Computer generated transcript

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

Cool. We've got half a minute until like five minutes past the starting time. Um Hope everyone can hear me if not. And you see just my face moving, just let us know in the chat. Um Well, on everyone's still making it at half six in the evening. Uh I'm Helen, so I'm one of the one's currently in leeds. Um And I believe you're all here today to try and know how to look at a chest X ray. Um So if, if so you're in the right place and if not, then um feel free to go, no harsh feelings. Um Like I said in the chat, there's gonna be some kind of interactive like element just to make this a bit more fun and there will be a quiz at the end. So, um just to, you know, consolidates there, there's knowledge and things that we've would have would have talked about. Um So, um without further ado um so this is um we kind of outlined just for today, we're gonna talk about some kind of general principles about a chest X ray um using some acronyms. Um And we're gonna go through some cases and having a quiz at the end. So if you don't remember anything today, that yellow highlighted acronym is what you need to take away from um today. So before we kind of go in and dive into it, I don't really know any of you and I can't really see you either. So I want you to let tell me like, how confident do you feel about interpreting a chest x-ray right now? Just trying to gauge how like what levels everyone is arts. So this is anonymous. So I don't know who's answering. So. Ok, kind of in the middle. All right. 00 no, got some slightly more confidence. Um But don't worry. OK. Um So what I'll try to do is I'll go through um like the wordy bits a bit quicker if people know um if you don't then feel free to ask as well. But if you feel like, you know, it's a bit repetitive then just let me know and I can move on a bit quicker and before I go into everything, um is there anything specifically you wanna know or any kind of comments you wanna make before I start kind of like ice? And that was it any concerns about chest X ray? And you should be able to ask me this at any time as well. Like put a question up. But um if there's anything right now, then can also maybe try and answer them, I don't think you need to moderate them here. Red flax, look up all fine. What else? Sure. Ok. Well, someone said red flax milk. There we go. Um, yeah, we'll go through what's normal and what's abnormal. Um, quite basically. And it doesn't matter if you don't get like a, I think the key thing is, uh, with our, our levels, um, it doesn't matter if we don't get like, a specific diagnosis. Right. As long as we can tell, like if you can tell what's normal from abnormal, that's already a very good start. Um OK. Yeah, basic principles. Yeah, we'll go through that obviously. Great. So, situation in med school and you would want to um chest X ray, probably it would part be part of like a station like a respiratory exam or something on abdominal, if it's an abdominal X ray, they were part of an ABDO examination, um obviously introduce yourself and wash your hands, those kind of things. Um And then in terms of actually interpreting the chest X ray, um that's kind of our first part of the, the um the mic for doctor like ripe and then ABCD E so the D stands for demographics to check the film's name um as the patient's name, the date of birth, if there's an like NHS number. Um And the other important things are noting the date and the time of the film. So, um because sometimes patients get more than one chest X ray and you need to make sure you're looking at the most recent one. Um, and the r is reason for film, er, like, what is, why are they doing this? Why are they taking it? Is it just cos they've got cough or any other indications? Um, and again, like, kind of like I said, if you got a previous one, it's quite nice to bring them both up for comparison because someone just might have a slightly different anatomy to um to the rest of the general completion and you might want to um you know, have a look and see. Oh, wow, it's there before and you're fine. Ok. So you don't need to panic about it. Um ok, so that's kind of a good start. Um And then next, I've kind of mentioned a few about this already. Why might you want a chest X ray just to pop this back up here? There we go. Um Free text type. I already said like, oh, someone had a cough and we do like a chest X ray. Any other reasons? Yeah. Any respiratory smptom. That's a good thought. Anything else. Shortness of breath? Yep. That's another respiratory symptom. Chest pain. Yeah. Infection screen. Yes, it is part of the infection screen. Yup. We can rule out cancer. Yep. That will be an OSK station. Anything else check for secondary Mets? That's kind of cancer, pneumothorax. Yep, fracture. Yes. Bone. Yes. Um II think that's a good range. Um I also had on my list, you know. Oh, things are coming in still M SK cos Yeah. Yeah. Could be if it's in the, in the, if it's in the ribs and NG tube, yep, ng tube check, that's what we also use that. Um Although I think depending on your trust, you might have to request, not just a regular chest X ray, you have to request a NG check x-ray um just so that they ensure that you've got the whole um all the way up down to the stomach covered, um and not just up to the, the base of the lungs, although really in any chest X ray, it should go a couple of centimeters below the lung anyway. Um I've also got, you know, if, um, they've got enlarged heart or uh even like a hiatus, hernia like a stomach that's just poked through the diaphragm, that could also be, it won't be an indication, but it could be like a check and be like, oh, has it slide up further? Um It could also literally just be a routine thing, a part of um a physical examination before you have surgery. Um And the other main thing would be kind of checking for correct placement of lines, various lines that go into um into the veins. It could be like a central venous catheter, different types of those or if you've got a pacemaker, those will also have some lines that goes directly into the heart. Um and you can see those on a chest X ray. So good. So I got um indication um of them. Um Right. And then, so um basic principles on an X ray. What is dark and what is light, this kind of the free text? Um II guess um any takers I you can pop it on the chat. I don't have a, I didn't have a quiz for this one. Anybody. No, that's fine. Ok, cool. I'll show you um this um so this is a X ray of a Aristolic tissue. Thank you, Zara. Um Yeah, and this is a radiograph on what I've just shown on the screen here is a radiograph of chicken leg uh like a bone partially submerged in fat water and then just a bit of air at the top. Um I wanted to show you this because um so, you know, well, hopefully you would think that the chicken bone itself is quite linear in its density but putting it against different material, different kind of substances. It appears slightly different, doesn't it? Um that contrast? And it's, but it's because of this contrast, we can see what we want to see in a chest X ray. You would imagine that your lungs are filled with air. So most of it is gonna be quite dark like the air here