Computer generated transcript

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

All right. Fantastic. So we're recording. So today I think I let the cat a little bit out of the bag. We're gonna go over lung cancer, but I want to pause real quick. I wanna pause. We're gonna ask some questions. Oh, thank you for the lung, emoji in the chat box. Let me ask some questions to you guys. What do you think is the most common, by the way, I'm having my green tea. I haven't finished it. So you guys are welcome to have a beverage with me. Um What do you think is the most calm? Put your thinking capsule in for a little bit. You see your shadowing with me? You're in clinic with me and I turned to us Stella or no. Uh You guys don't have to answer. You can drop in the chat box. Um And I asked you guys, what do you think is the most common presentation? The most common presentation of someone with lung cancer, cancer in the lung? What do you think the most common presentation is drop in the chat box? What do you guys think? What do you think? Do you think the shortness of breath. Do you think it's hemoptysis, implying coughing up blood breathing? The most common presentation is to someone showing up to clinic who has lung cancer difficulty. We've got some difficulty breathing, shortness of breath, hypoxia, hemoptysis. Iss, hemoptysis means uh, coughing up a blood Verena. It's just saying coughing, good, good. All right. So, the most common presentation showing up the clinic and we happen to diagnose you with lung cancer. The most common presentation is a lack of symptoms, asymptomatic, right. Your lungs are rather resilient. So the cancer is going to have to, to cause symptoms. The cancer is gonna have to do one of two things. It's either going to have to get really big. Right. Because even if it blocks a little bit of airways here and they're still got a lot of other airways, right. Your lungs will compensate. It's pretty, I had this 35 year old patient, I'll show you his imaging at some point where hit, like more than 90% of his lungs were covered in cancer and his symptoms began a month ago. Right. And I know that cancer has been there for some time. It didn't just happen overnight. So the lungs are rather resilient. Oh, hold on one second. Let me see what the five year old wants. All is good. She just wanted to brush her teeth. So. All right. So the lungs are really resilient it. And so to get symptoms, it's either got to be a really big mass. Right. That's gonna overtake a significant portion of the lungs, especially if it's overtaken the bottom portion of the lungs, not the top part, the top part, it's important, but doesn't have as much blood flow. So you're probably going to be a little bit more symptomatic. If it's growing at the base or you're gonna get symptoms because of what it's invading, invading. Right. So, if you get a good one invading the airway, you're not gonna get actually breathlessness, right? What do you think is gonna happen? What do you think your lungs do if something gets in the airway that it doesn't want? Right? As you're gonna make you, like, have chest pain, is it gonna say like, hey, like, I don't feel good. What do you think happens if it's evading the airway? What's that symptom? Anyone? So what? And don't think of it just as cancer cough. Yes. Your lungs have a ton of cough receptors, no pain receptors. If you swallow a needle and it goes into your lungs, you're not gonna feel pain, you will cough because it paints, paints purpose. Or if you think about it from an evolutionary standpoint, it's made to draw your attention. So then you can physically take care of it. If your lungs are gonna tell you have pain in my airway, what you gonna do? Like you can't put your arm down there, right? They'd rather just cough it up. They're not gonna waste receptors on pain, they're gonna just try to cough it up. So, coughing is, by far, I would say the number one symptom I get from lung cancer. If, if, and when they develop symptoms it is coughing and then, depending on how it's invading the airway, you might get some blood vessels bursting and then you just cough up blood. So your spot. All right, that comes to mind. Lung cancer is something that you know, if it's causing symptoms, it's rather extensive, right? You're one of the reasons we try to do screening is to capture cancers before the call symptoms because those are usually cancers that you can cure, you can cut out remove, call it a day. Once you're causing symptoms, you're shifting your stages, right? Cause there's four stages of, of how we stage cancers. 123 and four. And then there's some subgroups like to a to be. But once you're causing symptoms are usually a to be, if not greater. And that creates frustration because while it could still be curative with some surgery, you're still going to rely on potential chemotherapies and or radiation to help the patient. So it does become challenging is we want to do the appropriate screening on the appropriate patient's. Now, let me ask you something about cancer screenings in general. What are the two things you need to fulfill to get a cancer screening? Say it's breast cancer, colon cancer, prostate cancer um, cervical cancer. What are the two things you need and imposing this kind of in a clever way to put your thinking capsule on age. Yes. Age is one of them. Age is one of them you need the right age, right? I'm not gonna screen a colon cancer for someone that it's 20. Not so much gender, so much. Or sex. Yes. Go into the doctor. Family history. Well, no family has to actually may get you to be screened earlier. But colon cancer, you know, the whole population council. So it's a judge and the organ. That's it. You need these two things. You need to have a colon to get colorectal cancer screening, right? The reason men get breast cancer, but we don't have as much breast cancer incidents as women do because we don't have that much memory mammillary glands. So we're not going to get breast cancer screening because our rates so low. But people with more excessive mammillary glands will breast tissue, etcetera. So you need a judge and the organ. That's it. You need those two. You have those two, you're gonna get screened or we're gonna be recommended. What makes lung cancer screening different? Because I want to know if it's an age, you got to be 50. In order you gotta have lungs, of course, smoking history. Exactly. Hussein, you need a risk factor for it and the reason you need a risk factor for lung cancer. Now I'm gonna walk you guys through