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Welcome to today's presentation. My name is doctor and this evening we'll be talking about the basics of chest x-ray. Um Sorry for the delay in statin. We had some um issues with setting up, but we'll start now. Um Can you see my slides? Thank you, Haza. All right. Thank you. Um So we'll just begin. So today, we'll be looking at the basics of chest X ray. Um Basically, it's just trying to um figure out the essential things to look for and interpret in a chest X ray to be able to distinguish a normal chest X ray from an abnormal one. And to know the most common pathologist you can find um on a chest X ray when you see it. And most importantly, not to miss out um life-threatening conditions that need emergency resting on chest X rays to see a patient's life. Oh, so I had a big Oh, ok. Um Yeah, my come on and what you are functioning now, I'm so sorry. All right. OK. You can work. So I'll carry on now. So, uh learning objectives today will be to identify the anatomical structures or chest X because if you cannot identify what a normal chest X ray looks like. Then it will be difficult to identify what an abnormal one looks like. That will also be able to differentiate between the anatomical findings from the pathologist. And also, oh, I did, he says he can't hear any voice at all. Mhm. Um, I'll just carry on an picture. We'll look into that kindly. Um, and also to identify various pathologist on a chest X ray. Um by way of introduction, um I want to, as you majority of us know what um a chest X ray is, is basically um a radiologic imaging of the thoracic structures and x-ray images genera generally make use of low dose ionizing radiation and interpretation of um the chest x-rays require a good knowledge of anatomy and pathology. Um And we need to be important with some terminologies in order to facilitate the interpretation. Um First of all, we talk about the x-ray density which um generally is how the structures and the things you can see on an x-ray film appear when you have a first look at um at a film, what you see are black and white structures and you need to know what tend to use for the darker structures and those structures that appear white on the film. So the dark structures or the black structures are generally tend to be dense on the film while the white are less, I don't look for it. I don't based on based on um different um body structures and things you can see on the chest X ray from the most dense to less dense we have hair being the densest, it looks dark, very dark on the film followed by fat which is less dense than it. And the liver is less dense than fat and the blood muscle and bone appears white on the film. Now, talking about the projection, it just means um what kind of film you're looking at? Um it's the relation of who um is being imaged to where the film x-ray film or the case that is and where the x-ray beam is coming from. So in this time, we have the pa that's the posterior anterior views and the AP views, that's the anterior posterior views. So um the pa a view just means that the case set of the film is closer to the patient. So the patient is facing the film and the beam is coming from behind. Well, the AP is the opposite. Generally, most films you see will be pa films until proven otherwise. And then based on position, we can have an upright or Supine um film in an upright um image, the patient is standing or sitting down while the film has been taken. And in the Supine um view, the patient is lying down, generally, you know, well, patients that are not able to stand or to sit down, they'll go for the Supine views. Although these views are not usually optimal. So it's usually preferred to have like an upright film in most cases. But there are some in some conditions you prefer to have like Supine images. It is also important to note um the following information when interpreting a chest X ray. The first thing when you pick up any chest X ray film or even if it's digital, you want to know who x-ray you're reporting. I mean, if you have five patients you're looking after and for instance, you um request two and two chest x rays for different patients and maybe a nurse comes to tell you or doctor, I have the film ready for one of your patients and you pick it up and there is no name, no hospital number, nothing to identify the patient. You don't know whose film you're looking at. So when you pick up a chest X ray or film or any film at that, any investigation at all, you want to first identify whose it is checked at the date of that corresponds to the name of the patient and also the hospital number, whatever unique identification number um is used wherever you work. You also want to check the dates when the x-ray was taken. For instance, a patient came in three days ago, maybe with a pneumothorax and you want to do another x-ray today three days after to see if there's been any worsening or any change at all. And you don't look at the date and you are looking at a film from three days ago, it's gonna, it's not gonna give you the right information that you require in that scenario. So you want to look at it and then the image projection, which we talked about in the previous slide, you want to check the APA P film because um in APA film, um the structures appear slightly different in terms of the size, especially the um cardiac size compared to the AP film, we'll so we'll talk about that as we move on. So um in terms of image quality, you want to look at how the patient was posi