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Uh huh. Hi, everyone. Can you type in the chat box? If you can see the presentation, you can see. Great. Fantastic. Sorry. We had some technical blips, but I think we've I send it out now. Um, so nice to meet you. All my name is Kevin. I'm one of the doctors working at Sheffield teaching hospitals in the UK, So welcome to the next Webinar in the mind. The radiology series. So last week we looked at CT head scans. Tonight will be learning about chest X rays. So chest X rays are one of, if not the most common plain films that we requested the hospital. But the interpretation of it is notoriously quite difficult, and the findings can be quite subtle. So, Dr Rock, um, your are you who's one of the consultant radiologists at Rather, um, hospital is going to be teaching as a structured approach to chest X ray interpretation. Go through some common cases and some frequent pitfalls. Um, at the end of the presentation, I'll send you links to the feedback form to fill in. And after you complete that, you should get a certificate sent to you by email. Um, so I'll hand over to you if you'd like to take it away. Hello? Can you hear me, Kevin? Yes. I think everyone can hear you now. Yeah. Thank you. Thanks, Kevin. I'm just going to start my video. Hello, everybody. Good evening. And welcome to the webinar about chest X rays. Um, and how do you spread it? Um, So, um, my name's Rica and ask them to add, um, consultant, radiologist at the road and foundation Trust. So? So the objectives of today's, uh, today's, um, webinar is to have a system to approach the chest film. So we're gonna go through the system that I use and many of us use to approach a chest film, which is quite important. Um, And then we will go through a few cases or on chest X favorite pathologies, and recognize how to diagnose them and some salient features to help recognize the pathologies. And in the end, we'll go through some of the chest X rays with altitude positions and misplaced and YouTube, Uh, most importantly, because I know that that is something that the junior doctor come across in day to day practice. Yeah. So first comes first. Um So even before looking at the chest X ray, we need to make sure to look at a few things. One is the identification of the patient. Um, so it's not only, uh, it's very important, not only just in surgical or other specialty, but it's as important also in radiology to uh so we always make sure we look at the patient's name and identification and also, uh, the date of the examination. And, uh, it's always relevant to look at the patient's demographics, like age and gender, because when we see a pathology on the chest X ray, it becomes very relevant because some pathology are more common in some age group and also in some gender, so important to look at the age and gender. Um, and, uh, the third thing is the technical quality of the film. So, for example, is it an A P or PA view? Uh, the standard for performing a chest X ray is a PA view where the radiation dose is from the back side and the patient is opposed to, uh, to the screen. And this is ideal where, you know, this is the best. Uh, this is the best um, x ray, because then the capillaries are out of the lung fields. Um, And also, um the exposure is, um is optimum. Um, sometimes we'll have to cut the radiographers have to do an AP view, which is unprepossessing aerial view, for example, in a patient that is poorly or especially in the I t. U settings, Um, so, uh, in this situation, the radiography generally mentions on the film as a p and whether it is supine or Errict. And, uh, it's very important to also look at the degree of inspiration. And the way to determine that is to count one of the things to look at the lung fields and, um, in general and also count the ribs, for example, For a good degree of inspiration, we should be able to count, uh, so we should be able to count at least six ribs anteriorly and at least 10 ribs posteriorly, which is a good inspiration film. The next thing we look at it is the penetration optimal. Um, so the way to look at it is when we look in the spine, you know, just behind the heart there it should just be visible. So If it's if it's not visible at all, it is under penetrated. And if it is, uh, too much visible, then it is over penetrated film. And also, of course, look at the rotation. If there is an invasion by looking at the distance of these, uh, the clavicle from the spinous processes in the midline. So even again after after this, after looking at all these again before starting an approach, statistics that I always, especially in the ideal patients, I always try to look at any lines and that should and also assess its position and in darkness before we start the approach. Otherwise, there's a tendency to miss it in the end. So this is the systematic approach. So, um, the order of it is it doesn't really matter. Some people use a different order, but the most important thing is you adopt a system and you look at it in a certain order and you continue to do it over and over the same thing. So it becomes, uh, like a second nature. And in that in that way, you do not miss any, um, any pathology and you do not miss any any subtle abnormalities on the X ray. So let's talk about the lung fields. So it's on the chest X ray. It's always, um, we know that there are two lungs, so and the way to look at it is looking at the lung fields comparing the right with the left at supper zones and the middle zones and then the lower zones. Um, we generally can't see public fissures, but we should be able to see just about to see horizontal fissures sometimes, especially when it's normal chest X ray And that generally runs from the right hilum after the after the sixth rib in the midaxillary line. Actually, on this one, I don't think I can really, um, see it, but that's normal. Um, and, uh, next is hilum So the right hilum and the left hilum. So there are three things that we have to look when we're looking at the hilum. Uh, first is the position we know that the left hilum is generally placed higher than the right. And second, it's the density of the hilum. The density of the right hilum should always much of that left hilum. And it shouldn't be too dense. Um, and the third thing is that that it should be concave. If you put an angle there, it should be about used, and it should look on cave. So that's that's the angle there. So if it became convex, I would be worried that there's possibly a pathology in that, um And then the third thing I would look at is the mediastinum superior to, uh, to up to the level of the