The recording of our live Chest X-ray interpretation session that took place on 13/02/2024.


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OK, fine. Um OK. So if there's any questions for my part of the discussion, um just post in the chat and Andra or Morgan will, will let me know and I'll try to answer your questions as best as we can. So I'm gonna go through the kind of basic chest anatomy, assessing the quality of the chest X ray and the ad approach. Um after which Morgan and Andra will go through some cases. OK. So yeah, so I'll start with just like the basic anatomy of the chest x-ray. So um can you guys see my pointer? I assume you can see my pointer? Yeah. OK. Fine. OK. So um up here is the trachea. So basically the, the air on the x-ray is black. So it's hypodense and then the bone is more white. So you can see the kind of more darker area cause that the trea has air in it. So here and then it bifurcates at the carina here. Um after which it goes into the right main bronchus and the left main bronchus, the right main bronchus has a more vertical slope. So you get some aspiration, pneumonia is more. So in the right lung and inhaled foreign bodies as well. So you can see also the spinus processes here and the vertebrae coming down this way just behind the heart. Um You can see the uh kind of this is the clavicle and all the shoulder bones here, the two lung fields. And um then you get into like the cardiovascular side. So you see the aortic notch here and um the outline of the heart just right here. And you can see, so this is the right atrium of the heart, the left ventricle of the heart. Um and the mediastinum is usually just over the thoracic vessels here. And um you have the right hilum and the left hilum here, the left hilum is normally higher than the right hilum. And the hilar vessels are just the vessels that go in and out of the lung, like the pulmonary artery, pulmonary veins and the bronchi. So that's what what the hi are. And um then you get the cost of cardiac angles here between the um heart and the diaphragm. And so these are the two hemidiaphragms here, the right and the left. So the right hemidiaphragm is normally a bit higher than the left, um due to the liver. And then down here is the costophrenic angle, which is where the diaphragm meets the ribs and it's usually sharp and pointed. So here you can see quite a sharp pointed costophrenic angle. Um Yeah, and then obviously these are the ribs, right? So I'm gonna move on to how to analyze a chest x-ray. So there's three kind of main steps that I use. So one you have to identify the patient's details um to make sure the chest x-ray is of the correct patient. And then you assess the quality of the x-ray using the Pneumonic ripe, which I will go through and then you interpret the x-ray using the AD E approach, which I will also go through. OK. So as I said after you've done the patient details, you assess the quality of the x-ray using the Pneumonic ripe. So the assessing the quality of the x-ray is important both on the wards and in your osk. Um So it's important to remember to do this um cause assessing the quality of the x-ray um is important cause uh x-ray of not good quality can um hinder accurate assessment of the pathology, right? So um R stands for rotation. So it means the medial aspect of each clavicle should be equidistant from the spinus processes as you can see in this image here. OK. And then I stands for inspiration. So you're looking at the inspiratory efforts of the chest x-ray. Um So when a chest X ray is taken, um they have, they're, they're told to inhale as deeply as they can and hold it um so that they can get the maximal inspiratory effort. So, a good inspiratory effort is counting six anterior ribs and 10 posterior ribs. Um I usually count the anterior ribs. Um but it's up to you. Which one do you count? Um So a poor inspiratory effort could just be um the patient not understanding the instructions or being confused or the poor timing or they could just not be able to breathe in maximally because of pain. Um And if it's hyperinflated, so if you count kind of more ribs than there should be, um this could be the cause of a um obstruct obstructive airway disease like CO PD. Um So P stands for position. So, is it an AP or PA position? Um So basically, um pa position is the gold standard for chest x-rays. Um So this is when the beams of the x-ray come posterior. So it goes through the patient's uh back first and then towards their fronts, like in this photo here. Um in this position, it's best to get the scapula out the way as well. So it doesn't kind of go over the lungs as you can see in this patient here. Or you could kind of um hug your arms around the X ray machine as well or lift them up over your heads um over your head. Sorry. Um So yeah, it's taken on full inspiration as well. So, the problem with posterior um uh sorry pa view is that it has to be taken while standing or sitting upright on the stool. So not all patients are able to do that due to mobility or due to being unwell or hemo hemodynamically unstable. So, in these situations, you get an ap x-ray. Um The problem with ap x-rays is that um it makes the heart and the mediastinal vessels look falsely larger and often the scapulae cover the lungs. So again, it's only really used in situations where the patient can't stand, you're too unwell. So I've written here, ap is crap. Um cause AP is in the word crap. So that's how you remember that pa is the best um the best position um and E is for exposure. So basically, you should be able to see the vertebral bodies just behind the heart. All right. So um after that, you do the AD E approach. So um we'll just quickly go through that on this chest chest x-ray. So you can't see the patient details here. So it's