positioned for the um x-ray is the image rotated. When you look at the film, sometimes you're wondering, oh this doesn't look right. Is there a pathology? But sometimes it's just because the patient is not standing properly and they rotated. So it doesn't give you a very nice image quality. Then in terms of positioning, how do you tell whether your patient is properly positioned for the x-ray? When you look at the spinus process, um we'll get to that in a bit. I was going to show you an x-ray to explain that or get that in a bit. When you look at the spinus process on the film, they should be aligned vertically um from top to bottom. And then in terms of the distance of the spinus process to the clavicle there should be equal distance from the medial borders of the clavicle on both sides. So the right should not have a lesser, greater distance than the left or vice versa. In terms of penetration for you to know whether the image quality is good, you should be able to visualize the vertebrae behind the eye shadow. If you can do this, then if you cannot see the vertebrae, when you look where the eye shadow should be, then the penetration of the X ray is not very great. And then when you look at a film, you want to know whether a patient has taken adequate inspiration for the film to be captured. And this is easier appreciated on the PA film. Um on the pa A film, you should be able to count 9 to 10 posterior ribs or six anterior ribs. If you're able to do this, then the patient has taken good inspiration while the image was taken. So in terms of interpretation, you could be wondering, oh, they, there's so many structures in the chest, in the thoracic cavity, you've got the lungs, you've got the heart, you've got the ribs, you've got the mediastinum and there's so much going on that it can get confusing as to how to approach it. Um The 23 common approaches that you can use, that's the ABCD approach, the inward, outward approach and then the out outward, inward approach. So the ABCD approach, um it just means the um airway. So you're looking at the trach handle and then breathing, you're looking at the lungs c you're looking at the cardiac structures, that's the art, the aorta and the d you're looking at like the diaphragm and things and ease everything else. So if you have like a systematic approach in mind, when you can, at a film, there is a tendency not to miss anything. It helps you capture everything you should be looking out for. But if you don't have an approach, something catches your mind in the lungs. And the next thing you're looking at the heart and then you're looking at the ribs, it just gives you like a very, it makes you look organized. If you have an approach at his deputation, the inward, outward approach is just looking at the structure from the mediastinum out toward on each side. So you look at the mediastinum, then you look to the, to your right, you see the lungs, you see the wrists, every other structure you can see there and then until you get to the skin and then the opposite of that is the outward, inward average where you go from like the skin inward until you get to the mediastinum. So I already said um something about ABCD upper. So for the airway, the trachea, the carina, the bronchi and all structures for the breathing, you're looking at the lungs and the pleura and see we're looking at the size and the borders for D we're looking at the diaphragm and also the costophrenic angles and everything else is e we're looking at the mediastinal contrast, the bone cell tissues. If there are any tubes like an tube, if there is any valves, any pacemaker in the heart. Generally anything else you can see on the X ray. Sometimes you do an a um a chest X ray and it covers like a part of the abdomen. So you can see the gastric bubble, you can look on that diaphragm to see if there's any pathology. Like if there is um per bowel perforation, you can see under the diaphragm and things so that will come under everything else. Now we go through the A. So in this um discussion, I'll be using the ABCD E approach cause I feel like that's more organized and you have like a pneumonic that you follow and it just helps you go through everything systematically. So for the airway, when you are looking at your film, you should see the trachea and the bronchi bronchi, they should be visible. Now, when talking about the trachea, first thing you want to look at as when you're doing like a general physical examination for a patient is whether the trachea is central, sometimes the trachea may be slightly off the midline to the right at the level where he passes the aortic knuckle, but this is normal and then there should be branching of, of the trachea and the carina, the carina is just the point where the trachea branches into the left and the right bronchus. And this landmark is very important, especially when you're looking at a chest X ray to confirm whether a nasogastric tube is in the correct position. What we think to look at is that the um tube should bifurcate the carina. If the angio tube doesn't bifurcate, the carina, the tube is not in a safe position and should not be used. So, this anatomical landmark is very important in interpreting a chest X to confirm the position of an energy tube. So, while we're talking about trachea, deviation, uh it could be due to position and like I explained earlier. If a patient is rotated, it may appear that the trachea is deviated. But when you know what to look at to confirm whether the patient is properly positioned. And you