diaphragm. So it's generally have a well defined margin throughout. Um, some fussiness is allowed in the, uh, in the area that the superior mediastinum from, uh, emphasis to the hilum and also in the right, um, cardio phrenic angle. But generally it should have a well defined margins to it. Um, And then, uh, is the diaphragm so basically the right diaphragm is higher than the left diaphragm. And the way to remember is that the cardiac, because the heart is always towards the towards the left, it pushes the left diaphragm. Um, sorry. I think we should have Yeah, the heart. After the media standard, it's the heart. So again, the shape of the heart and the size of the heart and also the margins of the heart should be really well defined. So the right heart border is made of right atrium and the right appendages. And then the superior vena cava and the superior aspect and the left heart border is made of the left ventricle and the left. Uh hmm. And then the IUD knuckle here. So, um, so that and then you should also look for any, uh, density or a mass, which is hidden behind the heart as well. Um, so then the bones very important because most of the most of the time, um, you know, bone lesions are generally subtle and can be missed, especially if it is a metastasis or things like that. So it has. The bond review is very important. Um, initially, I used to when I was first year register, I remember asking the consultants, How do you count ribs? It's so complicated. I always miss it. But the more and more I did it, and I knew it was it was just, you know, getting into the practice of following through each, um, each trip and then also not forgetting to look at the clavicle and also the peripheries of the film, which is like you know, a shoulder joint and sometimes, you know, subtle metastases into the scapula. And and also, of course, the spine. Um, so after this systematic approach of each, uh, each field, it's important again to have a review area. It can be different for different people. It can be, you know, making sure if you've missed something on a film, then the next time that becomes your review area every time you see a chest X ray. So, um, generally, review areas are the cases where people can miss a very small pond costumer, which is very significant when you know it's it's important to find it early on. Um, and, uh, paratracheal strike. This is the paratracheal stripe. Generally, it's allowed to be as thick as 3 to 5 millimeters. Um, and so the things that we're going to look for in the paratracheal stripe is one is the thickness that it shouldn't be more than five millimeter and also the density if you can see that density on the right political stuff kind of matches with the left there, even though the left is not so obvious. Um, and if there was an increased density, then I would be worried that there's there's possibly some lymph nodes or some mass there. And the third review area for me is the RETROCARDIAC. Because, um, you know, there could be a mass sitting there just behind the heart. So little cardiac is always my review area. Um And then, of course, the cost of phrenic angles. Sometimes there could be they could be like, Yeah, your infusion, of course. And then they sometimes there could be, uh, mass sitting in there as well. And you can also add under the diet from gas and the guy from, you know, as your review area, because that is again clinically very significant. And, um, um, it's it's, you know, it's important to diagnose it, even if it's small. So generally, when we look at the chest X ray, you can you can characterize what you see. Um, as if the If, for example, if there was a abnormality, you can characterize it into being too white or two black or two large or in the wrong place. So, um, I think most of the abnormalities in the lungs can we can fit them into one of these categories. So so when you look at an X ray, you can first determine. Is it two black? Oh, Is there an abnormality? Is it two white? Is it two black? Is it too large or in the wrong place? So let's, um, go through some examples. Now, Um, what I think I'm going to do is show, uh, an X ray, and I want you guys to look at it. I'll give you about 30 seconds to one minute. I want you to be more interactive so you can see the chest X ray. And, uh, you know, you it's most of them are obvious abnormalities. And and then there are a couple of them which are settled. So I want you to write what you think in the diagnosis and message on the chat box, and and then I can explain the X ray and then go to the next one, if that's okay. So this is our first X ray. I'm just going to give you 30 seconds to one minute and then talk about it. Yeah, right. Okay. So, um, so let's discuss about this X ray. I think you can all appreciate that the, um this looks abnormal. Yes, Some of you have said it's tension. Name of drags left side to white. Yes, Hyper inflation and left white out. Yeah, White out. Yeah, well done. So the first this is you know, you first of all, you have to determine whether the abnormality is right being two black or left being too white. And if you see on the on the on the left, there are still lung markings, So it's not pneumothorax. So the abnormality actually is the left side, and it is the white out, long as somebody has a few of you have mentioned. So, um so it's it comes under the category of too wide the abnormality. Now the next thing we do is to determine because there are a few things that can cause whiteness or density on an X ray. So then you have to determine whether it is homogenous and whether it is causing, uh, shift of the mediastinum towards the abnormality or opposite to the opposite lung or opposite side. And then also, if there was some air Bronco grams. So if you look at this white out lung, which is the abnormal side, you can appreciate that even though it looks like homogeneous. You can see some Broncho, Broncho, grams and these these little linear, uh, duck. Uh, you know, the darker, darker, linear shadows are the programs. Uh, so this is a case of, uh, of left pneumonia or consolidation, and you can see that there is No, Even though there is no volume loss and or or neither, actually, uh, you know, increasing volume. So it's kind of similar, uh, there's no volume loss, or it is. And also, the most important thing to see is that there is a loss of definition of the heart border and the mediastinum here on the left and also, um, the left Hemi dive from. So this is called a sellout sign silhouette sign, which is nothing but loss of border of certain organs, which help us determine what the abnormality and where the position