this. The reason why you need that risk factor is because the smallest earliest component that we can find cancer. It's usually dubbed is something called a nodule. A lung nodule, lung nodule is ambiguous. It could be a scar, it could be an active infection. It could be an infection when you were five and now you're 50 I'm just picking it up because it's just a remnant. After the age of 15, you guys all look young, only anyone here is 15. So after the age of 50 if you send someone for a chest ct you better prepare to tell them abnormal finding, you're gonna find something abnormal. You got to understand your lungs are like your skin. Meaning if I did a full skin exam, when someone 50 older, I'm gonna find wrinkles, I'm gonna find scars, I'm gonna find bruises, lots of abnormalities. None of them are necessarily diseases and their lungs and their skin still works. Same thing with the lungs. The lungs are in the constant contact with the environment. After the age of 50. If you've gone through a bad moment of pollution, you may have scars, right? It's not a big deal. It's not causing any harm. And you don't need the chronicity of the pollution, right eye when we cat skinned people who went to World Trade Center bombings. Just that one exposure because of the high intensity they're still having remnants on their lungs, they feel good, they feel okay, but they still have remnants. So, what I'm getting at is the number one reason I hear from primary care doctors, why they hesitate to send people for lung cancer screenings is because interpreting the lungs without a pulmonologist, like, say it's auroral doctors like it's complicated. I don't know what to do. And a lot of these findings, I don't know how to make sense of. So over the age of 50 it's tough sending someone that, you know. So what we try to do is say, all right, let's just pick the highest risk population, people who smoke. Great. But right now, I will tell you guys in the next five years, the rate of lung cancer in never smokers is going to surpass, it's going to surpass lung cancer and patient's who smoke. And the big reason the big Italian that we think is contributing to it is AARP pollution. So all that said and done, let me present you the case for today in a 64 year old woman who came to us. Oh, shoot. Oh, good. I was like on my computer froze. Um 64 year old patient who came to us. Um Actually she came to the emergency room. Wait, hold on one second. Uh Who's any Brendan unmet yourself? Good, sir. Did you shadow me in the oncology? I see you or no, I didn't. I was at the HHT clinic. Uh God does anyone here? Alright. Doesn't matter it's all good because this is a cool case that we saw. Um but so uh week and a half ago I think it's time stamped. Um we had a patient come to the ed from the ed come straight to the oncology. I see you. Alright, Hussain. Have you done this with us before? No sir. This is my first one, first one, first ever one. Uh oh my gosh. All right. Where are you in your career? If, if you've never read an X ray and I'm gonna have you do it. But where are you from? Oh, I'm from Pakistan. I just graduated from med school. All right. Are you in Pakistan right now? Yeah. All right, good, sir. Well, it's up to you if you ever, well, you never read an X ray with me so I'm going to pass on you but continue coming to us in the future so you and I can do another one. Nneka, you have read David, you've read Perla? Have you ever read an X ray with me? No, sir. Have you come to these before? I've only been here one other time, so I'm not very familiar. Sorry. No worries. Okay. All right, let me do my A G you've done this with me before, right? Yeah. Alright. Anyone want to Perla? You're gonna do this with me. You've so you've done one more than who's saying? So you're gonna be doing this who's saying you'll do one with me next time, Perla. But who can, who wants to help Perla? Who's come to these class classes before? Throw your Gabby? Well, I know Gabby. G, I know you have. Who else anyone else, Andrew? All right, Andrew. You're gonna help me with Perla? Gabby. You'll do next time with Hussein. All right. So Perla, sit back and relax. You're in good company. You got Andrew and so you guys are gonna both tag team this together. Okay. All right. Let's go ahead and share the screen. Let me put this in presenter mode real quick. Is everyone can see the X ray. Well, Andrew and Perla, can you guys see the X ray? All right, good, sir. Right off the bat, Andrew. You have done this enough times. So I want to just get a, I want to ask you this question. All right, cause if you, after you guys start seeing a lot of X rays now, green it, I know working with me, you've probably seen maybe a dozen or so, but I'm hoping at some point after a dozen or so your spider senses make tingle. If it doesn't look if, if it just begins to scream at you, there's, it's abnormal. Andrew. Does this scream at you abnormal? Let's see your thumbs up. Okay. Yeah, I would say so. Okay. All right. So with that said, Andrew and Perla, let's dive in together. All right, let me move. This annotate another way. So I can at least see what I'm doing. All right, let's do this, Perla, you're up first. So this is going to be fascinating. Where are? So her spinal process actually is right here. And what I thought was interesting about this patient case off the bat is by the spinal process. She does look rotated. However, Tony also made this mention of looking at the clavicles if there are asymmetry and maybe she's not. So I'm not sure, maybe she could have some level of scoliosis that's throwing me off. So I'm gonna spare you guys the spinal process question. But if I do see the spinal processes are are shifted like that, I do then look at the clavicles like Tony was alluding to. So I'm gonna spare you guys that question. So next let's go to the carina right and find me the carina. You guys were ever on rounds with me. If I ask you guys to find the crying, the crying of pearl up is where the trachea splits into the right and left airway. Okay. The carina to see it on black and white imaging of an X ray is best seen if you lean back a little bit, becomes a lot more apparent. Okay. So, meaning if you guys are around with me like in July, when I have my new interns, every time I say to the intern, find you the crying up where they tend to do is just lean in and like uh lean back because when you lean back, you can see the colors, the shades of it take form and notice that yourself. Right. So if you find outlining here, the carina, which is right