Computer generated transcript

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

Um And I'll just give a quick introduction. Um Welcome everyone. Um As always, if you could please write your name, medical school, year of study and the police are coming in in the chat. I'll write that in the chat also. Um And also please fill in the feedback form at the end. It's very important for us um for the medical school to keep going. Um And I guess I'll hand it over to you professor. Okay, great. Thanks. So, uh thank you so much, Hannah and um thank you to the whole CRF team for inviting me to speak again. Welcome to term three for all of you. Um My name is Elizabeth Dick and I am a radiology consultant. My special interest is trauma and emergency. Um I've also got a big interest in medical education and uh this is going to be interactive. So basically you can put anything you like in the chat. Um Hopefully, if I don't see it straight away, Hannah will interrupt and tell me we're going to actually be doing um some voting's. Um So I'm just gonna have I should and I am showing my screen. Great. Uh So basically, um what I'd like you to do please is at some point if you can scan this QR code with your phone or you can enter this address on your um phone browser that will take you to some questions and the questions are completely anonymous. You don't have to put your name in. You can skip that step, just helps you to kind of enjoy the learning more. Okay, great. So we're going to talk about chest x rays and um think a little bit about chest anatomy. This is gonna be to talks 50 minutes each. I'll give you a break of 10 minutes in between. So we'll kind of start. Now, do 50 minutes have 10 minutes start again in one hour's time. Okay. Good. So first question is I would like to find out where everyone is in terms of their training. And so what I would like you to do? Oh, thank you. This is brilliant. Everyone's already started to vote. This is fantastic. Thank you. I really wanted to find out where you are in terms of first year, second year, etcetera. And what I can see is that let's just make this big um For those of you who haven't managed to vote yet, the actual address is on the whatsapp group or it is written at the top of the screen here and it's P O L L E V dot com forward slash E D I C K 900 So what I can see is that the majority of you are in senior years, which is fantastic. Um, so, um, I'm going to make this relatively, um, clinical, but we'll do a little bit of anatomy as well. Okay. So let's come back to, yeah. Where are we? Yeah. Yeah, great. Okay. So, what I want to do is build on your basic knowledge of chest anatomy and then make sure that by the end of the session, you've got your own system for looking at chest X rays. If you have an exam, you've got something sensible to say an exam. So you're not just kind of tongue tied. And also when you actually get back onto the wards or when you're on the wards as a junior doctor, you can be confident you're not missing something serious, uh kind of overnight. Okay. So we're going to learn a system of looking at the chest X ray and you're gonna use this to go through a series of common abnormalities. So here's the normal chest X ray. I'm going to use a system to go round that normal chest X ray. Uh So the basic anatomy of the chest um that we see on chest X ray starts with the airways, includes the lungs and then looks at the mediastinum and we're going to go through those in turn. So when I start with the chest X ray, I look at the mediastinal margins on the left and here, you can see the aortic arch, you can see the left pulmonary artery, see how that's dividing out. You can see the right pulmonary artery again, you can see how that's dividing out. And um uh you can see all of these structures basically at the hilum. So before I start kind of trying to find pathology, I do a little bit of technical stuff. And the good thing about during the technical stuff is it buys you a little bit of time. So I work out is the patient male or female. Do they have breast issue or not? Are they old or young? Uh have they taken a good inspiration? The way that you tell that is you look at the diaphragm and see if they are at least at the level of the sixth rib anteriorly, which this is, is it well penetrated. The way you assess that is you look at the vertebrae. If you can see the intervertebral disc spaces behind the heart, then it's well penetrated. And then you ask yourself, is the patient rotated or not? And the way you do that is you look at the medial ends of the clavicles, which you can see right here. And then you compare that to the uh spinous process and you want the spinous process to be right in the center. So here you can see the spinous processes are right in the middle between the medial clavicles. So that leads me onto my next question, which is, where are the medial ends of the clavicles in this patient? And let me just come back to my uh I'm looking hang on a second. Where has it gone? Not? They're here. Yeah, here we go. So the next question and let me just activate it. So hopefully, on the image, you are able to see this chest X ray. And I want you to show me the medial ends of the clavicles in this patient. So you can just touch on the screen. It's actually quite hard if you're doing it on the phone. Uh But obviously, some of you've got bigger screens than others, which is good. Very good. You're pointing out very nicely, the medial ends of the clavicles. Absolutely correct. OK. Fantastic. So let's come back to the power point. I'm sorry, I've got so many things open. Um So we can see in this patient that the spine is actually here and the medial end of the clavicles have kind of rotated around, which just tells us that the patient is rotated. Okay, perfect. So I've got the rotated patient on the left, the normal on the right, you can see the difference. So opening phrase um and sorry, one final thing, people talk a lot about P A and A P X rays. Now you can get yourself tied up in knots with those kind of things. Oh my gosh, wasn't there. Um Don't bother talking about whether it's pa or A P just call all X rays, frontal x rays. And then you've kind of avoided that. So my opening phrase, if I'm presenting uh in an exam, for example, would be this, I would say this is a frontal chest radiograph of a young male patient or an elderly female patient. I'd say the patient's taken a good inspiration. They're not rotated, the film is well penetrated and you're buying yourself a little bit of time as you talk about that stuff. But you also sound like you know what you're talking about. So while you're doing that, keep looking at the film, Hannah, I'd like you to um just tell me if anyone in the chat thinks that I'm going to fast. Uh in speaking, I'm just aware that you're kind of senior medical students. Can they just tell Hannah in the chat and then she'll tell me to slow down. Okay. So now what we're going to do is we're going to do a little bit of revision already. We're going to think about the structures of the Mediastinum and particularly the structures of the left mediastinum. And you're gonna label all these structures. So we're going to try and label them, label the aortic arch, the pulmonary artery, the left atrium and the left bench course. So let's come back to my votings. I'm going to activate this and then present this and what I'd like you to do. First of all, please is click where you think the aortic arch is. Mhm. While you're doing that, I'm gonna have a quick look in the chat. See if there's anything exciting going on? Thanks everyone for telling me who you are. That's always nice. They would have changed it, they would have changed it. Okay. Very good. So, absolutely. Right. So the majority of people put a marker here where the aortic arch is excellent. Correct. I'm going to clear those. Can you now show me where the pulmonary artery is, please? The left pulmonary artery or the right pulmonary artery can show me either very good. That's right. And the more you look, the more you see. Okay. So here is the shadow of the left pulmonary artery coming out and branching up and down. And thank you to the person who put the shadow, the marker on the right pulmonary artery. Again, you see it coming here branching down and branching up. Fantastic. Well done. Okay. Let's clear that. And now I'm going to ask you to show me where the left atrium is, please. So the good thing about doing this is it's the kind of wisdom of crowds. And what happens is the center of where you've all marked will always be the correct answer. So, very good. So the left atrium is basically here, isn't it? Trick question? The right atrium will actually, and the right ventricle will actually be very anterior, won't they? Especially the right ventricle which really is kind of sitting anti early. So it doesn't have any border of