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Hello, everyone. It is doctor G. Um Good to see one. Do you need? Um Can you see me? Yes, we can all see and hear you. Awesome. Yes, I'm uh your speaker today. Um Next time in two weeks when we return, I will have a special guest uh accompany me. So it should be a lot of fun. Um but we'll give it a sec for, you know, letting people come in, stretch your legs. Hopefully everyone's doing great. We have an amazing case for today. Um I think they're always amazing. Um And as always, I will launch with the initial discussion of um how to read a normal chest x-ray and then we will invite a few of you on stage to read the case with us. So if you're eager drop, uh we'll, we'll give it one more minute before we say drop in the chat box if you wanna come on stage with us and you know, help us read a chest x-ray today, not just read a chest x-ray clinical engagement. Uh You know, think about this case clinically um that we're about to consider and do so. It should be a lot of fun. And if you guys have anything exciting happen to you over the last two weeks, throw that in the chat box too. Let us make sure we can celebrate you guys. Um, and all your great accomplishments. Uh Let me see if he is here so I can embarrass him. Uh It doesn't let me send him a text. Hold on, I just texted one of my former mentees. If he's available to join x-ray rounds tonight, he may not be, which is fine. All right, it's 503. We'll give it one more minute, Deanie. How are you doing this afternoon? I'm doing good. How are you doing? No complaints, no complaints. We're rocking and rolling. Um I will say to the crowd here, uh my five year old is in the background. So if she interrupts, I apologize, but we will have fun. Um And let me message one more person. All right, it is 503 about to be 504 any second now. And I told you guys we'd like to start. So let me uh kick off again with a bit of introductions. Uh My name is Doctor Pas Satos, an associate professor at the Johns Hopkins University School of Medicine and a physician in Pulmonary and Critical care Medicine. We do these chest x-ray rounds for you all for several purposes. One for many of you coming from diverse backgrounds throughout the world. Um Staying sharp with your um ability to um read and interpret chest x-rays is always gonna be a, a kind of a foundational skill that every physician uses um globally. So that's what we're here for, to do and recognize the methods of how I interpret it and read it. It's more of the art of medicine. Everyone has their own approach of how to read it, which is fantastic. Um You know, when we invite doctor uh uh Tony Cheng again, our radiologist, he always, he does it a little bit differently, but we always get the same results. Well, he actually gets a lot more results than I do being a radiologist. Uh The second intention of course is to keep many of you excited to pursue medicine and the healthcare field. And I feel like being able to see and discuss these patients even if it's just your chest x-ray. Um I feel like goes a long way to fuel you guys as future physicians. And then finally, finally, the other intention and goal is to allow you guys to recognize this counts as vi as shadowing. So if you guys are doing um you know, preparing to apply for residency or fellowship or just med school or college, please make sure you guys throw this down on your resume. You devote the time to join us and uh you guys should get the credit. Um You know, when, if you have any questions of how to put on your resume email me um happy to help you out with that. There's a five year old in the background making a very slow exit. So without further ado for this again, I'm gonna kick things off by reading the x-ray for you guys. I'm gonna go over reading a normal x-ray that also allows me to make sure I'm doing this all correctly. And then after that, um DNE go ahead and throw in a chat box. Um If anyone would like to get on the stage, you know, and read the chest x-rays with me and the clinical case, we can take up the, you know, uh 3 to 5 volunteers, we'll have plenty of things to discuss. So with that said, let me go ahead and let me just make sure there's nothing in a chat box right now. Oh, it's just, the survey is fantastic and let's go ahead and read, oh, first chest x-ray. Remember I try to give you guys a sense of normal. Um But this one has a little bit of a curveball in it that, you know, we'll discuss what that means. All right. So present, let me see if I hit share screen and I, so it was my favorite part where it's like, am I showing the right thing? All right. Well, let's go. Oh, let's go here, share and then um, Deanie just so I uh know I'm doing this correctly. Can you see the presenter mode? Uh It is not in presenter mode. OK. So let me, let me stop sharing because we had the same issue. Last time I think what ends up happening is it just shares the powerpoint? So let me change one thing, share screen. Let me try this other way. Had share. All right. Can you see this now in presenter mode? Um We see her med screen now. OK. All right. Let me try figure it out. I promise. All right, let me do this in the chat at the top. There's a message from Metal on how to do it. Um So that you see a doctor. Yes, perfect. Fantastic. We will eventually get there, we will get there and now it's always time to try to find all the gadgets that make this. Uh let me hit hide and all right, here we go. The markup stuff. Perfect pen. All right. So as we always do, you know the intention of reading an x-ray. The first thing that we do is make sure that the x-ray is uh appropriately