at the top. Um And then where you've got some kind of fluid, it will look kind of this grayish color and where there's a bit more density, it looks a bit even more even white. And that's kind of what we meant. What we mean when we call, when we say attenuation is how much the X ray is absorbed. Um x-ray just goes through uh um fat, absorbs quite a bit of the x-ray. So nothing much really shows. Um And so if we apply that to when we're looking at a chest X ray before we go into ABCD E, that is the second part of the uh the mnemonic. So you think about rotation and that's all of rotation, inspiration and then projection and exposure. What are those of each of those mean? So rotation, first of all, we're looking at whether the person is looked like kind of facing directly at the X ray machine or whether they've kind of rotated slightly which on a two D image you can't tell, but there are clues on which um the X ray can tell us that the person's rotated, which is what I put there, which is the clavicles. Um I was zooming and looking that in details, inspiration is whether they have taken a very good breath. If you imagine that you didn't fill your chest with your lungs with air, the lungs might look a bit more, they, they look less kind of black in like in, in contrast because you just haven't filled it up with air. Um And so how we measure that is by counting some anterior ribs, um projection projection is where the xray was taken um from the front or back. And what that means is as in is the person kind of hugging where the receiver end of the x-ray is and the x-rays coming from behind them and then photo being taken or are they sat on like a chair? The X ray is coming from the front and then the image is taken from the back. And why that's important is um on APA or a posterior anterior. So if the X ray is coming from posterior behind to your front, you can um it's an indication that person's re like well enough to stand and hug the X ray machine and take a X ray. Um And also you can assess the heart size in APA but not in an AP where the person is like slightly more unwell uh and the heart borders which we'll go into in a bit more details, it will look a bit bigger, but you can't accurately um assess um the the the size um because of that reason because it's zoomed in. Um it's kind of like light fail, I wouldn't go into it. Um Exposure is um kind of how can you see the vertebral bodies behind the heart? So has enough x-ray been given to take like for an image to be taken er if you imagine other than air. Um you know, um a sufficient amount of x-ray needs to gonna go through um for you to be able to friendi between the structures. So if you can't see the, basically the spine at the, at the back, behind the heart, it's a bit of a poor image. So in this one, I was moving a little bit to see. Um So we start from the top. So we were counting. Um what were we counting clavicles? There we go. Um Not counting the clavicles end. This is kind of the, the right clavicle. Um This is the left clavicle. I don't know if you can see where I'm seeing. Can I bring up A I compare that point? Lisa points are out, always out. But um the end here um is equidistant to and the tricky is right in between. So that tells me that this, in particular XX ray is not rotated, inspiration of my anterior ribs. So we're not counting um you know, these obvious ones here in the back that curves like this way, those are posterior ribs, um anterior OK. It, so these, these ones, so it's one of them uh 567, that's quite a few of them. That's quite standard for chest X rays. If this is a good one, good inspiration projection. This one doesn't say um it might be just hidden within the demographics of the chest X ray, but I would assume this one, this one looks like it's a, it's APA um and exposure, you can see the vertebral bodies if I zoom in here. So I don't know if you can see here. This is like edge of the vertebral body. This is right behind the heart, quite a number of these. So that's a good, this is a good, taken well taken chest X ray, next part ABCD. Um So this is when you're really fully flexing you at OS and you're going through each of these things accurately. So air, we start with airway a um we where we're looking at the trachea um and then the carina, which is where the trea dissects into the two main bronchos, they look at the bronchus, they look at the bronchus and kind of and that should be the end of where you can see things not the airway, but you should be able to see them. We'll go on to it. The next next slide, um breath for breathing. We're looking at the lungs and the pleura itself. Uh Cardiac is a reminder to look at the heart, particularly at the border and the size diva diaphragm. Um go into more details later and then e for everything else, which is everything else that you can see on the chest X ray like we mentioned before, fractures. So bones, we used to look at like soft tissues, any of the tubes, like an angio tube, um cables, my cables are probably meant not lines um and pacemakers, et cetera. So let's start in airway. Um Tia, is it central uh in this one? It looks quite central to me. Again, we're looking at kind of clavicle, clavicle, trichia, central, nice um Korea, you can see it here where it's pointing and that is the split er, of the trachea into the main bronchus, right, main bronchus here and the left, main bronchus here, you normally can see the right one a bit better than the left just because there's the aorta in the heart on the left hand side. Um And care is important like I said here. Um because that's where you should buy sex if you're inserting. Well, that's the path of the MG sh of where it should go. Bronchi check for foreign bodies, it might always be visible. Um But if you don't see long here, that's a sign that it's been blocked off at the bronchus. Um, you shouldn't see like not other than main bronchus, the bronchioles and we, when they're spitting off a bit smaller, you really shouldn't see those. So these white lines, they're not, they're not lungs, they are what we call the highland vessels, um, which I think I'll point out later. Um And they're more kind of blood vessels against lung, which is filled with air, which is why you can see them. Um, because I it's all, all of your lungs should just be filled with. Uh, and there shouldn't be anything else there. Um Hilum symmetrical. That's the hilum. I'll go onto that. Now, I'm highlighting the trachea and just the start of the main bronchus is here, bronchi. Um And then this pink bit, these are, I'm trying to outline hilar vessels, whether they are symmetrical or not. This is arguably relatively symmetrical. Um You can tell me that I'm, you don't feel like that, but that is what it looks like. Um And then we move on to 34 breathing, which is uh looking at the pleura and the lungs. So we check each zone. So that's upper, middle and lower, it's upper middle, lower, um same on the left hand side as well. Um We call it zones rather than lobes because you can't tell on the E two D image which lobe exactly. It is. There are other clues to tell you. Um But mainly if you want to be safe, just talk about zones. Um And here with this is tracing long borders. Um And this is kind of