the heart. That's a bit of a trick question is if they, someone says to you point to the border of the right ventricle on this X ray, you cannot do that because the right ventricle is sitting right here. Okay. And then finally, can you show me where the left bench call is, please? Ok. Amazing. Great. So let me come now back to my chest X ray and I think we've got them all labeled up here just in case you need them, but you ordered. Great. Okay, good. So, um we've done all that jump jump. So let's have a think about the right side of the mediastinum now. So you'll see the spc shadow coming down. We've already talked about the right pulmonary artery. You can see the right atrial shadow, but remember that the right ventricle is anterior in terms of heart size, you basically want the diameter of the heart to be no more than um half of the diameter of the whole of the chest if it's more than half than the patient has cardiomegaly. And overall, you want about two thirds of the heart to be on the left side of the spine and then two thirds, sorry, one third to be on the right. Uh If not, you're thinking that there may be some kind of shift of the mediastinum. Okay. And thinking about the hilum So the normal hilum has obviously got pulmonary arteries on within it, which we see right here, it has pulmonary veins. You see those on CT better than on um X ray and it will have a main Broncos. So again, on this X ray, you can see this airfield structure on both sides. When it's an airfield structure, it's kind of hard to see on X ray, isn't it? Because it's just full of air, there will also potentially be lymph nodes and lung tumor's which you know, you can get at the hilum. Um Those will only shop if they're, they're, if they're absent, you don't see anything. So in a normal person, you see the pulmonary artery, pulmonary vein is coming a little bit lower down and then the air filled, uh left and right, main Broncos, okay. The next thing I do is I look at the lungs and I kind of go from one side to the other side a bit like when I used to listen to the lungs. So I start at the A P C S and then I work my way down and I compare left and right and make sure I look behind the heart and make sure I look below the hemi diaphragm as well and make sure that I look at the cost a phrenic and cardia phrenic angles to and I always look right to the periphery because that's the only way that you're going to identify a pneumothorax and pneumothorax won't jump out at you. You kind of have to look to the edge and then you're looking at these kind of little diamond shapes here for a lung edge. Okay. So, and this is my spiel for a chest X ray. I'll say the trachea central, the mediastinum is not displaced, mediastinal contours and highly are normal. The lungs are clear. There's no pneumothorax, no free air under the hemi diaphragm and the bones and soft tissues are normal. Uh Hopefully they'll have been something abnormal in all of that. But if there isn't, you can say I haven't yet identified an abnormality. So I'm going to look at my review areas again. You sound very professional, don't you? So now I'm going to ask you where your review areas are. We're going to go back to that. Um back to that. Uh Sorry, I need to find it and I'm so sorry. Um Is it here? Yes, it was here, sorry here. So I just need to shut this down and then I can see it all. Here we go. Yeah. All right, great. So, um let me just make this bigger and then we're back in business. So can you please click here on your review areas and it can be anywhere, any review area that you have? I'm sure there's more than one review area. Very good. Ok, fantastic. Thank you. Let's go back to the uh slides. So, yeah, exactly. The review areas are the apices as you pointed out, periphery of the lungs. You're looking for a pneumothorax beneath the hemi diaphragm and behind the heart. Okay. So now what I want to do now is to ask you some questions about the mediastinum and the mediastinum shifting. So let's talk about that now. Okay. So there's quite a lot of things to think about here. Um So we'll take a little bit of time for you to answer the questions. Um Please tell me if you're not able to answer the questions, if it hasn't um kind of lit up yet. So we're thinking about mediastinal shift. And basically, there are processes which push the mediastinum and there are processes which pull the mediastinum. And I want you to tell me which of these is true. So we'll go through these in turn, more than one of these could be true by the way. So first of all, a right sided pleural effusion pushes the mediastinum to the left. Um Second of all, a right side attention, pneumothorax pushes the mediastinum to the left that a right side attention, pneumothorax pulls the mediastinum. A right sided collapse, pulls the mediastinum to the right or a right sided collapse pushes the mediastinum to the left. So let's, I'm going to give you a little bit of a chance to um answer all those because I know it's complex. By the way, someone just ask, is there a chance of getting the video of the X ray class, it's being recorded, so it should be uploaded. Okay. So let's go through these. Thank you very much for boating. I'm going to show you what's right. Okay. So correct answers are a right sided pleural effusion pushes the media style um to the left. So that's correct. If you've got a large volume of fluid on one side, it will push the mediastinum to the other side. A right side attention, pneumothorax does exactly the same thing. So the pleural space can have fluid in it or it can have Aaron it, but once it gets big, it will push the mediastinum to the opposite side. On the contrary, if you have collapsed, so you lose volume on one side that will pull mediastinum towards the side where there is lost volume, okay. And then just to go through the wrong answers, a right sided tension, pneumothorax pulls the mediastinum. Definitely not. It pushes it not pulls it right and a right sided collapse pushes know a collapse because it's a loss of volume. It pulls things into it. Okay. Good. So well done. Everyone you did well on that. Um So we've talked about that a little bit already. Essentially, there are three processes, the trachea is pushed or pulled. So there are two processes which pushed the trachea and one which pulls it. And um if we have a pleural effusion or we have attention, you know, that will push and if we have collapsed, it will pull. Okay. So, uh I think I've got another question here. What has happened to the trachea in this patient? And I'm going to go straight back to the video, sorry to the poll everywhere. And hopefully this has activated. Here we go. So what do you think has happened to the trachea here? I'm going to ask you just to enter your text and actually, I think you probably need the question of the image again, don't you? So if this is a frontal view of the patient, uh this is the trachea right here, what do you think has happened to the trachea? Do you think it's pushed or pulled? Let me see what you've answered. Fantastic. So people have said deviated shift to the right pull. Yeah, very good. So what's happened here is we've got a white out on the right and that white out uh probably represents collapse of the lung. And the reason why I think that is because the trachea has been, has moved towards the side of the white out. So if you had the white out and then the trachea was on the opposite side, then I would think, right, this must be an infusion and the infusion has pushed it to the opposite way. But the fact that the trachea has deviated towards the white out is what tells me that there must be loss of volume on the right side. I hope that makes sense. Okay. Uh So basically, when you see right lung collapsed, the heart and the mediastinum, this is a different patient. The heart of the mediastinum are pulled over. So in this patient, remember how I said you want two thirds of the heart to be on the left of the mediastinum. Actually, it's all pulled over and the trachea is also pulled over to the right side. Okay. Very good. Now, in this patient, uh the trachea and the mediastinum are, are also deviated. You can see actually about half of the heart has moved to the right side. And there is this white out at the inferior part of the lung. It's actually got a meniscus. Um meniscus, remember from chemistry means that there's fluid. So this is a pleural effusion which has pushed the lung has pushed the mediastinum, sorry to the opposite side. Okay. Very good. Uh And then we come onto this problem. So this is a patient who's got a tension pneumothorax. There's absolutely no lung left here. It's just this little bit here that has completely squashed down like a sponge that you squeezed all the air out of. And now in the pleural space, we've got so much air it's pushing the mediastinum over. And in fact, if you look at the heart