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Ok. So, um I think we'll start now. Um So hi everyone. My name is Mahor and I'm the president of University of Lincoln's Radiology Society. Um I just wanna confirm, um Do you guys have access to the chat? I think you should be able to, can anyone message anything? Are you able to message? Ok. Great. Fantastic. Um So I just wanna confirm just really quickly, Doctor Carson. Can you hear me? Yes, my daughter. Yes, my daughter. Ok. Fantastic. So, yeah, just to introduce everyone. Um this is a teaching series that we've decided to start. Um Just so all of you as clinicians or medics can have a bit more experience in understanding and reading uh imaging, radiological imaging, which is the crux of diagnostics a lot of the time um for students is beneficial for your anatomy exams. Um and additionally, just further on in clinical years and in training as well. So, um I'll pass it along now to Doctor Garson. Thank you morning for inviting me to uh Radiological Society of Lincoln University. And it's a good opportunity that I can communicate with you people. And uh I encourage everybody to ask any questions. You are free to ask you either in the chat, I think. So the uh microphones are muted but uh they can ask in the chat and if you can convey me the questions, I'll be able to answer any question. Yeah, that's fantastic. I'll do that. Yeah. OK. My name is uh Doctor S Kasim and I am a consultant radiologist at University of uh University Hospitals of Derby in Briton for the last 15 years. And uh I'm, I do general radiology and, but my special interest is gen uh so today I have the opportunity to talk to you about the chest X ray. So we'll start with the chest x-ray. It is uh actually the most commonly performed radiological investigation in a any hospital setting is the chest X ray. And uh what are the indications? Um sorry and the mics are off. But again, I wanted to ask you people but uh again, uh probably it's just I will narrate it that uh uh can you tell me why we do the chest x rays? I given it already on the slide. But again, the most common is either it is cough or chest pain or you got a fever and shortness of breath, what we call it as dyspnea. And if there is any history of trauma and sometimes we do the chest x rays that if we got any known malignancy and we are suspecting that some symptoms are new, which are related to the chest to look for metastasis. So what we have to look in the chest X ray, it is ABCD. EA B is A is for airways, B is for breathing and C is for circulation and D is for disability and E we include everything. So uh I will show you the images later on, but as in a, we have to see for trachea, branching of the trachea into the main bronchi. And if possible, some smaller segmental bronchi and some tracheal narrowing, are there any masses? And is there any foreign body or is there any acute cut off of any bron uh bronchus? And there might be some cranial widening due to the cardiac enlargement or due to the presence of some masses. Then we go to the lung fields as such, we check that are, is there a good inspiration in the good inspiration? We should have that at least 10 ribs, posterior segments of the la 10 upper 10 ribs. And then we compare on both sides uh if there are any opacities or increased darkness or what we call it as leucs as compared to the other side, then we have to look at the pleural spaces, the cardiophrenic angles and uh also uh the diaphragms and then we have to look at the parenchymal vessels are those prominent and in the circulation, we have to look at the heart, the mediastinum hyla and aorta. So, and in disability, we have to look at the bones, the ribs, the clavicles, scapula, the shoulder joint and whatever is visible above the lower thru uh sorry, lower c and uh thoraco lumbar spine and in the e but we have got everything else is we have to look for any free air in the pleural space, what we call it as um uh pneumothorax. And then we have to look below the diaphragm until the diaphragm. If there is any area that is a pneumo peritoneum, then retrocardiac are in, in the center. We can see that if there is any hiatus, hernia, we have to look at the breast, there might be some breast masses, there might be a mastectomy, then the soft tissues of the thoracic wall and hepatic as well as the splenic flexure of the colon. And we have to look at the gastric as well as uh gastric bubble and the bowel shadows. So, so this is a normal chest X ray. Uh There are different approaches. How do you go and through the any exam? But for me, I prefer is that I go from outside to inside and some people, they start from the center and they go outwards for me, what I will do is I'll go from the outside of the film to the center or inside or from left to right as you think. So, when we are going from outside, what we have to look is number one, the positioning the clavicles uh median end of the clavicles are just turn clavicular joints. They should be at the same level. They should be good inspiration as I told you. And uh when we go out, look at first on the, this is the right humeral head, you know, humeral joint clavicle. And then we see the scapula. Is there any bony lesion? There are the soft tissues? Ok. Then going for the ribs, are there any rib fractures or any expansile or lytic lesions in the ribs? Then again is when you go to the pleural space or lung itself in, in most of the x rays and especially in the chest x rays, you have to look for very dark things or white things. The fluid on X ray, it appears white. That's why these vessels aorta is because they've got blood inside, these appear white. And if there is more air or pure air that will look very dark. So either we look for some fluid or fluid containing uh structures or the dark or free air or uh air loculated air either in the lung, parenchyma or in the pleural spaces. So we have to look at the lungs and the lungs. We can we how can we differentiate that? These are the lungs and not pneumothorax. We have to follow these lung markings. These are usually vascular but bronchial markings are also there. So if any space or if you see any lucency, which is free of lung marking and it is the, it is at the periphery. Sometime in the uh lying position, you can get it interiorly, but then we can think of, oh, this is something wrong there. This, this black thing should not be, there might be a pneumothorax. And the other thing is that there should be nothing white in the lungs, a patch, white patch or opacity, what we call it, either it is going to be an airspace disease, pneumonia, atacta, or it can be any tumor or it can be fluid which can be local. And if you go on the pleural spaces, if there is any free fluid or not, these are recorded test uh CP angles, uh the CP angles should be acute and uh there should be no opacity here. If there is any opacity, that means that this is fluid. Usually you need about 100 50 mils of fluid to fill the and the CP angles. And uh I know costophrenic angles and uh uh there is some effacement of the outline of the diaphragm as well. So we do look at the lung spaces, we see um the rib spaces, either these are widened or not, then we go immediately and immediately. Uh starting from here. This is the trachea, this should be central, it should not be deviated, it can be deviated by any enlarged thyroid gland or goiter and it can be deviate to the left side. There might be some uh mediastinal masses per mediastinal masses, which can displace the trachea and what we call it. Uh This is