positioned. Um I a few, you actually shouted me in the medical intensive care unit this weekend and got to see an x-ray technician in real time. Take an x-ray and you just what you saw in that x-ray technician is that they take a metal plate. This is for a patient in the intensive care unit who was intubated and they slide a metal plate uh behind the patient's back and then they position the patient to be flat up against it. So I promise you, they do everything possible to assure that there's no active rotation. And the way we confirm this is looking at the spinal process with the processes and the way we see them, they look great and not rotated. And the lack of rotation is evident by this kind of oval shape um pattern. Next, we go into the chest and it's not rotated. So we're gonna look at certain anatomical spaces. We're gonna look at the mediastinum and we're gonna look at the pleural space. These are the spaces that are s uh surrounding the lungs, the pleural space as well as kind of an an anatomical space made by the space between the two lungs. That's the mediastinum. When we talk about the mediastinum, we're looking for two things, right? One is, is it if it's shifted or not a shift of the mediastinum usually implies there's something pushing the mediastinum or pulling it depending on one of the lung spaces. Again, an abnormality that we should recognize. And then what I'd be going to introduce to you guys is something called the splaying of the trachea. Oh My goodness. If you share that with any of your physicians, when you shadow, they will be, wow. So what we do is we go down to where the trachea ends and this ending of the trachea is called the corona. And what once we find it, we just make sure that it falls in the boundaries of the vertebrae, which is a reasonable anatomical landmark to say that the mediastinum is not shifted, usually works out the majority of the time. And next, we look at the actual Carona, the angle that it makes and it should always make up more of an acute angle, right. So that's a normal looking uh carina. So all I would say here is finding the cara. It looks like it has not shifted and it is not splayed. You can add the splay part now, but we're growing a little bit from the kind of our first um teachings that we did about the trachea and the carina. All right. Next, we go into the uh pleural space and then the pleural space. I look at the base and then I'll look at the top and then what I'm looking for is to make sure that there's no air and there's no fluid in the space of the uh that surrounds the lungs. So the bottom part is the costophrenic angles, right? This anatomical creation really just when a chest x-ray cause chest x-rays take a three dimensional product, the human body, the chest sandwich it into a two dimensions and you get these angles that are made on the right side, it's uh the side that's your liver right there that I'm marking. And on the left side, that's your stomach. And above it is the diaphragm but these angles, if you can see them right, there's only really two outcomes you see them or they don't, if you look hazy, it usually means something's above it. Um like breast tissue for instance, but you can see two costophrenic angles here and they are normal. And in apex, what I'm looking for is just kind of this grayish colorization. Sometimes you can even see the lung markings making themselves go all the way above the clavicles that implies no air. So looking good so far next we go to the hilum on the right side, you'd see it really well. And again, what you're looking for here is some level of translucency transparency. So you can see through it and it takes kind of a kidney shape, look to it on the right uh left side, you just usually see that the heart is taking up the rest of the space. So as long as, as you see these patterns of normal for the hilum on the left side and on the right side where you're gonna see a lot more evidence of it. So on the left side, this little nugget that pops out is usually the right size. Um If it gets bigger, what it usually ends up doing is just kind of invading more of the chest ca uh space around uh inside the lungs, right? We just kind of drawing it out a little bit how to get a sense of if it's big, honestly just takes more and more of reading these and interpreting them, but it's usually the same size as the left atrium. That's how I've always kind of identified it. The right side as you can tell the kidney shape helps or the bean if you guys don't look at kidneys every day of be, um, and again, it should be somewhat transparent like it shouldn't be completely wiped out. Next, we're going to dive into the heart, the heart size. We're looking to see if it's a normal size heart or if it's enlarged. Those are the only two things you can mention about the heart on an x-ray. The one that I expect all of you guys to know is if there's a space between the apex of the heart, the left ventricle, remember the ape, there's an apex here for the heart as well. The cardiologists like to steal our terms. There's a space just that alone. You can say there's no cardiomegaly implying a large heart. Then you guys have also been taught the two slope system one and two. And this implies that the left atrium here is of normal size. If the pressures in the left atrium are too big, you get one slope. And I wouldn't imply that it's cardiomegaly. That usually implies a very immediate moment. The other part of the heart that I've been slowly introducing has been the right atrium over here and what we want out of the right atrium is, again, it should one not stick out further than the hilum and