border, this is the heart border here and this is the heart border here. Um Basically, it's about half, half and remember we said it should be two thirds, one third, this is half, half. So that's a sign that the mediastinum has been pushed over by the tension pneumothorax. Okay. Very good. So, uh here's another patient who has got mediastinal shift and I'm hoping you're going to be able to tell me what the diagnosis is. So I'm going to switch straight over to pull everywhere here. So take a look at this. First of all, think about which way the mediastinum has moved. Second of all, can you see lung markings on both sides? And I'm going to switch right over to um the next question and activate that for you. So what do you think the diagnosis is here? Let's have a look what you've answered. It's, that's a jump. Okay. Very good. And then our day before excellent, I'll go back to the image. So which way do you think the mediastinum has shifted? And I think you all realize that there's a pneumothorax. So the question is, which side is the pneumothorax? Is it left or is it right? Let's go back to see what you've answered. Okay. Very good. I may have been that I've set this up so you can only answer one thing. Um So the correct answer here is that there's a right tension pneumothorax and the mediastinum is shifted to the left. So let's take a look at that. So here, it's a little bit like the last example that I showed you, you've got uh no lung markings here. You've just got this little kind of squashed down residual lung on the right. So it's definitely a right pneumothorax. And then if you look at the mediastinum, the vast majority of the heart is on the left side, there is really no heart on the right side. So basically the mediastinum has been pushed over and you get that impression here, don't you? That the, that the air in the pleural space on the right is pushing things over? Okay. Very good, well done. So there's the collapse down lung that you can see. Okay. Any questions before we go on to the next part, we're going to talk about the heart. Now for a moment, let me just check and see if there's any questions. Yep, I do not see any good um For those people who are entering the answers in chat, the there is a, there is basically voting's which is written at the top of each boating question that comes up and hopefully some kind person, maybe Anna will repost that. Um oh, actually silly me. Look, it's written right here. You just have to enter this address in the phone browser and that will take you to the votings. The boating is completely anonymous. You don't have to enter your name and it should come up automatically. Okay. So now we're thinking about what are the causes of cardiomegaly. And um I would like you to help me work out what the causes of cardiomegaly. So, I'm going to ask you to enter as many answers as you can. Silly me. Yeah. There we are. We're ready now, many answers as you can. Causes of cardiomegaly that you know. Yeah. Mhm. Heart failure. Absolutely good answer. Yeah. Pericardial effusion. Very good. Yes. Which would cause cardiac tamponade. Agree. Cardio myopathy and hypertrophy. Absolutely. That's right. So, if the muscle is big, um, or indeed if the muscle has failed my card itis and certainly if that's caused muscle hypertrophy, yeah, valvular disease. Good coronary artery disease. Yes, because it would cause heart failure, right? Hypertrophy. So, this is very good. So you're thinking about it from the inside out, aren't you? So if you think about it, it could be that there's too much volume in the ventricles. In which case, the heart just expands and there could be too much volume because the heart's failed. It could be that the muscle is too big for whatever reason, like muscle hypertrophy, uh that would make the heart big. Then the coronary arteries, I'm coming out further, if the coronary arteries have failed for any reason, that would cause either the muscle to be baggie or to be trying to compensate. And then finally, we're coming out further thinking about the pericardium and if the pericardium is full of fluid, then that would also make it look like there is cardiomegaly, even though actually, the heart itself is not big, it's just fluid in the pericardial sac. So some brilliant answers there. Well done everyone. Okay. So let's go back to uh this list. Uh So the most common causes are congestive cardiac failure, as you've already said. But you've also got to think about pericardial effusion and cardiomyopathy, as you all said. So let's think about cardiac failure. You are definitely going to be seeing this at the moment that you're on the wards as a junior doctor. If not before you'll be seeing this, you'll be called to a patient who's sitting up in bed, they look absolutely grey color on the sweating and, and kind of really blue and uncomfortable and very unwell and very worried and agitated to because they know that things are going really badly wrong. And um then when you listen to their lungs, you'll hear all these kind of fine crackles in their lungs. Um and they definitely don't want to sit down because they're desperately trying to optimize their um kind of air exchange. And if you look at the chest X ray, you'll also see which you don't really need to do because you can make a clinical diagnosis. But if they have a chest X ray, you will see signs of heart failure. So you will see curly be lines. Uh Let me see if I can show you those. Uh we're going to um they come right from the edge, tiny, tiny, tiny little interstitial lines. Uh You will see bat swing. So a kind of perry hilar haziness. Hopefully you can see that it's like a butterfly. Um You will also see sometimes. So these air bronchogram. So what's happened here is that the interstitial uh fluid, there's fluid in the interstitial space and there's fluid in the alveoli. And the only thing that's okay is the bronch. I, those still have air within them. And so the airfield bronch, I stand out against the fluid filled space and I think I've zoomed in here. Yeah, here we go. So if you think about it, you've got the alveolus and the alveolus is full of fluid. And so the bronchial which has still got Aaron, it will stand out. So it'll be black against white and also you'll have um kind of the interstitial space as well filled with fluid. Oh, here we are. So these are the curly be lines, tiny, tiny, tiny lines, which is the fluid in the interstitial space. Curly was a radiologist originally. So those are the things that you see in heart failure. Uh I never really see upper low blood diversion. I think it's a bit of a tricky sign. But if you see someone with a chest X ray like this and they're what I'd have described clinically, you need to act very quickly. Would anyone like to put in the chat? How do you treat um left ventricular failure, acute, left ventricular failure? What would you do for the patient. It's a medical emergency. So you definitely need to know how to treat it. Uh Omar's asking are there such a thing as curly a lines? Yes, but you know, there never was trendy as curly be lines. So you don't need to worry about those lola says diuretics. Absolutely. Right. So you're going to give the patient diuretics because you're basically trying to offload all that fluid in the heart. Anyone like to specify which diuretic or what dose or anything like that cube eight Ace inhibitor. So in my day, we always basically gave Frusemide because it was quick. Uh and I think that may still be the case but someone else can answer that question. You can look it up for me. Um What are the other things that you might do with the patient? Um apart from give them a diuretic, uh any other drugs that you might give them or any other treatments that you might give them? Remember there sitting up already? Would you make them lie down? Yes, I'm uh nitroglycerin. Yes. So you might give them something like G T N depending on their BP, you might give them that might you because that will basically vino dilate and it will offload the heart. Um Lola is suggesting oxygen. I absolutely agree. I'm not up in, I just don't know about someone will have to tell me uh morphine. Absolutely. So morphine is very old fashioned drug, isn't it? It offloads the heart before and after. So, preload and post load, um which is a good thing in heart failure. It also makes the patient feel less anxious and that's really important because, you know, in some cases, actually, this is basically a terminal event. And uh I still remember a patient who I saw when I was very junior doctor and I kind of spent too long dithering around and not giving them the diamorphine as part of the treatment for their heart failure. And so when they died, they died, you know, very anxious and feeling terrible. Whereas if I had managed to give them some, some diamorphine, not, not, you know, to hasten their death at all, but just to