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Thank you. Hello, everyone. My name is, uh, uh, Doctor Khalid. Uh A, I'm a radiologist G, which is start at, uh, bar at the, uh, Royal London. So today I'll be talking about chest x-ray interpretation, which is considered one of the most, if not the most common, actually, uh, uh, scan that we do in most departments, uh, do. And my, the title of my session was in initially radiologist approach. However, it turned out you can't actually teach a radiologist, uh, approach in 10 or 15 minutes. So, what I thought we should be talking about is, uh, what a radiologist wouldn't miss or most likely wouldn't miss. And, uh, a general, uh, physician in different settings might. So the first thing is the normal chest x-ray. Let's start with this one. And I have some, uh, pos that I have prepared who I would, uh, like to, uh, everyone to participate in starting with this one. Can you look at this one? Now, tell me, what do you think of this one who thinks it's normal? Who thinks it's abnormal? Let's see what everyone thinks most people think it's normal. That's good. That's good. So, by the end of decision, we're gonna see whether this is normal or not normal. However, only two people have answered so far. So maybe some people have other opinion. Let's see what everyone think. So, going to the basics, I'll talk a bit about the anatomy. I will not get into a lot of details. Uh just the quality of chest x-ray and it's important then the things that uh would be important to a general uh physician and uh things that non radiologist and potential radiologist might miss. So the anatomy, it's very important for anatomy. There is the, we, we have the right uh lung, we have the horizontal fissure, the oblique fissure and we have the left lung as well. It's very important uh important for us also to uh recognize that the, we have two lobes on the left, three lobes on the right, the uh left upper lobe, uh it has lingula, which is at the left heart border, which represents the left ventricle. And we also have the right heart border where we have the middle lobe. Mean these uh markings are very important for us for us. And these uh lines, the hot borders along with the er, right and left. He, there are very important for us because they can tell us where the pathology is. Again, I will not get into a lot of details because I thought I should, er, be, we should discuss cases today more than just sort of uh going through anatomy because it's almost the end of the, er, conference and I thought we should do something a bit more interactive. Quality. Quality, quality quality is very, very important because the quality can either make or break chest xray. Er, we usually, er, focus on four things in terms of quality and they are there, which is right, basically, which talks, which describes is for, er, er, quality mes that we, er uh look at. The first thing is the rotation, we need to make sure that your chest x-ray you are looking at, you need to make sure that it's not rotated, that the uh both medial clavicles are centralized across the uh uh uh spinous process and none of them is crossing, none of the medial edges of the clavicles is crossing the spinous uh processes. You also need to make sure that if you know the, the radiographer or if you know the uh the radiology center, you're sending the patient to, to get the chest x-ray to make sure that the patient gets an inspired lottery one because inspiration like the one that we have uh here is a good one. However, if we do an expiration, we can see how much of the media is here and this with the outside the manage and many cases. So quality is very important for, for us to uh comment on. We also need to know the chest x-ray we are looking at is it A P A or an A, an A P. The standard is pa A, that's the standard chest x-ray we do. However, sometimes you can't get your patient to stand up. Sometimes the patient is lying on the bed, which is the case and uh most or in many of our emergency patients and the difference is actually huge. And this is, this is one of the, this is actually from raped, from one of the radiologists from Radio Pedia. And here we have two x-rays for the same patient. He's a patient who came in with a trauma with a trauma. And you can see when we, when they did the past uh chest x-ray, the patient was fine. So it was an A P uh one and it looked not good at all. You can see how big the me is. You can see how big the heart is. However, the patient was asked later on to a stand up e and had a ap a chest x-ray and you can see how it's totally normal. So it's important to uh look at that as well. Exposure. Again, you don't want to, you don't want your chest x-ray to be uh under exposed or overexposed. When it's somewhere in the middle, you can assist that by how much you are seeing of the uh spinal uh of the uh spine behind the uh vertebra column behind the heart. Now, interpretation again, uh I thought we should do it based on cases. So there's the ABC approach that most uh general physicians follow, which looks at the airway, bleeding and circulation. Now, let's see how good everyone is with, uh, with a chest x-ray. This is a normal chest x-ray. So this is the normal a chest x-ray. Now, I want everyone to look at this, this is abnormal. So I'm telling you that, however, I want everyone to tell me, take a look at it, take 10 seconds, 20 seconds to look at it. And now I want you to tell me where do you think the abnormality is? Take a few seconds to look at it? Do you think it's the right lung, left lung, airways, heart, it's anonymous. So no one is gonna know what you have guys have got it. That's ok. No one everyone thinks it's normal. Very good. That's very, very good. That's very good. So most people agree that the main abnormality is the airway. That's very good. And actually it is uh the airway in this one. We can see when we stop assessing the airway, we need to, to look at the trachea. We look at the trachea. We can see that there's something from the right side sort of causing the narrowing of the uh ca causing narrowing of the upper part of the trachea. And when