about here, right? And I make these lines go away, you can make, you can kind of see that optic trick yourself. Like I outlined it when I have to go away in a second. You know, you'll be like, oh yeah, if I'm really close up, I can't see it as well. So it's a really good trick to make sure you can differentiate where someone is in their educational level. But now you guys know. All right, but the Carina, at least here, Andrew and Perla, where do you think? Do you think it's falling in between these kind of the vertebrae boundaries to imply there really isn't a mediastinal shift? Yeah, I think so. Okay. Yeah, I'm leading a little bit pearl. Are you okay with that as well? I'm only in high school. I'm not that familiar with all this stuff. Oh my God. No worries Perla. So what this is the carina right here? Only in high school? Well, you're graduating now. Um This is the carina. The carina is where the trachea splits into the right and left airway. That's it. So all I want you to acknowledges that the carina right here falls in between these boundaries of your spine of the vertebrae. Would you agree to that? Perfect. If it shifted, if the carina will say over here, then that implies there's a mediastinal shift. And for those of you who are new, the mediastinum is a space in between the right and left lung, we just call it the mediastinum and it is the part of your esophagus, aortic arch, etcetera. All right. Now, let's go to the pleural space. The pleural space is that space that covers the lungs, okay. In a normal pleural space, you got about three mL of fluid and it's meant to kind of lubricate the lungs. So there's no friction as you take in a deep breath of the lungs against the chest wall. So, what we're going to look for is, hey, is there, look, you know, is there any abnormalities in the pleural pleural space? And the only thing that we're looking get in there is air or fluid. So we're to look for fluid. First fluid is heavier than air. So fluid should go to the bottom. The way you can tell if there's fluid or not is if the angle at the base known as the cost. Oh Phrenic, ankle, Costco for bone, phrenic for diaphragm, Latin or Greek, what? Either way one other languages um looks like a nice vampire fangs. Now, this is the right side of the lung and you know, it's also the right side because our radiology colleagues usually will mark it with a nice are. And so what let me postpone this, sorry software needs to be updated. All right. So where we're at here, this is a costophrenic angle here. Now, Perla, I'm gonna ask you first. Don't overthink this. This is just, hey, interpret the shape. Does this look like a vampire? Spang? Hopefully, you know, vampires. Yes. Was that, was that a yes. Perla? Yes, sir. Yes. Perfect. Andrew. You've done these a couple of times with me. It's not a disagreement. Yes or no. Right. This is a subjectivity. Does it look fang ish? I think we've probably seen some others that are a little bit more like that have a upper and reach down a little bit more. Um So like that might indicate that there's some fluid. Yes. So space but I do it is, it still has like retains a little bit of a fang shape. Yes. Yeah. No, no, no, you guys are look, look, this is awesome Perla. One of the reasons I actually, I'm gonna enjoy your presence with these conversations. Recognize this is because hopefully you guys also can see the growth of, of seeing these uh slides more and more so pearl up by all means you're doing fantastic. I promise you any Andrew, but I appreciate you is like, hey, you know what other imaging? Because that's your basis you're looking, I've seen all the imaging it used to, I've seen them sharp. Er this one kind of gets dull. Right. Look at this. This is an appreciation of a dullness right here. So you guys are both correct. If you were my intern Perla and you said, I don't know the right side costophrenic angle, maybe it's normal. Andrew who's seen a few more. Like there's something odd about it and that's what I love, love that. Like from your standpoint, you're like this is, there's, there's something that tells me isn't as normal as I've seen before and you're spot on. So again, neither of you are wrong. I want to point that out. It's just where you're at with your educational status and it's all very good. So Andrew your. So this is interesting. So look at this, what I'm about to draw right here. Do you guys appreciate that? There is something that goes up, look at where I'm drawing right, right here where that angle should be kind of slivers up a little bit. Do you guys appreciate that? So, right in this corner, this little bit of a slithering up because that there's fluid there, angels correct. This isn't as sharp as it should be. Whenever you lose the sharpness of the costophrenic angles, it's fluid, it's fluid until proven otherwise. But the fact that the fluid tracks up like kind of against gravity, something's going on there. So we're gonna get to this, this patient's gonna need a CT Scan, a three dimensional picture. I'm going to show you those cat scans in a second but nicely done. Now, Perla, to you, my friend. And again, this is just interpreting shapes. Nothing more. Nothing. This isn't like a skill unique to physicians. And I just want you to tell me what you see. We talked about this being Fang ish but not as sharp as prior ones. And again, a piece of knowledge that comes after seeing many, many of these pearl uh don't overthink this. Do you see any Fang here? Don't overthink it. The first instinct, first instinct. How do you? Yes or no. Do you see a Fang? I think I do, but I'm not entirely sure the fact that you're not entirely sure means no. So fangs and I mean this right? So I want you guys to take this like, I'm never gonna try to set you guys up for like failure here. Reading an X ray isn't one of them. Let me sit back and think it's kind of an immediate intake of a lot of data points. That's how Tony can get through 200 in a day. So if you look at this and you don't see the obvious one, if the second year is like, uh I don't know. Do I have to squint? Nope, it isn't there. Don't over, don't overread this, right? So there isn't one I promise you. So you're right. The fact that you're like, maybe I see it. No, that, that means there's hesitancy and that's correct. It means it isn't there. If you're hesitating, it is not there so perfect. Does that make sense? Perla? Yes, sir. Nicely done, my friend. Nicely done. All right, then we go for Air Andrew. Do you appreciate that at the apex? You can see lung markets coming all the way up. Yep. Agreed. Okay. Ferla, the lung, a normal lung should be somewhat blackish with a lot of gray in it. That's a lot of blood vessels. Her lung don't overthink this. Does this left side look the same as the right side? No, sir. No. What does it look like? Tell me in your words, use whatever vocabulary you are most comfortable with. And the reason why I'm saying this to Perla and to everyone else, this is what sometimes gets frustrating with medical school. You begin to try to use fancy language that may have some association with. Just tell me your own plain language. What is this? How is the left side different from the right side? Um Well, there's a lighter shade of gray so it's kind of foggy. It seems like there's something in there. Okay. Yeah, it's gray, it's white, it's definitely not black. Right? Perfect. All right, my friend. 