can tell if this is due to positioning or there's actually a pathology going on there. Um A deviated trachea could either be due to pulling the trachea of pushing away of the trachea. Now, a trachea can be pushed away by a mass. So a mass will push the trachea to the contralateral side, fluid effusion, blood um will push the trachea away to the opposite side. And when you have pneumothorax and will also push the trachea to the opposite side. The commonest cause of the trachea pool, it consolidation or collapse when there is lung collapse. What happens is that there is loss of lung volume and then the trachea gets pulled to the affected side. So, um I'm just gonna use this slide to go through all that we've talked about since we started talking from the A. So if we look at this x-ray, um if you can see my sa these are the spinus processes on this film, I can count about three of them. This is one, this is two and this is three. Now, you can see that they are a line from top to bottom. And also if you look at the clavicles, you can see that the distance from this end. So the middle of the clavicle on both sides are about the same thing. So it tells you that this patient was properly positioned for this x-ray. And then if you look at the trach here. So remember when we talked about densities at the beginning, we said hair is dark on the chest X ray film and the trachea is con with hair. And that's why you can see that the trachea looks dark, the lung looks dark. So you can see as I outlined trachea, it looks straight, it's not deviated to the left or the right. And then up to this point is where it branches. I'm not sure if you can appreciate that. But this is the car when where the trachea branches into the left and the right B goes and this is just the rest of the lung. We talk about um the different patho as we go on. But this um is just to give you like a general idea of what you should see on the chest x-. Obviously, this is not a normal looking chest x- because you can see here that there's something going on at this left um middle to lower lung zones. And if you look on this particular um image, um I want you to have a close look at the trachea here and this one and try to appreciate the difference and the location of the trachea. Oh Sorry, someone says you can't see my corsa. Uh Let me see. Is it visible now? Can you see my question now? Right. So if you look at the trachea on this side, you can see that it's pulled more to the right side compared to how it it is on this image on the left i on the imaging to your left. And if you look at the film on the right, if you can appreciate the right lung, I'm not sure if you can still see my sle but I'll try to be as descriptive as possible. So you can follow. So if you look at the right lung, the upper zones, you can see that your hair is white, yeah, white compared to the bottom part of the lung on the same side. So you can appreciate that something is going on here. And what has happened in this lung is that there is a collapse of that right upper lung zone that has caused the trachea to be pulled to the same side. Next, we'll talk about the is structures. Um The island just consists of the major bronchi with the pulmonary vessels and lymph nodes. Normally, we see that the left eye lump is usually higher than the right one and the size of the island on both sides should be similar. They should be of the same size and they should be of the same consistency, bilaterality. One island should not look darker or whiter than the other one. This should look the same. Um The point is the point where the upper and the lower lobe pulmonary arteries meet and this point should be clearly visible when this point is obscured. It could be due to a lesion, either a lymph node enlargement or a tumor that's causing this. Sometimes you could hear people talk about bulky island. It generally means that the island looks larger than it should occur and it's usually due to enlarged lymph nodes which can be due to a lot of things like what whatever we give like an inflammatory response like an infection, inflammation from malignancies, uh from inflammatory conditions can give you um a bulky hyaline and sometimes the appearance of an eye can help you know down what a diagnosis is in a patient. You can have bulky eye long in either one side or on both sides, um if it's on both sides, um except when you are used to looking at chest x rays and you've seen quite a number of films that makes you appreciate what the eye size should look like. Normally, it may be difficult to appreciate when there is an enlargement on both sides. So when you have eyeline enlargement, bilaterally, this is usually seen in sarcoidosis and in most malignant conditions when you have unilateral is enlargement, you have unilateral enlargement. Um Also when we talk about um push or pull the island could be pushed by mass or also pulled when there is loop collapse on the affected side. So this image is just showing us where the island is. If you still cannot see mycosal, the blue um marking on either side, point view where the island position should be on both sides and the slightly white area with the um where the blue me is shows you the entirety of the eye. It's not so big, but you should, you can't miss it on um a chest X ray. And this gives you an idea of what the normal is size should be. If you look at the image on the right, if you look at the position where the island is, if you use the left image as a comparison for where the location would be, you can see that