of the abnormality. So this is in the left lung, and it's a consolidation. So this is the second, uh, x ray. Have a look at it. And, uh, you know, see what you think. Yeah. So people have said pneumonectomy. Good thinking. Infusion. Yeah. And Imitrex on the left. Okay, trickle. Deviation. That's correct. right. Okay. Yeah. Left lung collapse. Okay, so let's discuss this X ray. Um, interesting thinking. So, basically, on this film, the abnormal side is the right one, and I'll explain you. Why? First of all, it's called the white out lung again, and you can see even compared to the previous X ray, that this is more homogeneous and does not have a Bronco Grams. Can you appreciate that? And also looking at the mediastinum the trachea, the hard shadow is all pushed to the opposite side. So there must be something filling in the right lung, which is causing deviation of the mediastinum and trachea to the opposite side. So it cannot be collapsed on pneumonectomy because in pneumonectomy and collapse, you would expect to be volume loss. And so the trachea and the mediastinum would be actually pulled in Rather pushed in. Okay, so this is a case of homogeneous, um, consolidated. Sorry. Homogeneous opacity with no air, bronco grams and, uh, deviation of the mediastinum to the opposite side. So this is a case of a large right sided pleural effusion. And you can also appreciate again there is loss of hard border. There's loss of diaphragm. You can see the data from the left base. Very well seen, but the right is loss again. The silhouette sign the chest X ray. The most important one of the most important sign is the silhouette. Sign everything because we are just looking at one image in the two D. The silhouette sign will give us a clue as to where, exactly or not always, But most of the time we can locate the abnormality. So this is right sided pleural effusion. Okay, so this is the third X ray. Have a look at it and see what you think, right? Okay. So if you if you have said right collapse Yeah, good. A chicken deviation to the right. Yes, right. Collapsed again. Most of you are thinking it's right. Collapsed. Anybody thought of, uh, yeah, right. Pneumonectomy. Yeah. Well done. So, um, this is a case of right pneumonic to me, as rightly said by some of the some of you. But again, um, the features to look for is again the wider pacification, which is homogenous, Um, and no lung markings. Whatever it's it's all, uh, homogenous. And also the main important thing is the loss of volume. So the deviation of the trachea and the mediastinum is towards the abnormality. And, um, and also again, uh, silhouette science. So there's no distinction of hard border on the right side, no distinction or definition of the right hemidiaphragm. So this could easily be, uh, you know, collapse right lung complete collapse. But, uh, if the things to look for in a pneumonectomy is first thing, is asking patients if the patient has had any previous surgery and then, you know, this is a pneumonectomy case, and the second thing is, most of the time you can see missing ribs, especially for pneumonectomy. I think you look for missing fifth rib, but it can be, you know, above or below. So there will be a missing rib. And also you can see how the the normal left lung has hyperinflated compensate for the you know, the deficit on the right side. And, uh, and it's also herniated towards a bit of in the eighties as well. So you can see some variation here. It's not as dense as in the lower zones here, So, um, there's no herniation of the the hyperinflated lungs towards the right as Well, so this is a case of right pneumonectomy. Very good. So we'll go into the next chest X ray, and I'll give you 20 seconds. Yep. Right. Any pots? Right. Low, low collapse, right sided consolidation. Right. Middle zone zone consolidation. Very good. So now we're dealing with global collapses. Okay, so this case, let's see, what are the positive features? So when you compare the lung volumes, there's a definite decrease in the lung volume on the right compared to the left. Yeah, uh, some of you said right there from calci. Maybe not because there is an elevation of the diaphragm, but also the, uh, the opacity here, which is not explained, isn't it? So, uh, so there is lots of volume compared to this. And because there's lots of volume, there is elevation of the diaphragm. The second thing is, if you see the hilum there, which is not really defined because of the again silhouette sign because but then the is in the in the same levels. It's kind of it's elevated. And there is also this haziness, which is, uh, along the right heart border. So you've lost the definition of the right heart border. Can you see the left heart border? It has a distinct line there. But you can you can know more. Draw a line here. So this is a case of, uh, actually a combination I can show you. Uh, here. This was the CT findings. So this is a combination of the right upper lobe because there was deviation. Elevation of the right. Right? I'll, um, and a significant loss of volume and middle lobe. So this is upper lobe and middle lobe. Uh, sorry. Collapse. This is a case of a global collapse, but, you know, both together. Well done. So one more. One more pathology that it's not pathology, but one more condition. You need to remember when you see some haziness around the right heart border with loss of definition of the right heart, border spectrum, excavatum. It almost looks like it all. Almost looks like the right middle lobe collapse. Just the right middle lobe, where the loss of a hard border and then some some haziness along it. But there is difference. You need to. First thing is ask history. So if you ask the patient and the examination of the patient, so if If in doubt, you can examine the patient, then then it's very obvious when you examine the chest. It's very obvious if if the patient has pectus excavatum second thing is there's no loss of volume. There's no absolutely the right lung is as you know, uh as, uh, irritated as the left lung. And the third thing is, if you look at the orientation of the ribs, it's very subtle. But you know, when you see more and more, you'll you'll appreciate it that there's more horizontal placement of the ribs. And there's this acute angle. It's almost like a hardship. If you follow one rib, for example, like that, it is almost making like a hardship. Yeah, so and of course, if you're if you if you want confirmation that the lateral X ray is best and sometimes you can also pick it up on the CT. So this is the next X ray and I'll give you some time. So, um, what have you been