looking at it like are we have we got some lung markings that are symmetrical if I go back to take off these color bits. So we've got higher vessels here long and they, you also see them on the other side. So that's good. This is a um they've got a good breath. I don't think there's anything abnormal there. Um The other bit is plora, do they extend all the way to the edge of the lung? Feel So this is why you're checking. Really have they got lungs filled all the way up to the edge, um, through the ribs. If not, then you're suspecting a pneumothorax. Um And really, at the end you don't, I say long markings, but really you shouldn't see any like particular fine lines. That's a different thing that we'll go on to talking about. Um, in the latest slide, it actually pathological, I would say. Um just because the vessels, not the vessels, the um bronchioles at the end of the lung, when they reach the end of the edges of the lung, it should be so small that it's just basically air and you shouldn't see a difference of it on a chest X ray. But if you see like a fine line of like this pink is kind of miss this pink line is mismatched with a long. But if you did see a long line like a line that goes like this, you were saying, ok, well, what's happening here? Why is there a gap at the top? So that's what you need to check. Cos sometimes very simple pneumothorax can be at the top. Um And you might miss it. So that's why it's important to check. Um Everything makes sense so far. Any questions? I don't see anything in the chart. Um Next stop me if I'm going too fast or slow. Ok. Um Cardiac sever, cardiac, does the heart size appear, appear normally sized? Um So again, like I said, this is only, you can only assess this on APA film. Um And the kind of rule of thumb, it's is the heart size kind of around 50 or less than 50% of the whole chest cavity this width. So just from your eyes, this one, the red line is kind of more than 50% of the blue. So this is an enlarged cardiomegaly. Um But if this was an AP film, you can't really say if it is enlarged or not. Um And then the other parts of the heart is the heart borders. Um So here, even though this uh x-ray might have an enlarged heart, you can still see the borders quite clearly on this, on the left side and on the right side. Um But if they were um obscured or b or, or kind of a bit fuzzy, you can't really see it properly. Um It could point to these two things if it's on the left, it's called lingular consolidation. This is lingular as like as a tongue. It means tongue in Latin, it means a little bit of the lung that looks like a tongue apparently. Um And that's where the kind of consolidation is and it s that's if it happens here, that's um uh basically a consult. Yeah, a consolidation there. Um uh Yeah. And on the right, a middle lobe consolidation again, pneumonia like you thought that's what I was looking for. Um on the right hand side, if it's obscuring, only the right heart border, you can kind of tell it's the right middle lobe one because it's right in the middle and it's right next to um the heart on the right hand side here. Um So if that is the case, you can't quite safely say it's the middle lobe consolidation, but otherwise, again, keep it to middle zone. Um So that's cardiac. Um And then here, I'm trying to show a picture of a left lingular consolidation, it a 10 year old, very young child. Um And you can see in comparison to the previous film that I showed you, this is like that's not, that's not a border is there, it's just a bit fuzzy. And so that's what you're looking for in a consolidation and the same would be um on the other side, on the right, it would just look a bit fuzzy. Um make sense so far. Yes, if not give me a thumbs bell. Um OK, cool. Um And this was after this was the same 10 year old and then had a repeat chest X ray and the pneumonia is gone, the consultation is gone and you can see that she's got her, he or she I can't remember um left heart border back which is nice. Um DD for diaphragm. Um So the right diaphragm is usually higher than the left. Um just because the heart is pointing to the left and there's, there's more stuff on that side. So naturally the diaphragm is a bit lower. Um, but in this case here, um, that's not quite normal. Um, and so, first of all, it's very much higher than the left, that's the first abnormality. And the second one would, it would be the costophrenic angles which you can't see. So, in this one, if we just ignore this gap here first and just look at the lung and then this which is the diaphragm, er you can kind of, I would say that is a OK costophrenic angle that is quite sharp is a triangle, but here, there is no costophrenic angle here, like the triangle that should be there is missing. Um And so is here kind of next to the heart. Um So this is like this is a pleural effusion really. Um if you imagine water just filling up outside um within the chest, but um between the pleural space and the lungs. Um and I don't know if you remember kind of back in the days when we did chemistry probably um when you're filling up a a long cylindrical um two and you lot of water, you see the um what, what is it called again? Uh I've lost the name but um because of the water's affinity to like attach to walls, it has that little shape, a concave shape, right? And that's basically what's happening in the lung here. Um So that's this abnormality now this one, the abnormality is free in the diaphragm, as you might have guessed. Um, you shouldn't see more darkness in contrast underneath the diaphragm between the diaphragm and the liver. This is the liver. Um, and then this is the stomach. You might see a gasp ball in the stomach that's quite normal. Um, but on this side, definitely something is wrong and there shouldn't be air there. Um, so, yup. Um, I had the abnormalities on here. There we go. Makes sense good. Ok. Um Quick note on pleur fusion. Yeah, I was just talking about pleuro effusions. We've got different causes of pleural effusions. You got, it could be malignant, it could be an infection, it could be chylothorax, which means pus um um a hemothorax could have blood. So if someone's had a trauma, um and it was bilateral, which is most likely the one that you probably see the most uh would be because of, because of heart failure or pulmonary edema. Um So, yeah, it's highly about the same um abnormality on here as well. Uh Last but not least everything else. So, er, we're looking at likely your child here. It's quite small. Um, it's an AP film that tells you here. So it's not very well, main abnormity obviously is this thing here. Um So that's actually you don't actually know where that is. Um, obviously it looks like a coin but it could be anything and you don't know whether actually that's in, is that in the trachea or is that in the esophagus? Is that on top of his chest? You can't tell in the two D image, which is why they've taken this one, which is lateral and you can see that this is stuck and it's flat and it's probably stuck in the, in, in the trachea and it's probably not very well. Um So bless him. Um That, which is why it's important to check everything else, but even his lungs is ok. It's, it's compensating quite well. I would say, um, cyanus