then two have a nice little good angle set up right there. That angle is lost right where it's mo when I say lost, it's usually because this bows out so much that the way it comes down is not as an acute angle, um, becomes a little bit, um, greater than 90 degrees we're approaching it. So again, you get, you pick up a lot of the reading of the x-ray as I'm giving you guys a little bit more information. It's something that takes a little bit of more time and time to kind of appreciate normal versus not normal as I'm drawing these out for you guys. So I know there's a lot of information and for many of you who have done this with me before, you're like, whoa, Doctor G's adding some more information, don't worry. Right. Take your time. But it's me slowly introducing this to you guys. So you guys keep learning more and more. Next, I'm gonna do something that I haven't really done with you guys. Part of it is because hm, it's not a belief, it's not, I don't believe it or not to be frank. I never really know what to make of it anyway, let me tell you where I'm getting at before we dive into the lungs and that's about counting ribs. I have plenty of physicians who like counting ribs cause it tells them, did the patient take an adequate deep breath? Well, the issue though, I will say whether you see the ribs or not, you know, if the lungs are over inflated and, you know, if they're underinflated regardless of the lung size. Right. So, that's what I'm gonna teach you guys a little bit today. Let me see if I can find a marker or an eraser. Sorry. So I'm gonna erase something because it covered something. Yes, little smudge. All right. So the rib counting, there's many ways you can do it. But anyway, what I'm gonna reveal to you guys, the ribs coming like this. Those are the posterior ribs. Those are in the back, your anterior ribs come out more like this. So counting them anywhere between 6 to 8, six to, you know, 8 to 10 usually implies an adequate deep breath. Now, Paul's here real quick, I'm gonna speak. You don't have to remember this. Whenever a patient takes an x-ray, we always ask him or her to take in a deep breath. The challenge is if they're breathless, if they're having an asthma attack, they're not gonna be able to hold a deep breath, they're gonna be panting, they're gonna be breathing fast. If my patients on a breathing machine, there's no way I'm gonna ask them to take a deep breath because they usually are unconscious. So I, I don't tend to count ribs. I just tend to count, not count I tend to find other hints that the patient took in a um uh not enough deep of a breath or if their lungs are pathologically overinflated. So let me give you an example here where you could count ribs and you're like, oh, the patient looks like they, they took an inadequate deep breath. But I would say maybe not. Um but again, maybe not, doesn't imply anything bad, but I'll show you something that's going on in these lungs. So when I look at the lungs, I do zig zagging, I think I showed you that last time I go back and forth, back and forth and I go back and forth, back and forth, back and forth, back and forth. And then of course, I go really back and forth. What I'm looking for is uniformity in the pattern. What I'm looking for, I'm gonna start erasing stuff. Now, I apologize guys. What I'm looking for is that the lungs are pretty consistent, um, top to bottom and, um, left and right now you guys know that I'm gonna allow a little bit of, uh, I gonna allow some allowance in regards to knowing that the bottom part of the lungs are going to have more vasculature, be prominent, be more evident, right? The base than the apex, right? That is gravity. There's a lot more vasculature, there's a lot more blood flow at the bottom of the lungs. So, yeah, you're gonna have more markings that are gonna be lot, a lot more predominant. All these markings should somewhat stop the middle part or, you know, 3/4 of the way through the lungs because they should not reach all the way to the ribs. Right. They should not, not come all the way out here. They only do in pathological states. So where that line ends is where I usually expect the majority of the lung markings to faintly begin to end as well. So I don't see that. Now, the lungs overall are normal. And honestly, if you read this with me or on rounds and you said doctor G spinal process isn't rotated. Carotid does not seem to be shifted, doesn't seem to be splayed. There's calci angles bilaterally es look normal with no air evident. The uh hilum looks of normal size, there's no cardiomegaly um on the left side and the right side looks also normal and the lungs look like they have an, um, an appropriate distribution of interstitial markings from top to bottom. You get an A, you'd be fine if you said, but I see something right here where this line is, I'd give you extra credit. I wanna give you an A plus because this is, this is like what a radiologist will pick up and erase it. Now, this little thing here is the mo world's most subtle of atelectasis. So, atelectasis we've discussed before that what it is is the lungs kind of self collapsing. When you, when one another and that self collapse isn't bad. It isn't pathological. It just, it's kind of an evolutionary frustration of the lungs and of themselves. And the collapse can happen to entire lobes where the right lower lobe collapses or the right upper lobe. Or it can just happen against a few of the bronchi. And uh you have a small segment. This is a and that segment is usually called a discoid atelectasis. Um Just because the, it looks like the uh meniscus of a disc. So that's what I'm seeing