the tracheal strip, the soft tissue thickening, uh soft tissue area here, it should be smooth, it should not be thickened. If there is any thickening here, we might think of any masses here. And this is the carina and this is the right main bronchus, left main bronchus and uh there should be no widening of the carina. And uh then these are the hila hila are also vascular structures. Usually these are made by pulmonary vessels, mainly pulmonary arteries and uh these hilar, yeah, these are usually concave natural. So we have to look for these that this concavity should be maintained. This concavity might be lost in the hilar masses or hilar lymphadenopathy. And uh then we have to look for a cardiac shadow. So this is a cardiac shadow and uh I'll go to the next image because that is easier to remember. Sorry, this is the same thing a bit hyper infer. Yeah. So this is the outline of the lung, right lung, upper lobe medially. And this is what I'm saying that this is the paratracheal stripe which should be smooth and there should be no mass here. And then this is trachea and these are the main bronchi, upper lobe, bronchus, lower lobe bronchus at the same here. And these are the hila hila made by the pulmonary arteries, main pulmonary artery. So uh so this bit is from the right heart border this right heart, it is sorry, the right margin of the Spiro Mediastinum. It is found by the Vena cava and you can get an arch of Azygos vein and uh here, but again, it is difficult uh to delineate. And uh then again, this is, as we see is coming here and it goes to the right atrium. So the right water is formed by the right atrium of the heart. And here we expect that this IBC will enter the right atrium. IVC is the vessel which is bringing the deoxygenated blood from the uh abdomen, pelvis and the lower limbs. And as we see from the upper limbs and head and neck, ok. So the right atrium, we got the oxygenated blood and as you know, it is pushed uh again, uh through the pulmonary arteries uh to the lungs and the oxygenated blood, sorry oxidative blood comes through the pulmonary veins. So then on the left side, the border is again, left paratracheal stripe here. And this is this Corus. It is flown by the aortic arch, aortic knuckle. We call it as. So this is the arch of aorta projecting itself. And just below this, this is the main pulmonary artery and this divides into the left and the right branches, I'll show you on the CT and uh we call it as pulmonary cornus as well. And then the, this is the area of the left atrial appendage, they call it as auricle as well. And uh this is the left ventricle, left ventricle mainly forms the left part of the heart and going. Then this, this is a fat pad here and same fat pad sometime you got it here. And then this is the left hemidiaphragm. So these are the structures. We have to look at any questions until now. No, if anybody would like to ask any questions, they're welcome to type them in the chat and then I can relay it to doctor Carson. So this is a chest x-ray. I borrowed these uh images. Most of these are from different websites mainly. Uh This is radiology assistant. That's a good uh website. And uh learning radiology is also a good website. I've taken a few from my things for radio pr some are from my own hospital. So this is as I told you that we have to compare as in any clinical examination. If you are examining the knee, you have to compare it to the other side. So that is we have to compare it with the right side, we have to compare it left side. Can anybody find out what is the difference and how somebody can get elaborate? What is there very shortly? Yeah. So just again, if any of you would like to answer in the chat. OK, great. I will ask that question in a moment. If anyone would like to answer the question that doctor caring thought. Uh Doctor Carson, there's a question in the chart for you. Yeah. Uh it says, how do you distinguish oracle and Atria? Sorry, it is, it means it's just because it has an atrial appendage. Atria is basically uh I mean that's more anatomical but on X ray, you can't differentiate it. OK. So it is the atrial appendage which is coming there and usually, you know, not, not much of the blood flows there. So it's on the top of the atrium. And this atrial appendage uh left atrial appendage it in this just below the B canals. This makes the border. Yeah. But yeah, I mean it's clinically that is not very significant thing. OK. There are some answers. Yes. Uh in the chat regarding the question that you asked earlier. Yeah. Uh So someone who said fluid build up and another person has said right, middle and lower lobe consolidation, someone has also said lower right lobe consolidation with blunting of the costophrenic angle on the right. Yeah. Uh and the good answers I really appreciate. Somebody has said the right upper lobe uh uh uh sorry, middle lobe, right, middle lobe and lower lobe consolidation. So uh we divide the lungs into zones and lobes, uh zones are basically xray thing, the upper two ribs, this ones, this upper zone and from 2 to 4 is the middle zone and four downwards, it is lower zone and there are lobes, lobes are the anatomical division of the lungs. On the right, we have got 23 lobes on the left. We have got two and basically upper lobe and lower lobe and uh upper lobe is further, has got lingula uh later and medial. And uh this is the difference between the size. We got 10 segments on the left and one on the right. Those are the anatomical ones. So yeah, somebody has had a consolidation. Yeah, it can be a fluid but fluid is usually very well demarcated that is homogeneous. OK. And uh that's not the place for fluid, fluid really goes to the pleural spaces. So there is inhomogeneous airspace oration with some bronchogram. And what you can see is you can, you cannot outline the right hilar margin. Here, you can see the hilar very clearly. This is the lower lobe pulmonary artery. These are the upper and the high left hilum is clear, right? You can't see you can see the cardiac border. OK. And here again, you can see the diaphragmatic outline. So when you will have lower lobe consolidation, then the diaphragmatic outline will be blunt. It will not be as crispy as it is here. This is crispy on the left side, I will explain it further. But because the hilum is low, so it is upper lobe, the hilar loss loss of the hilar cout is usually in the upper lobe. The cardiac outline is lost in the middle of pneumonias and the diaphragmatic outline is lost in the lower lobe pneumonia. So these three things you have to remember, highline upper lobe, cardiac borders in the middle lobe and um diaphragmatic outline in the lower lobes. So this is a pneumonia and sorry, what happened? I sleep tonight. Three. Yeah. No, this is a very subtle finding. Uh Can somebody tell me? So once again you have a message or and yeah, so quickly just in five seconds or whatever the people think, just write down one word. What do people think? So? No, any answers. Not as of yet. No. OK, no worries. So what I would say as we have to compare both sides, if you compare this right eye limb with the left eye lump, you see an opacity here which is extending to the left eye lump and the left you can see here that the lower part of the right eye limb is very clearly demarcated here. You can't see it, but the cardiac outline is almost clear. So it looks like again in upper lobe, left upper lobe pneumonia. Now, this is I've written it already. So you people must come to know as I said whenever the hilum is lost, it is upper