01 other question to you, Perla, would you say it's uniform? Like, hey, no, it's from top to bottom and from left to right. This is all one consistency. Would you agree to that? Yeah. Uh Yeah, meaning compared to when I say different consistency is like stuff like here like, hey, no, like, you know, this is a little bit blacker. This is a little bit grayer. That's heterogeneous. That's variable. But here this is all uniform. This is all pretty solid white. All right, good. Now we go to my second favorite organ, we go to the heart and in the heart, you're gonna struggle to see anything, right? You may see a boundary right here. But guys don't ever think this. It is really hard to make out a heart border here, right? Like, would you guys all agree that Andrew? Do you agree? Yeah, I can't interpret the heart here. I can't interpret it. I can't tell you if there's cardiomegaly or not. No clue. So I'm leaving out the heart hill. Um I skipped over briefly but I will tell you the hilum is nice and plump here. This is no longer a kidney beach, kidney shaped. The hilum is where the blood vessels airways and the lymphatic system all come out together as one. And if you should form a nice kidney shaped beam like that, this is nice and plump. So the hilum on the right side already looks too big. Now, let's go into the lungs and, and let me, let me take a look over a little bit on the right side because the right side I will tell you is relatively normal. Ish. As Andrew already mentioned, there's markings that come all the way up here, Andrew. Why are the markings at the base going to be a little bit more prominent than the top. What's the force of physics there we have like gravity is drawing like more fluid down towards the base. Uh Like there's gonna be more blood flowing that can be more blood flow. The bases of the lungs have a lot more blood flow than the apex and the top of the lungs. So, yeah, the the blood vessels here going to be a little bit more prominent. The challenge I will tell you though is that prominence, uh like there's a nice sharp line here that goes all the way to the chest wall, there's a nice sharp line that goes all the way to the bottom. Like one thing I want you guys to hear me say, out loud lines in the lungs and a normal lung should be relatively sharp, the closer they are to the high lung, but you really shouldn't see the lines, the closer you get to the chest wall, they really should fade out because it gets so small and tiny. So anytime you see a line get, make its way all the way over there or make its way all the way over here or make its way all the way over here, something's going on. And to me, you see those kind of lines and markings because either it's fluid in the space of the Fishers, for instance, the fissures or what separates the lobes of the lungs. The right has, has three, upper, middle and lower or the blood vessels are just so prominent that like, because they're just congested. So there's something. So if I reinterpreted the right lung, the way I would say is, um, you know, the right lungs, main abnormality is prominent because I can see them really well, interstitial markings, markings because of these lines. That's the markings that I'm saying and I'm calling them prominent because the fact that they extend all the way to the edges to the diaphragm and to the chest wall, interstitial is the lung tissue. That's all it's implying. That's it so prominent. I can see them really well. Interstitial. Is there any lung tissue markings? Now let's go to the left Pirlo. You already said the left looks weird, right. Correct. Yes. So here's the kicker that Polyp mentioned, this is what I wanted to draw your attention to. This is white and uniform. Okay. It's one solid whiteness. That's it when you have one solid whiteness. Let me pause here from share ing so I can go over the differential. Can you guys uh hold on one second, my girl. Yeah. Uh You look very pretty. Do you want to say hi to everyone? Okay. You can uh okay. A book. Sorry about that guys here. All right. So back to this uniform, Austin uh reviewed in the ankles often. Were you there with me? Yeah. You were. This is depression. Yes, nice. Thank you, Austin was like, who was there with me? All right, when you see a patient with a white, uh a uh a uniform white pattern on an X ray, there's four things that this could be okay. This could be blood in the airways, blood, blood will white something out. This could be uh fluid, fluid in the pleural space, right? And we've seen that before, right? We've seen fluid, you know, if it's nice and white it out and they'll be at the basis. But this is all at the top. So you're like, well, what else could this be? It could be a pneumonia. Now, it's got, uh, not a pneumonia, sorry, sorry. A mass pneumonia's won't do it. I apologize. Mass, a mass, a solid mass, a large cancer, large tumor short. And the last one that this could be is add Elect Icis. We've had a lesson on this before. Add Elect Icis is when the lung kind of self collapses. Okay. So, if I ever see a nice white it out part of the lung, I'm thinking is his blood is as fluid as, as a mass, is this atelectasis? Those are the things go in the back of my mind. This patient's main symptom coming into the emergency room was just breathlessness. That's it. So let's go to a CT Scan because this is where it gets really fascinating. So in the CT Scan, all right. This is a CT Scan. So a cat skin is a three dimensional X ray, a chest X ray that we just saw this. This is a two dimensional X ray. This is taking a three D human being and smooshing them. Right? That's why you get the costophrenic angles on a CT Scan being three dimensional. I don't