help with their heart failure, they would have been in a better place. So I always remember that kind of mistake that I made. Okay. Very good. Thanks for that. Um So yeah, so you set them up, you give them oxygen, you give them frusemide, you may give them diamorphine, you may give them a um G T N depending on their BP. Excellent, well done. And when you do your final exams, medical school, final exams, you're gonna be asked how to treat medical emergencies. This is a medical emergency and you need to have your answers. Boom, boom, boom. I think you always start with A B C, don't you A B C? And then you say what you would do? OK, great. Well done. So this is a different, it's a different patient from the last patient. This patient uh was seen at nine o'clock and then by 9 30 no, sorry, by 11 o'clock they look like this. So we've done something to this patient. What do you think we've done to the patient between in the before and after photo, you got to think a little bit laterally here and I'm going to get you to vote again. Hang on, activate it. It's activated now. So looking at the two X rays in this X ray, there's a very big heart in this X ray, the heart sizes normal. I think the lungs look okay. I don't see any signs of heart failure here. Um So let me see if you have figured out what's happened to this patient in between. Someone says diuretics, uh diuretics, diuretics. It's pretty dramatic though, isn't it? And the other thing is is you'll notice that the lung fields are actually fairly black. So what this patient doesn't have is pulmonary edema. So some other reason for the heart shadow to change very dramatically from very, very big to normal in a very quick length of time. And remember how we classified the causes of cardiomegaly. Remember we started with the chambers, then we thought about the muscle and then we thought about the pericardial space. So have a think about that. Let me see. Uh someone has answered right? Pericardiocentesis is exactly this is a bit of a trick question. Really, isn't it? What's happened in between is someone has put a needle into the pericardial space and they've taken off the pericardial effusion that the patient had on the left and they've actually got a normal part. Very good, well done. Okay, good. We're gonna move on now to um thinking about the hilar. So, first of all, can you remind me what structures lie at the highland? Uh We kind of talked about this already, but this is a bit of revision. So just tell me about structures that you might see. Whoopsie, sorry, wrong, wrong one. Um Tell me about what structures you might see at the hilar. Very good. Thanks. Keep going. Pulmonary artery vein, lymphatic duct. Absolutely. Very good. The double stroller, pulmonary vessels, lymph nodes. Very good. And then there's one other thing at the highland that no one's mentioned so far. The bronch. I excellent, well done. Okay, good. So all of those are the structures that we normally see at the highland, right? I'm going to actually move on to the next slide and activate it. So I don't have to keep jumping backwards and forwards. Okay. Great. So, um we've talked about that at the in the highly, you've got three structures, the vessels, the Broncos and the lymph nodes. And normally you don't see the lymph nodes because they're small. You don't see the Broncos except it's airfield. You just see the vessels but if the patient has pulmonary hypertension, then you see bigger vessels. If the patient had a carcinoma in the right main bronchus or left main bronchus, you would see that. And then there are a variety of causes of limp nodes in the hilar, aren't there? Infection, tumor, lymphoma, sarcoidosis, those are the kind of top four. Okay. So now we're gonna look at some cases of people with enlarged hilar and this is a patient who's got lymphoma and I'm sure you can all see that the highlight are really big and bulky, aren't they? How do I know that this is lymph nodes and not pulmonary arteries that are enlarged or the way that I know is that if you look very carefully at this, you can actually see the arteries through the lymph nodes. Can you see that? So, um basically this is the hilar mass and then these, this is the pulmonary artery. So that way I know that it's not the pulmonary artery, that's the problem. It's lymph nodes and because it's bilateral, uh it's got to be lymphadenopathy really hasn't it, it can't be a a primary luncheon, right? You'd be very unlucky. Okay. Good. Now, by contrast, in this patient, you just see these big rounded things at the hilar, but you can't see the pulmonary artery separately. And what this is is pulmonary artery hypertension and what's happened is the arteries they come out and then they curve around and they're so big, it's like they don't know what to do with themselves. And so you see these big rounded vascular masses, there's another patient with pulmonary artery hypertension. And what's great about it is it shows you the big artery that comes out here. There's another one here and then see how it narrows down. It's very typical in pulmonary artery hypertension for the artery to narrow. Okay, great. Now, here we've got a completely normal looking right hilum, but on the left, there's this rounded mass. And if you see a mass on one side, you know, the first thing you've got to think about is is there a cancer just checking the timing we're doing okay? Okay. And this patient here has got a whole bunch of rounded lobules that you can see all the way up including in the right parotid Kriel region. Would anyone like to hazard a guess as to what might be causing all this lymphadenopathy? And if you could put that in the chat, that would be great. There is a differential diagnosis. Basically, I'm really asking you causes of causes of lymph nap, diffuse lymphadenopathy. Let me see what you put in the chat. Someone said TB. Absolutely good idea. The steak. Every time I told you shit, there's some rules in life. You can, whenever you say TB, no one can say no TB can always, there's typical TB. So for example, you would expect TB to be, you know, more unilateral, wouldn't you? But no one can ever disagree with you because TB has so many forms, doesn't it? Someone has said lymphoma. Absolutely true. Lymphogranuloma tosis. Think that's one of those other ones where I can't say no, why not? Someone said autoimmune. Yeah, that's a really good answer. So, things like, um, in rheumatoid disease, some people get this kind of, you know, really florid lymphadenopathy, don't they? And um, also you could argue that for example, uh sarcoidosis is actually autoimmune. And then someone said metastases. Yeah, always. I think that's true. Great. So the things that I would say here would be uh lymphoma um infection full stop and then also um sarcoid, those would be the things okay. So we've talked enough about lymph nodes and hilar and things let's move on to the lung spaces. So remember how we look at the lung spaces normally. Well, I want you to remember um kind of what the normal lungs look like and now we're going to see this patient. He's come into the emergency department. He's very breathless and he's very thin and um tell me what you can see here. It might be a little bit tricky for you. Uh Let me see. It's got chest pain on the right kind of like um pleuritic chest pain. If anyone tell me, if anyone can see anything, you can just pop it in the chat. Thanks. Mm Wow. You guys are good. Yes, exactly. There. Is a pneumothorax. And I really like when someone's pointed out that the rib spacing is wider on the right than on the left. That's true. That's because there's a pneumothorax and you can see the lung edge right here. But also because there's increased air within the pleural space, the lungs are kind of hyper expanding to try and accommodate it all. So that's a really good pickup. Very good, okay. And it's difficult to see um pneumothorax edge, you really have to look hard, look close. So um a sign is often that just one side of the lung looks a little bit blacker than the other side. That's how, you know it's on the right side. Um And then if you start to follow these branching vessels all the way out, you can't see them right to the edge. And that's another sign that it's a pneumothorax, okay, good. So with a pneumothorax, I say either there's no shift in the mediastinum. So no tension or I say there is shift indicating tension and this is another medical emergency, isn't it? And you have to then be able to say how you would treat it, which is by inserting a large ball cannula into the pleural space. Very good. Um I put this in because um in this person, you can see that there's airways in the subcutaneous tissues. And if you see this degree of surgical emphysema, you have to assume there's an underlying pneumothorax, which has given rise to the air even if you don't see the pneumothorax