it's way bigger than what you're looking at in the other image. And in this x-ray, there is bilateral enlargement of the art. So maybe patient probably, probably has sarcoidosis. Now, we move to the lungs. Um when you're interpreting a chest X ray and you're looking at the lungs, it's easier when you ate the lungs into zones. And um you divide each lung into three zones. So you have the upper zone, the measles z middle zone and the lower zone and each dear medication is just a third. So you have one third of mon needle and mon at the bottom. And this is same for both sides. Kindly note that the zones do not correspond to the lung lobes. So it's different because, you know, you have three lobes and then two lobes. Now for the purpose of the chest X ray interpretation, we divide each lung into three zones. So generally, when you look, when you're looking at the lung, how do you tell whether there's an abnormality? So at first glance, we said, because the lung is filled with air, it should look dark, the entirety of the lung should look dark. So when you see an area that obviously strikes you as, oh, this area doesn't look quite like the rest of the lung if you raise the suspicion that there is something going on in that area. So it's easy to look at both lungs at a glance just to see if you notice anything abnormal on picking at a grossly and then you pick each lung individually, look at the zones to see if you pick anything. So if you pick an abnormal area of the lung, you want to compare that area to the surrounding areas in the same lung to see whether you notice any difference. And then you also want to compare zone for zone. So you compare the upper zone on the left to the upper zone on the right to determine whether there is any asymmetry due to a pathologic condition or due to um anatomical structures, that could be bilateral pathology in the s in, in the, in the same individual that may make differentiation very difficult. For example, a patient with heart failure that has pulmonary edema and has got fluids in the lungs, you have this in both lungs cause this is a system systemic problem. Yeah. And the changes will be in both l. So you are looking, does this look normal because I can see everywhere or does look abnormal. So the more x-rays you see, the better you get at identifying what's normal and what's abnormal. So in this kind of situations, it can actually be tricky to tell if this is pathological and what's going on. But other things like history taking and speaking with the patient and knowing the signs and symptoms, the patient presents with can help you tie things together and actually help you decide what's going on on the X ray film then when the, when asymmetry is abnormal, we can decide which of the sites is pathological. An abnormal area could be less dense that is dark or it could be denser that is still have white depending on what the pathology is. For instance, an infection that result in consultation or lesion like a tumor will appear dens while air will appear less dense. So air like if a patient has got a pneumothorax, you see that the film, the area uh where is affected will appear darker. And if there is like infection that's causing consolidation, for instance, it will appear white and absence of markings could be due to pneumothorax. We'll talk more about that in a bit. So we have more films to look at um the, if we start with the film on the left, that's the one with the circle. If you look grossly at the lungs, you can tell that there's something going on on the right side. And from what you said, if we split the zones into three, um we can roughly say that the affected area is in the right mid zone and lower zones. So a bit of the mid zone and a bit of the lower zone and it appears white, it appears whiter compared to the rest of the lung. So you're wondering what's going on here and this looks more like consolidation. Sometimes you just look at a chest X, you feel like, ok, there is an opacity here. You can't, you may not really be able to tell whether this is a consolidation, whether this is the mass. But remember I said any other, however, the patient presents will give you an idea of what may be going on there because the patient came in like say with coughing for a few days with fevers and you get bloods done, the infection markers are high. Then you're likely to say that this l change is due to a consultation or a patient comes to you with this x-ray maybe with a history of weight loss. Um an Orex surgery that has been going on for weeks. We are wondering this is not likely to be an infection. Maybe there's something more sinal going on here. And sometimes in many cases, you need further investigation to really be able to tell what's going on exactly. So, uh if you look at the um image on the right and look at the red arrow, it may not be very easy to appreciate. But if you look closely, you can tell that there is a rounded kind of circumscribed area in the left lung. Again, it's around the left m, mid, mid zone, actually more intermittent this spine. And it's well-rounded. If you look at this change, it's different to the rest of the long one. And you're wondering, mm this looks white, could this be consolidation or something else? Consolidation is most stands when it's still an infection doesn't have like a specific shape except when you have like a lung abscess. But in this case, the change, the um white area is homogenous looks the same. You can't see any fluid levels within it. So it's more likely that this is an