here. This is incredibly subtle, but it's a very common one that we often see. One last thing. If you guys pay attention to this faint line, I'm gonna make it go away. That's this a fissure and it is separating um your right upper from your right lower lungs. So subtle things on x-rays and hopefully over time, your eyes begin to pick up more and more and more of. So let me stop here because I am about to bring up the Keys Deanie. Are we getting uh some good volunteers? Not yet? It seems people are shy today. Ah OK. All right. Let me stop. Did I end up stop sharing, by the way? Be dead? All right. Fantastic. Does anyone wanna come on stage? And um All right, Kusum. Awesome. We got Kusum. Anyone else wanna join Kusum on stage to review a case with us. We got some, I might call them people if it uh let me see. Chelsea Stevens. You haven't done this in a while, have you? Oh, I lie, Ryan. Are you there, Deanie? Can you unmute or Ryan? Can you drop in the chat box? Are you there? All right, we got some, we got Amna Ryan. You're coming on stage. Doesn't matter, man. You're like, I wasn't prepared for this. Doctor G Ryan. Come on stage. All right. Uh Deanie. Uh and as you're adding, Amna and Ryan, let me um let me know once it happens or is there a way I can help you? I have invited everyone to this stage. Um So they should all be able to join. All right, I see just some on my screen but it ba uh all right, I got Ryan Ryan. Hello. Hello. And that's ur you, you've been part of these lectures with me for a while, right? Yes. Yes, I have. And you know, I tend to embarrass a few men tease when they have something awesome to share. Correct. You try good. What happened, June 23rd when you and I uh spoke, you tell it was a little bit before that uh I just, there was too much going on. I'm just happy I managed to reach out to you. But um I ended up uh getting into and accepting uh the offer to go to med school from University of Rochester. Proud of you, man. Proud of you. Um Brian emails me IMA about call. That means like 10 o'clock at night, we end up connecting the next day. Um But I couldn't be proud of you, my friend. Um And everyone else here like you look, Brian's story is a one of great success um that many of you guys will follow. But this is why um at least from my standpoint, I love investing in you guys, Ryan. Any, any look, anything you can share to them. Because if there's someone who can model grit and tenacity matched only by their intelligence, it is you my friend. Anything you wanna share to the group here? Yeah, I mean, II I appreciate that you flatter me as always. Um But really what I would ultimately say is if this is something that you wanna be doing, um you just can't end up giving up on it. This was ultimately uh my third time that I ended up applying before I finally got in. But I knew that nothing would make me happier than to be able to be there and work with patients and work with their circumstances to bring the best care to them. And I think that, you know, if you know that if you've had that experience and you feel that you will know and please just don't ever give up because that same determination is what's gonna enable you to give the best care to your patients to Awesome Ryan. I appreciate you. My friend, you're uh dragging you on stage so you can read an x-ray. I also, you taught me something that when I invite students to shadow me in the IC U, I gotta make sure I give you guys um a dress code because you showed up in a suit and tie and that I was like, if this guy gets blood on his suit. Yeah. So um nicely done man. You're already inspiring the next generation which by the way for all of you that when you guys get in, I you guys will get a call from me. I promise, but I make you guys promise me like a you got to pay it for it. That's it. You got to make sure you pay it for it. So, thank you. Good, sir. Yeah, absolutely. And if anyone else has any questions about the process, um I can drop my personal email in here. Um I know there's not much I can offer. I just got through it myself. But if you have any questions, you know, feel free to, to shoot me an email and I'll try to get back to you. Appreciate Ryan. Appreciate it. All right, Kusum Ana and Ryan, you guys are on stage with me. Let me set the stage for, we'll take five minutes to go over this case and then we will throw on the x-ray and you guys will tell me we'll read it together, we'll read it together. And you guys will tell me, you know, in your best way, what could be going on. So I have a 52 year old female presents to me. This is actually my first time meeting her a few months ago, uh, or some time ago. Everything feels like a few months ago though. This could have been years ago. 52 year old female presents. First time I'm ever meeting her, meeting a lung doctor. And the reason for it as a referral from a primary care physician is she's developed some breathlessness. I'm gonna give you a little bit more and then turn over you guys to ask me what else you'd like to know her story is that three months ago, she developed kind of a really bad toothache, went to, you know, put off, going to a dentist, finally saw one, they got antibiotics. She felt life was good, then started developing these kind of fevers at night. Couldn't shake them off. Takes Tylenol, didn't think anything of it. Still, still thought. No, she's like, oh, fevers just happen randomly. Then some myalgias, myalgias is the medical term for like some muscle aches just overall, just not feeling well. So she goes to see her primary care who's like, well the tooth looks fine. You know, maybe you caught a virus, maybe it'll