lobe pneumonia. On the left side, you don't see the hilum clearly. You can see the outline of the heart throughout. So this is the upper lobe and you can see the outline. Ok, the costophrenic angles are clear. So this is a left upper lobe pneumonia. So again here, what you see is that there are bilateral opacity, ill defined and you lose the phrma outlines, bilaterally. Uh cardiac outlines are ok. This isn't mm uh by portable x-ray, but this is due to the aspiration pneumonia, bilateral aspiration pneumonia. So patient might have aspirated vomitus or something and it's bilateral. Yeah, this is very simple one. Can somebody tell me what is this? Uh someone has mentioned that it's a loss of the left lung? Yeah. And then another person has said consolidation of the entire left lung field. OK. Yeah, that's good. Uh The one that someone, someone has mentioned that it's a left lobe collapse, left lobe collapse, left. Yeah. Yeah. Just I will add one thing back by most of the people. So what you can see that if you compare it with the right side, this this is the left hemidiaphragm, it is very clear. So it means that it is not something consolidation is not in the left lower lobe. OK? And you can see a little bit of the lung here. This black thing is the air in the lung. And you can see that costophrenic angle is clear. What you could see is that the hilum is not clear, the cardiac border is not clear. And you can see these, this is the trachea, this is left main bronchus, lower lobe, bronchus and these are the bronchi. So you we we call it as air bronchogram, usually these are seen in uh pneumonia. Sometimes these are seen in collapse as well, but mostly in the pneumonias, the airways remain patient and this, these are completely collapsed. So we have lost the hila, we have lost the left cardiac border. And as I told you that left upper lobe is mainly lingual lobe, uh is the middle lobe and uh rest of the lungs we call, call it as upper lobe. It's basically the entire left upper lobe or lingular lobe. Both left middle, upper and middle lobe is collapsed. Uh uh sorry, uh pneumonia is there. So if you see this lateral projection, nowadays, we are not doing it. But if you see this, this whole thing is opaque. You, this dark thing that you are seeing is it is from the right lung, but this area is all. Ok. And you see this is left lower lobe, this is called as oblique fissure. You must have that in the anatomy which divides the left lung into the upper and lower lobes. And you see the lower lobe is completely plaque or as we expect that it is inflated and the diaphragm is clear. So good, good, good, big and yeah, this was left lobe pneumonia with high acylating. And yeah. Now these are s same type of pneumonia just one minute, uh sorry, five seconds. And just somebody tell me what is this? They are the same type of pneumonias. I think it takes a couple of minutes for the answers to get in. So. Ok, that's fine. That's fine for a couple of seconds. Yeah. Yeah, because I don't want to make it for you. We have got so many slides, right? Ok. Do you have any hope? Any hope someone has mentioned lobar pneumonia and someone said right upper lobe, very good. It's right upper lobe, upper lobe, if you see it hilum is lost here in this x-ray, even in this x-ray and this x-ray, you don't see the right eye lm clearly. So this is right upper lobe pneumonia could break and yeah, again, yeah, it was right up lobe pneumonia. So anybody this one, the lateral is very right lower lobe. Yeah. Exactly. Exactly. And this is just you don't see you, you can see the left hemidiaphragm clearly, but you don't see the right hemidiaphragm here outline is lost. So this is right lower lobe. And if you see the lateral x-ray, we are not doing, it is an old x-ray. So this is the right lower lobe which is opacified. So it is right level of pneumonia. Yeah, this is I told you and again, similar picture there is a pneumonia. You, you can see a very crisp margin of the right hemi from left. You can't see it probably there is an ill since you might be there, an abscess is developing in that pneumonia. So this is left lower lobe pneumonia and you can see another thing I wanted to add, you can see the cardiac outline very clearly and you can see the hilar outline. So it is left, lower lobe pneumonia and again, in the right side and you can see the cardiac outline, but you don't see the diaphragmatic. I think. So, I've shown you so many, you should not forget it anymore. This one is interesting if somebody can tell me what is this? Yeah. How much are you? Sorry, we have about an hour left. But people have mentioned that it's right, middle lobe opacification, right middle lobe lesion and just the right middle lobe. Very good. Very good. All are correct. Yeah, there is opacification of the right middle lobe and as they are pic it very nicely that we don't see the cardiac border now. Um and there is some loss of the hilum as well, but it is mainly we can make it hilum through this opacity. The images are not that great, but you can see the hilum through the opacity. So it is the right middle lobe pneumonia. Very good pick. And yeah, no, this anybody can anybody can volunteer. Someone has uh said that it might be pleural effusion. But I assume that this is actually for the last one, the last option. OK. Uh Simple right sided pneumothorax. Good, good. And uh uh I will just explain it. Uh as I told you that we have to look for black and white in any x-ray, especially in the chest X ray. So if you compare it to the right side, the left side, this left lung is not dark or jet black as on the right side. Let me see some lung markings here here in the right classic cavity, you don't see any lung markings. Everything is homogeneously black. So what is this? This is here? So this is pneumothorax and this, you know, uh lung is like a balloon. So when, when it is compressed by the air or raised uh atmospheric uh outside uh muser pressure, because that is more than the negative pressure in the lungs. So this lungs, they collapse like a balloon to the hila. Why? To the hila? Because the center is the hila is an in the lungs and the trachea and the bronchi uh and then, then this collapse around the bronchi there. So this is the collapsed lung here and this is the pneumothorax. OK. Uh On pneumothorax, you will see some binding of the spaces. It's not much here. And somebody has said it is simple. There is not much flattening of the diaphragm. I will tell you in the next one. So again, can somebody tell me any answers? So someone has mentioned that it's another right sided pneumothorax. Someone else has said that it looks like trachea shifts. Yeah, very good. So as as somebody has mentioned, we have, as II told you to compare both sides So this is the pneumothorax. You don't see the lung markings here, you see the lung markings here. So this is the collapsed right lung. But if you see the lung has crossed the midline, this is the margin of the right lung. It is crossing the midline. See, and if you compare these rib spaces with the left side, these are not that wide, these are very wide, especially lower down. And as somebody has rightly picked, if you see this is the tracheal outline, this is the lung margin here and this is the trachea just lateral to the right lung margin. It has shifted to the left side and this is the left main bronchus. And if you see the heart, you don't see the cardiac shadow behind the right lung, it is difficult to see uh to appreciate, but there is some shift of the cardiac shadow as well to the