abscess, this looks more like a mass more than anything else. So sometimes the appearance of the change can actually tell, help you tell what's going on in that particular one. So we, I mentioned pneumothorax in passing briefly earlier. Um So on the film, on the left side, if you look on the left lung in the upper zone, um ca and can you appreciate the dark area? Yeah, I'm sorry if you can still see mucosa, but if you look up at the upper zone compared to the rest of the lungs, you can appreciate that it looks darker on that side. Also. Um if you look, there's like a demarcation between the dark area, it's like a thin line between the dark area of the lung just around the border of like, let's say the um upper and the meds, that's like the visible pleura. Normally, you shouldn't be able to see the pleura and this typically happens in pneumothorax. And if you look at the dark area, you won't be able to see any lump markings. So looking at the image on the other side, um you look at the right lung, it doesn't really appear dark as such. It's difficult to tell. Mm, look at this lung is actually anything going on. It may be difficult to tell because the pneumothorax is affecting the entire lung. So you cannot compare a zone of the lung to the rest of that to the rest of the zones in that particular lung on the right. So you may not be able to tell, but let's go a step further and try to see if you can find any lung markings on an Mr chest X ray. You should be able to see the lung markings up, answer the edge of the lung. You can't see any compare the lung on the right. That on the left, you can obviously see the lung markings up to the edges of the lung on the left, but it's not the same on the right. Also, I mentioned that you should not be able to see the pleura. If you uh if you look at the right lung, especially at the um upper zone, then lateral side aspect of the lung, you're gonna appreciate that there's a line just like maybe two thirds um distance away from. So if you go from me to that, I'm doing all these explanations because I'm not sure whether you can see my. So if you look like two thirds from the medial border to the lateral border at this point, you can notice like a clear the medication of the lung compared to the rest of the thoracic cavity and that's the visible pleura, which you should not be able to see in a film and this happens when there is no. Um So next we talk about the pleura and the pleural space. Um So I've mentioned that the pleura is only visible in pathologic states. Normally, you shouldn't be able to see it. Um There should be visible lung markings all the way to the chest wall, which you already mentioned. And this is absent when there is a new moac in a pathological state, there could be pleural thickening. So, in conditions like mesothelioma, which are causing um asbestos exposure over time, the thickening of the pleura and it will cause it to be visible. Normally, you shouldn't be able to see the and when there is fluid accumulation, um like the pleural effusion in the pleural space, it should result in increased opacity. Sometimes there could be a mix of um hand. So this x-ray is obvious when you look at this, you can obviously tell that something is going on in the right lung, there's a complete white out of the right lung. One, that's the first thing that jumps at me when I look at this chest chest X ray. So you said there's like com complete ova of the right lung of the right in the um this can be from fluid from not likely infection, infection will typically not give you a complete white out of the lung. This typically the one you see like one side like is not there most times it's because there's fluid like a very large volume of fusion and in the left lung. So you can notice some changes or some amount opacity in the left, right. We talked about pneumothorax earlier is basically when there's dropping, ok in the pleural cavity and the air accumulates between the perecta and the visceral pleura. Um We talked about the fungus which includes absent lung mes, there could be collapse of the lung and there could also be megasin shift to the opposite side. This typically happens when there is tension, pneumothorax, extension, pneumothorax, presence of the hand in the cavity. In addition to this, you typically get a patient that's instable with hemodynamic compromised the tachycardia. You have low BP, it's a medical emergency. Someone is to intervene as quickly as possible as it's a life threating condition. So it again, we can appreciate this little um x film showing pneumothorax in the right lung. It's obvious when you compare the right and the left, you can see that the right lung at least darker than the l room. So this uh in this lung and if you look at the trachea, you can see that the trachea is pushed away from the affected side. So this patient most likely has tension pneumothorax. Next, we talk about the cardiac structures. Um Remember at the beginning, we talked about um projection of the film and the that is the P and the AP films. Now, if you have a film normal, in most times, the film will be labeled. If you look at maybe the top corner or the bottom corner on either side, you, it should be marked AP O PA. In most cases, if a film is not marked, the chances are likely that it's APA film because that's the commonest, just a film you will see around. If it's not, if it's an AP film, then it should be marked AP. But if a film is not marked, chances are likely that it's AP film. Now, when we talk about the cardiac size, you