anonymized. Um Then R stands for rotation. So you can see kind of the clavicle heads, eq equidistant from the trachea. So that's good. Um Then it's inspiratory effort. So if you count the ribs, there's more ribs than six anterior ribs. So these, these lungs are a bit hyperinflated. Um And then p position, you can uh it doesn't say the position on this, but it is apa x-ray and um exposure. So you can see the vertebral bodies behind the heart. OK. So we'll go into the AD E approach. So the, so a is for airway. So is the trachea central. So in this case, the trachea is central, you can't see any form of deviation there. Um If it was deviated, you have to think is it due to the patient being rotated or is it due to a pathology? So, if the patient isn't rotated, then it's, it is due to a pathology. Um so volume loss in the lung can cause the trachea to come towards that side of volume loss, kind of pulled towards the side of volume loss, like a lobar collapse or lung collapse. Um or the trachea can be pushed to the other side due to kind of the increased volume like a pleural effusion or a mediastinal mass. Ok. Next is breathing. So you just look at the lung fields, I usually go um do it in a systematic manner of the upper zones first. So I look at this upper zone. Um and then the, the left, upper zone, the right middle zone, the right, the left middle zone, the right lower zone, and the left, lower zone, it's important to call them zones, not lobes, cause the lobes are different and the left lung only has two lobes. Ok. Um And if you see something abnormal in the lungs and you're not sure how to describe it, I would normally describe it as a opacification if you're not sure. Um because that's more of a vague term than say, like a consolidation or a calcification. So you could say something like, oh, I see a um opacification suggestive of lumbar consolidation cause that, you know, you're not saying it's definitively that, but it's suggestive of that. Ok. So, um and also make sure I usually go around all the the peripheries of the lungs to make sure that the markings go all the way to the peripheries. Um This is to look for any pneumothorax where the lung markings will not go all the way to the peripheries. Ok. So next is C for cardiac. So there's three kind of things that I look for in cardiac. So first you look at the outline of the heart border, so make sure that they are crisp as they are in this um image, then you look at the size of the heart. So um the heart should be less than 50% of the chest diameter on apa x-ray and less than 60% on the ap x-ray. So you can see this heart is less than 50%. So that's fine. And then it's important to remember to look behind the heart as well cause you can get retrocardiac masses. Um uh such as hiatus, hernia will show up as a kind of increased um kind of um hyperdense mass behind the heart. So, um it's important to look behind as well. Ok. Next is diaphragm. So the diaphragm is down here. So first, there's two things to look for in diaphragm. First, if it's flattened, which I would say that this diaphragm is slightly flattened and, um, if there's any free gas below the diaphragm. So it's important. So you're looking in this case for a pneumoperitoneum. Um, so it's important to distinguish between that and just regular stomach gas or bowel gas. So here you can, this gas is normal, it looks like gas in the stomach. Um, but a pneumoperitoneum is different because it's basically a thin black line that's kind of going along the edge of the diaphragm. So, um, so yeah, that's just presence of air or gas in the abdomen, usually due to perforation of bowel or peptic ulcer. Ok? And next is a fusion. So this kind of goes along from diaphragm. So, um basically, you're looking at the costophrenic angles here making sure that they are sharp. If they're blunted costophrenic angles, then you're thinking of a pathology such as a pleural effusion. Ok. Next, I do fractures. So I just look at all the ribs, make sure they're equidistant parts and that they're not, there's no fractures in any of the ribs. And I look at the clavicles and uh the, the bones of the shoulder. Oh, sorry, the bones of the shoulder joint as well. And then um the great vessels. So you have the aortic notch here, look to make sure that you can see that and the mediastinum, it should be over the um thoracic vertebra here and you need to make sure it's not widened. So widening of the mediastinum, it could be one, it could be ap projection cause, as I said before, ap projection causes the widening, well, you know, false wide. It, it looks falsely widens the mediastinal vessels. Um But if it's not that it could be aortic dissection or aortic rupture which are emergencies or masses in the mediastinum um or lymphomas. OK. And then also look to see if there's any mediastinal shift. OK. Um Then lastly, you do you look at the hila, so the hilar vessels. Um So normally the hip left hila is slightly higher and you look to see if there's any lymphadenopathy like bihilar and lymphadenopathy, which is seen as in um tuberculosis or sarcoidosis. Look to see if there's any masses or calcifications in the Hila as well. And then you look for everything else. So that's kind of foreign bodies, surgical clips or lines, endotracheal tubes, et cetera. Um So, yeah, this ae approach is quite comprehensive. Um Some people just go airway, breathing, circulation, diaphragm and then everything else. Um I like to include like, II like to, you know, make sure I included everything. So I just go all the way to h um So that way you won't forget anything. So, um and then it's important, very important to compare the current x-ray with the previous one. So during an OSC, you can ask, you know, to get maybe extra points, you can ask. Um Is there a previous