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Ok, everybody. So, um welcome back. Um I'm hoping that most of you um were with me last week, uh when we kind of did the first half of talking about chest xrays and we're now going to kind of move on to the second half and there's a little quiz at the end. Um Have, could I ask you obviously interrupt whenever you want to, if there's any kind of relevant questions? And second of all, um could you tell me when we're about uh 10 or 15 minutes from the end? Because if, if I'm going slow, that's when I'm gonna skip to the quiz. Lovely. No problem. Great. Thank you. Ok. So, um what we're gonna think about now is we're going to think about when there is extra shadowing in the lungs. And um basically, there are two types of extra shadowing that can happen. So it can either happen in the air space or it can happen in the interstitial space. And I'll explain to you what I mean by that. So if you think about it, you have the bronchio which branches out and then eventually ends in the alveoli and that's the air space. And then you've got around those bronchioles, you've got a potential space, which is the interstitial space. And both of those spaces can fill with um substances. So, um if the airspace fills, there are basically four things it could fill up with. And the most common things are fluid as in pulmonary edema, plus as in infection and less common it can fill up with blood. Uh Either if there's some kind of strange um syndrome, like good postures or if there's been uh trauma and very occasionally tumor cells. And what happens is that the alveoli filled first, but the bronchi are still air-filled. And so they stand out against the white alveoli. So the white alveoli full of pus or fluid and the bronchi are still air flu fill, so they're still black. Um And this is called airspace shadowing. And the key feature of airspace shadowing is that there is no loss of volume. So if we look at this patient here, I've zoomed in on their x-ray, you can see that there's um a branching black line on the right and the same on the left with whiteness around it. And this is an air bronchogram and this is air space shadowing. Now, by contrast, the interstitial space, which is that kind of surrounding potential space can also fill up with fluid or indeed with fibrosis. Um And depending on which way you're looking at that interstitial space, it will either look like a nodule or it will look like a line. Um And if you're kind of looking at say lots of um bits of interstitial thickening, which are running in different directions. It will have both line and nodule component. And as I say, the causes of interstitial space, uh filling up is either fluid which could happen in pulmonary edema. It can happen in lymphangitis or sometimes with inflammation, particularly when that leads to fibrosis. So let's think about interstitial shadowing, first of all, and if you look at the lungs on this chest x-ray, they just look dirty, don't they? So kind of as you look in the periphery, uh you kind of start to think hang on, there's some extra lines here. And um on this ct this is a different patient. This patient has sarcoid disease. And on this, you can see that there are lots and lots of little um rounded nodules, but there are also some linear um components as well. So this is a combination of um nodules and linear components. And what we tend to say when we're talking about nodules and lines is to say it's reticular nodular and you can kind of cover a lot of bases by saying it's reticular nodular. And you know, if you in an exam, your t your examiner might say, well, it's more nodular, isn't it? And then you can kind of say yes, it's more nodular. Um So I would say there's reticular nodular shadowing whichever zone it's in. And then I'd also comment on whether or not there's loss of volume because when you've got interstitial fibrosis, uh eventually that causes loss of volume, it contracts the lungs down, it pulls them down. So here's someone who's got advanced fibrosis. And if you look at the periphery of the lung, instead of having a very clear edge of the hemidiaphragm, for example, you've just got these kind of radiating white lines and the same if you look in this region here, um you can see these kind of almost curvilinear um shadows and then there's some bits which are a bit more um dotty. Um And basically, this is what fibrosis looks like. So just to revise that air space shadowing versus interstitial shadowing, so they can both affect any zone, air space shadowing, you get these confluent white shadows, but with air bronchogram and interstitial shadowing, you'll see reticular so linear or nodular shadowing and the causes of them. So air space shadowing, the most common cause is either fluid from pulmonary edema or puss from an infection. And the common cause of interstitial shadowing is fluid or inflammation leading to fibrosis. So, why is this airspace shadowing? Well, um oh I think I've actually, I've got a vo a voting thing here. So I would like you to vote if you can. Um Yeah. OK. So I've activated the voting. Uh I'm not sure if you remember this from last time, but um Basically if you go to this address, so pollev dot com forward slash EIC 900 on your phone, you can choose to be anonymous. You don't have to um, put your name in and you can vote. I'm actually just gonna post, post this in the Oh, so you're ahead of me. Thank you. Great. So hopefully people will be able to start to vote now. So why do we think this is airspace shadowing? And I'll just go back to the x-ray. And what I've done is I've zoomed in on this bit. So I want you to look at this bit. I know the patient's got lots of chest drains and things like that in. But I want you to look at this area, a white shadowing and then look within it and look at what you can see. Um and tell me what you can see here. So is it that you can see air bronchogram or is it that you think there's reticular nodular shadowing? Remember air bronchogram? Is that branching black line that you see outlined by white uh lung? And I'm just gonna have a look at the answers. Well, it's reducing. Uh isn't it? So I think the majority of people are saying it