itself. Okay. And here now is the ct of a patient who's got surgical emphysema. And you can see the lung edge here very, very beautifully. Can't you, you can see this, which is the air within the pleural space. I mean, this is amazing, isn't it? Look, here's the trachea, you can see how air is tracking into the mediastinum as well, which it does, doesn't it? And then there's all this air within the subcutaneous tissues as well. So this is typical pneumothorax and um surgical emphysema. Very good. I think I got very excited about this. I didn't ask your CT as well to show you not only is this the lung edge and the pneumo thorax, but this is the pneumomediastinum. So, can you see this is the pericardium here and actually air tracking along it. Okay. Very good. And I think um in this patient, the cause of that was this little fracture of the first rib that caused all those problems. Okay. Now, really important point here what happens when you have someone who comes in and they've got really bad emphysema uh and really significant bullets, lung disease. Well, that is a problem. Here's a patient who's got bullets, lung disease. They had a road traffic accident and now they've got multiple flail, uh multiple rib fracture. So fail segment. And we're kind of thinking, oh my gosh, they've got a pneumothorax. Well, we need to put a chest drain in and my question to you just show you here. See, these buller right here. This is the bullous lung disease. So this patient has pre existing multiple bullet in the lung and they've got the surgical emphysema too. So the question is, is, have they got an acute pneumothorax that needs a chest drain. But if we put a chest drain in, what is the risk? And I'm going to go straight to the questions here and see if you've answered. Perforation. Always. Yeah, bronchopleural fistula, someone has said exactly. So there's lots of risks of, um, putting a chest drain up in, aren't there as with any procedure you could cause bleeding. Like for example, you could, uh catch an intercostal vessel and then cause a lot of bleeding. Uh, you could go too far, go into the heart that would be very bad, obviously could cause infection. Um, but specifically when you've got bullets, lung disease, if you put a drain into a Buller, you basically end up setting up a permanent fistula between the buller and the pleural space, which is called a bronchopleural fistula and almost impossible then to rectify. So if you have someone who has really bad underlying lungs like this, my advice to you would be called someone senior before you to put a chest train in. Okay. Very good. Right. So we're moving now onto the airspace now and I want to think about the air spaces um and the peripheries of the lung. So you remember before we were talking about the LVO lie and how they are, they're kind of like um bunches of grapes, aren't they? And the inside of them contains air and they communicate with the bronchioles in between the alveolar. Like you've got a kind of potential space which is the interstitial fluid, interstitial space. And if the interstitial space fills up with fluid, then what happens is you get um either a line um or adopt depending on whether you're looking at it straight on all that way. So it's as if you're filling in all the cracks around the alvie oh lie. And if the viola I fill up with fluid or pus or blood, then you will get an air bronchogram. So the air space can basically fill up with fluid in pulmonary edema. It can fill up with pus. If you've got infection, it could fill up with blood, I guess in trauma and in something like Goodpasture syndrome, which is an inflammatory disease, isn't it? Or it could fill up with tumor cells occasionally. And what happens as I say is the alveoli fill and then the bronchitis cause they're still airfield, they stand out and you get something called an air bronchogram happening. And the key thing here is in this airspace, shadowing you don't lose volume. It's just that instead of containing air, the LVO like contain fluid or puss. So here are some examples of airspace shadowing where you can see the dividing air bronchogram and then around it, this white area and that's the alveoli which are full of fluid or pus okay. The interstitial space, as I say, that's the kind of surrounding space. When that fills up, you will get reticular nodular shadowing. You can either get that in, you know, acute edema or, or a lymphangitis or you can get it in fibrosis for whatever reason. And quite hard to see that on chest X ray, I mean, it's much easier to sit on CT. But in general, you just get this kind of, it's kind of messy shadowing really on the chest X ray much easier on CT. So this patient has sarcoid and you can see lots of nodules, but then you can see how some of them are more criss cross and this is kind of all in the interstitial space, okay. Uh So, um if I see um any kind of funny little nodules or lines in the periphery, I don't spend too much time trying to decide are they lines or nodules, I just call everything reticular nodular. So I would say there's reticular nodular shadowing, it's in the lower zone, it's interstitial lung disease. And then I'll mention whether or not there's lots of volume in general. Once you see reticular nodular shadowing, there usually is loss of volume. And for example, here, once you've got advanced fibrosis like this patient has, instead of having a nice smooth outline of the hemi diaphragm, you actually get um this kind is very shaggy and furry. And that's because the interstitial space which goes right up to it is full of fluid and fibrosis. Okay. So I'm just going to finish with this and then we'll kind of have a break and then we'll come back. So just to summarize really the difference between airspace, shadowing and interstitial shadowing. So airspace, shadowing can happen in any zone. Uh you get confluently white shadows and air bronchogram which stand out against them. And the cause can be the RVR life filling with fluid or pus or blood or cells. Whereas interstitial shadowing also any zone you get this linear or reticular nodular shadowing. Uh and what's happening is you've got fluid in the interstitial space, uh or lymph in the interstitial space or fibrosis in the interstitial space. So that's the difference between the two. Okay. So I'm now going to say to you go away, have a 10 minute break if you can come back. Exactly. So uh in London right now it's 10 to 3. So in 10 minutes time, basically, um whatever time zone you're in. So come back in 10 minutes. Uh and we'll kind of all be refreshed. I will see you then. Okay. Hi, everybody. Welcome back. Um So let's just do a little refresh of what we were talking about before our break. Um So we were talking about the difference between airspace and it's the interstitial shadowing. So both of these can occur in any zone, air space fills up the Salvio lie and what you have is the air bronchogram standing out against the LVO lie which are full of fluid or pus or blood. Whereas with interstitial shadowing, you get reticular nodular shadowing because you've either got fluid or fibrosis within the interstitial space between the alveoli. So we're gonna look at some examples of that now and whoopsy, hang on. Sorry. Um So, um let's take a look at this and think about why this is airspace shadowing. And um you can see this is obviously a very sick patient. They've got um an E T tube in place. They've got lots of chest drains. I think this is because they've had surgery. Um But the thing I want you to look at here is um the lungs and tell me why, especially if we say focusing on this bit of the lung on the left. Why is this airspace shadowing? And I'm just going to go back to um so kind of focusing in on this area here just going to go back and um start up the next question it's mhm So the next question is why is this airspace shadowing? And we'll keep looking at it? Is it because you're seeing a bronco grams or is it because you're seeing reticular nodular shadowing? Remember air bronchogram? Has come about because the alveolar light are full of fluid and then the bronch I stand out, they still are full of air. So you see these branching structures, whereas reticular nodular shadowing is basically dots and lines. So let's focus and see what you've come up with. Uh just see what your responses are beautiful. Absolutely. So everyone got this right. The reason why this is airspace shadowing is because there are bronchogram. Let me just set up the next question and activated. Okay. Very good. So you can see the branching structure here. This is the air bronch. This is the bronchus which contains air and it's surrounded by white stuff which is fluid within the LVO lie well done. Great. So here you would say they're shadowing in the air spaces. You kind of describe which stones they are and there's no loss of volume here. It's just that um the