x-ray I can compare it to with his patients? And I've just included a regular like a normal chest x-ray here for you to look at as well. Ok. Is there any questions with any of that? I know I kind of plump through that quite quickly? Ok. Um I'll stop sharing my screen then and I will um I think Morgan will take over. Thank you very much. So, um Morgan and I will go over our cases. This part of the presentation will be highly interactive. So we strongly encourage you to type in the chart, answers to our questions and ask questions as well. And Morgan when you're ready, uh feel free up. OK? Sorry, slowing. Um So yeah, I've got a couple of cases here just, I'll present three cases and Andrew present a couple more just touching upon the principles that we've just learned on how to inter chest x-rays. So I've got this first case here. A 45 year old man is involved in a high impact car accident. He's now complaining of right sided chest pain on examination. You struggled to examine his chest expansion and percussion, given the pain in his chest, but he has decreased air entry on the right side. I've included his stats. So his heart rate's 110, his Respi rate is 20 his oxygen sats are 90%. So using the at approach, what findings are present on this chest X ray. So feel free to put some entries into the chat or turn on your microphone and we can work through the example. Um Somebody just let me know what's going on in the chat. And then I can also someone mentioned diaphragm paralysis, broken ribs, eight P OK. So using the A to approach to start off with a, so his tech looks nice and central um and then we'll move on to the lungs. So you'll notice that on this right side, there's decreased lung markings here because obviously the lungs are supposed to have air in them, which will show up as sort of these dark spaces. But here you can see there's sort of a space, a lighter space here when compared to the contralateral side, which is always a good habit to get into. Um if you're concerned about areas of consolidation or masses, um things like to be symmetrical. So it's good to compare this. Um For argument's sake, we'll say it's APA film. So looking at the cardiac shadow, is it greater than 50% of the width of the diaphragm, which in this case, it isn't. Um in B as well. I should add, I also like to go through soft tissue markings and bones. So given the clinical context of his trauma, you'll notice that there's some rib fractures here as well. Um Moving on to d the diaphragm uh costophrenic angles are intact. Um The asymmetry here can be sort of explained by the anatomy. Um doesn't have any signs of effusion and answer sort of any equipment in the film either. And we're not particularly concerned about the great vessels of hilum. So given the interpretation of the X ray and his SATS and his background, what is the most likely diagnosis? Um So feel free to enter that into the chat as well. So let's move on to this next slide. So this is a presentation of a primary pneumothorax because it's associated with trauma in secondary pneumothoraces. The patient will normally have a background of some sort of lung pathology like CO PD. Um And how is this condition managed as an fy, you'd be expected to go through your at assessment. So particularly if this gentleman starts the borderline, you can stick on a 50 m non rebreathe mask and then monitor for improvement. Um An ABG is also good to quantify the amount of hypoxia um as well as your bedside tests of your pulse oximetry. Um So typically with patients who have a pneumothorax, they can get um respiratory alkalosis on account of the hyperventilation. Um Given this gentleman's background of trauma as well, you'd want to get IV access for fluid resuscitation and or blood transfusions and then obviously get your standard bloods off that as well. But a exam question that sometimes comes up is the management of pneumothorax depending on its size. So the size is measured from the level of the hilum. And it's basically how much, how much space can you see where there's those reduced lung markings and depending on the size that alters the management. So this schematic is from the BT S guidelines and it's a good thing when you have access to the slides to just be familiar with in your own time. So, case number two, we have a 30 year old man who's recently been diagnosed with HIV, and he presents with a new onset of shortness of breath on examination. He's got one peripheries, equal chest expansion and air entry, although he's got added crepitations in the right upper zone. His observations, his respirate is 16, BP is 1 22/83 and his oxygen sats are at 95% and he's pyrexial with a temperature of 38.3. So what abnormalities are seen on this chest X ray? So again, just working through our at e his trichia looks nice and central and then working through the lungs, you'll notice on this right side, we've got some consolidation in the right upper zone. It's quite focal up here. Um You could probably argue it's diffusely scattered in the middle and sort of lobe as well. When you compare it to the left side, it's nice and dark and see again, it's pa film. So not concerned that the heart's greater than 50% of the diaphragm here. Um Diaphragms nice and symmetrical cost phenic angles, not a concern. You can see this is the gas in the stomach, um Hila masses and um the hilum looks intact as well. There's no sense of fusion and again, no equipment in this film either. So given the context and observations and chest X ray, um what are we thinking? And what do you think the cause is? So again, um, feel free to answer question too in the chart if you'd like. And I'd like to emphasize the HIV kind of background and past medical information. Yeah. So P CPI got an answer here. So this case uh is someone that's