cannot measure a cardiac size when the film is AP because AP films generally tends to overestimate the cardiac structures. So it appears bigger and gives you an inaccurate um size. So in key images, the size of the art should not occupy more than 50% of the thoracic cavity, given a cardiac thoracic ratio of less than 0.5 or 50%. So if let me try to go back to this image, for instance, I don't know if you still can see my but just do. So you're not imagining things that you, if you look at this chest X ray and you measure the distance, the widest distance from the um rib cage on one side to the other, that's the thoracic diameter and then it goes to the cardiac order. So from here so you can see like the art like occupies like the middle of the tac if you can still, but see my culture. So focus your attention to that area, the uh area that looks appears white in between the two lungs. And then, so that is where you'd expect to find the heart in most individuals. Yeah. So you look at the largest diameter of the heart and then from one border to the other, from left to right, from right to or right to left to measure that. And then we calculate the ratio in a normal size. It should be less than 50%. If it's more than 50% then we say that the art is enlarged and there is cardiomegaly and this could be due to different cardiopath like cardi cardiomyopathy or longstanding hypertension or when there's pericardial effusion before we talked about the um out size occur larger than it should be on an AP film. And it's not the best for measuring um size in the absence of a pathology. The card borders should be clearly visible. You should be able to make out the heart line of the heart. When there's nothing pathological going on there, the right atrium makes up most of the right side or while the left um is made up by the sp when there is increased ossification of the lung, it can cause obscuring the asper on the affected side. Typically, it will affect the right middle lobe when there is consolidation or when there is lingual consolidation. Um So if you look at this X ray, now, looking at you greatly, you can tell that your heart looks bigger than we should normally have. But our peak is a is it you want to measure? So, like we explained earlier, measure the diameter from one end of like the rib cage to the other that gives you the thoracic size. And then the cardiac size, you look at the largest um di diameter of the heart and then you measure the heart issue. Um Also sometimes, like you said, at the beginning, you can see other things in the e of the ABCD approach, like a pacemaker. So this patient has got, has got a pacemaker in the future and that usually you can see on the X ray. Now we go too deep. Um What's the diaphragm is just a structure that separates the lungs from abdominal organ? It's one of the muscles that helps us with breathing on a chest x-ray, what should the diaphragm look like? It should be dumb shaped, be smooth um and not have any um ridge or any contours. Um Yeah. So I'm just trying to find the X ray that shows it. So if you look, this is the diaphragm on the right, you can appreciate the shape and the fact that there's no ridge or any contours, it is smooth and also on the left side, this is what it should look like. Um So let's go back to our slides. So normally, um the right and the diaphragm when you look at the level on the x-ray should normally occurs higher than the left. And this is because of the pres presence of the liver on the right side that pushes up the diaphragm. On the left side, you have the stomach lying below the diaphragm, the left in the diaphragm. And you normally recognize this by the presence of a gastric bubble that appears dark. Um One there is displacement of diaphragm inferiorly. It could be due to either lung hyperexpansion like you see in patients with COPD um and erased him. A death from on either side could be due to phrenic neph pulsing the diaphragm on the right should not be distinguishable from the lever on an erect film. So like the image we saw area, you can tell like where the liver is. It should I feel like I know, but when there is accumulation of hair under the diaphragm on the right side. So what happens is that the air comes in between the diaphragm and the liver causing a lift in it. And then there is a push of the diaphragm from the liver. So you, you'll be able to appreciate and the diaphragm. So you just see. So let me go back to that x-ray film. So if you look, this is the diaphragm and then you just have like white below it. That's where the va re pies. So when they, and that is that you see like a dark room in between the diaphragm and this white area. And that typically can suggest that there's been bowel perforation that has released uh into the abdominal cavity. Um OK. Right. So this is what I've just finished explaining. You're gonna appreciate the previous film, film I showed you comparing it to this. So this shows here at the bathroom. So next we talk about the costophrenic angles. This um is just the meeting point of the chest wall and the diaphragm on a frontal chest x-ray, the postic ankle should form an ac should form an acc angle. And when there is lump, th there is loss of that ankle and this could be as a result of fluid accumulation, excuse me, consolidation of when there's lump hyperexpansion. When there's flu. For instance, it makes that area at a um white. And you can see that like that ankle is not, well, that's the same for consolidation. But when there's lung hyper expansion, the