air spaces are full of fluid. So this is airspace shadowing by contrast, remember we looked at someone with left ventricular failure before when you see these tiny little lines here, lines or dots. Um this is kind of typical of interstitial fluid. So this is um reticular nodular shadowing. Okay. So now I want to think about when you get collapse of a lobe of lung and the lungs can collapse for various reasons. Basically, if you've got something in the proximal airway like a plug foreign body neoplasm, it will collapse down behind it and it collapses down in predictable locations. So I'm sure that you all remember your anatomy of the lobes of the lung. But basically what you do is you use the normal crisp borders of the lung. Uh and it's margins and if you don't have a crisp border that tells you which labor's involved. So, uh for example, we know that the lower lobes sit on the hemi diaphragm. So if you see, um if you lose the border of the right hemidiaphragm or left hemidiaphragm, it has to be that the left, lower lobe, the lower lobe is involved on the left or right. If you lose the right heart border, that's where the right middle lobe sits. So that has to be a right middle lobe problem. And then if you start to see a pacification up here and a lot of volume, then you're talking about the upper lobes. So remember the anatomy of the uh of the lung lobes. And um this picture here roughly shows you um where they sit in relation to the adjacent structures. So let's look at some examples. So when you lose, when you have labor collapse, you lose volume. So it's different to airspace shadowing where you do not lose volume in collapse, you lose volume. The mediastinum will shift towards the side of the collapse because it's pulled towards it. The highland will also be pulled, the fishers maybe pulled up or down and then the rest of the lung that isn't collapsed has to expand. So it looks blacker. And um so just to kind of recap collapse versus consolidation. So they both affect lobes of the lung. They both can cause white areas consolidation, which is the same thing as airspace, shadowing. You don't lose volume, you have air bronchogram collapse, you do lose volume and you don't have air bronchogram. So let's look at some examples here. Question here is, is this left lower lobe collapse or consolidation? So I know it's the left lower lobe because I can't see the left hemi diaphragm. Well, how do I know whether it's collapsed or consolidation? So I'm looking at the lung space is one side blacker than the other. That would mean that the left upper lobe had had to expand. And what's happened to the hilar vessels? Have they had to move around at all? Remember one of you before was talking about the spaces between the ribs, the spaces between the ribs bigger or smaller on the left than on the right. And can you see anything behind the heart? So let's see what your answers are. I'm hoping that you've all voted. Everybody says collapsed. Fantastic. That is the correct answer. And I'll show you why that is the correct answer. So basically, um this is the hard border, this is the edge of the left lower lobe. And what you see here is there's no air bronchogram in it. So that's one reason why there's no consolidation. Secondly, what you can see is that it's blacker on the left and on the right. And if you look at the pulmonary vessels, they're a little bit pulled down compared to the right side. And that's because they're having to fill up the space. So the analogy that I always use is if you have a room full of people and then you take half the people out quite quickly, the other half the people will spread around the room, won't they? And this is what kind of the left upper lobe is having to do is having to spread out over a bigger space. So that is a left lower lobe collapse. Um Here is another example. Um this is another person with the left lower lobe collapse. So it's very characteristic to see, we call it a sale sign behind the heart border. Okay. And again, I think in this patient, um I'm just thinking, can I convince you? I'm not sure I can convince you. But anyway, there is a sale sign behind the heart border. Now, by contrast, in this patient who's also got shadowing um in this region, you can see these dividing little um structures here and these structures are the air bronchogram. And again, this is the lateral view, we don't do these very often. This is anterior, this is posterior, this is the oblique fissure between the left upper lobe and the left lower lobe and you can see the air bronchogram which are dividing there. And so this is consolidation, there's no loss of volume. Okay. Let's keep moving. Um And in this patient, um the left side is abnormal, it looks like someone has taken a kind of veil and hung it over the left side of the lung. And when you see a veil like capacity that makes you think about upper lobe collapse and that's what's happened here. So, in this patient, they've got left upper lobe collapse and here's the CT and here you can see this is the left upper lobe completely collapsed. There's no air bronchogram in here at all. And that's relatively likely to be due to something like a primary lung tumor. Here's another example of someone with a left upper lobe collapse. Again, it's like someone's hung avail and there's also you get the impression a mass here and that mass is the tumor uh that has caused the left upper lung collapse. I'm just looking to see if everything is okay. Yeah. Great. Right. Let's keep moving. So it's always good to look at a lot of examples here. So this is someone who's got right lower lobe consolidation. I know it's right lower lobe because the hemi diaphragm is not very distinct and I know it's consolidation because there's no loss of volume. But we just see these branching air bronch grams. So you work out which lobe it is and then you work out if it's consolidation or collapse. Okay. Another patient here and in this patient, the right heart border is not very distinct and you still got a bronchogram is here. So this is right middle lobe consolidation. Uh If I just zoom in here, you can see those branching air bronco grams and the right middle of the right heart border, very difficult to see, isn't it? And then finally, this is a very old film. Now, actually, this is someone who's got right upper lobe consolidation. So this is the right upper lobe and you can see the horizontal fissure which is right here, hasn't moved. This branching thing here is an air bronchogram. So it has to be right upper lobe consolidation. Uh And by contrast, in this patient, the horizontal fisher is no longer horizontal. It should be here shouldn't, it's been pulled up. Uh You've got whiteness in the right upper lobe zone and no air bronchogram. And so therefore, this has to be a right upper lobe collapse. Okay. Finally, last case, this is someone who's had a left pneumonectomy. So the entire left lung has been taken out. And so what's happened is the left hemidiaphragm pulls up the chest wall squishes in the mediastinum moves over and you may see people with pneumonectomy. Okay. So, uh next, we're going to think about nodules in the lungs. So multiple nodules, not with a reticular or a linear component, just nodules and you can basically divide them into two groups, so small and large. And that depends on whether they're kind of over or under five millimeters. So small nodules, uh the causes of things like miliary TB means like seeds, uh sarcoid and occasionally metastases. Whereas with large nodules, uh that will be metastases um and occasionally things like inflammatory nodule. So things like rheumatoid um inflammatory nodules, which someone mentioned before. So here we are, we've got a patient who's got lots of tiny, tiny little nodules all throughout the lung. And I'm going to go and see if you can, if I can activate this. What could this represent? So your choices are Sarcoid miliary TB miliary metastases, pulmonary edema or left lower lobe collapse and can vote for more than one thing here. But just notice that you've got all these tiny little nodules right here. Let me see what you voted. Very good. So, a lot of people have said miliary TB miliary metastases. I agree. I would also put sarcoid in because sarcoid is the answer to everything. Um The reason why I think this probably isn't pulmonary edema is because it's very much nodular. I'm not seeing a reticular nodular component. If I saw lines as well, then then you might think about interstitial fluid. But um and therefore pulmonary edema, but it's mainly nodular. So the answer here is your differential is basically miliary things, sarcoid, miliary TB miliary metastases. And I suppose if you live in a mine ing region. You'd think about the pneumoconiosis. Okay. So, thinking about sarcoid for a moment thing to say about sarcoid is you can put it on any list for anything