thinking? Hyperinflation. Yeah, it is. Actually, I agree with you. There is a bit of hyper inflation looking at the left lung Lung meds. Yeah, I see why some of you think it's language, but actually, it's the It's the bone and the costochondral junction. Is that look like there's something going on there? Um, heart failure. Um, it's an AP film. If you look at that, it's an ap Eric film. So, uh, the heart, uh, heart is not enlarged, allowing for protection. Is this a child? Yes, it is. Young. Yeah, it's wrong. Cactuses. Um right. Trickle deviation. Yeah, I agree. There is light trickle deviation. Okay, so this is a case of, um right. Lower lobe collapse. This is the importance of review area behind the heart. If you can see, there are two borders for heart, this is the normal border. And you can see there's a triangle or the sale shape density just in the right. Uh, you know, just next to the behind the heart. So this is the collapsed right lower lobe. And what it has done is loss of right hemidiaphragm definition here on the medial aspect. And you can also see that maybe you can appreciate the the Left Island here, but you can't see right island here because it's been pulled into the collapse. So it's kind of move downwards, so yes, there, You know, comparing right from the left. Yes, there is some volume loss in here. So this is a case of, um, right, lower lung collapse. So, looking for the sail, sail, shape or triangular shape, uh, capacity behind the heart and loss of heavy duty from on the right. Well done. Oh, okay. So I think of Miss the one that you can you can see what it is, but yeah, this is a case of left upper lobe collapse. So things to look for in the left upper lobe. First of all, it's difficult to spot. It's really difficult because because the upper lobe is anteriorly placed in the left lung. It's when it collapses. It just forms, like a real, like capacity on the left hand. So the things to look for is a way like capacity, uh, just increasing the density suddenly more than the opposite lung. And then also, uh, minimal loss of volume. And compared to the opposite lung and loss of hard border. So you can see that the heart border is not very well defined, like we've seen in the previous chest X rays. Um, and also a position of the hilum You know, it sometimes can be higher, a little bit higher than expected. So So this is a case of left upper lobe collapse. And as I say, this is one of the one of the subtle find, you know, one of the difficult, noble collapse to diagnose. But once you've seen it once you, you know, go through the silhouette, sign the volume, loss, the density. You should be able to pick it up. Next one. What do you guys think? Mhm. So? So somebody thought that could be a runner. The dive from I think that's the gastric problem. But that's a good thinking. Okay, left lower lobe collapse. Okay. Yes, I think, uh, left lower lobe collapse is yeah, is correct. So you can see again exactly how we saw on the other one. Right? Lower lobe collapse. This is the left side. So you see the sale sign and you see the double heart border. So you see the double heart border there? That's one. And that's the other one. So that's the normal heart border. What's normal? And then this is again another triangular shape capacity which is homogenous and behind the right heart. right heart. So this is another reason why we have to make sure we look at the review earlier as retrocardiac or behind the heart. Because this can be subtle and mist if you don't look for it. And there is some volume loss. Definitely when compared to the right, uh, and again. And I can't appreciate the hilum here. Can you see the hilum here? That can give thing. They're the abuse angle there. So that's the That's the right hilum. But the left hilum is pulled downwards into the collapse. So this is a left lower lobe collapse. It was This is the CT which confirmed the left lower lung collapse. So when the left lower lobe collapses, it's posterior. So it that's how it looks on the CT. Can you see the capacity even compared to that right side? Right? Next one. I think this is pretty obvious, but I wanted to discuss how we approach it. Right. Um, I see the chat that somebody wants to look at the sale sign again. Okay. I'm just going to go back. And so, basically, because there's lower lobe collapse, the the definition of the left hemidiaphragm is lost So as you can draw a line on the right diaphragm, you can know more. Do a line on the diaphragm because they're still out sign. And can you see this density here? It's almost like a sail there. Or or a triangle or a triangle. Yeah, this is more obvious. Sometimes it's smaller than this. Sometimes it's bigger than this. So it can vary. Right? Okay. What do you guys think of this one? Okay, left side. The tumor. Somebody says Very good. Yeah. Yes. Landmass. Yeah, I think it's pretty obvious I've taken a really big lesion. That's very obvious, but I wanted to. The more important thing is, I wanted to discuss how we approach when you see, uh, solitary lung mass or which is also a coin lesion. So basically, when you see a lung mass, the things that you need to look for is are the borders irregular? Okay, this seems to have a really round and well defined border. Generally malignancy, You know, if it is if it is cancer, it has speculated irregular border, too. It Is there any cavities? A shin for this? I don't see any capitation. It's really smooth and Are there any calcification? Because some some malignancy are more, uh, with calculation calcifications within it and some don't. So that's and and and in general, if it is benign, longstanding, they can have some calcifications. So that kind of points you towards benign or malignant. Are there any, uh, recent rib that's been destroyed by the mask? Because if it is malignant lesion, that will cause destruction of the adjacent ribs, which looks okay here. And are there any lymph nodes? Mainly in the highlight region highlight and the mediastinum. So if there was a malignant mass in the lung, it would expect some lymph nodes, high alert and mediastinal and supraclavicular so on. So it's important to check that. And also your infusions are their pleural effusion, especially one sided. So if there was a lung tumor on on left, you'd expect there would be some unilateral pure effusion on the same side. Um, so these are the things when you when you see a coin lesion or the solitary mass in the lung, these are the things, and one more thing is the location of it. Just to, um, determine that it is in the lung and not the pleural. Yeah. So one of the things you look for is the angle that that