lung increases in size on all sides and then it becomes flat. So there is loss of that shape that don shape of the diaphragm, which also affects the ankle. So flattening all the way even up to the ankle. So there's um loss of the ankles. Um So these films show blunting of costophrenic angles. If you look at the film to your left and the left lung you can appreciate when you compare it to the right lung. Look at this right lung, the costophrenic ankles are curves, you can appreciate like the acute angle. But if it compares to the right, you can see that there is a less likely due to consolidation in this film. And then if you look at the film on the right side, the entire mid zone and the lower zones are completely wiped out and this likely to do po eus in this case. So next we go to eat, that's everything else. Um What else? So we've talked about the heart, the lungs, the trachea, the bone plan and things all other structures can you see in the thoracic cavity? One we talk about the melain, the metal comprises um the art the good vessels, the lymphoid tissues, the aortic mark and some of the middle intestinal structures are not in the chest X ray. Um Tic knuckle is just um the left lateral edge of the aorta and its definition can be lost when there is a presence of aneurysm or lung consolidation. So let's look at this film, for instance, you can see, look at the either of the films um if you look at the left lung and so let's use the um film on the right for a reference so that everyone is looking at the same thing if you look at the left lung, um just around where the normal lung starts. Remember I said that there is consolidation in the mid and lowers. But if you look at where the normal lung starts, you can appreciate that there is like a curvature which is comparable to the film on the left side. So that's the aortic knuckle and that's normal. So we already talked about the uh technical, another thing that is very crucial. Oh We talk about with your um is the size of the mediastinum. The more you look at chest X ray films, I'm just going through the slides so that you can have a look at what the size of the mediastinum should look at. Essentially the mediastinum is. I don't know if you still can see mycosal, but if you look at this film, for instance, if you look at the upper lung zones, yeah, ignore the lungs, look at the area in between both lungs. So the area in between the lungs essentially all the way is the mediastinum. So look, I want you to look and appreciate the size as I go through um the slides to find different films that we've looked at before. So you can appreciate give you a rough idea of what a metastin size should look like. So one critical thing to note is when you think the patient has got widening against it, should raise your suspicion that this patient may have an aneurysm. One, there's an aneurysm, it causes widening of the mediastinum and that's not something you don't want to miss cause it can be life threatening. So we talk about other structures such such as the soft tissue. What else can you appreciate on a chest X ray? You can see the breast tissue um you want when you're looking at it, typically you won't be able to appreciate if there's any mass. But you can see whether there is symmetry on either side, on either side that can raise the suspicion that there could be something going on. One thing is should um always remember is even the patient is coming to you. And what you're trying to look out for is a chest pathology because in most cases, that is why you request a chest X ray. It's unforgivable that there's another pathology on the X ray, which may not necessarily be related to what you're looking after that uterus. For instance, the patient comes to you and you think the person has got a pneumonia or if you and the patient has a wide media and you miss it. The fact that you were only looking out for a lung pathology is not an excuse to miss any other pathology that's going on in the chest. And that's why it's important for you to look at all the structures and have a systematic approach at interpreting the um film. So we look at the breast to see if there's any asymmetry. Also, sometimes when you have a chest X ray. When you have a chest X ray, sometimes you can see um uh uh normally the nipple shadow will be around the lower zone for most people. And you're wondering whether this is a, a normal or an abnormal finding. It can be tricky because looking at the image, you may not be able to easily tell and you can easily mistake um A L needle for the nipple shadow. So sometimes we have nipple markers. Like the radiographers have nipple markers that can help you tell the position of the nipple as opposed to a pathological condition. In most cases, what we typically do is to repeat the image in a few weeks if you're not sure because the nipple markers are used when the image is being done. So if it's already done, the um film has already been taken, it may not be it, it wouldn't be of help. So you ask for repeat imaging and ask them to use no markers so that we can determine whether this is a pathology or it's actually and the nipple sure you can other things we can see when um the x-ray, you can appreciate the ribs. So when you look at the roots, what are you looking at on this x-ray? You can see the the waves if you will capture the ribs. Now, for you not to miss a rib fracture from these things, you need to look grossly. Sometimes you look at the film and be able to say, oh, I can see a fracture here, but sometimes you