left. So this is basically attention pneumothorax we pick. So now can somebody tell me these are two different patients? Someone has mentioned that a uh might be left sided pleural effusion. Good, good. OK. It, it's almost similar picture on the right and left. The e as he has mentioned, there is pleural effusion. And as we said, I told you before uh that this foot in effusion is more homogenous. The loss of the diaphragmatic outline. You don't see the CP angles, angles, the cardio angles are lost as well. So this is and you see a straight line of fluid level there because the patient is standing. So this is left sided pleural effusion. The thing, what we have to see else is that we have to compare both sides. You see the lung markings here and but on the left side, you don't see the lung markings. This is dark as we have seen in the pneumothorax again. And what is this structure here? This is not present on the right side. So this structure is the collapsed lung. So this is left-sided, hydropneumothorax. Similar picture here. You see the fluid level here. OK. And this is the diaphragmatic outline. There is loss of the costophrenic angle and the extreme lateral margin of the diaphragm. And here you can see the lung markings. Some white areas are a little dirty areas here. You don't see the lung markings. So this is a pneumothorax and you don't see the hila very clearly here. And there is a structure here and that is the collapsed right lung. So these are left and right sided hydropneumothorax bilaterally. So the other thing we we do the chest x rays for trauma. So this is a chest X ray also and we do it for trauma. And uh can somebody point it? I mentioned rib fractures but perhaps even I don't know where are the refractions if somebody can help me? And is there any hemothorax or what I told you as effusion or something? Someone has mentioned that it is MC but another person has mentioned that it might be left upper or middle area. Yeah. Uh that's fine. And as I told you, uh that we had to compare both sides for the ribs. It is difficult to pick up the fractures. On X ray, sometimes we miss the fractures and on ct we see, but we have to follow the ribs throughout your contour. Right side means II usually start from outside or if you form pro your ribs, see if the ribs are OK. So I don't see this look, the contour looks OK? You just have to be uh short. I will just tell you if you follow the left side. This, this is the first rib, second rib, third rib, fourth rib, when you're coming on this side here, it is OK. But if you go on this rib, this, this some break here, OK? And you see a segment here, then again the next rib, you see a break here, some displacement here and this is a diaphragm. And if you see the other rib which is shown through the diaphragm and and this is basically uh this is gastric bubble and this is the splenic flexure of the colon containing gas. So again, you see the fractures here. So these are the left sided, lower rib fractures and these are middle acid, somebody has said from middle to the lower rib fractures and predominantly poster lateral segments or I will say posterior segments and the cardiophrenic angle is uh the fragment outline is clear. The cardio and costophrenic angles are clear. So I said no pneumothorax. If I want to say something might be this area posterior, this might be a continuing there. But I think so it is some of the of both ribs which you're looking at. So these are left-sided rib fractures and here can somebody point the right on the answer for me? No, it is difficult to pick. But the major thing which I told you in the uh previous uh 34 slides that you can write it down. Sure. Someone has said right sided pneumothorax. Good. Yeah. Again, I it's a very good bit. This is right sided pneumothorax, the left lung, you can see it is dirty, this is all black. This is right sided pneumothorax. And if you compare it to the left costophrenic angle, it's crisp. And here you can see there is a fluid level here and right costophrenic angle is gone. So this is rightsided hydropneumothorax. But I will change my statement later on. It's very difficult to differentiate it is blood or fluid. But if you see the ribs coming from here, here, here, here, this rib is a little bit irregular in outline. This is the right posterior segment of the rib and you can see some irregularity of the ribs here also. So these are right-sided rib fractures associated with hemo pneumothorax and this pneumothorax is leading to collapse of the right lung. So this is the right lung here. This much is left. You can see the uh lung markings in this area only but not above this level. There is a little bit of tracheal shift, not much, but there is a little bit of the tracheal shift. And so there is a slight element of uh tension, pneumothorax as well, but very little if you compare the sleep space with the other one. Yeah, there is a very good pick. Now this is a very quick one. Anybody can tell me uh Doctor Carson, someone's mentioned that it's left lower lobe related, yeah, is not obligated and you see the clear and there is a curvilinear margin which is very short and you, you can't see the left cardio water water and it is very homogenous. Sorry, doctor, if it's possible. Um Do you mind going to the previous slide and pointing out the fluid again that was present? Uh Someone has requested that. Sorry, sorry, how do you go back? Ok. So yeah, that's very good. Uh So if you see on the right side, as I told you, these costophrenic angles are very crisp, OK? You see the lung marking lung going here, OK? And there is under the diaphragm. You see this fluid level here, this is the fluid, this is the gas. So this is the gastric bubble. So there is some fluid and gas in the stomach. Ok. So now keep this thing in mind here, you see and other level here see this straight line because diaphragm is going up, diaphragm uh which is a projection. So diaphragm is going up and you know the uh inferior margin of the lungs, uh inferior surface is concave that are from, pushes in. So you see the posterior part of the lung also in the AP in the P rejection or AP. So here you see the cardio, the costophrenic angle is lost. There is a fluid level here and this is the air same dark as in the stomach. Ok. So this is the fluid level and this might be another level because it is uh in front and behind the dome of the left. So it is basically fluid, right sided. And uh as I told you, this is the collapsed lung here. Yeah. Is it clear? Yes, they, they said thank you. Yeah. Yeah, this is left foot here and there is some congestion of the eye there. Hi. And uh that's a long subject to discuss. So what uh about the congestive cardiac failure? I got slide for that one. But I think so that will take long. But yeah, so anybody can tell me what is this, I can find this area. So someone has mentioned a pacification in the right lung field as well as right lower lobe opacification and right lower lobe pneumonia. Good. Very good. Uh You see a round opacity. Here. There is loss of the diaphragmatic outline, some some airspace disease here in the right lower lobe and this round opacity, one might think it's a tumor. I might think it's a tumor as well. The tumors look like this because consultations are usually not that strong, but there is loss of right costophrenic angle. As you can see on the left side, it's very clear, you don't see the diaphragmatic outline there. This is almost a straight line there. So there might be some consolidation associated with pleural effusion and