the mask makes to the chest wall. And if it makes an acute angle, then it's probably in the lung. And sometimes you can see that the mass has an obtuse angle like that. Which means it's probably in the in the pleura or or, you know, beyond, like a soft tissue, your ribs or something like that. So then it makes an obtuse angle. I have another example which I can show you. So this one turned out to be a benign lesion, but quite sizeable. And it hadn't changed for many years. But these are the things you look for and comment on when you're looking for a lesion. Solitary lesion in the lung. Yes. So, uh, this one I just wanted to show you this is a okay. I think I'll give you some a few seconds to go through it and see what you think. Yeah, I can get somebody says cannonball lesion. Perfect. Yeah. So this is, uh, lung metastasis. So they are, like, fluffy. Not, you know, regular shadowing throughout the lung. More so in the lower lobes because of the increased blood supply to the lower lobes. And there are varying sizes. And if it depends? If it was, if it was a primary from a sarcoma or a few other, like malignant melanoma, you would expect some, uh, some capitation within them. But in general, or if it was, uh, sarcoma again, you could expect some calcification within them. But in general, these are cannonball appearance and in keeping with lung metastases, well done meant Yeah. So this one let's give 30 seconds and see what you guys think. I think this is a bit more subtle than what you've seen so far, but it will be interesting to see if you guys can pick up the lesion or abnormality. Yes, some of you thought this something in the in the right Emphasis. Mhm. Can anybody be more specific? Right, Hyler abnormality. Uh, pancoast humor, right, clavicle more prominent. Yeah, I can I can I can see that you got you. You people are thinking in the right area and, uh, yeah, so well done. Basically you said right Apex. So when it is an abnormality in the apex, you would see as in just that proportion, mostly. And you could see it different from there. But here, if you follow my, uh you know, my pointer, I can I can actually draw a line up till here like that, which looks much denser than compared to the left side. And it's got that concave border. Do it. So this is a classical example of right widening of the right paratracheal strike that I was speaking as one of the review areas. So if you can appreciate, this is much denser than the left side. It's got a concave border, and there is widening. It's way beyond 53 or 3 to 5 millimeters. So So, um, now I can show you the CT for this patient. Can you see this was a large, superior mediastinal mask, which was causing widening of the paratracheal stripe on the right. It's It can be really subtle, but, you know, very satisfying when you find out right next X ray. We'll give it some time, so concentrate more on the right side, left side. I know it's a bit busy. It looks like there's some, uh, increased lung markings, but it's, uh, it's I think it's a bit uh, over penetrated. So don't worry about the left side. Right. Highlight condition. Yeah, something's going on. Going on in the right. Hilum. Yeah, I agree. Right. Tyler dilation okay. Yeah. So, yeah, you guys have found the abnormal abnormality that it's something to do with right Hilum, isn't it? So I was telling When you review the hilum, there are three things that you look for. One is the position actually here. You can't even make the position because it it's kind of lost the highlight look of it, like you see here on the left side. First thing, the second thing is it's got that concave. Something there, Can you see? That's just very concave. It's no more having that con. Sorry, convex. I'm sorry. So it's got that convicts convexity to it, whereas the left hilum is still normal. And you can see that it's got that conk your body to it. And when comparing the left with the right, you can see that it's increased in density. Definitely. And it's lost the right heart. Border is kind of fussed out. So and also just just to note that there's a fracture of the wrist here. Okay, So this when we did a CT, this was what we saw. So there was a big right hilar mass. And that's why you know, the right island was denser than the left. Well done. So this case again. So we're talking about something in the right. I'll, Um So it's again, right, Hilum. As you can see, you can still appreciate the concavity here, But then, you know, you know that there is something going on here, which was which is not seen on the left side. So and it's it's just not density, isn't it? Because the last one you saw that it was more dense, but this one seemed to be a bit, uh, in homogenous or heterogeneous. So this can anybody tell what it could be, right? Lymph node Enlargement. Yeah, but I'm expecting What kind of lymph node Hamartoma. Yeah, If it was just lymph node, I would expect it to be homogeneous density. But this looks a bit heterogeneous, isn't it? Capitated mass? Yes, absolutely correct. So this is a capitated mask, and you can see some fluid level. Maybe here, but but this is got the border to it, and then it's got loose and, uh, center do it. So this is a candidate English in And this? Yeah. So this is how it looks on the CT. So when you when you're dealing with the cavity eating lesion, the questions you need to ask and look for Is it single, or are there multiple cavity eating lesions? And when it is single and large like this, you have to look at the borders to see if it is thick wall or thin walled. Because there are three. There are three things that can be, uh, that can present as a single large cavity in English. In one can be carcinoma, abscess and TV. So if it is a malignancy, then it'll have a thick wall to it. And if it's absolutely it, generally it's thin wall. But it you know, it always overlaps the findings and also look for any fluid levels within it, which is very important. That shows kind of, you know, active process happening. Or is it, like chronic long standing? Um, and also, sometimes you can see some soft tissue ball in it, and that is typical, and it's like an aunt mean, even we see a soft tissue ball within the cavity eating large cavity in lesion we think of as papilloma and, uh, generally as papilloma happens in a patient who is immunocompromised. So whether it's an HIV patients or or a TV, especially tea captivating lesion because of the TV, they can be as papilloma complication. So yeah, good. So can anybody support the abnormality? I think with the projection of the X ray, you should be already able to guess what I'm looking for. Sorry, somebody