trachea, esophagus, tr esophagus. Yes, debatable. I don't know where that is. Exactly what we know is a coin and we probably should cut it out. Um This next one is, um, the lines we talked about. Um, so this pacemaker, we've got two lines here. There's one that's going, if you follow it around, it kind of goes around here and it goes to the atrium and then there's another one that's a bit longer and it goes to the tip of the left ventricle. Um, so that's, that's one of them here. You got some E CG stickers. That's this one here, this dot And then another one here and there, I would imagine there, there's another one here and there's another dot Here as well. Probably just a four lead E CG. Um Yeah, actually I've got a note here to say he's actually swallowed it. That should be in his esophagus. Um, good. Right. Um, everything else. Number two, this is a real life case. I've just seen this, uh, this, I asked for this x-ray to be taken in patient not too long ago. Um, and the very obvious thing is there's a line here, isn't there? I think, hopefully that's quite obvious for people to see. Um, I was going into, can I assume in, let me assume in, um, line, line, line into, I would say around here that's where it kind of stops. You might have to just adjust your screen's brightness if you can't see. Um So this is a, this is a Hickman Line. Um And that we did this uh x-ray to check whether it's in the right place or not. Um And a Hickman Line is basically like a indwelling catheter for for long term. Um So you don't have to keep poking the patient for Cannulas and things. Um And I thought this was like, I was like, well, is this blind in her chest or like, is it on top of her chest? So then I had to look at a previous X ray and it looked exactly the same. So what this was is this angle um this bit where it's kind of like the most dense, if you imagine that's the line kind of coming out of her chest and then it kind of falls, drops due to gravity. So that's all this bit here. And anyway, kind of this bit is inside her. Um And we, we thought like, oh, has it moved? Has it not? But now that we've got an X updated x-ray, so we're sure that she can have her treatments um which is good. Um So that's another indication for chest X ray you can see here, there's the stomach bubble that I mentioned earlier as well. So that's not air under the diaphragm. That's just a stomach bubble. So good. So, so far, so good. Yeah. Um Just mentioning here, I just want to point out some tricky hidden areas. Um So at the apex, we need to look very carefully because um you've got so much things going on there, we've got your clavicles, you've got your first rib. Um You know, even neck pathology can sometimes um have lymph nodes, et cetera that can kind of get swo swollen up there. So it's important to look at that carefully and see if you've not got anything there. Um Hilar vessels, as I mentioned before is important to look at the symmetry. Um And also because they are hilar vessels, they've got liquid fluid in them. It obscures anything that could be inside along or like if you imagine they're behind the hilar vessels on a two D image like you won't be able to, you might not be able to tell um cardiac shadowing can hide quite a bit of the lung as you can imagine. So, anything that happens in front, right in front of or right behind the heart, you might not be able to see. Um And there is, there's a part of the lung that's posterior to the diaphragm as well. If you imagine the diaphragm is kind of like a dome, isn't it the dome on kind of from your x axis? But also if you're coming in and out um of the plane, it's like that as well. So there will be, you might see the front bit of the lung, but you might not see the back. Um So those are just things to look out for when you're thinking about whether someone's got infection or cancer or et cetera. So if you're trying to look for some a mass that is um right next to the heart, a chest X ray is probably not going to help very helpful. Um And the clinician might then therefore have a CT which um is a 3D construct uh of um multiple X rays. So you can see all around it. Um But we won't go into CT S in this session, right? Medical jargons. What's consolidation? What's a ground glass of pacification? Broncho, ground blah, blah, blah. What is, what does this mean? Ok. So I'll tell you here um consolidation is when the lung alveoli is actually filled with fluid, it can be any kind of fluid, it can be possibly water, it could be blood, anything and there'll just be a shadow on, on the X ray. Although a lot of people just use consolidation as a, a word to say that something, there's an area um of something on the X ray, but we should only really use it if you're thinking um there's something filling um the alveoli, some kind of pathological things. Um ground glass of pacification is a term for CTS. So we'll go into too much details here. Bronchogram. Bronchogram is means seeing more of the bronchi branches because alveoli is being filled with things that are done air. So it's kind of the most similar um to consolidation. Um And you remember I mentioned about the Hila kind of vessels and then the you're not seeing belong because it should be filled with air if you're seeing more of those, that means it's also being filled with fluid like vessels would be. Um And so it shows up a little bit differently on X ray. Um silhouette sign, silhouette sign is, do I have a picture of a silhouette sign that's possibly not a silhouette sign that should be a air Bronchogram if I can convince you with my little orange kind of in notation there, that is an air bronchogram. So you can see more of it. So I would, I'm assuming this is kind of a zooming version of the left kind of main bronchus. And then you see the more kind of not vessels, the bronchi bronchioles extending and in a normal chest X ray, you don't see that. Um And we're seeing it here because of the reasons I've I've mentioned, does that make sense? If not stop me? Um And then silhouette sign, do I have a picture of a silhouette sign? I don't I have an explanation. Um interphosphate Asian or density the border of the heart. Um So it can be, it can be anything from like consolidation or it a bit of a l it basically what it means is it sticks to the border, either border, either left or right um of the heart. And instead of seeing just nice clear air, you see a bit of kind of whiteness to it, it can be, it can be any anything. Uh it doesn't really, unless you're looking for something really specific. You're like, oh yeah, it must be n pneumonia. There must be some infection in there. That's, that's a sign, but it can be caused by other things as well. So if you've got like quite a bit of in a slightly um in middle aged people, actually, they've got, they might have mediastinal fat. So within the heart and with which is inside a mediastinum, they might have a bit of kind of fat tissue. And in that, that could be a silhouette sign in itself and it could show up a bit differently. You would keep thinking the person has some kind of infection when they don't. Um So be cautious about using this term I would say but if you see it mentioned, mentioned anywhere else, I would say that's what it