around opacity here. Ok. So sometimes the pleural effusions, they go into the fissures. The fissures are the uh pleural uh divisions between the lung lobes. So the fissures are basically we can call it as extra outside the lungs. So, the fluid from the pleural space goes into the fissures and it becomes incited. Uh It is if you see the lateral projections or sometimes even in the ap projections, they become as uh a lenticular shape or lens shape, but sometimes they look around like pseudotumors. So it is very difficult to differentiate. Is it a tumor or is it a fluid in the uh mm fissure? So we used to do the lateral x rays before but now we go for CT. So this is a loculated pleural effusion and it was not uh I mean, I don't have the lateral X ray for that. But yeah, it was a loculated pleural effusion. So this is another very small pleural effusion here. And uh you know, ultrasound is very good for looking uh for very small pleural effusions and marking the areas for aspiration. So, on ultrasound, you can uh mark the area for appropriate area for aspiration of the pleural fluid from the body of the patient. So this is an ultrasound. I know it's difficult to interpret and uh interpret. But again, well, this is the right sided pleural leaf here can and this is the cardiac border and this is the diaphragm. So again, this is a much better picture. So this is the liver margin and this is diaphragm, diaphragmatic margin of the liver. And this is all liver, this is collapsed lung and the fluid on ultrasound, it looks dark as uh opposed to the X rays. So this dark thing is fluid and this is pleural effusion. So this is CT CT is a very good modality and it shows you everything and as like x-ray, uh the fluid, it looks a little gray uh on CT and uh lungs, they look uh ear looks dark. So can somebody tell me what is this? So, uh someone has mentioned pneumothorax as a possibility as well as pleural effusion um uh about six as of now. Yeah, that's good. That's good. We, we see we have got different windows, we got lung windows and soft tissue windows and mediastinal windows on uh there is a mediastinal window we don't see the lungs, parenchyma clearly. So it's difficult to diagnose pneumothorax on a mediastinal window. So what somebody has bilateral approval if you, as I told you, the fluid, it looks gray on. So you see CT E because the patient is lying on his back. So these are the dependent fluid here bilaterally along the posterior lobes. And this is the thoracic aorta, descending thoracic aorta and this big structure in the center is the heart. And you see thi this is the vertebral body, thoracic vertebral body. These are the ribs. So this heart is surrounded by another film of similar gray colored fluid. So this is bilateral pleural effusion along with pericardial effusion. Ok. Good, good big. And now we have done pneumonias and uh pneumothorax and hemothorax and pleural effusion will go to the no lung masses. So lungs masses. Uh we have to, as I told you, we have to compare the both sides. That's the more important thing. So if you see this right hilum, it is concave clearly outline on the left, you don't see it and there is a shadow here. So this can be either a large lymph node or as such a central hilar lung mass. So this patient needs a CT scan to confirm it. So this is a left hilar mass and we have to compare the both sides. Anybody, someone has stated a left sided opacification. Very good. Yeah, it's complete white out on the left thoracic cavity, uh the trachea is still central, but we don't see the left main bronchus from that down. So there might be some endobronchial mass or even extra bronchial mass, which is compressing the left main bronchus and leading to complete opacification of the lung. Why there is complete pacification because lungs, the there are discussions, mucus secretions and everything. So those cannot come out and that's why those are retained and the lungs become white as I told you that when there is fluid and uh same is consolidation. What is that? That is um fluid in the interstitium or alveoli, which appears uh white on X ray. Due to the inflammation, there is increased capillary permeability. It's like like edema, some. So it's all inflammatory process. So that was due to a mass uh because we did the CT I know about this thing. Anybody this is uh can tell me what is this? Uh someone is highlighting this is a pneumoperitoneum. Very good, very good. So this is, you can see that there is a crescent of air below the right hemidiaphragm as well as the left hemidiaphragm. And this you can see the both line, the both sides of the wall of the colon. So this is basically pneumoperitoneum and uh bilateral might be a hollow viscous perforation, wet bowel, or it might be a dial perforation or gastric perforation. There is an NG tube, this is the tip of the NG tube. It is just at the distal end of the esophagus and it is below the diaphragm, but it's not safe for feeding the patient and the patient might test period. So we have to look at these things and we have to inform or call the clinician that please push the NG tube more further down before feeding the patient. And uh no, this, this is an emergency. And nowadays for every GT we do the X rays and we immediately report what's the position before treating the patient? So that was air under diaphragm. And again, this is a very good picture. You can see that there are presence of free air under the diaphragm. Bilaterally, this patient had uh intestinal anastomosis and that leaked and there is some left-sided pleural effusion. Mm So this is congestive cardiac failure, probably it is to be too much for you. So we'll go to some interesting cases. We can discuss the CCF later on whenever if somebody is interested and uh we can discuss how to look for CF in. But uh if, if they are interested, I can quickly go through, we are left sometimes. Would anyone be interested? I think we could probably go ahead, we have around half an hour left. So whatever you um deem as appropriate, doctor carton, I think everyone will be ok with that. That's fine. So yeah, so I don't, I'm not go into the details, uh much details, but uh again, uh what is CCF uh or congestive heart failure. Uh Usually the clinical presentation is u usually shortness of breath, especially on exertion. Patient can't walk more than a few steps. And uh basically, it is more fluid is coming into the heart or the venous blood is coming and the heart is incapable of pushing that fluid into the general circulation. So it ultimately initially to the left ventricular failure and results in decreased cardiac output and increased pulmonary venous pressure. And uh later on, it will leads to the uh leads to the right heart failure as well. And there is right ventricular failure as well. And uh you end up in uh edema, especially lower limbs and the fluid which cannot be pushed from the lungs because more fluid is coming. So the fluid accumulates in the lungs, especially in the bases because those are the dependent parts and it is less air entry or less. Uh lung tissue is available for ration and people get dyspnea dysnea, especially on exertion because when they need more oxygen, what more work is required. So the findings, what we see in the CC number one, as we said that the heart dilates because it it becomes, it is decompensated, it cannot compensate for the requirement of the body. So those that first there is left ventricular hypertrophy then goes to the right side and the entire heart especially the right dilates. Ok? And there is