presented with pneumonia. Um sort of been through the chest X ray and noted the right upper opacity out of interest on this right hand side. This is the same patient, but on day 11 and the consolidation has progressed and you'll also notice that they've been intubated. Um Just here, you can see the tube. Um It's good to make sure that it's adequately above the crena because this ensures that both lungs are inflated. Whereas if it's too close to that junction, it can inflate one lung, but consequently, one lung can collapse. Um And what is the most likely organism causing this presentation? Uh This is what's known as PCP pneumonia. Um So the rates of this do fall as public education awareness around antiviral therapy for HIV increases. But so this is an atypical sort of type of pneumonia. Um but it's good to know your sort of b or community acquired pneumonias or hospital acquired pneumonias and the types of bacteria that cause them because they like to ask those in exams as well. And case three, a 76 year old female presents her GP with two episodes of hemoptysis. She has a significant smoking history. So, on examination, you see that there's finger crossing. She has warm peripheries. Her observations, she's got a heart rate of 100 BPM. Her respirate is 18 and her SATS are 95%. And when you auscultate her chest, there's areas of reduced air entry bilaterally. So again, what is the most likely differential diagnosis? And you can go through A to E and pop your answers in the chat just a little bit more time because sometimes again, oh, sorry, I was central um working through both of the lungs. Um You'll notice that there's a sort of right mass just lateral of the hilum on this side. Um Otherwise, if so, no other findings in that right one and on the left side, we also have another lesion here, but you'll notice it's sort of less focal and and less concentrated than this lesion. And so this is actually a cavitating long lesion and then working through the rest of the at sort of the bones are intact. No other soft tissue markings. See again, the cardiac shadow, we're happy that it's not enlarged if this a pa a film diaphragm sort of looks flatter in this film. Um, but again, costophrenic angles probably all gets a bit hazy on this side, but it's nice and sharp. She's got this gas in the stomach. Um, no sort of signs of fusion and there's no equipment in this film either. So be mindful that this patient is presented to the GP what further investigations are required. So again, feel free to pop stuff in the chat, share your answers. So this is the presentation of lung cancer. Um She's obviously sort of a sitting duck for this kind of thing, giving her significant smoking history. Um And because she is a smoker, it's likely to be squamous cell lung cancer. It's good to be familiar with your small cell lung cancers and non small cell lung cancers for the purposes of exams. Um And again, the chest X ray findings that we discussed, um there's a right mid zone mass and this peripheral left zone cavitating region. Um So what further investigations are required? So when this woman would have presented to the GP with this background of hemoptysis and a smoking history as well as ordering the outpatient chest X ray a two week wait, referral would have been to respiratory would have been made for this woman. Um given the red flags for lung cancer. Um And then so once those results come back, then in secondary care, she could, then she'd then be moved on to bronchoscopy for a biopsy and then as well as getting confirmation for any metastasis for the CT chest abdo pelvis and a pet CT for staging. Um, you'd also order your sort of normal bloods as well and in particular, your serum calcium because a lot of patients that have malignancy are at risk for hypercalcemia and depending on the severity of that, it would need to be treated with fluids and IV bisphosphonates. So, uh so doctor in those three cases, but if you have any questions, then just yes, there were a good questions. So um for this case of lung cancer, um depending on kind of if you know where the case was taken from, do you think that it was a car metastases or a primary lung cancer? Um There wasn't any mention of a cannonball metastases in this and I feel like there could be sort of, there's some really good examples um if you guys want to check that out on radio pedia, but there tends to be a lot of them sometimes, but that could have just been a earlier on in the clinical picture as well. Yeah. So cannibal metastases are most commonly noticed in patients with renal cell carcinoma. So it's most likely arising from the exam situations from uh from the kidneys. Um and renal cell carcinoma, perhaps less common lung cancer, lung cancer, that'd be one of the most common cancers. Um uh Unlike, for example, in the liver where it's most likely to get metastases rather than primary cancer, which is very rare. Ok. So next, I'll go through further cases with other kind of presentations as well. Um And similarly with a few questions, so I'll start sharing my slides again. So your entire screen. Ok. Can you see my, oh, sorry. Can you see my screen? I'll just go full screen just now. Um Anna, can you see my screen? Uh I can't yet. Sorry, I would just uh and oh sorry would you mind kind of reading off any questions or answers from the chat as well? Yeah, for sure. Ok. Oh well I gave up the answer for some one of the. All right. So um case for so II still can't see your screen. You can't see my skin. No. Oh no. Um ok. I could also share my screen and go along if this doesn't work if you want me to just um can you see now? No still can't. Hm I see. Mm. They said in the chat it keeps going black but for me I can just see your video. Um let me just try again. Sorry about that. I didn't