because there are air broncho grams and you're correct. So, what we see here is this branching black line which you can imagine is the bronchus and then around it is white lung which is fill of alveola and we'll go back a bit more and talk about why this is airspace shadowing rather than interstitial shadowing. So, um I, I guess part of the issue is that when you have left ventricular failure, you definitely have airspace shadowing. So you have fluid within the um alveoli, but you will also have some fluid in the interstitial space. And what you can see here these little lines, the curly B lines that we talked about last week, this is fluid in the interstitial space. Basically, the lungs are so overloaded, fluid just goes everywhere. And so sometimes you get both airspace, shadowing and interstitial shadowing, which makes it a bit harder. Ok. So the next thing I want to think about is collapse. Um And basically the lungs can collapse if there is some kind of proximal obstruction. And the key feature with collapse is that um you get loss of volume of the lungs. So the lung instead of being inflated, collapses down, and it's going to be in a predictable location because we all know where the lobes of the lung are. So you can work out which lobe is involved by looking at the normal contours. So normally, for example, we've got a crisp contour around the arch of the aorta around the heart along the left hemidiaphragm. See how I can follow this left hemidiaphragm all the way here. It's clear and the same the right hemidiaphragm. It is a very clear line and the right heart border, it's all clear. So, what you're looking for is to see, can you see those clear margins or not? And when you get collapse of a lung, depending on which margin is lost, that will help you work out which lobe is lost. So for example, if you lose the left hemidiaphragm, that makes you think about a left lower lobe process. And if you see something behind the heart, um then that makes you think about left lower lobe collapse. If you see um a loss of the right hemidiaphragm, that makes you think about right lower lobe. If you can't see the right um mediastinal contours clearly, that's where the right middle lobe sits. Remember the right middle lobe is anterior and then the left upper lobes at um kind of obviously are to do with the upper mediastinum. So let's look at some examples. So remember when you have volume loss, the mediastinum will shift towards the site of collapse, the hilum will get pulled and you may see the horizontal fissure being pulled as well. And the other thing that happens is that the rest of the lung that is still inflated, uh has to kind of fill the space. And so that becomes blacker. So let's take a look at some examples. Um So this patient, um I would like you to help me decide is this left, lower lobe collapse or consolidation. And um you know, I'm gonna get you to vote actually. Uh So hopefully people can come vote. And while we're voting, I'm gonna explain what, what's going on here. So the first thing to say is we know this is left lower lobe because we've lost the left hemidiaphragm at this point. So we should be able to see the left hemidiaphragm all the way across and we can't see it. And then we have to decide, is it left lower lobe collapse or is it consolidation? And the first thing I do is I look at the heart border and ask myself, can I see something behind the heart border like a kind of sail shape or not? Then the next thing I do is sit back and I compare the two sides is one side blacker than the other. And if one side is blacker than the other, that implies that the lobe that is left has to really kind of expand to fill the space. And then the third thing I do is I look and see, can I see any of those air broncho grams? I can't see those here. So let's see what you've answered. And I'm glad to see most people have gone for collapse, which is great. So that's correct. So the reason why this is collapsed is first of all, it's got a sale shape behind the left heart order. Um Second of all, I don't see any air bronchogram and third of all the left lung. So only the left upper lobe is left, is is remaining inflated rather. And that's blacker than the right side because the left upper lobe has had to expand to fill the space. So that's left lower lobe collapse. This is another example of left lower lobe collapse. Again, you see this, it's called a sale sign behind the heart border here. And by contrast, this is someone who's got left lower lobe consolidation and uh it's not the best x-ray in the world, but you can see that there are branching air bronchogram within it. Um And it's kind of extending beyond the heart. Um And again, on, we don't do uh lateral views very often anymore, but you will remember that the left lower lobe is posterior, isn't it? It's behind the oblique fissure. So this is posterior and within these lungs, you can see this uh branching air bronchogram surrounded by white pus within the lung. OK. So here's another patient and this patient has definitely got um a problem in the left upper lobe, haven't they? Because you can see whiteness in the left upper lobe. Um I'm hoping that you'll all appreciate that these are air bronchogram. So, branching air filled structures surrounded by this white um pus or fluid within the lung. And I actually put the um ct up as well. So again, hopefully, that convinces you even more. This is what an air bronchogram looks like. And in fact, in this patient, so this is left upper lobe consolidation. And this patient, it was all infectious and they, it resolved with antibiotics. Ok. This is a different patient. And on this patient, I think this is a very hard film actually. But on this patient, they've got, it almost looks as if someone has hung a veil over the left lung. Um And when you think, oh gosh, someone's hung a veil or it looks like a veil is there start to think about left upper lobe collapse. Um And the other feature that tells you that this is left upper lobe collapse is if you look at the mediastinum and the heart, it shifted over to the left. So there has to have been loss of volume on the left side. So that's why I know this is left upper lobe collapse, not