increase in the cardiothoracic ratio. The cardiac thoracic ratio is usually we take the maximum transverse diameter of the lungs and the maximum transverse diameter of the heart and the lungs divided by the heart. It should be less than 2.5 or half. Means the cardiac diameter should be half of the lungs or when it is more than half, then we call it as increased cardiothoracic ratio and it leads to congestive heart failure. And as I told you that there is fluid accumulation, the fluid accumulates in the interstitial septi. And those interstitial septal markings are more prominent in the right lower lobe. And we call it just curly B line. So you see that those markings there and these will look white on x- and there is some ac combination of the fluid in the CP angles. And then, so you see some pleural effusions bilateral. Most of the times that I've seen is it is this start in the left side of the lung and then there is some central congestion, airs doing or a bad wing appearance. And as I told you that because the blood vessels, these are compressed by the fluid in the lung, parenchyma. So less blood goes to the lower lobes as and the blood is redistributed to the upper lobes and the upper lobe vessels, the veins, especially these become more prominent. We call it as redistribution or upper lobe diversion of the blood vessels, they become more prominent. And again, the vessels become more prominent as compared to the bronchi, we call it as vessel to bronchus ratio that is increased and the hila become prominent because the hilar are mainly remained by the pulmonary arteries and the veins also. So these become prominent. So these are the things we have to look at the X ray. And again, this is so if you see uh this is upper lobe, diver of blood vessels and widening of vascular particle. So all this hilum, this area of the mediastinum, it is made by the blood vessels. So when these hila become prominent, so these widening of this, we call it as vascular pedicle, you can see this mediastinal or mediastinal widening is there and these blood vessels, these become prominent. If you see this one, this become if you compare the right uh sorry. Yeah, this is my left but anyhow, uh my left to the right and this particle is widened, these blood vessels, these are the vascular marking, they become very prominent. This is what we call it as upper lobe diversion of the blood vessels. OK? And this is widening of the pedicle due to the engaged vessels. So again, as I told you, there is increased artery to bronchus ratio. So this is the artery, the blood, as I told you, it will purify, this is an end down artery or vessel and this is the bronchus and this becomes bigger in the chronic uh failure. And again, I will show you this, as I told you, the interstitial lines here because in the dependent part, these become prominent on the no, but you don't see any lines here. But here you see these lines, these transverse lines, we call it as curly B lines. These are basically fluid in the septi and these septi become permanent ti becomes prominent. So this is this is the early sign of cardiac failure on chest X ray. So same as I told you that uh again, interstitial and that this is uh prominence of the hila. This is the normal and if you see the Hila have become very prominent and congested and there is upper lobe diversion of blood vessels. So this is a CT and this also shows the signs of uh heart failure. So there are bilateral, this, this is a lung window. So the fluid, it is looking white like heart. So this is this is a mo more prominent right sided pleural fusion, left sided pleural. And these, these are the lines here. These are the septi here, Septi here again, which were as the uh and these, you see these all septi are very prominent. Yeah, actually we call these as BS and this is the interstitial septi because of the fluid accumulation, these have become prominent. There is some dependent brown glass haziness also due to the fluid accommodation. Well, this is no edema. You see you can't see the highlight, it difficult to differentiate even from the um yeah, um bilateral pneumonias. So, but there's a little bit of effusion, not much and the heart is not enlarged. So this is uh sorry, the heart is enlarged. So, and this is uh a patient who presented with peripulmonary edema at admission. And you see when some diuretics were given in that patient had uh significantly and resolved. So this is, yeah, these are the things I told you, edema consolidation. Uh bronchogram are there and prominent as I, as I told you and cardiac enlargement, you can see it. So this is the patient. Again, he had Lasix treatment, uh sorry, uh diuretic uh treatment. And after treatment, you can see that the lungs are clear. So it's a good response always if again, same patient at remission, you see the pulmonary edema and this pulmonary edema can be due to allergy, can be due to drugs as well. So it can be uh due to many causes. So this is after treatment, you see that the patient has resolved. So, yeah, again, bilateral pleural effusions and this is the ct tissue in bilateral pleural effusions. Don't worry about this one. This is the hiatus, hernia containing stomach and this is the heart is being pushed to the left side. So again, same patient lung windows, you see the pulmonary fusions and here again, prominence of the interstitial septi, some thickening of the fissures. So, again, bilateral pleural effusions on X ray and this here, you see the loss of the costophrenic angle here as well. So this is the ct the window. You see the fluid, the collapsed lung here and this is right sided pleural effusion. And these are lung windows and you can see this bit of the lung due to the pleural effusion, it is collapsed. So same patient pleural effusion is associated with uh because ultimately, this is compensation and the fluid cannot go uh cannot be pushed. So there is back, pressure changes which lead to the liver failure ultimately. And uh there is some ac combination of the fluid inside the abdominal cavity in, in the subcutaneous tissue. So in the abdominal cavity, you will see the ascites, this is the fluid here along the liver margins here anteriorly as well. So, mm sorry or do we go back? So now the things which you are going to discuss is that uh can anybody point out what is this any answers? Mah? No, not. Oh wait. Um Someone has said cotton balls lesions. Um men very good, very good, very good take. So we see multiple round opacities of variable size like like cannonballs. And uh these are in both lungs and these are mets most likely. Ok. And you see there is some obesity here along the right apical uh right pleural and some deformity of the R as well. So these are most likely matters. So now we are discussing the tumors. So this patient has got a CT and you see some similar lesions, these deposits here, some space you are doing. And this one is showing a crescent of air as well. So this is another big metastatic deposit. So there is some necrosis in that metastatic deposit. Uh Yeah. And uh again, we go there. So this is basically, can somebody tell me where is the primary tumor? I've taken a CT scan, this coronal view. It's difficult uh because there's only one image. Even for me, it is difficult to say something. Someone has mentioned that it might be in the kidneys. Very good, very good pick. I really appreciate you. And you see this is a big tumor here. You can't see the kidney clearly on this one. And secondly, on the even you can't compare it to the left side with the left kidney is