the heart's not being, you know, being a bully to my lungs. But we end up having to be rheumatologist, oncologist, hematologist all at once to try to slough through of like what could this be when I find something infectious disease doctors constantly like we were the jack of all trades, right? You will, you may learn the physiology of lungs but the diseases that will cause them, man. It is, it is game, it's game for everything. That's why like, you know, I, the media tours I used to do during the pandemic. They're like, why is the lung doctor talking about COVID? It's like cause it's impairing my lungs. It's comparing the organs that I studied so extensively. So. Excellent Hussein. Your, where are you at at the moment? Good, sir. Uh I'm in Pakistan right now. Excellent, sir. I'm so sorry. It's so late there, but I love that you got the light on. Excellent. Um And thank you so much for and by the way, you guys are a lot of you are brilliant. Some of you are in med school, some of your physicians, if people are asking questions, feel free to answer them and if there's any outstanding ones I'll tackle. But any other questions before we wrap up here, Roger at Ernesto. Anything on your end? Good, sir. No, Erin, are you good, Erin flexure, you know, I'm looking right at you, sir. You're good. Two thumbs up. All right, full disclosure. Next week we'll be off, you'll get this video and I apologize because I think I did X ray rounds before in an airport and it worked out. I just can't promise the same thing uh airport in Maine. I don't know how I'm not putting down main, have no idea. But last time I was in, there was a very small airport so I was like, I can't promise you it'll be good. Um, but in two weeks we'll be back. And after that, I promise you every week of June and July will get on together. August will take some time off and then we're back in September doing it every week. So, and then as I said earlier for some of you, I, I just discussed, we'll try to get a certificate program out of this whether just for hate, I did shadowing. I've watched arbitrary like 10 hours of the videos. Great. If some of you want to learn to do some teaching later on, let us know, you know, we'll, we'll try to get you guys. I want this for you all. Like I want to promote you guys. So whatever you guys need, just let me know and to date, I think I've done about a dozen or so letters of uh recommendations for med school. And I go back and look to see if you watched or downloaded the video so I can be like, yeah, they're clinically shadowing with me. So just here to help you guys. But and they only go back to look, not that I don't trust you guys. I do. But that way I can just, you know, count and also try to make a note of who what I called one. So here always for you guys. Listen, I'm gonna stop recording now, so I stop rambling.