has mentioned the previous. Could it be, um, sorry. Could it be a bullet? And the answer is unlikely because if you see it's got such thick wall. And, uh, bullies don't have thick wall to them. They're very, very thin, thin, very thin wall to it. So, yeah, it's It's unlikely unless the bullet is infected. Shoulder surgery, ribs, broken dislocation. I think I'm more looking for long abnormality. The bones are all right. Pneumothorax. There we go. Yes. So pneumothorax is very important Diagnosis on X ray. And, uh, when I was getting trained, I started to look for any any X rays. I started to first rule out pneumothorax and then start looking at everything else because it's important and, uh, the things to look for. Can you see that is the lung margin. So you you you will be able to see the lung edge when in pneumothorax. And, uh, if you can appreciate their our lung markings up till up till the line there and then there are no long markings past it because there's no lung there. There's only area in the in the pneumothorax there. So So always when diagnosing pneumothorax epical nematocyst Rx, uh, Democrats can be subtle. So look for the lung age is if necessary. And that's why I put this projection because, uh, to rule out, um, a small pneumothorax is subtle Democrats. You need to zoom it to the emphasis and sometimes change the contrast. And you can also see, you know, if it is large enough, then the mediastinal shift towards the opposite side. And also importantly, when you see any more cracks Yeah, it can be spontaneous, But also look for any cause causative factor. Like is there a bully bulla, which is ruptured? Um, is there a fracture? Is the patient had a trauma or, you know, road traffic accident, and is there a fracture Or is there a shoulder dislocation? Uh, those are all quite relevant because that can cause edema. Correct. So this one, I just wanted to show this one because this is the Imitrex. But it's, uh it's a tension pneumothorax, which is potentially federal and needs immediate intervention. So it's a medical emergency, so we should never, you know, miss this. And it's an urgent finding, so the lung you can see is completely collapsed in the medial aspect. The whole of this is filled with air. So this is a This is a large left side of pneumothorax, and I I'm sure you can appreciate there are no lung markings when compared to the right here. Can you see that's all the lung markings. But you can know more. See the lung markings there. So this is kind of comes in the category of too dark and and also the most important thing for telling that this is attention. Pneumothorax is when there is significant deviation of the trachea. Can you see? It's not no more central, it's gone towards the opposite side and the heart. It's almost like the hardest pushed completely towards the right side. So, um Okay, So, um, so this is a tension Imitrex. And if ever you come across this, it's a medical emergency, and, you know, you need to have an immediate intervention. So somebody wants to look at the look at the previous one with subtle pneumothorax. So this is it. Um, So this is the language. If you take a pencil, for example, that's how I see the margin is you know, the edges seen if you take a pencil and you should be able to draw a line there like crisp line. And you see, there is no long markings, bastard, like you see here. Okay. So moving on to the next one. Any ideas what this is? Yes. Um, someone has said cardiomegaly as I agree. Tamponade? Yes. Very good heart failure, right? They they might. Yeah. There is some congestion. Pericardial effusion. Yeah. Perfect. So this is a case of pericardial effusion. And yes, uh, you know, it is basically enlargement of the cardiac shadow, but then the shape of it is slightly odd when compared to normal cardiomegaly. So this is almost like, uh, like, uh, you know, global a football shape. And, um, and Yes, there. There's just some degree of heart failure. I guess so. When we did the CT, it's This is how it looked. Can you see this is credit card or effusion. So this is the normal heart, and it should just have a thin line surrounding it with no fluid, you know, very, very trace of fluid, which we can't generally appreciate. And if you see the this, uh, from the x ray patient, you can see that there is some soft tissue. Like, you know, there is some fluid completely in encasing the heart. So this is a case of pericardial effusion and possibly patient is in Tampa. Not Yes, it's again. You know something that you have to, um you have to, uh, flag up. Well done. So, this one? Yes. Um, some of you have suggested. Yeah, most of you have said the right thing. Nemo Peritoneum air under the right hemidiaphragm. Well done. I consider this X ray as a subtle finding. And, um, it becomes more obvious when you do the review areas and go under the diaphragm. So it's important to again, you know, do the review areas. So can you see that line. And so there is a Lucent line under the diaphragm. So, uh, the the the advantage of doing a challenge, Eric, chest X ray for query. Uh, sorry. Query, Nemo. Peritoneum is that it can deduct as low as tenement of gas. So it's quite specific and, um, sensitive as well. So this one on the right side, generally, if there was a runner, the diaphragm on the right side is much more easier to diagnose than the left side. Only reason being, you know, somebody mentioned about the air under the diaphragm for the gas bubble in the in the stomach. So that is the difficulty. You know, the gas has, you know, the stomach has a gas bubble, always most of the time, and then it's quite difficult whether you know, determine this is gas under die from all the gas bubble. Um, so the the point. So somebody is asking me, how do you differentiate? So the point to differentiate the air bubble in the stomach Stomach bubble basically. And the gas under the left hemidiaphragm is you know, how can you can you appreciate the diaphragm? It's a thin line. So if there was an air under the drive from it should be a thin line above it, whereas in the in the stomach bubble there's a PICC line above it because it's it's obviously other, you know, soft the ship. And, um, and also the lucency is more like a crescent shaped, uh, which would be here. But if it was a stomach trouble, as you saw on the previous X ray, it's more like a rounded or over shaped. So, uh, so that other features, you know, you differentiate from a gas bubble. Um, so, yeah, it can be subtle sometimes, but it's it's, uh and it has to be electricity X ray. So this is very subtle finding. I would want to see if anybody can pick it up. So