expect that it keeps going black again. Ok. And so you know we still can't see it. Ok. Did you want me or Morgan to? Yeah, if you can share the slides, that would be great. Yeah. Ok. A case number five and I think it's black for me as well. Now it's back to normal. Um ok. Now, yeah, that's, that's good if you can go towards the case number five. No, case number four. Sorry. Uh back, sorry. All right, perfect. So we have the next case. Um these next few cases will perhaps go beyond what is expected to know as part of your exams, but they are quite common presentations in clinical practice. So it's good to have awareness of them. Um So the first case, we have a 65 year old woman presenting with acute and chronic shortness of breath at the emergency department. Um and she has a past medical history of ischemic heart disease and atrial fibrillation. And you just uh to examine her and you notice she sent SINOS and has school extremities and she's also tachycardic hypotensive has high respirate and low oxygen saturations. You perform a respiratory examination and you notice she has widespread crackles and wheezes on auscultation and you notice that her ankles have kind of edema and they're swollen. Um So let's go through the A three approach in this x-ray and starting with A and B. So first of all, a, do you think trachea is central or is it deviated? Is there any kind of issues with trachea or airway? Are we happy that it is central? Perfect central? Um Then in terms of breathing, what sort of a abnormalities do you notice in terms of lung fields, how would you describe them. So B and lung fields, any abnormalities? OK. So we have a right lung consolidation. Any other thoughts? Oh, this is um a an APA sorry. So it's a kind of the good one. The heart outline is fuzzy. That's a very, very good notice but other kind of descriptions of the lung fields themselves. But what's, how would you describe this kind of widespread thingy whiteness? Ok. Lowers and ossifications bilaterally, that's a very good uh kind of description and other kind of description infiltration for congestion. So the way we can describe this in kind of more kind of vague terms. But at the same time being specific, we can see, we can say that's a widespread opacification um diffusely across all lung fields. And can also notice that we have what is called septal lines or curly B lines which are lines that arise and are perpendicular to the kind of pleura at the edge. And we can also see um as Anna points out um kind of diffuse lines across lung fields as well. And these are theoretically called curly A CD. But you don't have to remember which are, which the idea is that these suggest um kind of interstitial infiltrations of fluid in the interstitial. So everyone made really good suggestions. Um So far um moving on to see someone already noticed the kind of heart outline is fuzzy, which is very correct. Any other problems with the cardiac side of things any other abnormality that you can notice when it comes to the heart and mediastinum looks enlarged, seems to be more than 50% trans dimeter. So, yeah, there's a cardiomegaly present as well in dim. So in D I usually include diaphragm and costa angles. Um so are cost offering angles. Ok. Sharp. Any problems with the position and location of the diaphragms? What do you think in terms of cost angles and diaphragm? Right looks sharper than the left. That's very good point. Very well noted. Oh, actually, uh the other way around. So the left looks sharper than the right. Yeah. So we can see and if you can point out on the right hand side of, of the X ray, so there is kind of blunted costophrenic angle, um suggestive of a minor pleural effusion. Um whereas on the left hand side, the costophrenic angles is reasonably well defined, although you may argue there's a minor pleur effusion there as well. So in presentation, you would say that um this patient has blunted costophrenic angles indicated of a minor pleural effusion with a more pro pronounced um sort of uh bluntness on, on the right hand side. Um then moving on to ee include kind of everything else our meniscus. Yeah, that's it well noted on um on the right hand side, um presence of fluid essentially. Um and then in terms of everything else, what other obvious abnormality you can notice and what, what is that kind of device that you can spot on this x-ray pacemaker. Excellent. So remember going back to the history this patient has atrial fibrillation. So it makes sense they have a pacemaker, right? So after the discussion, what do you think is the most likely diagnosis in this patient? If you put on the um letter for the option that you can, it's correct in this case. Mhm. So heart failure, e pneumonia. Ok. Ee you have failure. Excellent. So 80, all right. So uh just a little bit on the previous slide before moving on to. So the diagnosis in this case is um acute pulmonary edema, which is most like which is the radiological presentation and diagnosis, which is caused in this case in this patient by acute heart failure. So pulmonary edema can be caused by a wide range of things. For example, having liver failure where patients have a low albumin can also cause pulmonary edema by reduced oncotic pressure in the blood vessels. But in this case, a failure of the blood of of the heart to pump blood into stic circulation which then backlogs the blood backlogs into the pulmonary circulation and that cause kind of fluids to accumulate in the lungs. So first of all, it's going going into an interstitium, then the fluid from the interstitial space can go into the alveoli and they can also accumulate um sort of eary fusions as well. So that's kind of the mechanism um pneumonia. It's an underscore a similar presentation. However, in the history, we can see kind of a