consolidation. And if we look at the CT on this patient, do you remember on the other patient who had a left upper lobe problem? They had air bronchogram. That's how we knew it was consolidation. Well, in this patient, um we see that there's whiteness in the left upper lobe, but there's no branching air bronchogram. So this is truly a left upper lobe collapse. And here's a different patient who's got a left upper lobe collapse. Again, it just looks like someone's hung a veil here. And you can see the mediastinum has shifted over. But the important thing is that also it looks like there's a mass here. And actually this patient had a tumor at the left upper lobe bronchus and that was causing the left upper lobe collapse. OK. Let's move on to the right side. So this patient has lost their right hemidiaphragm. I cannot get a pencil and draw for you where the right hemidiaphragm is. So I know it has to be right lower lobe and then I have to decide is it consolidation or collapse? Well, the heart and the mediastinal contours, they're pretty uh right. They're much in the right position. And the other thing I'm hoping I can persuade you is that we have these branching air-filled structures. So air bronchogram um within the consolidation. So this is right lower lobe consolidation. This patient, I can see the right hemidiaphragm clearly, but I'm not seeing the right heart order clearly. And so, um in this patient, it's a problem with the right middle lobe because we know that the right middle lobe sits next to the heart and then I zoom in and I'm hoping you can see these uh bronchogram again. So this is how we know it's consolidation, not collapse. OK. Couple more to look at. Um So in this patient, the right hemidiaphragm is the sorry, the right horizontal fissure is in the correct position. And then there's this kind of white out above it with some branching as well. And because there's no loss of volume, so the horizontal fissure is in the correct position. I know it cannot be a collapse, it has to be consolidation and I know it's affecting the right upper lobe because it's above the horizontal fissure. And then the fact that I can see the branching air bronchogram helps me to be certain that this is consolidation. OK. Uh I think this might be my final case. So in this patient, do you remember how the last patient the right horizontal fissure was in the correct position? Well, in this patient, the horizontal fissure has been pulled up. So there's a loss of volume here and I don't see any air bronchogram here either. And so this is right upper lobe collapse rather than consolidation. Um I think I put this chest x-ray in just because sometimes they'll put this kind of x-ray and the exam for you. And this patient's actually had the entirety of their left lung removed. And so what happens then is the chest wall collapses down and the left hemidiaphragm comes up. So everything kind of shifts over to take up the space. But if they show you this in an exam, basically don't panic, ask if the patient's had surgery before. OK. So we've talked about collapse and consolidation. And the next thing I want to think about is um when you see nodules in the lung. And so this is n not, not linear, just nodules and the nodules can be small or they can be large and the cut off is five millimeters, usually so small nodules. I think about miliary tuberculosis. I think about sarcoidosis and I would always include metastasis because it's common whereas larger nodules uh basically think about metastases. Um So for example, breast testis tumors, G I tumors, kidney thyroid, and occasionally and again, in the exam, this will be more likely because you know, they kind of want to put rare things in the exam. We would be thinking about inflammatory nodules like rheumatoid or Wagner's granulomatosis. So let's look at some examples. So, in this patient, there are multiple tiny nodules, there's so many aren't there that they're almost joining up. And I'm wondering if you could tell me what you think this could be. There's more than one answer here, by the way. Um So you could answer more than one thing and I'm just gonna go back to the image so that everyone can take a look at it. So multiple tiny nodules or less than five millimeters, I'll give you a better chance just to answer and more than one thing could be a cause. So let's see what you put. Very good. So, yeah, so could it be uh tuberculosis? Could it be miliary metastases? Could it be sarcoidosis? Uh Let's see what the answers are? OK, good. So, um you, I think you've all answered correctly. So the three things that it certainly could be are sarcoidosis. Don't forget sarcoid can look like anything. Millie Tuberculosis. Yes, because it's tiny little milia. And by milia, we mean, it almost looks like seeds and millie metastases as well. So the differential diagnosis or miliary shadowing and by millie shadowing, we mean tiny little nodules less than five millimeters is tuberculosis, sarcoidosis metastases. And sometimes, I mean, we don't see these very often but uh industrial type lung diseases. So pneumoconiosis um I put in um this patient just to remind you sarcoid can have many different appearances. So, in this patient, they've got these kind of slightly dirty looking lungs which on a CT uh will show you reticular nodular shadowing. And they've also got very bulky hilum bilaterally. And so this is um sarcoidosis because you've got the lymphadenopathy and you've got reticular nodular shadowing. Um I've just zoomed in here. So you can see these tiny little nodules and you can see funny little lines as well. Reticular nodular shadowing. Ok. This patient has got lots and lots of pulmonary nodules and they're all quite big, aren't they? And this um in this patient, it was due to metastases. And um the next patient I want to show you I'd like you to point to where the abnormality is on the x-ray and there's more than one abnormality. So you can point to more than one spot. So let's just see there's the image and I'll, I'm actually gonna go back to this image so that I don't influence you but touch the x-ray uh on the uh oh by the way, you con zoom it in on your phone um and tell me where you think the