also not seen there. So, but this is the tumor here. Irregular, very good P I really appreciate and this is the primary tumor. And as I told you on x-ray, there was some irregularity of the ribs. So there is an expansile lesion in the right, upper lobe rib, uh upper rib as well, which we have seen on X ray previously. So, very good break. So OK, these are the XI and this is the tumor here. If you compare it with the left kidney, this is the left kidney and this is the XL CT. You can see the kidney here you can see half of the kidney but this tumor is presenting from here, anterior the anterior cortex. So this is metastasis, another X ray and your body. One thing I can tell you we are discussing now, lung tumors or metastasis. There are no answers as of yet. OK, no problem. So you see some estis here in the right lung one here. And probably yes, someone has mentioned right lung lesion as well as right middle lobe. Yeah, exactly. Exactly. I agree. And there is prominence of the hilar bilaterally and probably there is some some shadow here. This patient has got a hiatus, hernia also. So that was uh this is uh so that was metastatic as. So this is a bit difficult for you. But it, it's a, it's a congenital abnormality. They call it a humor syndrome. So it is a normal pulmonary venous drainage. So this scan was done for PE but we saw it as this mm pulmonary in anomalous pulmonary vein, which reduces directly into the IVC. So that if you want to search it as a Ator syndrome, you can see it on the internet. But I don't think so. It's something that you should know it here for everyone asking for everyone asking in the chart. We'll write the syndrome down into the chart in a moment. Sorry. Uh People in the chat were asking what the syndrome was. So I suggested that I'll just write down the syndrome in a moment. Yeah. Um Yeah. Yeah. Yeah, I see. It is basically a Turkish her name because that, that if you go back. Yeah. How are you not to? So see, so this is a sore like vein here. So on X ray it looks like so is basically, I think it's a Turkish so name the cortex and it's basically an anomalous pulmonary vein. It's not draining into the heart. It's going down to the IVC. So can somebody tell me what is this? Oh, sorry. I went to the next slide. Any answers you have mentioned that it's an apical right lung mass or a right upper lobe lesion. Yeah, exactly. Very good big. And if we see uh th this is basically not in the lung, all right, if you see it here, the margin, it looks like that it is extra pulmonary, but it is very difficult to see on C uh X ray to be honest. So this is the CT scan of that patient. And if you see this right upper lobe mass, we were seeing it's basically an expansile mass in the ribs with some calcification, chondral calcification, we call it. And uh further you see this lytic area, same soft tissue density areas. So this is a metastatic disease. It can be from anywhere. But mostly if you got some calcifications might be got and some thyroid uh metastasis, uh these appear like this and there is some a deposit here in the left rib as well. But this is a metastatic disease and sometimes the colon cancer is causing, sorry uh like uh once they call this, uh they lead to as well. So again, so this patient is an IV drug user. So this x-ray was 13, yeah, 13 days before and this one is after 13 days. Can somebody tell me what has changed in the later? X-ray? I mentioned that this is pleural effusion bilaterally. OK. Very good. Yeah, very good pick. And there, there was a effusion already here uh on the right side, sorry, my toe down. So if you see this area here, there was blunting and some straight line here. So there was pleural diffusion and you can see a little bit of lesion on the left side, abd lungs and probably probably a nodularity here. Here. You see the pleural effusion has increased more. You can see a uh margin here and loss of dir outline. There are some multiple opacities. Now, this one, this one, this one, this one there is probably a cavity one here. And this is the pleural effusion going up there and probably small opacities here also. So he's an IV drug user. So make because you know, they are not worried about any nasal hygiene or anything. So they get the infection and uh the infection travels through the veins to uh to the right heart and then it goes uh to the lungs and what we call it as septic thrombi. So basically these are multiple infected olide. So and there is some cavitation now. So it's common in IV drug users but sometimes it can be seen in very immunocompromised patients. Yeah. So these are uti infected emboli. Mhm. So this is the old x-ray and this is new x-ray. This was done in August 20 this was done in May 22. So this x-ray looks normal and was reported normal and it is normal. But uh you see within a span of two years, you see a large mass here and this patient presented with this big mass here, right? Hilar. And these are um I will just explain you a little bit of anatomy so that you should come to know. So this is thoracic aorta. These are the pulmonary veins and uh this is tricky dividing into right and main uh left main bronchi and this esophagus, this is descending aorta, this is the descending bit and these are enlarged lymph nodes. So this is a right central mass or hilar mass with enlarged lymph nodes. So, within two years, it's got a big mass. So this patient had act scan for trauma purpose and uh I know it's difficult for her to integrate. Uh But if there are any junior doctors, they can tell me what they can see in this one, I've mentioned it right? Middle lobe lesion. So where is it exactly? Can somebody point it out it is averting which area? Yeah, this is oblique fissure and you see there is a small lesion here. This scan was done for a trauma, there were no pulmonary symptoms or anything. And incidentally we picked up the tumor there. And again, I mean, these are incidental findings but perhaps we missed it long time before. So if you see sorry for to go to backslide. So this patient had an X ray 2015, I don't know which one is which. But anyhow, two X rays and uh 2015 and November 2000 uh 17. So there was a grade that is there any left upper lobe opacity here? It looked almost OK. And if you compare it, it is very difficult to pick, but there was something and it was not reported with this area. If you compare it to the right side, it's difficult on your screen. But this area is more dark or more black as compared to the left side. So this was the left upper lobe mass which was missed and patient suffered. So sometimes we miss the masses even on CT. But x-ray is easier to miss because most of the lungs are not visualized on the x rays. So yeah, but again, going back, there was a complaint about this patient and you see there was nothing significant on the left side, lower lobe only we were worried about upper lobe and we didn't mention it. But when we did a chest X ray for this left upper lobe follow up which we thought mass. There was nothing in the upper lobes, but there was a tumor here down and it was if you see the time difference, November 17, there was nothing here in June 22. So within four or five years, he got a big mass here. So she got the big mess. So, oh sorry, I didn't mention about the breast. So in the female, you will get these breast shadows here. So you can differentiate male or female on this one, but sometimes breast shadows are bigger in male as well. So you have to check for the gender of the patient and you might see mastectomy. If there is a mastectomy, the right