means. OK. Do we, are we good so far? I've taken 30 minutes, I think around off your concentration. Do we need a break or should we go on to some cases? Um I'll pop back on to my a house slides. Maybe if it louds. Oh results. No, keep going. Give me a minute. Um, so Park stage, is this showing? Just not sure? Ok. Hydros. Oh, ok. That, well, it's a case. Now. There we are. We've gone to our cases. Um, so we've got Betsy on the care of the elderly ward who is 99 years old. Well, on Betsy, um, she's losing it free. Unfortunately, she's got a bit of a slightly fast. Was ok. On the high end respiratory rate, she's got good saps. Um, a bit tachycardic. Um, BP I would say is quite normal for her. She's not got a temperature and she's come in with confusion. What else do you want to know? Um, I think I've actually shown her the kind of answer instead of what I wanted to show. Two seconds. Five. Ok. There we go. What else you want to know? I think she should have put up her clinical history. But the, the, your meds you're rejoining one for pin tree. That's, that's very smart. Yeah, I like that. So we're thinking about, yeah, let's do a history that, that would be helpful, wouldn't it? Um, pain infection, nutrition, drink about constipation, hydration, medications and environment. So, that's good. Uh, yeah, we might do some investigations like bloods, um, existing, existing medical conditions that will be helpful. Medication history. Yes, we should always do a very thorough history. Allergies. Yes. Medication like green allergies. Uh, yeah, we can consider doing ABG, although she's, her stats are quite high at the moment. I would say she's OK, but we could consider that can also use ABG as a quick kind of screen of like how her electrolytes are doing. But um you're in it for confusion. Yes. Yes. Um I'll take one last one. Yeah. Blood including therapy for infection. Good. OK. Um So um you were very keen and you did the E CG as well. Um Came up with nothing. She actually did have a UTI so the urine was a good shout. Um Her ABG showed respiratory alkalosis but nothing else really obviously because we're in a chest X ray station we're gonna interpret bes chest X ray. Um Let's interpret it. Mm Bring it back up. Um OK. You can describe bait's chest x-ray. Now I'll bring I'll keep this up so you can see we're going through kind of what we just went through anyone. Let's see. It was a buck. Cool. Yeah, it's normal. Good. Um That is a normal chest X ray. That's very good. That's what I wanted. To hear if we go through it just quickly look, you're here, central normal. You can see the main bronchus is good. Um, long spaces, it reaches to the edge, reaches through the edge on both sides. Uh We've got some hilar vessels that look to see the cardiac knuckle, which I didn't mention before, but this is, um, the aortic arch and it normally shows it was a knuckle there. We've got a heart border here, a heart border here. That's good. Diaphragm, slightly high on the right. Uh Compared to the left little small gastric bubble here. That's good. Um Everything else. She doesn't look like she's got a fracture. She's a very healthy 99 year old. So this is a normal chest X ray and then she just had a UI think what was her problem again? She was, she was losing her three but I think she was fine. She was uh probably free for confusion, isn't it? Um But yeah, UTI was the thing. Um She didn't have a chest infection. Good. OK. So um we've got Case two. This is Alan, he is a 55 year old male who was waiting for a bed on hu I can't remember what hu is. Um But he is at the clinical decision Decisions unit, which is the place you go after A&E and they're kind of deciding whether they should admit you or not. Um We'll send you home. Um And he's not very Well, he's been at 10 for those parameters stated there. Um, the nurse said like, oh, he sounds very chesty. He's very sweaty and very unwell. Any differentials? Yeah. Good. Maria. Yeah. Sepsis. Yup. Yup. Always be aware of sepsis. Could be, be a year. Although, did you, did you have a temperature? Let me just go back to this. Yeah. Axial. Mm. Anything else infection? Yeah. Most likely. Good. So, we're thinking about obviously could be heart failure but I mean it sounds very acute but that's not unreasonable. So I think maybe he has something else on top of the heart failure as well. Um Good. So this is his let me bring up his chest X ray. Um What did that look like? Let me bring up here. I will let you describe it all. Surely answer it. It's almost a bilateral consolidation. Yeah. OK. I can see why you said that anything else anyone not clear borders pneumonia. Some foundation on. Yeah. Yeah. First of all, it's a very crappy. It's blurry. I'm sorry for the for the resolution of the image, but it's just a generally very poor fluffy x-rays in it. It just looks a bit. Mm You're not getting a lot of air into it. Um um Consolidation wise. Yeah, I can convince myself that although I would have like obviously a higher kind of resolution x-ray um there's no clear, no clear lung markings. Yeah. It's just a very poor x-ray in general though. Um as we remember going back to our doctor, right, like, II can't even see the ribs. I can't see the vertebral bodies. I don't know how well um in the first place this X ray has been taken. So um your first comment would be, this is not a very well adequately taken X ray. Um And it, I think so you've actually got um acute heart failure. So on top, on, on top of kind of having chronic heart failure, this is kind of what it looks like. Um You can see what we call it described in interstitial edema. This is actually what it is. So it's not like a like an area in particular that's got consolidation as ap but whereas this is like it's just everywhere, um there's very extensive alveolar edema. So like all the alveoli now being filled with air, it's being filled with like fluid. That's what it is. I saw a question about what's a shiny thing on the right? That's a very good question. Could be an artifact. Um What else? What else is shiny on an X ray? Could there's either dense metal er or clothing, that's what I imagine this would be. Um Even we think this is II, you can't, I don't know if this is on the rib inside him or on top of him. So II wouldn't worry about this, but his lungs are kind of what I worry about because it looks quite crap. That's what I'd say. Um on this kind of fluffy coo appearance is what you'd see in a very, very severe, um kind of pulmonary edema, acute heart failure kind of picture. Um Does that kind of make sense? We got a chat? No. Ok. Um So I'll talk about it a bit more detail here. Um, bilateral. It's what I'm saying. It's not really a focal area of consolidation. So I described it as like blunted costophrenic angles. Instead, there is no clear triangle that I can see fluid in the fissures. I will try and convince you of it, but normally you see. Um so you know how the right lung is divided and it's got three loads and then you've got two on the left um within the fissure, it's like a, like a straight line. And if you can see that that's like fluid filled there, which is why you can see it because normally you don't. Um My, no, we demonstrated very well on this one, but that's what you