this patient had a ac T scan, we found this uh large uh right thyroid lobe sort of narrowing the trachea and he was a very young uh uh patient in his twenties. And the only finding we could see was how narrow the, the trachea is on chest x-ray. So, uh if you are a general physician, if you are working in one of these uh emergency, uh sort of clinics in Jordan, and you see, at an x-ray like this, yes, there's no consolidation but you don't want to send your patient uh straight home without appropriate uh, referral because there's something else. It's not uh necessarily emergency at that point, but might become at another point. So it's important to check the trachea, the right and the left. I mean, uh, bronchi when we assess our chest x-ray, that's what we should start uh with. Now, another one, let's everyone take a look at this one and I'm gonna send another pulp, take 10, 20 seconds to look at it and you can now vote and tell us what you think the abnormality is. This is another area that actually even the radiologist we, uh, tend to miss at some, yeah, we missed the ab that abnormality and it's an important one just gonna wait until we get like, yeah, maybe 2030 responses. Some people think it's the mediastinum. Some people think it's a pleura, some people think it's the right line. Most people actually think it's the right lung now. Suddenly the right lung is gonna go up. Yeah, it's gonna go. So, actually the abnormal was in the right lung. Usually when we look at the lungs and chest x-ray, we tend to look at, you know, at the M, maybe a bit at the upper low, but we do not assist the ABC S where we have the CLA and where we have the first and we have the lung apex. That's a very, very important part of that. Many people tend to uh not look at basically. And in this patient's a chest x-ray, the right apex. If you look at it, there's sort of a radiopaque around the structure with a Radiolucent center, that's actually a gravitating le region. And this patient had CT after and we found uh this uh uh this developing uh TB. And if that was missed at that point, then this patient might have his lung destroyed by A TB. And usually the things that you have in the A P are things are bad infections like TB like uh aspergillosis or it's a bad tumor. So please, in your general practice, make sure you look at the, you look at the uh uh lung A disease, especially when you know that radiologist might not report it if you are in the community or uh if your department has policy, not immediately reporting chest x-rays, so that they are very important to assess and do not forget about your uh uh A P CS, do not forget about your A P CS. All right. Now, another one So this one before we put the on, there's a left hyalur density. I'm not talking about that. There's another abnormality. There's another abnormality as the left hyaline is tense. But there is another abnormality that I want to see whether you guys can identify it because again, this is another easy mess for uh uh many of us charly two minutes, please. Ok. No one maybe. I guess that's fine. I guess it's ok. No one's gonna know. So actually no one's gonna make any guess. There is one answer and it happens to be me. So now I get why do you think you did doctor? I think. Yeah, you're absolutely correct. Actually, there is 32 responses to the questions. So. Right. Oh yeah, they are showing now. Yeah, they are showing now. Actually, doctor was absolutely correct. It's the left lower. So if you look behind the heart, there's around opacity. Can you see it? There's a round opacity just behind the heart and that's re cardiac area and that's an easy mess for uh many people. And this patient had ac TT scan and we found out a deposit here from a lung mets from endometrial cancer. Unfortunately, unfortunately. So looking behind the heart is important, looking under the diaphragm is important as well. Remember once they go below the diaphragm, but assessing the pleura is important as well. Looking at your nic angles, the heri and the HS but I do will not be presenting any cases on the pleura or the hilar. The ha looking at the hilar is important, but the hilar is very tricky because it's easy to say it's permanent. As long as it's symmetrical, as long as uh bilaterally it has the same and there's nothing, you know, like looking at you huge that we should me in it. It probably usually not very easy to make, to look at. Now. I'm gonna skip this one because of the time. But I'll just say, look at this is the normal chest x-ray on the right on the left one. Look at the sides of the trachea. There is fullness. Think there might be something this patient, he had fullness and he ended up having a leukemia. Unfortunately, uh assessing the heart is important as well, making sure it's only half the size of the chest. And now back to the where we started this one, let's see whether you guys have learned something. And uh I'm telling you there's no, no pathology, but let's, let's do a pulp, let's do a pulp. So I this is the last one which I will end with and let's see what everyone think this is the same one we started with. What do you think? Uh what do you think of it? What do you think of it? Look behind the heart? Look under the diaphragms, look at the A PS. They all look clear and nice. Just get a few more responses. Well, so this one, yes, there's nothing behind the heart. There's nothing in the A PC. There's nothing under the left arms as well. However, the heart is not in the right place. Is it the heart is on the right? This is a case of uh uh this is a case of sight and versus, or dix uh Dexia and you can see the heart is on the right side. Just make sure the heart is on the side. Basically your chest x-ray. If you learn that today, I think I would be happy enough and just make sure you have a systemic approach to your chest x-ray. Look at your airways ABC S, make sure the heart is on the right side. And uh if you have any questions about uh radiology or yeah about the radiology in the UK or if you want to ask me any questions, please feel free to contact me. I am on uh different platforms of social media and thank you, everyone.