abnormalities are. Um Ola I'm gonna come back to your question. It's a good question. OK. Fantastic. This is brilliant. So uh I'm very happy with the uh many of these answers actually. So um especially and what you can always see when we do an image like this where people have to touch the abnormality is that you always get the most correct, the most answers in the correct position. So this to me is the most obvious lesion. I also agree with this. I can see why people are wondering about this region here. Let's have a look at the x-ray properly. So actually, there are multiple cavitation lesions here. This is the most obvious one. It's so it's got soft tissue on the outside air on the inside. There's another one here. I absolutely agree with all the people who pointed to this. I think that this hilum is a little bit funny looking. So I think you were right about that. And then people have also pointed to this region here. And I agree it's strange looking, isn't it? And I suspect that there are some further cavities here. So this patient has got multiple cavitation masses and I put this up to remind you of the differential diagnosis for cavitation masses. Um So squamous cell carcinoma classically will Cavitt and then infect infections and there are three infections that Cavitt Klebsiella, staphylococcus and TB. So, um, what about when you see a and I'm just gonna double check the chat to see if there's anything anyone's asking here. Uh, no. Ok, great. So, um, let's move on now and think about if there's a single nodule or mass within the lung. Um, so if you see just a single mass, then either it's due to infection or it could be due to uh malignancy. And how do you know whether something's benign or malignant? Well, when it's malignant, you will often see that it's got an ugly, um edge, very irregular spiculated, whereas something that's more benign like a round pneumonia and I will show you one in a moment has a kind of smoother edge. It's rounder. Also, if you see a pleural effusion, if you see hilar lymphadenopathy, those would both be signs that there might be malignancy. And don't forget of course, that any primary mass in the lung can always Cavitt. So it's not a very specific thing if you see cavitation. So, in this patient, um who's got a big mass in the right apex, I'm sure that you can all appreciate this. This is the so called panco tumor and um basically panco tumor, as I'm sure you all know, are they, they, they're basically lung tumors, but they're important because of where they arise. They kind of compress multiple structures. So, actually, I'd like you to put in the chat, if you wouldn't mind, please, what kind of things could be compressed by a panco tumor? Anyone can do it. And there's more than one answer here, there's many answers aren't there. So, between us we'll work it out. So someone's written SVC. Exactly. Right. So definitely the venous structures, both the subclavian vein and the SVC can be compressed, can't they? What else? So, I absolutely agree. The trachea for sure. Um Also, so you're right that the bronchi within this mass or near it will be compressed. Someone's written the common laryngeal nerve. I think that's correct because that kind of loops around the trachea, doesn't it? Phrenic nerve is also there, isn't it? Um I think S MS stands for sympathetic. So, um, someone's talking about the sympathetic um ganglion, um which also kind of goes down that um kind of a chain, a vertical chain, doesn't it? And that's correct. And so, um, people may well have sympathetic type symptoms, mightn't they? And then someone's written the vagus nerve. That's also correct. Exactly. So, would anyone like to tell me what kind of clinical picture might you see with um, this um, if someone's got a panco tumor, what might they present with? So, face and upper limb swelling. Yeah. Ortho uh Horner syndrome. Yeah. Can someone tell me what Horner syndrome is? Please fill it in the chat. Thanks. Um Hoarseness of voice. Yes, definitely esophagus for sure. Could happen. Couldn't it? Uh congested red face. Yeah, because of the lack of venous return. I agree. Breathless, for sure. And problems with breathing. Who wants to tell me what Horner syndrome is? That would be great. Uh So someone's written here? Oh, lovely. I like this. This is brilliant. Well done. So. Um ptosis. That's right. Uh With your kind of eyelid drooping miosis, I believe that's when your um pupil gets smaller. Correct me if I'm wrong, please. An hidrosis. So, basically sympathetic issues. Correct. Yeah. So I'm hoping someone's gonna fill in for me. Is meiosis when your pupil gets smaller or is it just that it doesn't, you've all got the right answer? Yes. Thank you. OK, good. Thank you some revision for me. OK. So this is a pancreas tumor. So those would be the things you're thinking about. Now, we've got another patient here. What causes can you think of for um this appearance? So I'm hoping that you can all see what's going on in the right apex. And I'm hoping that you're all expert enough to recognize that within this mass, in the right apex, there's something going on in the middle. So what kind of things do you think might be causing that appearance? Mm. So it could certainly be a cyst, some kind of weird cyst uh Klebs staff TB. Very good. So you're mentioning all the causes of cavitation, which is brilliant, well done. Um Metastases. Oh and uh squamous cell carcinoma. Fantastic. You really learned a lot. It a absolutely brilliant, well done. So that's correct. So basically, there's cavitation here in this right apical mass and the differential is the infection that we talked about before. So TB, Staph Klebsiella and a cavitation carcinoma. So I wanna talk about TB for a bit. So TB can be primary or secondary. And when it's primary, you get a peripheral lung mass anywhere and entire the lymph nodes and consolidation. And then in secondary TT B, it tends to affect the upper lobes. It can cavitation and you don't get lymph node, uh mediastinal lymph nodes. So this is a good example of a patient who had TB a long time ago. And um what's happened is the lymph nodes and where the primary TB have calcified. So they've almost told us a story about