um the heart is just very, a bit more dense than normal. Um Lot pleur efs. Yeah, this part, this part here is a bit, I think Meniscus was the word. I also was given a clue. Um Curly beelines, right? Curly beelines is people like what people like to talk about as well. Basically, it's kind of like a fissure but at the end edges of very, very short ones, short lines at the edges of the lung. Um That's like this line here. I don't know if you can see this being pointed at. Um It just means that the interstitial space has been filled so much. Um You can see these lines, it's fine if you can't see them, like no one can ever, no one's ever gonna zoom into an X ray and look at it like if I, if your mother zooming out as an X ray, it just looks a bit fluffy, wouldn't it? There's way too many lines that you can see. Um And so long as it's not being filled um with air as much that's kind of the take um got into the demonstration there. Um I think I tried to, this one's a bit more clearer to see. I think if you see these lines here, this one, this one, this one and this one, there's what I'm talking about. I try to highlight it in green, turn off again so you can kinda see what I mean. Yeah, cool. Um Any questions so far? Can we see your previous slide? Oh Sorry. Um Sorry. Me. Which lies. So which sl do you mean or is that other case? Can I form? Yeah. Oh, she was OK. I'll go back to these slides after. Um So this is Duane um Clearly not looking like this if he's on the trauma ward, but it's for this d the D I'm talking about on trauma ward is 48. Um, it's using at six. Uh, it's got ankle fracture. It's been in the hospital. Um, he has been walking on the walls um, but had a cough. Ok. So that's kind of the background. Um um, this is his x-ray. Can we? The scribe is x-ray. Let me go to the next one. Ok. Ok. Prescribe Twain's x-ray. I'm gonna bring the x-ray back up there. Yeah. What does he have? Right. Lower consolidation. Yeah. Consolidation. Consolidation. Yeah. Stop. OK. Right. Lower base. That's the question I would, that's the answer I would have preferred actually rather than the right lower lobe. Um Right, lower right side vision. Yeah. Just be a bit general. That's, that's fine too. That's good. Um That is exactly what it is. Um Oh, I don't have, I can't go back. Yeah. So this is again, you can't really, you know, this bit along here. So there's still worse lung and it's not exactly like the right lower lobe is gone because if it was, you can imagine like you wouldn't see this bit, um, or like this bit that works. So this is somewhere probably it's more likely that it's in the right middle lobe actually. Um But you can't say for sure. So just say, yeah, I will stick to right lower. Um And that's definitely abnormal. They're all fine on the, on the left hand side. Um I everything else quite normal. Um It might also be a, or is it this effusion that's covering it? Who knows? But this, it's definitely, um, abnormal and it's in keeping with the clinical things that we talked about. Isn't he had a cough? So, um, it's likely that he's also got a bit of a temp, so he's probably got some kind of infection. So we would start him on antibiotics. Probably makes sense good. Ok. Um, last case, uh, I believe before we go into the quiz, which everyone's been working for. So case four, she's a 55 year old lady. She's fine losing zero but she had a persistent cough and it's been generally she would say unwell, I would say um it's been eight weeks, small amount of weight loss, sorry, I was being lazy there. Um But it was intentional cos she wanted to keep fit. Um So that's the background and you like acute medical unit, by the way? Um So this is her x-ray. What does everyone think? Uh Let me switch it to normal question page here. You describe Rainbow's x-ray. This is a bit difficult one I have to say in case you're all wondering, I will explain it anus the questions they, they wish. Oh, cloudy things. Yeah. OK. I can you see why I say that? Yeah. Anything else? Life long border is narrower. Let me see. Oh, do you mean do you mean this, this bit compared to this bit high lymphopathy and you're getting? Ok. So, is getting quite close, uh, fuzzy patch. Oh, ok. Yeah. So we're actually looking at the top here. Um, higher lymphadenopathy probably. But it doesn't really normally show up on the, like, unless it's, unless something's happened to the lymph node that it's like calcified or, like, um, it's growing normally against other kind of soft tissue structures. You wouldn't see it as much. Um, ah, yes, we're looking at the top here apical bit that I told you to look at very earlier and she was very fussy. I don't know what's going on. So, you know, that's kind of where you would say, like, that looks a bit suspicious and obviously with her clinical history, what are we thinking? And we're thinking, I know she's very young but we're thinking some kind of either some kind of long term infection, like, you know, like something like TB or like, you know, weight loss as well. She say it's intentional, but we haven't actually asked her how much and how fast that weight loss has been. Um, so k is also at the back of our minds and a lot. Oh, of these. Um, just because that's the, that's the most kind of like aerated space and it's nice and hidden. Um, and so that's where, where people like to go or not people. But, you know, the infections and cancers like to grow high. If, I don't know, I can see why you said that II wouldn't be so sure. But, yeah, like I said, it kind of looks a bit abnormal, going back to the borders. I know you said something about someone said, if you're referring to these two things here, that's just the border of the Scapula. Um, and so it's, it, it's, it's normal. You can see it's continuous of this and this side is continuous of that. Um, and yeah, actually scapular is another thing that kind of obscure you from assessing the lungs properly. Um, I wouldn't say there's anything too bad there. So it's also a mesothelioma. Yeah, it could be. Um, we're gonna have to look into her, um, work social history a bit more. Um, but basically in, in, in the sense this is an abnormal, um, chest X ray and you want to definitely get your seniors involved in reviewing it. Um, is that ok? Ok. Anything else? Probably the chat or? Cool. Excellent. Um, next bit quiz time just to finish off. So I think we're scheduled to be until eight o'clock, but I don't think people can actually concentrate for that long. So quiz time it is. Um, whoever is still here, you, you're doing a great job. I hope that you will be able to 20 Chris. Uh, let me see how many people are actually here or supposed to be. There's only four people on, um, two seconds before I go back to that. Um Yeah. Ok, cool. Let's go back to this we, I think we in. Oh, that's what I wanted this time. There you go, talk to play. Uh Right. So it is a time to as in, you know, the faster you answer the more points you get. So. Right. Uh uh Thank you says I have to wait for you to join you. About to click a button to join. That's also coming out and joining us. Do more people wanna join it now. Yeah. C seven positive. So if not, then I will start without delaying. Yeah. 000, ok. That's all seven. Excellent. Ok. Friday. I