need to look really, really closely and I to I want to see if I have um it's like a should be fracture. No, not on this one, right? So typically it's easy. What do you want to do? You trace each rib and look, you should not see any break. It should it continues. You look at each one from top to bottom, see if you can find any abnormalities aside from fractures, you can see lytic lesions. For instance, for metastatic devices from cancer, it makes you look like all this doesn't look right. So if you don't look and find it also, you look at the clavicles, it's easy to miss the clavicular fracture. So for bones, all you need to do is just trace the outline of the bone and see if you can see any breaks, any discontinuity on either side. So don't forget, compare an abnormal area with the surrounding areas on the same side. And then co if you notice anything abnormal, compare with the other side to see if it's symmetrical or not. So that's that for the bones. And next we talk about um going back to this side. So we talk about tubes, we talked about angio tubes earlier. Um and the importance of the current when it comes to the position for injury to also involve, you already saw a pacemaker on one of the films we saw earlier um that brings us to the end of this presentation. Thank you for your time and thank you for listening. If you have any questions, we'll take them. Now if you have any questions, kindly type them in the question box and it come up. Does anyone have any questions? Thank you so much ma um I like I have to find out before I go back to a question if there is any like I see. Um I'll just OK. Yes. The same question um back on your drug with this. Can you hear me? Yeah. Yeah, I II think you and you'll be able to share the slide. Yeah, sure. I can share the slide to um share a link to the slide after this presentation. OK. Then um also the second question is on all um radiographs and the, the, did they fix the um do they indicate which is left and right? Is it like compose you on all that they indicate which is the right and which is the left on most films and then the right carry on? OK. On most films. Yes. Carry on. And I wanted to ask the, if it's indicated, it's the right and left, is it coming from the position of the patient or is it coming from the position of the person that's taking that um radiograph? Right? So for your first question on most films, you'll see a labeling of the um left or the right. So to have either L or R, so that tells you which side is the left and which is the right, if it's not labeled when you own a film, imagine that the patient is standing in front of you when you're interpreting a film, just imagine like the patient is standing in front of you. So that can tell, help you tell where the left or the right side is. So when you're holding a film, if you're holding like in purple orientation, then your right will be the left of the patient and vice versa. Mhm Thank you so much, ma'am. So um this next question is calling by says, do you have any THS on counting ribs? I usually find it difficult, differentiating an posterior ribs while counting. All right. So remember when we talked about um projection for AP and PA. So if you're looking at an AP film, for instance, or let's say pa cause that's the um commonest when you come across. And um I'm not sure if you can appreciate, I trying to see if I can find OK, on this slide, if you look at the um film on the right. So what you first try to do is you try to um make an outline of the rib. So if you look, there are some ribs, it's usually very difficult, but we practice, you get used to it. There are some ribs that are pa coughed like um I would like. So um convex, that's our best. I can explain them if you can look. So I I'm not sure if you can see my cost. So I'm counting one. So three. Oh sorry. So take it again, I'm counting 12, three for five, six. I can count seven. Yeah, those are the posterior ribs. Now try to see if you can pick the ribs that the shapes appear like opposite to what I just counted. So the very obvious ones appear concave. These ones are more convex and they are more difficult to appreciate. So you just need to look closely and try to count them like follow the outline of the ribs. So for the convex looking ones, I'm taking it from the bottom this time, I can count. There's one here. It's not. So 12345. So the more you practice, the easier it gets. So first you need to be able to distinguish these ribs look a certain way as opposed to the ones you can see less clearly or more clearly. So for the posterior looking ribs, they appear, the shape are more concave and the the anterior ones are convex looking and a pee. So OK, thank you so much. I don't know if there's anyone that has any other questions before we can call it to be right night. You you can drop and your comments. If there's any question there is no, there's no other question. Um I don't know if anyone has a question if they can um, send you like a mail email or something. Yes, I'll drop my email address in the um message box and you can send me an email if you have any more questions. Ok. So uh that's my email address. So you can send me a message if you have any other questions or remember anything, any clarifications that come up later. Thank you so much. Now, we are really grateful. So I'll be sharing, I'll get the so I'll get the slide from you and I'll check on the group and that's it. Thank you so much. You're welcome. Have a lovely evening everyone. Thank you for your time. Good night. Mhm. Mhm.