what's happened. Someone said, can it be met to the lymph nodes in the case of pancreas tumor? Yeah, I would have thought so because you can certainly have lymph nodes up uh in the peral region. Can't you? So sorry, back to um TB. So primary TB calcifies uh has calcified in this patient. And so we can see where the primary TB was and where the lymph nodes were. This is someone uh I think we just looked at this one, didn't we who's got secondary TB or they call it post-primary? Uh Someone said, can you show the difference between TB and Sarcoid on x-ray. So what I would say is sarcoid mimics everything. So, sarcoid can look like absolutely anything. This chest x-ray could be sarcoid. Um There you could never ever say this isn't sarcoid whereas TB has the pattern that we're just looking at, which is that um in primary TB, you'll have peripheral focus plus lymph nodes, secondary TB will be apical and we've already looked at Millie TB, haven't we? So those would be the TB patterns. Now, I put this chest x-ray up um because this patient is breathless and um they've got a fever and they've got a rounded mass here and you might think, oh my gosh, what's going on here. But in fact, this was a round pneumonia which happens in young people. So it's actually infection, it's consolidation and it completely resolved within three weeks. So just to remind you, not all masses in the lung are malignant. I mean, obviously you've got to follow up, but they're not all malignant. OK. Finally, and we'll get, we'll get on to the quiz soon. Um I just want to talk about the review area. So remember how we started at the A P CS and then we kind of worked our way down. Um I'm coming back to the question about the veil, by the way, in a moment. So we're gonna start with the A P CS and on this x-ray, I'd like you to take a look at the x-ray and tell me w where you think the abnormality might be, you can write it in the chart if you like. Ok, good. So, we've had a variety of answers. So there is indeed. Whoopsie. Sorry, I didn't mean to do that. So there is indeed a mass here in the left apex. Other people have pointed out that it's kind of not quite clear in the left lower zone. I think that's probably true. Um, and someone said there's media time or shift to the left. Very good pick up who said that? Yes. Uh and someone, several other people said losing volume. Absolutely agree. Ok. Very good. So basically, this person has got a palpitating mass in the left apex. They have also lost volume on the left, right. Next kind of thing that we're thinking about when with the review areas is free air and you can either get free air under the hemidiaphragm or you can get it in the medias dim. And this is a patient who had a history of severe vomiting and then sudden onset of chest pain. And I wondered if someone could tell me what syndrome that makes them think of s uh so just to reiterate by loss of volume, I do mean lung collapse. Exactly. Right. I mean that instead of having a, a lung that is nice and inflated like a big sponge, it's just squashed down. So, back to this question. So I've got a patient who's been vomiting a lot and they've suddenly got terrible chest pain, central chest pain. What does that history make you think about? So, the on a lot of the answers you're giving are good answers. You're quite right that, you know, you got to think about things, like, is there aspiration? Is there something like, um, Angina, um, in the pa, in this kind of particular scenario, severe, severe vomiting and then sudden kind of chest pain, um, you've always got to think about Boar syndrome, which is where you get a sudden tear in the esophagus, isn't it? And in this patient, it's quite subtle really, but you can just see the pericardium, there's this kind of separate line here lifted off the heart border. And so this patient's got pneumomediastinum and because they've got pneumomediastinum and they've got that history. We've got to worry that the esophagus has ruptured and a little bit of air has gone into the mediastinal cavity. Uh, what's the next review area? We're going to be looking under the hemidiaphragm. So, in this patient who should you contact next? And you can, you can write this in the chat, who should we contact next? Should we, uh, phone their mother, tell them to bring them home, shall we? Um, and phone the psychiatrist, phone, the medical team, phone, the cardiologist, neurologists, surgeons, who should we phone. So I'm thinking about free air and I'm thinking about where the, um, free air is. And so I think the mediastinal contours are ok. But I'm looking at the diaphragms now quite carefully. So a lot of people are worried about the heart border. And I, that's an interesting one. I think what you're looking at is here where it looks like there's a black line by the heart. And that's actually just where you've got a very sharp border between the heart and the lung. It's not abnormal. Um, ok. So, yeah, so, um in this patient, what we can see is if you look at the hemidiaphragm on the left, it's OK. This is just the stomach bubble, but on the right, you've got this black line between the diaphragm and the edge of the liver. So you're gonna need to phone uh the surgeons about that because it means they must have free intraabdominal air. So basically s uh surgery very good. All those people who pick that up, well done. Um, ok, then, um the last bit of my kind of checking is to look at the soft tissues and the bones. And in this patient, they've got a history that they have got really bad shoulder pain and we don't really look at the scapula very often. Do we on x-ray, we kind of ignore them. But if you look at the scapula on this patient on the left and the right, I think you can appreciate that actually, on the right here's the bony contour of the scapula. And can you see it on the left. No, it just disappeared, hasn't it? So it's actually absent. And so this was a metastasis, sorry, a metastasis within the scapula, which it completely destroyed it. And this is a kind of similar story in this patient who has had breast cancer. So you can see there's less mastectomy. If you look at the ribs, these are the normal ribs, but then if you compare