don't know if all your devices if you heard them. Have you got your FS in normal? Excellent. Yeah, it is. Well done. All of you. Uh there was nothing much on the, on the X ray at all. So it was quite next one. No abnormal. Well, what did the music go out of music? Mhm. Good. So we know what, um I think it's a very good start. We know what our abnormal and abnormal is. Obviously there was a, there was a um, opacity in the right lower zone, didn't we trying to use the correct terminology there? And so it's an abnormal x-ray. Uh, what would be the going back to the same ago? What would be the likely diagnosis of it? It, it's not choice. Ok. Yeah. So it is pneumonia. I don't know if I can go back to the, to the picture um, I might bring it up after. Um, but yeah, there was the middle lobe haziness. Um, and if you remember, I said from the start when the right heart border is obscured, which is what that X ray showed is consistent with some kind of pneumonia. Um, uh, the right middle one look a bit more different. Um, and you might even see kind of using the ribs. I might show a picture later if I can find one. on the other side, kind of, it's hyperventilate and I can expand even more because it's trying to, that's the only way it can kind of push air in. Um And that would be kind of more of a clue. The ribs on that X ray was the spaces between the robes. They look kind of similar. Um I'm sorry, it's I wouldn't be consistent with that. Ok. Next, what's happening here? This is a hard one. It's getting harder, it will get progressively harder and harder for you guys. It's a challenge. Oh OK. Yeah, I, like I said, this was a hard one. I wonder if I can actually probably be able to bring it back up. Um So that was, this wasn't it? Um Yeah. So as you can see, there's probably quite a poorly patient. We've got some, some wines here. OK. Uh Someone about what about some great I can get you to see that there's a edge to this here. Um And that's, that's the lung, that's a collapsed lung. Um And it's, instead of so it's not like a pneumothorax where, um you see air kind of outside the lung. And so the lung is being kind of pressured in and pushed in. Um, this is just like the lung just collapsed. Um And you can see that kind of all of this white stuff here, that's the media style content. So the heart, instead of actually being on the left hand side now is all just kind of pushed to the, to the right because it's not being filled with air. And so there's space there. And so that's where the heart is gonna kind of been pushed around. You can also see that with the way the tria is deviated as well. So instead of this looks fairly like, um if you look at the kind of the scapular, this, it doesn't look like the person actually rotated for this, for the Tria to be also rotated. Um They are a great distance but then from the vertebral bodies at the back as well, like this is quite straight, but then Tria itself is just kind of gone like to the right, the person's right kind of shifted to the side. Uh The thing is on uh the the abnormality is on. Um And um the left is trying to, trying its best to, to breathe um and gas exchange as best as it can um on this bit here. I don't know if you can convince yourself to see cause obviously, the brain, the trachea and then the bronchus um like it kind of stops there. So I move my marker away, it just stops there and there's like nothing else after it. You can't see any hilar vessels, etcetera, obviously. Um But it could be, this could be due to something like a, like a mucus plug that's plugging of the main bronchus and it's stopping, therefore, air from going in. And so the lung just collapses instead of being filled, it's like a balloon that's just deflated. Um And in a lung collapse, you're gonna have lung collapse like this, like it just collapsed and there's nothing else, you can have a lung collapse due to a pneumothorax or you have a new lung collapse due to pleural effusion as well. So, if some kind of fluid is being filled on this side, um and also the lung has collapsed because of that, it will look a bit different because the trachea will then therefore actually go away from the to the other side. Um because it's being filled with fluid and fluid is quite, can be quite heavy and it's gonna push against the whole media and its and the heart and all its contents to the other side. So this one is a um a lung collapse without um any effusions or any extra air outside. I ie pneumothorax, if that makes sense. Yeah, Um So yeah, the tension pneumothorax would be, you would see um the air outside as well and then obviously it's pushing. I won't actually won't go into too much. Maybe we'll have a different one. Um Right. Hang on. Oh, no results. Yeah. Sorry. I just read quick essential pneumothorax twice. Yeah. Essential pneumothorax. Um Oh I'm so sorry. I didn't realize that um that happened. Um Whoever this is, I'm sorry, you should have a point. Um And we go back to this. Um So that was this photo, wasn't it? Um No, that's not this photo. There we go. That's this photo. Um Is this, so this is we got two bits here in, in this space, there's just air and there's no longer. Mhm OK. Because that's all, there's no vessels on that. So that's just air, pure air. You can see the arm you've got this ball of very clearly. Um because there's nothing there to obscure it like to, to kind of hide it away and this little edge here that your lung um and trachea instead of being deviated towards it, it's being de deviated away. So that means whatever it is getting in. But for whatever reason why the air is getting into the space between the outside the lung and within the chest cavity is pushing everything in the other direction and that's quite bad. So as the person's breathing in the air is being drawn in into the incorrect space um, and it's not coming back out. So that's what attention to is not, that's the emergency because it's, the more the person breathes, the more air gets trapped in the wrong space. Um, and they're not actually doing efficient gas exchange. And as you can see on the other side here, there's only very little bit of long left that's oxygenating them. Um, you can also d D yeah, the other bit. So you can see us in front of the forefront and then some of that a bit more around, around the side. They're actually in the right space we can, um, but they could be placed in the correct position, but that's not the main issue here. The main issue is that this person's got attention pneumothorax and they probably shouldn't have gone for a chest X ray. Um They should have been able to pick that up on examination and the immediate management kind of given. Um But I won't go to that. Cool. Um uh Let's close this. Let's go back to here we go. All right, next question. OK. For you guys, I won't take any more longer of your time. I'm sorry, what's going on back? I want the dress away. I can speak up if everyone answered. I can't tell her a pulmonary nodule. Yeah. Those are the two top, the, like I think of the other two are obviously nonsense. Um It's uh maybe I'll explain later. Um I'll go through the size later I'll go from next first just to try to speed things up. Ok. Next question. Just typing. All right. Um, a