heavy emphasis on cardiac issues and you're not getting the kind of high fever, um, acute kind of um change in symptoms. Whereas this patient had acute on chronic. So, had chronic shortness of breath indicated uh by potentially chronic heart failure and that heart failure decompensated into acute heart failure. So that's kind of the presentation, a very classic presentation of acute heart failure. Um So if this is a pa so basically the x-ray, um it's taken from kind of the back and then projects onto the X ray detector. Um So ba basically the X rays come from behind the patient to the back and then project. So the the cardiac here is enlarged because it should be normal. It shouldn't be kind of an artifact of being an AP view. All right. So moving on to the next question more for kind of medical from clinical years, how would you initially manage this patient as an fy one in an emergency department? So what's the approach we use when there's a medical emergency and how we, how do you go about it? Ok. So someone mentioned oxygen furosemide and prop up so long term chiropractic medications. So, ABCD, yeah, a a three assessment essentially. Um So in any kind of emergency situation, start with your basics. So A stands for airway B for breathing. So now, um uh and if you can switch to next slide. So yes, we will um post the slides and feedback. OK. Very good. So a to assessment, first of all, airway and breathing patients are hypoxic. What do you give oxygen? Um In this case, an emerging situation with such a low oxygen saturations, we give um 15 L via no rebreathe mask. So high flow oxygen essentially, then if the patient is gonna be improving on high flow oxygen, then you can call ICU as a junior. Um So you can give them, they can give them CPAP or BIPAP depending on expert opinion. Um Then in C and B, you also s uh did a chest X ray, you can also do an ABG to assess CO2 and O2 and ph of the blood. Then you see you can do an E CG as someone correctly suggested and you can rule out things like stemi because heart failure is a common complication of acute micro infarction. So you want to rule that out. Um Then you can also do a bedside echo in most emergency departments. The the emergency doctor can also perform bedside echo and that can give a clear indication if this is a heart failure and estimate the ejection fraction as well. Um And it can also rule out other causes like tampon out, for example. And then when you establish access or before giving a a furosemide, you establish access. So by cannula and then you can also take some blood of the cannula, importantly, troponin again, as I've said, Tr M I BNP. So BNP is a test for heart failure. Um A very high BNP can suggest heart failure but also o other causes. However, if the BNP is low, then um the patient is highly unlikely to have heart failure. It's like ad dimer test. And then a very importantly, an important differential here is P so pulmonary embolism, which can present with pulmonary edema, especially if there's a big clot, particularly obstructed the pulmonary strunk like a saddle embolism if some of you may have heard of that. Um And that can present quite which the patient can be shocked with that. So the diamide can also do to rule out pe in this case. And of course, as someone said, and IV furosemide both if you're quite sure that this is a um acute heart failure and furosemide, this is a diuretic. So drains the fluid out of the lungs and should patients should improve quite quickly with that? Ok. So that was probably the more complex case. The next case are a bit quicker. Um And II think a bit slightly easier. So, and I can move on to the next slide. Ok. So just a revision of how you can remember acute heart failure, uh presentations on x-rays. So you have the a three of heart failure uh on radiology. So a stands for ovular edema as I mentioned before. Um OV edema uh is presented as bad wing ification um which present as kind of whitish area along the hilum which form like a bad wing shape uh in each lung field. Um And that usually follows interstitial edema or B curly B lines. Um And um that's the initial stages of acute heart failure and pulmonary edema. Then CS uh you've mentioned before as well, cardiomegaly d dilated upper blood vessels because of the backflow of the blood because heart can pump um blood into the systemic circulation. And then e stands for effusion or pleural effusions as we've seen in that case as well. But the pleural e fusions can be much even more pronounced in some patients with heart failure. So, next slide, excellent. So next case, we have a 40 year old female patient with a one week onset of cough fever and malaise or feeling unwell. She has a previous history of rheumatoid arthritis and she's on biologic medication, which also is is immunosuppressant. You're given this chest X ray. And what do you think is the most likely diagnosis based on the chest X ray and the history? And we're not going to the to the full a approach here. Just what's diagnosis to go see. Anyone want to bet for another option. See, see, excellent, well done, so nice and easy this case. Um Here we have quite an obvious abnormality. How would you describe this obvious abnormality? How would you phrase it, how would you present it? Say if you were to present this chest X ray? And I think Morgan has mentioned the term that's used here in her presentation as well. What's if you're not really sure, it's a lung abscess. How would you present it as an X ray presentation? OK. Cavitation. So it's a cavitating lung lesion very well with um an air fluid level. That's um a very well um mentioned. Um So here is a quite a large round cavity lesion um that's dark on the upper side, uh and white on the lower side and the opacification of the side is just a second