the ribs on the left side, there's this kind of funny sclerosis here and that is because there's a metastasis. Um I will go back to the previous slide. Um So on the previous slide, what we see here is we can see the clavicle, we can see the acromial, we can see the humerus and we see no scapula whatsoever. The whole scapula has been completely replaced by tumor. OK? Um So I'm just gonna move on to. Oh yeah. So I think we're pretty much there to the quiz. Yay. So let's do the quiz and in the quiz, I'm gonna answer the question about the veil like sign. So what I think we'll do here is I'm gonna get you to, you just have to enter, you can either enter the diagnosis and the chat or on this. I don't mind which one you do? What's easier you can tell me, is it easier to use this voting system or is it easier to just put in the chat? Uh OK. You can use what you like? I don't mind. Ok, great. So let's look at the first patient. So first patient, you can either vote or you can put in the chat. What do you think is going on with this patient? I think we'll stick with the chat, by the way, chaps and we'll go for the chat for everyone because it's just a bit easier. So you can put in the chat. What do you think is going on in this patient? They present it uh to A&E they're very, very, very breathless. They're getting more and more breathless by the minute. What is the key emergency that you've got to identify? Um, and then you've actually got to treat immediately and when you listen to the chest on this patient, you, you can hear normal breath sounds on the right on the left, you hear no breath sounds whatsoever nothing. And the patient is getting more and more breathless as we speak. So a lot of you are writing left lung collapse and that is true. The left lung here is kind of all squashed down. But what's going on in the left hemothorax? Do you think? Can you see lung markings on the left? Like you can see on the right or can you just see black air within the chest? Yeah. So there's no lung markings. Absolutely agree. And so, um, uh so interesting question, this is not a mass, this is the left lung, which is completely collapsed down because there's so much air within the left pleural space. And um the fact that the lung is completely compressed down and there's all of this air makes you worry very much about uh tension. This is certainly a pneumothorax. Is it tension? Well, it's about to become a tension pneumothorax. So he of course, this is an emergency. You need to put a needle in straight away. Very good everybody. So this is a pneumothorax. Next patient, patient, we're going to look at what do you think is going on with this patient? And uh first of all, you can just tell me what lobe do you think is affected? Could be more than one lobe? But what lobe is affected? And then is it consolidation or collapse? What do you think? So, I think there probably is a bit of pleural fluid here as well. I think that's true. And so exactly. So this is the right lower lobe. Very good because we've lost the right hemidiaphragm. And can we see the right heart border? Not really can we. So I think that's right middle lobe as well. Those people who said right middle lobe are also correct. So we know it's a right middle lobe and a right lower lobe process, there's a kind of white out isn't there. And now we just have to decide is there collapse or is there or is it consolidation? And what about the volume loss? Has the heart switched over to the same side as the white out or has it been, or is it kind of in the same spot or even maybe been pushed over? So, I think most of you agree that this is consolidation and the reason for that is because we haven't lost volume on the right. So there's no collapse, the Mediastinum has not shifted to the right and therefore it can't be collapsed on the right side because we haven't lost volume. And in fact, if anything, the media stum is slightly shifted to the left, which I think probably is because there is a bit of a pleural effusion. So very good to everyone, there's no volume loss. We've lost the right middle lobe, we've lost the right heart border and the right uh hemidiaphragm. So it's right middle lobe and lower lobe that's affected. I'm not sure that I can really show you air broncho grams, but we would certainly expect those to be there. Very good. So this is right, middle lobe and right lower lobe consolidation. Excellent third case. OK. So in this patient, uh what's happening in the trachea, um I think the trach is fine. Um So in this patient, uh third patient, now, um the first thing I want you to do is to look at both lungs and decide is one side blacker than the other cause that will help you. And then um you're gonna try and um kind of look at in your review area So look at the A PC, see if there's any asymmetry. Now, let me sit back and see what do I think about blackness? Uh I mean, I kind of feel this bit here is blacker on the right than on the left. Now, lots of people are giving excellent answers here. Um So this line here, I'm, I'm hoping someone can type in what this line is. Someone has mentioned that there's tracheal deviation. I think that's correct. The trachea is kind of pulled over a bit, isn't it to this side? Probably. Also, the mediastinum is shifted over to the right, isn't it very good? And what's this line here? Should it be here or where should it be? So, most of you are saying right, upper lobe collapse and most of you are and you're right, basically. So we've got this white out in the upper zone. There's no air bronchogram and we've lost volume, haven't we? Because the mediastinum has shifted to the right? I personally think that this lung is a little bit blacker and this line underneath it all, which is defining the, the gap between normal lung and between white out lung is the horizontal fissure. So that should um actually be here, shouldn't it? So, the fact is it's been pulled up and um that's, that's another sign that there's right upper lobe collapse. Very good. Everyone you're doing great. So this is right upper lobe collapse. OK. This patient uh is elderly. Um, they're on lots of heart medication and they've, you've been called to see them on the ward because