have costophrenic angles because it's all nice and round. All right, Andrew. No. Let me go to Perla first Perla. We're sticking with you, my friend. Do you appreciate that here? While there's blackness? There's a lot of white streaks and here there's blackness but it's just solid and black. Nothing in there. Okay. Do you appreciate that? Perfect. This is your trachea and this in here those are your lungs. All those white streaks are just blood vessels and so the air coming into the lungs, it's gonna look blackish a little bit darkish. I'm sorry, grayish because you're getting a lot of gas exchange. If you ever find something just nice solid black like this, it means there's no blood vessels. So there's no gas exchange happening like in your trachea, Andrew. I'm gonna ask, I'm gonna ask you to put your thinking cap on. Are you ready? All right, man, I'm gonna, I'm gonna graduate you to a pulmonary fellow. So I'm going to try to set you up for this. All right, you appreciate that. This is a cylinder right here. It's the trachea, correct? So, if it's the trachea, am I closer to the top part of the lungs or my, closer to the bottom part of the lungs, uh, you're closer to the top part of the lungs. Yes, because what's the anatomical feature that ends the trachea that we haven't seen yet? The carina? Exactly when you guys are around with me, especially by pulmonary fellows. Whenever you know, as long as we see the trachea, that means we're still in the upper part of the lungs. That's it. So you use as that the trachea is your anatomical landmark on cat scans of the chest Perla. I'm gonna ask you, there's a black hole right here behind the trachea. I know you said you're in high school. However, I think the world of you, I think you're, you're intelligent. You got this. However, I know I put in your spot. So if you get it wrong, no worries. Anything else you think is behind the trachea? Um And if you swallow air and it goes it and it goes down, you're gonna end up burping a lot. Do you know what that organ is that connects some mouth to the stomach? If not. No worries. No worries. And do you want to help her out phoning a friend? Yeah, I think that would be the esophagus. His soptic is. Yes. Pearl. Is that okay? You got it? No worries. Hey, listen to your lungs since your second time in Hussein. It's your first time, make your mistakes with me. I think the world of you guys and what you guys make mistakes with me. So you guys, that's how you learn and more importantly, that's how you'll impress others moving forward. So yes, the esophagus is right behind the trachea. Now, Perla, you already said this is nice and black and white. Andrew describe to me in your words, what you see here, it is very white. Um Yeah, no, no air whatsoever, right? So when you guys describe a color, this is important, you say it's white? Is it uniform or is it variable? It's uniform? Uniform? Perfect, right? So let me go to the next slide. Now, Andrew, what has happened to the trachea? What what, what did we just bypass? Yes, I think we have bypassed the carina moved lower. Yeah, we moved lower. Yes. Correct. Um Now in this lower part that we're at this is, you know, you're right airway and this is your left airway now in the right and left, I'm gonna help interpret these a little bit. So we have the right lung, okay? It's looking okay. It's looking good where I'm circling. It all looks nice and good. I promise you. But here you guys should start appreciating something's happening here. Ok? There's a white uniform space right there in the left lung. You have a little bit of airway here and then, then this is all white. It out. Now when I see this. I'm gonna have the, so the CT Scan windows quote unquote, that's it. I know I'm throwing a lot of information out at you guys at the moment. I apologize. But the CT Scan windows, these are called lung windows and you know, their lung windows, there was in lung windows. You can see the lung markings. You can see the blood vessels when I change the lung. When I change the windows into something called soft tissue. Do you guys all appreciate how the all the lung markings went away? Perla? Do I'm looking at you, my friend look, it's nice and black in the lung, but in this picture you see the lung markings back. Do you appreciate that? Alright, this is soft tissue. Why this is important? Andrew over to you my friend. Uh please don't overthink this. I'm just I want you to make appoint for me. Would you agree that, hey, while this is all white, it does look pretty uniform, right? Uh Yeah, but in the next slide, once I change the windows, would you agree here? There's a different shade like there's an obvious border that's happening right here as compared to out here. Would you agree that there's two shades of gray here? Yeah, perfect because that's what I wanted to. That's why you change these windows because when the lung windows I'm like, oh man, that's all one uniform color. But the second I change now what I'm being include into is there's, there's two processes happening here. I can tell you with confidence that this out here that I'm highlighting this is all fluid and it's fluid in the pleural space. And this right here is Azilect icis, that's a lung that self collapsed. Yet I'm gonna give you guys what's happening in a second because I want to, let's go to the next window now, Andrew over to you. You already told me, hey, we split the airways here. Do you see any? There's no trachea here, right? There's no, we're way past that, right? Yeah, and you got a lot more of the heart right here. This is a lot more of the heart Presidente right here. Now, here we are in the base of the lungs of the left. I'm going to pause the left. I'm gonna interpret it in a second but not through these windows. But what I want you, Andrew to comment on is look, I'm drawing out these borders right here, but do you appreciate that through the border is kind of like kind of like a crack that goes right through it. Nice and black right there. Yeah, Perla. Do you agree with that as well? So this is why when I if I see something like this, I need, I need my soft tissue windows because again, when you go to the soft tissue windows, Perla, do you appreciate there are two shades of gray one that I'm outlining here and one that I'm outlining up here. Do you appreciate that, Perla? Perfect. What's going on this up here again is still add Elect Icis. And actually even if I didn't change the windows, I could have told you that I could have not you, I wouldn't, I could have told you this