of dense fluid. So most likely pus and the way the reason why it appeared is so because the patient is sitting upright, so the full a commute to the bottom and air at the top. So very, very good suggestion and large cation on right sided with an air food level. So very well, very well done. Um Next slide. So, lung abscess is only one of the causes of um cavity lesions in lungs. Um And you can use the pneumonic cavity to formulate potential differential diagnosis in a patient if you have less information or it's less obvious. So, cancer, as Morgan suggested previously is one of the causes of cavitating lesions and most frequently. And um to put a note in your notebook for exam questions is squamous cell carcinoma is most likely associated with ca with cavitating lesions. Sorry. Uh Next autoimmune rheumatoid arthritis actually can present with cavitating lung lesions. As, as we've seen that patient also has rheumatoid arthritis. However, rheumatoid nodules tend to present as multiple lesions rather than one single lesion that's so large. Um And they don't tend to be filled with fluid. So it's kind of a fuzzy area or it's filled with air, then V stands for vascular, some pulmonary emboli can present as cavity lesion, but it's quite rare. So you have to border with this particular cause. Then we have infection um an important cause as we've seen lung abscess or TB. So in multiple choice questions during exam or in clinical practice, if you have a patient with HIV, presenting with an insidious onset of shortness of breath, low grade fever, think TB and ac lesion, think TB then trauma. Um and I've included their pneumatocele. So pneuma stands for air and seal kind of stands for cyst. So in a patient with an ICU intubated because of the invasive ventilation that can damage lungs and form this air filled cysts that presents this cavity lesions, but with air in them and Y stands for you. So, congenital pulmonary area, malformations. So very rare stuff. So we don't have to bother with that and I don't know if you can change the slides. Ok. So this one is a bit challenging. Um So we have a 75 year old woman presenting to the emergency department with worsening shortness of breath and cough, which has been chronic to add on to this. Um, the patient is also a known heavy smoker. And for this case, I would want to go through the four, a three assessment. So we given the chest x-ray, which is apa view as you can just barely see. Um, let's start with the airway. Do you think the airway is essential or deviated, deviated towards which side? Ok. I would think it's more towards if you can show the airway ana so the airway is more towards the left side. So this basically the left side is the left side with the heart. So the airway is slightly deviated towards the left. Uh Yeah. So this is L so where the heart is, is left side. So usually sometimes it's confusing but you can hear you can see a slight elevated towards the left. Yeah. So L stands for left, but sometimes it doesn't write on the, on the X ray. But you can think of if the heart is sitting towards the left unless a rare case of cytis in versus in a patient. But that's very uncommon then kind of think of towards the left. Um So here we can see that the area is di towards the left and let's move on to B stands for breathing, stands for lung zones. What abnormalities you can spot in the lung fields, Wolong field, so to speak. OK. So, right lung field is more, um, is hyper or right. Yeah, hypodense and left lung field is more hyperdense. That's a, a good, um, point and opacification in the left lung field. Very well. Opacities in the left. Ok. Um All right. What about the lung margins? Do you think they are normal consolidation, diffusive ossification in the left lung? Right. What about the lung margin? Um, ana if you can zoom in to the apex of the left lung, I'm not sure if it works to zoom in kind of. Oh, well, I give her the answer but it's fine. So, um what I was trying to get here is that, um if you, if you can point at uh to the uh left lung margin, you can see that it's not sitting just across the apex. And if we were to zoom in, I can, uh we'll show you the slides afterwards. You can see that there's a lot of lung markings at the apex. So on the right hand side, you can actually spot the lung markings. The lung markings are basically the fine white lines which are normal vasculature of the lung. And if you zoom in, you can't see that on the left hand side. Uh Right. So, ok, um then what is meant by that is that the lung is kind of deflated? Um And someone also noticed that all looks folded in uh essentially, um and know someone also noted that the lungs are hyperinflated. And you can argue that uh some non smoker probably has CO PD. So it does look hyperinflated. So that's another uh good point. Um And then, right, so, um there's also this diffuse of pacification is not necessarily caused by consolidation. Um And it's rather caused by kind of a loss of air within the lung. So the right lung has more air in it. Therefore, it's darker, whereas the left lung being deflated has less air in it. So basically more lung tissue to air ratio and therefore it's denser on the X ray. All right. So I know I've already given you the answer some. Oh yeah. So sort of like white out, kind of like that. Yes. Is the art enlarged. So I think it's more of an artifact of if this was black all throughout, it wouldn't appear enlarged. I don't think it's particularly enlarged this year and the kind of cardiac border looks slightly diffuse or not very well defined on the left hand side because of the lung being kind of a white out as someone mentioned in less um technical terms. Um I don't think there's any other kind of abnormalities. I know the media looks a bit fuzzy. Um But it's, I think