the nurses say, oh, this, this lady is very, very breathless. She's literally sweating. She's pale, she's clammy. She looks as if she's about to have an arrest. What is going on with the lungs in this lady? So I say almost everyone has got this right. So basically this is the classic appearance of pulmonary edema because it's perihilar. So in a butterfly like shape, all the people who said consolidation are absolutely right because we can see this white patchy shadowing and then we can see the branching air bronchogram and wow, someone's even pointed out the curly B line is very impressive but it's the distribution, the fact that it's in this kind of butterfly shape that makes you think about pulmonary edema, isn't it? So this is airspace shadowing but the airspace shadowing is not pus, it is fluid um because of the um left heart failure and um fluid in the alveoli. And someone said back wing edema. That's absolutely right. That's great. Now someone said pe the reason why I think you're very unlikely to ever get asked about ps on a chest x-ray is that you basically can't identify them on a chest x-ray. You can only really identify them on a CT. So Pulmonary embolus is very much ac T pulmonary angiogram diagnosis. I'd be very impressed if you could diagnose it on a chest x-ray. But when you see this classic bat swing or butterfly perihilar haziness with airspace shadowing. Think about pulmonary edema. And with that old lady who's sitting there drenched in sweat. Uh, really, really breathless, sitting up. Um, this is another medical emergency, isn't it? Um So how would you treat acute pulmonary edema? Would you like to enter that in the chat? Diuretics? Yeah, I agree. Yeah. Uh, someone will have to tell me what am Moa stands for because I don't know, prose which is a diuretic, correct? Uh morphine oxygen, nitroglycerin. Thank you. Yes. So that's correct. So, uh, the first thing you do and when you're gonna get asked about this in your final exams, you need to have an answer. You need to say this is a medical emergency and I will treat it. Um, ABC. So you always start off when you're doing an exam, you know, airways breathing, um, and circulation. And so the first thing you would do is you would set them up and give them oxygen as you said, um, because that will kind of help to offload the left heart a little bit. Um, you certainly would consider giving a diuretic um, immediately intravenously and I think giving morphine is very reasonable as in, as is given GTN. I know that there are some, um, there are some reasons why you might not give, um, a ni triglyceride. Uh, for example, if they've got low BP, you don't want to make it lower, do you? But you basically are trying to offload the heart morphine, I think has multiple effects, doesn't it? So it kind of, it helps um with in, in kind of, I think three or four different ways. Um But certainly again, an acute LVF, it's a very good drug. So it's really important that you learn all your medical emergencies, left ventricular failure being one of them. Um And say that when you get to your exam, this is a medical emergency. I would treat it with ABC. And then I would, you know, sit the patient up, give them oxygen, give them a diuretic, et cetera, et cetera. Um It's, and, and, you know, learning it, you're not just learning it for the exam. I can guarantee you that when you're on the warts um in your kind of first year, certainly, you will be called to an old person who looks like this and you will have to deal with it. So, um I think it was probably the most common emergency I dealt with as a junior doctor. Ok. We're getting into the end of this. Uh We're doing great on timing though. So this is pulmonary edema. Uh OK. Next one here we're back to is there collapse or consolidation? And I'm wanting you to look at this kind of patchy shadowing here. So, uh I'm going to actually, I think I'll put the answer up for you. So this is actually this is a bit of a mean one. So there's actually both going on here um because we've lost volume, see how the left upper lobe is blacker. So there has been some collapse, but there is also some airspace shadowing here too. So it's a mixture. So having kind of told you that you must differentiate between consolidation and collapse and their different things. Um in, in all honesty, they often will slightly coincide. Right? Next patient has come in and is incredibly breathless. In fact, they're about to have a cardiac arrest because they're so breathless and um things are going badly wrong for them. And so this is another medical emergency. Someone said did the Mediastinum shift to the right and the previous one? Yeah. So the Mediastinum I think here has shifted to the left because there's loss of volume. Yeah, agree right back to this one. Uh So I'm very much hoping you're gonna recognize what this is. Um because again, this is another medical emergency and someone can tell me how would they answer the question in the exam? Say I put this chest x-ray up here in for you in an exam. You can tell me what is the spiel that you would use? Spiel is the kind of like little um almost like a AAA poem that you recite at the beginning. So everybody is getting that this is a tension pneumothorax which is fantastic. Um So absolutely agree. The whole of the right hemi Thax is just full of air, isn't it? And the mediastinum is completely pushed over. And do you remember how the first pneumothorax we saw, we could still see um the lung kind of collapse down here? We can't even see that. So the spiel that I would give in this case is I would say this is a medical emergency. There is a right sided tension, pneumothorax, pushing the mediastinum to the left and I would treat this with ABC again. And then um basically, what you have to do is to immediately decompress the tension pneumothorax by um inserting some kind of decompressive device. So a needle would be absolutely fine um in the intercostal space. This is very good. I like what you've written. Anu I will start with ABC, then start to treat the tension by decompression. Exactly right. OK. Good. So tension pneumothorax uh then I've put a couple in here, this patient um something's gone wrong here. They put