variety of answers are, are accepted, uh, depending on what you write. But I hope you try to, you, I hope you'll be able to try and get my main point here. Do you have anything? Yeah, ca ok. Except is, um, this is accepted TB ads. A lot of people would think that lung masses. Hm. Hm. I think II can give you that the past t, is a bit vague. Um, I do not, cannot, how do I click it? Oh, ok. I said these two. yeah, it's a classic picture of cannibal Mets. Um, I'll talk about laser. Next I go, I, it, it. Mhm. The leads in the right place. CBS or pain pneumonia? No. Yeah, it's not. Um, I'll go back to the, how it looks, how it should look. Um, next question. Oh, I didn't, I have a slide anyway. Right. So, in the first one of the earlier slides there was a pacemaker, a short lead going to the atrium and then a longer one going to the tip of the ventricle and the one that we had was somewhere up here and then that would not be a very good place to, um, have the pacemaker out because it's not gonna do anything. Um, yeah. No, no. Oh. Um, oh, it's in a small, in the context. In the longer description of the question that isn't show the screen, it should be on the devices A um P for heart failure. Yeah. Yeah. Yeah, I can think. Um let's talk about about the No. What did it look like? Um It was pe it was, it was just tachycardic. There was nothing else on the chest X ray. Um I will go back to as two. You're the last questions. What do we think? Pleuro aspiration? Yeah. Yeah. Uh oral probably would have help it. She might be in pain. But yeah. Um I was gonna explain the difference between pleuro aspiration and pleurodesis via this question. So I will do that in a second on question first. The clue is an image. So look very carefully. Yeah. BC stent because of the way. OK. Um From rolls uh because it just gives me from rolls. There we go. You, wow. It's very nice. Congratulations. Ob Kenobi. I think, I hope I pronounced that right. Um I don't know what the price is again. Like I said, I'll, I'll let me know with that one. And congrats to the CDC for holding a longer street record. That's, that's very, that's very nice. Let me if you've answered most of these questions correctly. Um Go back to my sides. Um So we talked about this one. You know, all right, this was the Aspergilloma. So that's what look at the present moon shaped uh around. OK. A very a funky looking, very round mass. Um And that is very classic looking for Aspergilloma. It's normally in Azole. Um if you move the patient, it also changes in kind of how it could look. Um But yeah, Pulmono was the other sense of all differential. This was kind of bo me I wouldn't go into too much detail as um uh it's associated obviously with um TB and other things, but I've got a link on the slides which I can have after um uh on radio. Yeah, about this was the pacemaker and yeah, I not much on the I know we might be suspicious about one of these. But um if you imagine high the vessels coming out at different directions, sometimes it could look a bit denser than just like fun cause if they come up this way, you're gonna have higher density um something else. And then, yeah, um he's fine. Um So he, you can't, you can't see him that. Uh So we should do an E CG next. Um And then this was a case of the lady who's got pleural effusion. Um And like I said, so the difference between pleurodesis and then pleural aspiration. So poor aspiration is just like you put a needle in, you take a sample and send it off to cytology or something. Um And yeah, so in this, you would think that's causing her lungs to not function very well and fluid is building up. Um, and it's very commonly seen in not just breast cancer but also lung cancer, lymphoma and also mesothelioma as well. Um, but you, you're not, you might not be sure it might not a b breast cancer that she had that occurs. It could be a new lung cancer that she has, which is why you need to take a sample of it and set off pros is on either hand, it's like a more definitive management of the um for the pleural effusion is actually injecting some kind of drug. It's um uh irritant drugs to help the lungs to kind of stick to the flu, like the wall, the chest wall. So that fluid can't build up there again. Um You would think like, why would you do that? But it, because it doesn't, which is not good for the patient. So it be long term kind of management would be a pleurodesis that wouldn't be straight away that you do for her. Um But it could be something that you can consider. Um down the later down the line. There are also very interesting other findings in this chest X ray, which I won't give the details. I at least have a read um um at your pace, this is uh this is one with advanced cancer. So this is a stent um in the SBC of superior Vena cava. It's bronchial because it is, it's definitely in the wrong place. Um because otherwise it should look like that in that angle here. It's not under here otherwise, and I can't remember what the other ones are, but um this is kind of the location of the s going towards the right atrium here. Um So that's the biggest clue. Fine tops. So we've gone through a doctor, right ABCD today. So that's what, that's all you need. Um In terms of the chest X ray, if you're not sure about it, comment on it. Um You can even have it in your own style. So, you know, cut on the most obvious abnormal things first, but make sure you still go through it systematically, especially during an oscular situation. So you've not missed anything. Um And then obviously, if you wanna even even better, you think this is a bit easier than finest your kind of terminology that you use to describe what you see um be suggest, be ready to suggest the next steps. I think that's what would make you stand out as a candidate um in an office exam. So like after x-ray, you've got someone who's, you know, go back to other cases for someone who's thinking that they got pe but what would you do next? A CG and you know, anticoagulation, things like that. Um Always remember to treat the clinical pick up of the patient and not just three. So the resources that I would go to and more information and obviously you should follow us on the middle page. Um So yeah, that's, that's all for me. Really? Thank you everyone for listening. I believe if you're registered on me all you should automatically receive a feedback form. But if not, you can also scan this QR code to complete it as well. Um And if you've got any questions, obviously feel free to email me or get in touch with exposure who will be able to find. I think that's ok. Ok. Thank you so much. Thank you. Um So if you guys want to follow her, kind of an amazing, she does a lot, she will be doing a few of our other sessions that are coming up. Um So next week, we also have our ay station um scenario case as well, we'll be going through how to best approach them. So you can practice the skills that you learn today and that's on the fifth um of December. So watch out on our Instagram to know the place for that. And we've also got M SK and Abdo and Euro coming up. So again, um look out on the Instagram of that. Thank you everyone for coming. See you next time. Remember to fill out the feedback form to get your certificates. Thank you. Bye.