somebody suggested emphysema. I see. Uh, it's well inflated, but yeah, rib fracture, is it? Right? Left left, Sided. The hemothorax. Right. Rib fracture. Um, left lower lung consolidation, right? It's not the left lower lung consolidation, because I think I think I know what you're seeing. It looks like there's a triangle here, but actually that this is a female patient and always remember, if there was a female patient, you have to, um, you have to consider the breast shadow. So this is her left breast and the right one so that that's what making look like a triangle opacity behind her. But it's actually not. And this is almost, like, straight and heart border. There's no double border here. Somebody mentioned left rib only met, and I agree. So that was very subtle and belt on for finding it out. Because when you follow the bones, then you come to this and suddenly there is an expanse, a lesion in the left rib. So counting 123456 trip. So can you see the cortex should always be. You should be able to write in a pencil. Uh, the the cortex should be able should be traced with a pencil, and then you can see that it's and then suddenly you kind of lose it. And then it's kind of expansile there. So if I draw around it so that's so that is a a metastasis on the trip, and can you see that capacity? It's kind of making an obtuse angle if you I mean, it's it's not the ideal case, but if you see it's actually making an abuse, and it's not making an acute angle. So we know this is something not in the lung, but outside the lung and the chest wall. So when we did the CT, this is what we found. Can everybody appreciate? So these are the ribs. And then suddenly there's an expansile, uh, destructive lesion with some soft tissue component and pleural thickening. So this is in keeping with metastases. I just put this chest X today to show you guys it can be you know, everything is not just one pathology and straight forward and looks, you know, uh, crystal clear something. It just like it is so, uh, complicated. It can be very, very tough sometimes. And especially when the patient is an I t u. There's an AP projection line, you know, supine and the patient is in recess. There's so many things you need to look at the tubes and the positions, and these are all the e c G buyers. And then there's you can see there is this this line here. That's because the patient has got pneumomediastinum. Um, so you can see there is some lucency here between this line and the and the heart border. So this is the gas in the So it's basically pneumomediastinum. And can you see some bubbly shadows here? Uh, lucency. So this is, uh, surgical emphysema in the neck. And there's some capacity here. So, uh, so basically, I put this one to show that, you know, when there's so many things going on, uh, you know, you need to calm down and say, Okay, I'll review one area after the other and find what all they're might be. Multiple findings. So just a systematic approach would really help in this as well. So well done, all of you. I think most of you, I hope I hope that, You know, uh, most of you have got an insight of, you know, findings on logistics. We'll also go through some of the cases of the n g tube placement. Uh, you know, on looking at the G two positions on the chest X ray. Um, because again, you know you as medical, uh, junior registrants is where you face it again. So n g tube placed generally in patients who need feeding or for aspiration purposes, or sometimes when the patient has got obstruction or something, so they need the gastric decompression. Um, so when the n g tube is in position, we call the n G. Tube is in position when the tip of the n G tube that at least 10 centimeters beyond the gastroesophageal junction. And the reason for this is generally you can see the tip of the N G tube as a dense, uh, you know, denser than the normal tube itself. So when you see that, you know that that's the N G tube. And the other thing is, the N G. Tube itself has some holes side holes in the distal. And so if you didn't, you know, advanced the G tube 10 centimeters beyond the gastroesophageal junction, then maybe the you know the holes are in the lower esophagus than being in the stomach. So that's the reason that you know, you always make sure that the N G tube is advanced 10 centimeters beyond the gastroesophageal junction. Um, I'm straight going into the G tube in the wrong position. Uh, so this is a case where you can see that the n G tube can you see? That's the attitude. And as I said, the N G tube tip of the N G tube is dense so you can see. First of all, it's not gone beyond the gastroesophageal junction. And also one more clue is you. You can always, always generally appreciate the trickle deviation, so it has to be below it. If it hasn't advanced below it, then you have to look where it has gone, and then you can. If you follow it, you can see that it's straight gone into the right lower lobe bronco buster. So these cases, when it goes to the lo lo bronchitis or in the lung, then there is a risk of aspiration because patients, you know is being fed. So that's that's the importance of making, you know, making sure it's in the right position. So again, another case where, you know, can you see the dense line there? So this is the MG two, and you can follow it like that and then has it come down below the trickle division? It hasn't have you. Can you see any below the gases of your function? You know, the line that you're seeing here is the pacemaker wire. Can you see? You can follow it all to the pacemaker there. So it's in the left ventricle and the right atrium, the another one. So this is a dual lead pacemaker up so that that the G tube itself, you can follow it. It's again gone into the light right now, you know, low low broker and into the lungs. Actually, again, this got aspirations, so this has to be removed. This is a case where N G tube is in the left lung with left side anymore products. So if you follow the N G tube, it's gone. There are other lines, like the Central Line and other things, but if you concentrate on the denser dip here, this is the N G tube. So if you see it's followed and can you see it below the trickle deviation, you cannot, because it's gone into the left, left lower lobe, bonkers and all the way outside the lung, and has caused pneumothorax on the left side. Can you see there's no lung marking and it's too dark, and it's caused collapse of this lung here. So this is a case where N G tube was in the left lung, causing left side anymore. Correct So that's another complication. One is aspiration. We spoke about the other one's name. A