an NG tube in and they said, is it OK to feed the patient? And the answer is definitely no, very good. OK. Uh Al Karma, I like the way you said no. Um It's, it's definitely no because actually the NG tube here is telling us where the right main bronchus is. And if you put um feed down, then you will cause a pneumonitis, won't you? So I put this in to show you where the correct position of the NG tube is and you will be asked about this a lot. So, what you have to say is that the NG tube is in the midline, it bisects the carina. Um it extends below the um hemidiaphragm. Um And the, the, the tip is kind of low segment. Sorry, it's below the hemidiaphragm. Very good. Ok, great. Here's another patient who's got um an NG tube in the left main bronchus. And I have a horrible feeling. It's actually gone beyond that. And I think you can all see as well that there is a um there's a lot of air, air bronchogram and airspace shadowing here. So I think this patient has got a pneumonitis after being fed via that NG tube. Uh We're getting to the end. I think this might be the last one. Ok. So in this patient, um it's quite a tricky one. This one actually, um let's just go straight to the answer. I think. So, in this patient, what we see here is that there are lots of um peral soft tissue. The hilum is, is kind of too bulky on both sides and the lungs aren't quite clear. So this is sarcoid. Um And I really put this in just to remind you sarcoid can look like many things. And last case, I think, um if you would like to tell me about this case, you can write down what you think is going on here first of all, what side do you think is abnormal? Is it left or right side sailboat sign? Very good. Yeah, right side. Very good. Ok, great. So, that's correct. So, what we see here is, it looks like a sail behind kind of adjacent to the right um Paal region, isn't it? And we've lost the left hemidiaphragm. So, uh someone's asked about, I'll come back to that. So this is a right lower lobe collapse and we know it's collapsed because there's no air bronchogram and the right lung is blacker than the left lung, isn't it? Ok. Uh Someone's asked about sarcoid. So what I would say with sarcoid is sarcoid can look like anything. So you can put it in any differential diagnosis. If you see bilateral lymphadenopathy, got put sarcoid in. If you see lots of little nodules, you've got to put sarcoid in. If you see um habitation even that could be sarcoid, someone's asked about sailboat sign. So do you remember we looked at a left lower lobe collapse and it had, it looked like a triangle behind the heart. Um That's the sailboat sign. And basically, it looks like when you go sailing and you have a sale, which is a kind of triangle and it's the sail that is out if that makes sense. So it's not fed up. It's like this. So we usually see that on the left, don't we as a left lower lobe collapse? But in this patient, we've got a triangle on this side. So it looks like a sale and that's what the sailboat sign is. Now, I'm just gonna dive back. Um because I want to go back to Ola's question about the left upper lobe collapse. Yeah, that, so Ola, I just wanted to go through this with you one more time. So when you look at this chest x-ray, um there's a couple of things to notice. First, this person has got left upper lobe collapse. So the first thing to notice is that the mediastinum has shifted to the left. And the second thing to notice is that um the left side of the lung, it almost looks like someone has hung a curtain or a veil over the left side of the lung. And as soon as you see that just start to think, hang on a second is their left upper lobe collapsed. So it's actually quite a subtle sign. And obviously, it could be, for example, that the patient has got some extra clothes on, on the left side or it could be that there's a problem with the right lung and the, and the right lung is too black. But ultimately, if you see the mediastinum is shifted and then this kind of veil like shadowing, that's what left upper lobe collapse looks like. And the reality is that most people today nowadays get CT pretty quick, don't they? And so I think you're unlikely to miss it, right. I'm gonna dive back. I hope I'm not making you all feel travel sick by moving backwards and forwards so quickly. Uh So I think this is the last case that is coming up. Uh Great. OK. Ola. Um So um this is the LA I think this is the last case. Yeah. So let's take a look at this. What do you think is going on in this patient? What do you think might be the cause? So, Alade, I like the way that you've taken my learning and you've applied it straight away. Um And put s uh sarcoid in as a possible cause you're correct. You can never answer wrong about sarcoid. Really. Um So everybody has written some really fantastic answers. I don't disagree with any of them in this patient's case. They had pulmonary metastases. I don't know what the primary was, but you certainly could include um tuberculosis in this. Uh um Aspergillus has multiple different presentations, doesn't it? And one of them is lots of random things. Uh Someone's written TB always, it could be TB Sarcoid, it always could be someone's written Cannon balls, which just really means big metastases. That's absolutely correct. Oh My gosh, I didn't mean to do that. Sorry. Um So um so yeah, basically you've got all of that correct. Well done. OK. Good. And I think that is it right. OK. So I'm gonna stop sharing. Uh Thank you very much everyone for your attention if you've got any questions, um, just go for it and, um, I'm sure Miss Ab will kind of intervene. Thank you very much. Everyone. No one has any more questions. Just give it a minute for people to throw in their questions because we've got another lecture in two minutes. Oh, gosh, you need a break then chats, don't you? Mm. I think no one's got no question. Thank you very much professor for this amazing lecture yet again. And um I hope everyone can fill out the survey please. That's very crucial for us to continue. And um I think that's all. Thank you very much, everyone. Great good luck, everybody. Bye. Alright professor. Bye bye. Can you just make it for all professor when you're leaving.