was gonna be atelectasis here because this is an airway making its way through a collapsed lung. That's it. So the literally, there's long what you're capturing this CT Scan is lung collapsing around an airway. Okay. So remember with our adolescents lecture, I told you guys that atelectasis for the most part, it's not a big deal. I don't make a big deal about it. However, that and then the majority of atelectasis, like I told you guys, you guys can all replicate your own atelectasis, lay flat in bed, take rapid shallow breaths and in about a minute or two, the bottom part of your lung is going to self collapse. Okay. However, there are, there is gonna be moments of times of lung self collapse that is gonna be really significant and you really need to know what the heck is going on. And this is that so in this patient, she also in her pleural space that's more evident here. This is what I was going to tell you guys, I'm gonna interpret. The pleural space is thickened. Andrew. Do you appreciate that? Like where I just drew the border? I mean, that's a, that's thick, thicker than you. Probably like pleural space. You really shouldn't be able to make out. Like here is probably some level of normal pleural space and this space right here is much thicker. Take my word for it. Do you appreciate that? And the other thing too, now, just bear with me guys, this solid line surrounding the heart. There's actually fluid around the heart. The heart is in uh the heart is encapsulated uh in a sack. It's kind of like a sock on your foot. It's called a pericardial sac. There should be almost no fluid in there and the fact that I can see some means there's some fluid entering the pericardium. So let me pause here and tell you guys what is happening to this patient. This patient came into the emergency room with like a week's worth of breathlessness. A week's worth a week's these findings here. I promise you are not a week old. They've been here for quite some time. What's happening here that you guys can't appreciate it. I want you guys to take away this imaging first. What's happening here is that she developed a cancer in her lung space, but it, it went into her airways. The second it goes into the airways, it blocks the airways by blocking the airway and not having aarggh oh into the lungs anymore. The lungs are going to collapse. That's what atelectasis is, is atelectasis means there's not a lot of air flow coming down here. So we're gonna start self collapsing. Okay. It's like a balloon, balloon needs air to stay inflated. If you remove all the air, it collapses, right. This significant amount of lung collapse is obvious. Definitely up here. And as you get lower, the atelectasis ist begins to fall apart where you know, if, if there, if the atelectasis ist, you know, is causing so much lung collapse, what's going to happen in the pleural space? Because the pleural space is a lot of negative pressure. Like think of a vacuum when you flick on the vacuum, all that negative space not would not a vacuum take that away because that's a force a syringe, syringe when you pull it back, stuff flows into it because of the negative pressure in there. That's what happens in your pleural space. What ends up happening is as the lung collapsed, fluid just entered it. Tons of fluid. The fluid was just reacting because it's like something's got to fill up the space. So what we were asked to do, Austin, I can't recall if you were awesome. Were you there when we did a thoracentesis on this patient? Or? No, unless it was, I mean, I got left around noon. So unless it, so you didn't see us, put a needle in her, correct? Know? All right, not a problem. Then we probably only the only, the only thing I was there or was the ultrasound got it. Got it. Got. Oh yes, you were there Saturday. You weren't there Sunday, which is fine. It's fine. So what we ended up having to do for this patient is we put a needle into her pleural space to take some of that fluid out. I can tell you she, her breathlessness did not improve, but we used, we did it more for diagnostic purposes. But the reason why I wanted to show you guys this case, let me stop sharing as well is because when I brought up, add electricity's to you guys. Ad elect Icis is not something that's going to make me as a physician just being told there is that elected cyst immediately jump. I need to know the context and it showed you guys um three now versions about Alexis's one where yeah, I'm gonna sit my tea and say move on. It was a patient who showed you guys with a bronchoscopy after it a little bit of lung collapse. Yeah, that's expected he'll take a few more deep breaths and it'll be fine. Sip my tea. I'm not getting out of my chair. The second um add electricity was kind of more of the same. There was a pneumonia happening there. You got my attention would have put my T down but I'm doing it in order to order some antibiotics for this patient. I'm putting my T down and getting up out of my chair because after I saw the CT Scan. I need to try to see what I can do to re inflate the lung. The challenges I can tell you we gave the thoracentesis a shot but nothing happened. We drain some fluid out but because the lung collapse, the way it happened was something plugging the airway and that we needed to go into the airway. So on Sunday, we did a thoracentesis actually did it on both the right and the left lung. That the reason why we did on the right lung, you're like, oh, but doctor G I saw those imaging, not a lot of fluid there. The reason why we did in the right lung is to see if the cancer is also spread in the right lung or is that just communication just because of just hydrotic hydrostatic fluid ships, guys, men and women, boys and girls, students of all ages. The reason the way we stage can't lung cancer has also a lot to do with. Is it just staying put in one side of the lungs or has a crossed? So the left side, we put fluid out in order to kind of just see if the lung can kind of expand a little bit, give the patient a little bit more breath back. Nothing happened. We and we took at like about half a liter, nothing happened. And then we went and put a needle again into the right lung. And we talked about about 200 ccs no difference in symptoms, but we sent them off to the lab because if she has cancer on both sides of the lungs, she gets staged high or 3 to 4 depending on the cancer. So that's why we, we would sample both. But what's fascinating about this case to me is that here's atelectasis happening from a significant pathology. So hearing