this is because of the whole kind of trich airway shifted towards the left. So that kind of makes the the media tend to look kind of there's a mass there. Um But overall, the main abnormalities on the left hand side, the lung being deflated. So I know I've kind of given the answer already. But what is the most likely diagnosis? And if you can be more specific than the uh multiple choice questions that like the, the answer, if you suggest the cause and what's the most likely diagnosis and what's the most likely cause of the diagnosis? Ok. We have pneumonia. Any other thoughts? Right? Apo hyperinflation. OK. DD. Ad OK. Lung collapse. All right. So quite a variety of answers. So here in this case, tumor has caused collapsed. Yes. So in this case, um we have a collapsed lung and the reason why we have a collapsed lung is that we cannot see the lung margin on the apex. So we have a collapsed uh left uh upper lung lobe. So um upper lobe of of the left lung essentially is collapsed and that collapse is caused by the tumor blocking the airway. So the air can get into the left lung and that makes it to be collapsed. And because it has less air in it, that's why it appears like a diffuse white out opacification all throughout which is homogeneous. Um So if it were a pneumonia, it would affect us a specific lung lobe normally and it wouldn't be as homogeneous. We see a kind of consolidation, grainy kind of whitish opacification. Whereas this is quite homogeneous. Um And yeah, CO PD is kind of a preceding chronic condition and as, as patient being a smoker, but the patient is a smoker which increases the risk of lung cancer, lung cancer causes the collapse. That's kind of the, the story I wanted to get off this um presentation. And also if you want to know more about it, I've included here the radio radio pia uh ID. So if you put into radio pia, the ID, you'll also get more information and more different views of this patient as well. So, moving on to next slide, I agree here, the common causes of lumbar collapse or ectasis in more technical terms. So as with any kind of surgical presentations as well, we have Luminal causes, basically something obstructing the lumen of the airway. Um and this can be an aspirated foreign body. But of course, this would present as a very acute shortness of breath and usually in Children who tend to breathe in things. They shouldn't mucus plugging and CO PD, acute bronchitis that can also cause collapse. Um But more like I think it's more cystic fibrosis and CO PD that usually until it gets that bad in the CO PD patient might have present to the GP they had some sort of pulmonary rehabilitation medication and so on and so forth. So, mucus plugging, I think is more of a collapse in cystic fibrosis patients, um endobronchial mass as we've seen and misplaced endotracheal tube in um patients in ICU. Then we have mural causes, of course, lung cancer, as you mentioned. Um and extremity causes so compression by nucin mass, it could be a mediaster mass, for example, that causes uh collapse of the lung and moving on to the next slide. OK. So I have a final case in case we had uh a few more times. So I think I'll just go over this case as well. It's quite in a way similar to the previous case. So we have a 70 year old woman presenting um who uh sorry, who underwent an uncomplicated hip replacement in hospital. So she's in hospital and three days after the surgery, she experiences a sudden shortness of breath with decreasing oxygen saturations. And again, I want you to tell me and go through the A three approach and tell me what abnormalities can you spot on this, on this airway? So again, um is the central or deviated and towards which side is the trea deviated? Ok. To get left, left side, deviation, give it to the left, excellent left side. So that's all we got it correctly. So, um there's a quite a marked deviation if you can show that on um uh on the slide, there's a marked deviation of the trichia towards the left. Ok. Um And harbor is not clear, that's the next, the next uh kind of aspect I wanted to, to go on to. So, breathing and cardiac. Let's take it both. Um So breathing and cardiac um what can you see what, what's the abnormality you mentioned? Heart border is not clear where exactly not clear. And what kind of unusual, strange thing you can notice about the heart and lung left. Now that's getting closer left. All right. Um So it does anyone know what the sign is, sale sign? Yeah. So, um double margin line. Yeah. So basically this is a lower um left lobe collapse. So on the left side, we don't have a middle lobe, it s most on the on the right side because the heart is on the left. Um So there's a left lower lobe collapse, which causes this a very kind of eponymous famous sign that usually some exams want to ask about even though it's very niche. Um You can see kind of the the the the sale of a boat um appearance of the heart. This is because the left lobe has collapsed. So there's a white out of the lung behind the heart. And then you can also see overlying that the normal shape of the heart and the heart lining seems slightly obscured. Of course, with the deviation, which kind of shifts the mediastinum as well, that can cause uh a blurred appearance of the heart margins along with the collapse as well. So um if you can um switch to the next slide, I know this diagram shows very clearly where the collapse is. So that's the lower left lung lobe that's collapsed. Which can be seen behind the heart and then overlying that is the heart shadow and that is very uh deviated Rickia. So cell sign, uh I know some, it's quite difficult to spot, but again, this may come up in some, some exams as well. So that's the end of my cases and presentation overall. So I'm happy to take any questions on my part or.