breast is removed, then the lungs will become more opaque, uh sorry, more recent uh because the soft tissue hindering the x rays is not there, the breast tissue is removed. So that side will be more dark. So this is a tumor again. So again, these, these, these are missed cases. Actually, I don't I should mention it or not, but it is difficult to say. So, yeah, this patient had uh uh chest x-rays in January 20 22,015. Uh but there was means if I um I mean, ii couldn't figure it out if there was anything and it is reported as normal. But later on this patient had got a disc disc cancer here, most likely a small cell carcinoma. But these are very aggressive ones, a very small one. And he had got this hir lymphadenopathy and this is a pet scan which is showing the hia and probably the tumor there. So again, similar situation is 18 and 20 we didn't see it. But if you go the, but we might say that if you compare it this right paratracheal stripe, you can see the lung margin here here. This right paratracheal stripe is replaced by a soft tissue here and you don't see the decency of the lung here. And uh it is yeah, just a two years gap. And you see a big tumor here and there are some lymph nodes. So it is metastatic again, this was the July x-ray. July was more clear. And uh so we saw this tumor and did the CT and so on the similar pictures. This is a special specification here. We did the CT and yeah, the CT is showing a tumor here with some cavitation. So sometimes these can be cavitating tumors. But if uh considering the ethnicity or exposure to the tuberculosis, sometime you can get some cavities, tuberous cavities with fungus balls in the lungs. So yeah, these are tumors again, probably I will leave it now because these are missed tumors. So, yeah, this is interesting. Can somebody explain me the x-ray this one, the big one, usually the lung tumors, the prediction for the metastasis is adrenal glands. So whenever we are scanning for a tumor, a suspected tumor for the chest, uh we always include the upper abdomen and that excludes the adrenal or liver metastasis. So this is this is a large tumor here seen on X ray in September 2021 and we did the X rays. Yeah, that here if we go back again. So this was November 18, the X ray was normal and this was a CT angiogram as well. For shortness of breath, there was nothing there. So from November 18 until September 2021 he developed this big tumor. And unfortunately, this is the CT uh Coronal image and this is the tumor here. And unfortunately, he had this small hypodense area in the liver and this is metastasis. So again, you see multiple tumors here, metastasis and this is the CT showing this tumor, lymph adenopathy metastasis and these are subcarinal lymph nodes, lymph nodes and this was a metastatic deposit as well. Doctor as I am mindful for time. Um Can I suggest maybe if we potentially do this as our last example and move on to any questions that the group might have? Yeah, I think so. That's fine. We have done most of the tumors and everything if people have got anything, I mean if you want to. So we'll just wait for any questions to come through in the chat. Yeah. Uh In the meantime, do you kindly uh mind going to the last slide of the sorry uh presentation if possible. I think so. Uh Yeah. Um I don't have much to cover. Uh I think so. We covered all. Yeah. Ok, fantastic. So, um if any of you have any questions, please kindly leave them in the chat. Uh after this event, you should be able to access a um feedback page, er, and potentially, um if you give us feedback, you should be able to receive a certificate saying that you've attended today's event. Um But in the meantime, if anybody has any questions, you're welcome to drop them in the chat. I just wanted to show you one or two cases. These are basically most of our hospital cases during the COVID time. So this is a CT scan and uh you see some peripheral consolidations here. So usually these are drawn last time and uh COVID pneumonia was usually presenting as peripheral consultations. Initial chest X ray might be normal. But on the CT, you can see these things. So these are again some patchy peripheral consolidations and this this is diffuse ground glasses and more towards the periphery centers are a bit spared and then patchy consolidation, ground glass consolidation there. So they, but unfortunately, this patient had a tumor as well which we never knew. We scanned him for COVID and we came about this. Yeah, great, fantastic. Thank you so much, Doctor Carson. Thank you. Thanks. Um So does anybody have any additional questions. Thank you for your comments in the chat. We really appreciated it. Um I know it's been an hour and a half of um radiology. It's really so it may be long and tiring for some of us, but I hope you guys have found it educational and beneficial as well. Um If you have any suggestions, you're welcome to email us on our email or uh account on medal. It's available on there. Um Additionally, uh if you follow us on Instagram, you'll be updated with um regular posts about uh any additional events. Er Doctor Cross will be hopefully a recurring um clinic. Yeah. Yeah. Yeah, I just wanted to ask the participants that if they are interested in any particular subjects like any um acute abdominal imaging or anything else of their interest or any imaging or CT imaging, I'm more, I would be more than happy to uh discuss some cases. Uh And we can, yeah, we can get, you could drop them in the chat or if you're unable to access the chat and if you could kindly email us, um I will put our Instagram handle in the group chat as well. Uh Just for anybody who's interested, it is at Lincoln Radiology. So, but I will type that out for you as well. I got you. Thanks. So people that they're interested in seeing a abdominal emergence. Mm Yeah, that's why I've seen about the brain imaging as well. So, yeah. I know we will try uh next topic, we can go for abdominal imaging or brain imaging uh rather uh if you want, I can briefly go through the most commonly performed urgent radiology investigations and that should cover the brain as well as uh the lung specialist ct pary angiograms and abdominal imaging as well. Sorry, I think I experienced a technical glitch there. Um I'll resend. Uh Yes. So the message has come through by our Instagram. Er additionally, Doctor Carson, I think people have messaged in the group chat regarding um things that they're interested in. Yeah, so I hope that that's been ok. Ok. So um you should all be able to access, I think a feedback screen after this potentially and then you'll be sent uh certificates regarding your attendance. So, um I hope everyone's enjoyed. Uh and we'll make a note of everything that has been mentioned, everything that people have requested. Um And we'll definitely involve it in our future teaching sessions, but I hope just as a beginner that this session has been beneficial to you. Uh Thank you, Doctor Carton for joining us today. We really appreciate. Thank you mono for inviting me and yeah, it was a pleasure. Thank you very much. Thank you. Ok, everyone. So thank you for coming. We really appreciate it. I think that we will end the session there. Great. Thank you. Thank you so much. Thanks. Well, stay for a couple of minutes if anybody else needs anything at all? Um You're welcome to message us in the chat or even email us or email um or message us dms on Instagram if you'd like as well. Thank you. Can everyone hear me or can anyone hear me? I think I'm having issues with my hearing. Well, potentially.