correct. This is extreme cases. I just wanted to show you guys, uh, this was a case. I mean, one of the consultants radiographers just provided me with these images. Uh, but if you can appreciate this patient had a a a traffic accident and he hardly for the fracture, which means, like the base of the skull fracture. I don't know the degree of it or anything, but then if you can see the n g tube in instead of going, uh, downward has actually gone up words and has gone all the way, penetrating the fracture bit into the brain. So it's actually in the brain. Can you see it's in the brain? So this is actually, I've, you know, it's it doesn't generally happen. And this is another extreme case. Can you see the n g tube? This is the, you know, the actual view of the CT bone window, and you can see that this is the nasal cavity. It's penetrated the posterior nasal fossa and then all the way sphenoid Sinus, and it's gone through it and reached if you can see on the sagittal view, you can see how it's gone through it to go into the spinal canal. I've never seen this before again, Right? So we've come to the end of it now, and, uh, the take home message for chest X ray review is a systematic approach is the key. Uh, and the chances of missing things are very unlikely if you go, if you have a system in your approach, every chest X ray the same way as you do. And of course, when in doubt, we're all the radiologists are always there to help you guys. Thank you. Thank you very much for that week. I certainly learned quite a lot this evening and, uh, definitely apply that when I go into my next shift, you should all get feedback links email through to you in the next 5, 10 minutes or so. Um, I will also paste it onto the chatter box as well for this session. Um, once you feel in the feedback forms, you should get a certificate that will get sent straight to email that you registered with, Um so next Wednesday evening at eight. PM this time. So this time next week, Dr Hughes will be presenting, um, approach common cases and pitfalls of abdominal and pelvic X rays. Uh, next Saturday morning at 11 AM, Dr Double be starting off the plain film sessions for M S K. So he'll be starting on the approach to hand and wrist X ray interpretations. I'll hop all this down in the chatter box below. Um, also in that, I'll put in the chatter box is the link to register for those sessions. So don't forget to sign up for that or you'll miss out. And the last link that I'll put in is, um, the link to the mind of the website where you can sign up to all these webinars. Um, I will just give it about 30 seconds to a minute, just in case anyone has any questions about this session. Um, and then after that, if there are no questions, then we'll wrap up. So I'll just give it about a minute or so just to see if there are any questions. I'm sorry. I think I had these myself. So record there is a question. Can you explain the first case again? Um, they said there they know what you mean by air. Bronchogram is how do you differentiate whether it is pleural effusion or consolidation? Yeah, of course. So I have to go back to which so I'll show you. I'll show you all the first one which was a consolidation, and then compare it with the second one. So this was the first one which is consolidation and and and then can you see that there is some blackness in it and it's not really homogeneous is some blackness there? And if you actually carefully look at it, it's linear. It's coming towards the hilum. So these are the airborne programs that we see. But if you see the next one, keep this in your mind and then see the next one. Does it have any blackness in it? No, not at all. It's very, very homogenous. And no air bronchogram. Yeah, right. So I have I have popped in the chat box. Um, the links to the various things said earlier. So 24 at eight PM, 24th in November. That's the abdominal and pelvis plain films. And then on Saturday, the 27th of November at 11 in the morning, I'm afraid this one's the weekend. We'll start the Escape Plain Film series. So that's hand and wrist on Saturday, which is notoriously quite difficult to interpret. Um, and the last link is just to sign up for all the mindedly webinar series. So that's radiology, and there's a lot of other ones on there. There's a medicine series and the urology series, too. Um, someone has put. So the first one is pneumonia, is it? I think, um, you did yourself record. Yes, that's correct. The first one is pneumonia and the second industrial effusion, which doesn't have air program. Fantastic. So let's put, where is the gastroesophageal junction on the chest rectory? Right. Let's go back to uh, yeah, So if this is the normal, Yeah, this is the normal chest X rayed. And, um, in fact, we can never see esophagus until it's dilated, and if it has a role in it or fluid level, and it will never be able to see because it's a soft tissue and it will merge with the soft tissue in the in the mediastinum. So, um, we should, as you can, you see the gastric bubble there that is the gastric bubble, which I said It's either round or oval. And so basically the junction would be at this place where you know they die from meats, the spinal junction here, So it kind of goes through there. I think that's all the questions. So don't forget to sign up to the future sessions. If you click on the mindedly profile on metal, you should be able to see all the radiology ones that we have coming up. So they're generally weekly up until mid January with a break over Christmas time, because I don't think anyone wants to be looking at Webinars over around Christmas. New Year time. Um, someone has put Can we have a QR code for feedback? Let me try and sort that out for you. Now give me a second, right? So I've had let me see if I can put this in the group chat because it's come up as an image. I don't think it's impossible to get you the QR code. Do you have the If you look at the email, you should have a link to be able to get the feedback so you can get your certificate. Um, if you can't do that, then, um, if you email mind the bleep. So that's mind the bleeding at gmail dot com. Um, then we can send your QR code on that. All right, So if there are no other questions, then we'll repeat this session. So this does get recorded, and it should be uploaded on on metal afterwards. So you can watch it again if you've missed anything during the session. All right? I don't think any other questions. So thanks so much everyone for attending. Don't get to fill in the feedback, and I'll see you next Wednesday. All right, Take care, everyone. Thanksgiving. Bye. Thank you. Bye.