because it has a multitude of appearances. So it can cause little miliary nodules. It can cause lymphadenopathy. Uh it can cause reticular nodular shadowing, it can cause anything. And this is a patient who's got big Hyler lymph nodes, lymph nodes in the right paratracheal region. And then if you look carefully, all these tiny little nodules as well, uh We're just turned in there. OK. So we talked about small nodules. Now, let's move on to big nodules and this is someone who has got multiple pulmonary matatus ease. So these are all big and um that's I think pretty obvious, isn't it? Um Here's a patient who's got a couple of abnormalities here and I'm hoping that you'll be able to point to these on the image. So let me just go to the next screen. Okay. So what I'd like you to do please is 2.2 as many abnormal areas within this lung as possible. Mhm Okay. So let's take a look at what you've done. Oh, very good. Fantastic. So you pointed out multiple areas, which is great and I agree with you. So certainly here, for example, there's a rounded area with a cavity in the center here. There's another rounded area. It looks like it might be Cavite Ating. Same here. You pointed all of those out, didn't you? And then you also wonder here as well, don't you? So basically these are multiple Cavite ating masses. And the list for multiple capitated masses is squamous cell carcinoma. Um infection and the three infections are TB staphylococcus and klebsiella. So remember that list TB staphylococcus, klebsiella and squamous cell carcinoma. Okay. So now we're gonna move on to when someone has just one nodule and what would be on your differential diagnosis there. So now you're thinking, you're still thinking about infection like TB, but you're thinking about neoplasm and the things that would make you think something is more likely to be a tumor are if you see um that it's speculated if there's a pleural effusion or lymphadenopathy. Um The cavitation isn't particularly useful because it can occur in both infection and squamous cell carcinoma. Here's an example of someone who's got a pancoast tumour. And what's happened is that that is growing in the right apex. You can, I'm sure imagine all of the structures it's pressing on. So like the sub Clavin vessels, uh the brachial plexus will be pressed upon, won't it? Um uh the recurrent laryngeal nerve. So typically these patient's get hoarseness, don't they? Um So multiple things that will be pressed on by this tumor. Okay. So, now we've got a patient here and they've got a single mass with cavitation in, in the right apex. And I'd like you to think about what the possible causes of that are and just type that into the chat, please. I'm just looking for the chat. Where's my check on? Um, uh, okay, here. I know where it's gone. Chat. Great. Anyone want to type that in? What causes do you know of a Cavite? Ating mass abscess? Very good. Yeah. TB. Absolutely. TB, I agree with you. Very good. Any other causes that, you know of a Cavite ating mass? Yes. So, fungus can cause it also fungus can infect it to, can't it? Yeah. And metastatic and tumour. Absolutely agree. Very good. Thank you everyone. That's great. So, yeah. So when you have capitation like this, do you think about infection and you think about a cavett ating carcinoma that brings me onto TB? Uh TB will always be with us. So when you have a primary TB, you get a peripheral lung mass and then you get Hyler lymph nodes and then when you have secondary TB, generally that affects the upper lobes, it can Cavite eight. But you don't often see lymph nodes. And thing to remember with TB is that it can affect any part of the body via hematogenous spread. So, just to remind you, this is someone who had TB in the past and you can see the primary gone focus has calcified just here and then, so have the lymph nodes that were infected. So this is like a great chest X ray to remember what TB does in primary TB. And then this person has got secondary TB. Uh So they've now got cavitation in within the apex. So more commonly in the apex of the lung. Okay. Finally, we're going to talk about the review areas and one of our review areas is the apices. Remember. So above the clavicles and thinking about that in this patient, uh what do you think is going on in the apices of the lung? You can just type that in, in fact, just tell me which side you think is abnormal, left or right left. Absolutely. Right. Absolutely correct. Rather. Uh So what you see here is there's a mass in the left apex and actually you can see that there's airway within it and someone said pancoast tumor. Very nice. Yeah, exactly. This is a pancoast tumor, isn't it? Very good? Ok. Other review areas. Uh So this patient, we're thinking about free air. Now, this patient was vomiting and they suddenly had chest pain. Uh So when you have that history, really severe chest pain, when you have that history, what do you think about, um, what's the kind of clinical scenario that you're thinking about their lots and lots of vomiting and then suddenly very, very severe chest pain, aspirated pneumonia? That's certainly possible, isn't it that they've aspirated? But this like literally came on in seconds. Uh Good. So someone said perforation and someone said bore have syndrome. Exactly. Right. So what we see here. It's quite subtle. You can see the pericardium. Remember how we had the pericardium on that earlier ct. So you've got a real here between the pericardium and the underlying heart. And that's because they've had an esophageal rupture from the vomiting and air has gone out of the esophagus into the mediastinum and that of course, is not a good thing because now the mediastinum is full of kind of dirty food. Uh, so that's a surgical emergency. Um, okay, um, hair, hair under the hemi diaphragm. Who would you contact? Now, in this patient? Anyone like to tell me who you'd contact? Yeah. So the patient patient has got air under the hemi diaphragm. There's a different patient to the previous one, by the way. Um, so this patient's got air under the hemi diaphragm. They've got abdominal pain. Who are you going to contact? Yeah. Gastro or surgical team. Exactly. Right. Because basically they've got free air in the peritoneal cavity which has risen up sitting up under the hemi diaphragm. And, um, it's a sign that they've perforated. If someone's perforated, they've got to go to theater, haven't they? Very good? Okay, good. Um, finally we're going to just finish with the soft tissues and always remember to look at the soft tissues and the bones if you don't look, you kind of MS stuff. So, for example, in this patient, it kind of looks okay and then you suddenly realize the whole club, the whole scapula has gone because they had metastases. Uh, same with this patient is not obvious what's going on until you start looking at the ribs in turn. And suddenly you see, oh, gosh, there's a sclerotic left fifth rib again. Motasisis. Okay. So by the end of the session, I wanted you to have a basic system for looking at chest x rays, uh sensible kind of spiel to say in exams and for you to have a kinda logical approach. So you're confident you're not missing stuff when you're on the ward. Um I'm hoping that's the case. We're now gonna do just a quick fire quiz. I think I've got 10 cases and then you're done. So actually, we're finishing ahead of schedule, which is great. And um I think what I'm gonna do is I'm going to ask you just to type the answers in the chat. Thanks. Okay. So this patient here, uh What do you think is going on with them? You can just type the answers in the chat. I'll give you a few minutes. I give everyone a chance to answer. There's only 10 cases. Okay. So most people have said um a left pneumothorax and collapse of the left lung and that's correct. So, there's no normal lung tissue here. It's just black air, isn't it? In the pleural space? We can see that this is the lung that has collapsed. And then of course, you've got to think to yourself, has the mediastinum shifted or not? Because if it has shifted, then you're worried about attention pneumothorax. I think certainly in this patient, you'd start to be worried, wouldn't you? Because the lung is very collapsed down, even though the mediastinum hasn't shifted over. Okay. Very good. Next patient. So, in this patient, what do you think is going on? So this, the clue here is, it's a, it's a, you're trying to decide is it consolidation or collapse? So the first thing to decide is which lobe is involved. And the second thing to decide is is it collapse or consolidation? So is there a loss of volume or not? And you're going to decide whether it's lower lobe or middle lobe by looking at the hemi diaphragm. Can you see the hemi diaphragm? Yeah. So actually, I have to say this is not the world's best case, like maybe I'll take it out. I think this is actually a mixture of