the words atelectasis and all of you will Hussein who graduated medical school to um Perla who's uh in high school. But on the trajectory to becoming a physician, but you guys will all hear these words. And the best thing that I can tell you the way we think is clinicians, someone tells me there's atelectasis. I immediately respond with what's the clinical picture? Because there's some atelectasis that won't get me to bat an eye and I'm gonna sit my t right. So this happens a lot of times with primary care doctors who sent someone for lung cancer screening, they'll call me like Panahi's can look at this imaging, there's atelectasis ist. And actually before I even open imaging, I'm like, where is it? And they're like, oh, it's at the basis at the base of the lungs. I'm like, uh I'll look at it, but that's probably because the patient didn't take a deep enough breath to expand their lungs enough. And sure enough, that's usually what I find or if they call me like, hey, there's atelectasis where I don't know the entire top of their lung has collapsed. You got my attention, that's not normal. There's something happening there. So the patient this week had to go in um not for any curative situations, but we went in um with a bronco bronchoscope in order to put a stent. Well, that's what we thought we wanted to do. We want to put in a stent to try to open up that airway. So air communication could go out like meaning even before we can actually actively look to cure the cancer or fight the cancer, we just trying to provide her some symptomatic relief because she's so uncomfortable. Um And we know if you can expand along a little bit, it should help. Um But when we went in there, that tumor is complete, like there's no way around it and it actually was rather friable. So the fact that she was breathless without any coughing or at that any coughing up of blood was pretty remarkable. So we went in and immediately aborted. So right now, we're still waiting on her response to uh some of the chemo, but it's a little promising because she has certain genetics of the cancer that she qualifies for certain treatments. This picture never smoker, never, never had one cigarette in her life, but we're finding more and more of these kinds of lung cancers. These are called adenocarcinomas common in older individuals. And the big risk factor that can tell you that globally is happening has a lot more to do with what you breathe in. So, air pollution, etcetera. But anyway, the big takeaway from me for you guys for this first of all, imaging around atelectasis. I think this completes the kind of the talks on add Elect Icis. And I promise you guys in the next few weeks, we'll have all these lectures on one website they can go to and re watch over and over again. Enjoy my jokes and so forth and learning moments. Um But at electricity, just like anything else in medicine, you got to know the clinical picture, you've got to understand what is happening in order to prompt you to do the next thing. A lot of medicine is data gathering and a lot of the times it's immediate data gathering like Perla, I put her on the spot and said, tell me if you see this or not. And the fact that she said, I don't, I don't think I see it as much means you don't see it right. That's it. You have to make these decisions pretty darn quickly. Granite Perla. I do it quickly because I've done years of doing this. I promise you. But you also saw Andrew kind of also be able to make some interpretation even doing some, you know, so many times with me. So that's it. A lot of modern medicine is data interpretation, but you got to understand the context what's happening to the patient the fat and I'm not trying to scare you guys with the fact that lung cancer really doesn't happen without any symptoms for the as it grows. And this patient a week, a week of breathlessness and that imaging should freak you guys out cause you're like, oh my gosh, that must have been growing for some time. So today you guys learn more about add elect icis a little bit of plural effusions. Let me stop here, questions, comments. Um concerns any questions you guys may have. If not, no words, what's the, what's the difference you might have explained this? But when you look at like your soft tissue slide of the ct good question, what what is, what is allowing you to like what is giving that difference so solved. So it's, it's uh the way the difference happens. This is where probably 20 kids explaining more elegant, eloquently. Um because the windows of a CT Scan you can, it's black and white is always gonna be black and white. But the way the x rays are shot, it can give you a different version of the intensities of those X rays there. So when you change the windows, it diffuses a little bit of the intensity. So say I want to see the liver a little bit better. Well, yeah, you can see the liver better if we make it less of a balance of gray and white or say, hey, I want to see the bones better. Well, on the lung window, you're not gonna see the bones that well at all because everything seems so bright. So you need to change the windows. So it's taking the picture. It's kind of like when the TV, you're like, oh, that's too bright. Let me just lower the contrast a little bit. That's it. It's just playing with the contrast and depending on the organ system you want to see, it's gonna help you do that a little bit better as a lung doctor, the fact that we have lung windows should imply it. It's just so I can read the lungs, soft tissue windows help me interpret the pleural space a little bit better. The media steinem a lot better, especially the hilum. And if I gave you contrast, I can also make out the blood vessels a lot better. So yeah, I I will, you know, I will do soft tissue windows, but I just got to know my back of my mind. What am I looking for? Um with them, Aiden, you asked how do you know there was cancer? He didn't point out and yeah. So Aiden, I can't point out any time there's no tumor for me to point out per se because it's being masked by all the lung, lung collapse around it. So all I could point out to you is there's a ton of lung collapse and there's a ton of fluid around it that filled up where the lungs should have been. So even without knowing there's a tumor there, if I see this, I suspect some things in the airway, majority of times, if something's growing in the airway, it's going to be a cancer that you can make a case for some autoimmune processes and maybe even some infections. But you know, probability wise something to cause a lung to collapse that much. It's usually going to be an airway tumor. So great question Aiden like seriously cause you're like, hey, you never pointed out the tumor man. Where is it? Can't see it, can't see it. It's massively masked by all those lung collapse around it. Austin, you have a question. I just was wondering if, if there's only a week of like actual symptoms and this has clearly been going on for so long. What are people supposed to do to try and screen early if there's no risk factor behind that? And maybe they're a if age and risk factors are your reasons to get screened? How do you know to get screened or how do you just, so this is what makes actually before I answer a question, Andrew, did you have a question too? You're on mute if you do. Yeah, it was, it was just like when you order the CT, if you have to be ordering it with a specific window in mind. Nope. Nope, you got it. You can, yeah, you can just order, you just have to have a specific organ in mind. And then if you want to have contrast or not, and this patient didn't need contrast based on that imaging cause you're like contrast will muddy the water because I'm not looking for a blood clot in your circulation. So good question. Like the reason why I wanted to ask yours before insurance also because this gets complex men. So to screen almost every other organ, you just need to a Gyn that organ, that's it. Lung cancer screening is really tough because your lungs are going to have a lot of abnormalities and I don't have anything else to tell someone that it's not cancer. So, meaning when they did the big trial in 2014 to say yes, we're gonna start pursuing lung cancer screenings. If you ask the patient and they did on retrospective reviews, they hated doing this. It was being told like, I don't know if it's cancer or not, but let's let's image you again in three months now about an, again in another six months, 12, meaning patient's had to sit there being like, do I have a cancer in my lungs? And I've got to sit here waiting for that many, you know, time period is what you're looking for in that time here to see is that if that Nigel grows and if it grows, you can make an argument, maybe it is cancer and I gotta go biopsy to. But oftentimes you're picking up something that's less than a centimeter big and it's gonna be almost impossible to get to. So, one of the biggest frustrations of this, of lung cancer screenings right now is that even in our smoking patient's patient's, you smoke, it's still tough if I find something, uh, that's, I'm going to probably the most likely responsible to do is that, hey, we're gonna just repeat this in a few months and maybe you can do different types of scans to kind of give you a better answer. But it's frustrating. Then the other part of it, all the lung cancer screenings, this one, lung cancer screenings actually had a kind of uh unreasonable when you compare to colonoscopies and you compare it to um, breast cancer screenings, lung cancer screenings actually had a one in 200 individuals died because of the lung cancer screening one and two hundreds a lot. I mean, it may not sound a lot, but when you compare to others, how did they die? Because they had to get worked up for this nodule, they went into surgery to try to slice it out and see what the heck this is all the ultimately be told it wasn't cancer but complications happen from the surgery like this is tough. So what do we do for the non smoking patient's where we know lung cancer screenings or lung cancers are on the rise. I don't have an answer right now, but hopefully we do in the next five years. And we're doing some research out of my own clinic to try to give you guys were trying to get patient's at, I'm not saying this to scare you guys, but I want you guys to understand some of the gaps that we have in modern medicine. We're trying to get those answers. But this is the biggest one. This is my hope that in the next five years, we do have better guidelines for lung cancer screenings that is beyond um smokers. But at the same time also helps us get the answer faster. That way, we don't trouble people with benign findings and we really put more attention to those with dangerous findings. Good question, Austin Hussein, you have a question. Um Yeah. So I just wanted to ask that, is it common for the tumor to invade the pleural space first before it invades the airway? Um It just depends on the cancer squamous massively common to be much more airway invasive. This was adeno. So the fact that invaded the airway just many grew pretty darn big to get to it. So it just depends on the cancer itself and what guys for those of you who may not have jumped into histology, the cell, there's different cells, there's um uh squamous cells, for instance, that's why I was calling uh huh, squamous cell cancers. Um I don't know, carcinoma just implies some of the gland cells and so forth. So, depending on the cell that took off and became the cancer, it gives you a little bit of different properties. But yeah, it wasn't because that's what she had was an adenocarcinoma. It's not common to see that presentation. It just implies it grew for quite some time. There's a direct question to me. So the risk factors for lung cancer, the number one still is smoking by far. The second one is radon exposure that tends to happen in the soil as things change into uranium and then you breathe it into your home. Um And after that, it's family history, air pollution, maybe you got some radiation to the chest because of um prior other cancers. Actually who we screen a lot also are flight attendants and pilots because flying in a plane exposes you to a lot of X rays right from the sun. So we uh tend to do lung cancer screenings on them. All right, I know it's past 6 O2 guys. Was this good? Did you guys like this case? Okay. Come back in two weeks. So moving forward, we're gonna do every lesson like this. A brief conversation of clinical presentation X Ray Hussein. You're up next man. All right. And then a pearl, a nice job for Perla round of applause. Nicely done and Andrew nice for walking or through it as well. And so I'm also gonna be introducing you guys cat scans sometime in May. I'm gonna bring a colleague and you're gonna actually, it's just the, the colleague and like you guys should join us, but we're gonna just kind of go back and forth and talk about a case and you're gonna see in real time how we kind of uh how we kind of interpret data and so forth. So it should be fun. All right, guys, enjoy your evening. Take care.