consolidation and collapse. So it's definitely right lower lobe, you all got that right. It's right lower lobe. You don't see the hemi diaphragm, do you? Then the question is, is, is there consolidation or collapse? So I think for collapse is the fact that the lung above looks a little bit blacker than the opposite side, doesn't it? Which makes you think there's loss of volume here. However, you do see some branching air bronchogram is here. So in reality, and this is what happens in reality a lot, isn't it? Is you get a combination of collapse and consolidation. So uh the story slight fudge here, this is kind of right lower lobe consolidation and collapse. And then the other thing to say here is you don't see the right heart border as well. So then that kind of makes you think, oh maybe there's some right middle lobe involvement. And so this is the kind of really world chest X ray. Okay. Next case, uh this patient um it's another which lobe is it? And is it collapse or consolidation? So let's see what you have to say about this. This is much more straightforward than the last one. Okay. So you're doing really well. Absolutely, everyone got this right. This is right upper lobe collapse. We know that because this is the horizontal fissure which should be here because it's horizontal, right? Uh it's pulled up. So we know there's a loss of volume. We know it's above the horizontal fissure. That's why it's the right upper lobe and there's no air bronchogram. So those are all reasons why it's right upper lobe collapse, very well done. Okay. Let's move on to the next case. Ah So this is a patient who's very breathless, uh sitting up, um kind of sweating, um you know, breathing very, very rapidly. What do you think is going on here? Okay. I'm just looking, people are saying, or some people are saying consolidation there is consolidation. You're absolutely right. But um um there is consolidation but actually, and there are air bronchogram visible. That's all true. But actually, this is acute pulmonary edema was actually just trying to look up some of the drugs that you mentioned um in terms of heart failure. So, acute heart failure, I think the main drugs will still be the uh things like frusemide, um G T N and morphine, things like eight inhibitors that you mentioned are kind of, I think more longstanding type drugs for more longstanding um heart failure, but I'm sure there will be a cardiologist along to tell you that. So this is a classic picture of left ventricular failure. Okay. Very good. Now, what's going on in this patient, we're back to uh lobes of the lung and collapse versus consolidation. So, first of all, decide which lobe is involved. Can you see the hemi diaphragm? Can you not see the hemi diaphragm? Um Can you see bronchogram seems um have you got lots of volume? Those are all the things you're thinking about here. Someone saying air bronchogram is visible. Absolutely true. That's correct. We can see air bronchogram is branching here which pushes us towards consolidation, doesn't it? Very good? And people are saying left lower lobe, exactly right. We've lost the left hemi diaphragm. Um This is actually the heart border. It's a little bit confusing isn't because remember we had the sale sign and the other patient, but this is the heart border and then beyond it, you've got all of this airspace, shadowing with air bronchogram. So that's left lower lobe consolidation. Well done. Everyone. You did it really well. Okay. What's going on in this patient and what should we be doing with this patient? Okay. Uh So people are saying right side attention, pneumothorax, that's exactly right. Isn't, it's pushed the heart over to the other side. Uh There's a lot of lung here and you can see how the air in the pleural space is just pushing hemi diaphragm down. Very good. And then um a, a needle decompression. Exactly. Right. So you go to second intercostal space and put a needle in there. You can just put a kind of very simple needle in just to decompress it, but you don't have to do a kind of dedicated chest drain. Do you? Okay? Very good. We're getting there three more cases I think in this patient. Uh So this is a patient on I T U. Um They've got an internal jugular line in, you can see that they've got heart failure because they've got all these air bronchogram. So they've got pulmonary edema. Um and um what else is, and then they put an N G tube in. So what do you think is going on with this N G tube? Do you think it's a good position or not? Uh It runs into the right main bronchus. Very good. Exactly. Right. So you can see that this N G tube is here in the right main bronchus. And that is a problem because if you start to feed the patient, you would basically be causing pneumonitis because the feed is so toxic. Exactly. It's wrong feed. You want it to come down the center cross the carina come below the level of the diaphragm and then be somewhere in the region of the stomach. Very good, well done. Okay. Uh This is someone who's got an N G tube in the right position, isn't it? Okay? Uh This patient is another example of things where things have not gone very well. Um The N G tube here is in the left main bronchus and it's actually I think penetrated the um lung as well. This is a very bad position, isn't it? But it's another example of airspace shadowing throughout the lung. Okay. Next one, I need two more to go in this patient. What is going on with this patient? What, what can you see is going on uh around the mediastinum? Um Someone's bilateral hilar enlargement. Very good. Yeah. So the hilar are big and actually these lymph nodes are extending all the way up, aren't they? Very good? So you just think about the causes of lymphadenopathy, things like lymphoma, things like sarcoid, for example. Very good. Okay. It's another collapse versus consolidation question here. So first you're going to decide which um lobe is affected. So think about, can you see the heart border? Can you see the hemi diaphragm? And then you're going to decide, is it collapse or is it consolidation? So let's get you to answer that. So, most of you are saying it's collapsed and that's correct, isn't it? We don't see any air bronchogram and it's just got that kind of flat look, hasn't it? So now you just have to decide, is it right middle lobe because you can't see the right heart border or is it right lower lobe? Can you see the hemi diaphragm? So that's tricky, right? Let's keep coming. Uh So here, I think it's entirely reasonable. I can see why people have said right middle lobe, you don't see the heart border either. So I think it would be okay here to say this is probably right lower lobe and middle lobe because you've lost both. You've lost the hemi diaphragm, not completely but partially and you've also lost the heart border as well. So anyone who said anything about right middle or lower lobe collapses, right? I think that's my last case actually. Oh, case nine. Okay. What do you think is going on in this patient? So quite a few people are saying metastases. I think that's by far the most likely answer, isn't it? There are other causes of pulmonary nodules. We talked about inflammatory causes like rheumatoid and stuff, but basically this is very likely to be pulmonary metastases, isn't it? Yeah, Exactly right. Okay, great. I'm going to stop share ing now. I think I am done. Yeah, I am done great. So um I hope that was useful. Well done for sticking for a long time, an hour and a half. Um I think this is all on video so you can rewatch it again. And if anyone wants to send me any messages, please do. Thanks very much for your attention. Ok, bye everyone. Thank you very much, professor. Welcome. Um Before everyone leaves, please do fill in the feedback form. Um And if you could confirm that you filled in the feedback in the chat, then I'll send through the certificate um for this lecture. So if you could please confirm that you did the feedback and then send it through. Um Also just to address a few frequently asked questions today. Um as we've mentioned before, all the lectures are recorded. So they're all going to be on the medal platform. So the lectures from last um from term two are already on there. Um And we're gonna put the rest up as we go along for this time. Um As fast as we can. Uh There's a whatsapp group. Um if know, if some people aren't on the whatsapp group, I'll put the link for that in the chat. And again, the certificates will be posted in the chat for each lecture for the time being. Um So please download them from the chat and if you're using your phone, you won't be able to see the certificate, so make sure using your computer. Um But that's about it. So please, if you could do the feedback and confirm you to the feedback, then I'll send through the certificate in a few minutes. Thank you, everyone and thank you very much, Professor. Thanks very much Hanna by.