go away in a couple of days. You know, she's 52. She babysits a lot of her grandkids. So nothing of it. Then she calls back, she's like, look, I'm experiencing some like chest discomfort, some breathlessness. Um And ultimately, you know, the primary care is like, look, you know, with the fevers and everything I could work you up. But let me see if one of my colleagues can actually just see you first and he or she can just guide this. So the primary care put out a call to the pulmonary clinic and that's how she stepped into my clinic. So 52 year old, only past medical history, right? She takes no meds until her toothache, saw dentist fixed it. Um But then it's been having for three months off and on fevers, muscle aches now, bit of breathlessness. What do you guys wanna know who's some, you're up first because you volunteered first. You're like, I'm never volunteering first again. What do you wanna know about this patient? And when I say, what do you wanna know the way we think as doctors when I ask data point questions, Kusum, you shouted me a lot, Ryan. So have you in the past, you know, like the way you ask patients questions, there's a massive intention behind it because in my mind, I'm trying to figure out what's going on and laying out some differentials in my mind that I'm like, oh, that confirmed that, that didn't confirm that. That's how we think, right? So om what's a question you wanna ask our 52 year old female Um Is this her first time getting breathless like that or I always have been? Yeah, but just not recorded. Always good. This is good for many of you guys. So your patients, I promise you will always have the answers. Either literally, we have the answers or they will um Literally, when I say literally, I'll say like, have you ever experienced this breathless as before? Because I've asked that cause it would be like, oh yeah, you know what, when I had a pneumonia 10 years ago felt the same way, my God, you know what pneumonia feels like? All right, there's the answer. So Kusum, great question. This is why I meant to say patients will have the answer either literally or you got to get around to it. Um No. So you've never, she's never experienced this before, first time. Good question, Kum. I, no, you jumped on second. You get the second crack at this. Uh What next question do you want to ask? Um I would like to ask her if she has any exacerbating um factors or any relieving factors as well. So I'm gonna, I'm gonna take that question and just kind of put it into a pattern like when's it happening? And you're right. Does anything make it worse or better? The myalgia which is muscle ache, the scientific term of it. She will tell you she's like, it just, it's kind of like all day. She just feels like her muscles are aching. Um, it gets worse. Obviously, if she overworks herself, like she, if she's chasing her grandkids, she's got rest more. It's not so much breathlessness. The breathlessness really seems to happen kind of out of nowhere in the middle of the night ca, like she wakes up like needing to catch her breath. The muscle aches are usually what limits her overall fevers also tend to happen more at night, but otherwise not during the day. She takes an Ibuprofen or a Tylenol and it tends to relieve it, but the myalgias get worse with really a lot of activity, fevers and the breathlessness tend to happen at night. Um And it's rather concerning for her, the breathlessness just kind of goes away on its own. But, um, you know, she, she doesn't push herself hard enough to know if she can recreate that sensation during the middle of the day. So great question Ana Ryan, what else would you like to know? Uh That's a great question. Um I guess I would like to ask, you know, uh, is there any distant past medical issues that you've had like as a child that might resemble this or really anything at all that occurred during a developmental phase? Again, stealing my own conversations like you have with patients cause you guys again, that have been with me while I care for adults. And I ask them a lot of information in the immediate sense. I do ask them to time travel with me being a lung doctor. I think I'm the only profession. Honestly I'm being biased here. Maybe my ID friends, maybe my allergy friends. Never mind. I see my o the only doctors but there could be others. So, um, what happened to the lungs in the past? The lungs? Don't forget. So, I do tend to ask them their pediatric history. How was your birth? Right. Were you born premature. Did you spend any time in a needle? Needle, ICU How was childhood? Did you have a lot of ear infections? A lot of lung infections? Were you constantly on antibiotics? Were you on a lot of smoke exposure, air pollution? Could you keep up with your peers when you were running at recess? I asked this because what I'm looking for is am I dealing with right off the bat a potentially healthy lung that just something's happened to it or am I dealing with a lung that got short changed somewhere in life? And right now it's crossing a physiological threshold that it just, you know, can't keep up the compensation it developed, right? You'll be surprised how many patients develop these symptoms later on in life where I'm diagnosing them with essentially accelerated la accelerated aging lungs because of their premature birth, right? So that's what I'm looking for. So Ryan, great question about the time traveling. As far as she knows, everything was great, you know, could keep up with her peers, you know, she really wasn't sick as, um, as a youth. And if they ever went through pregnancy, another great question, oh, so many pulmonary diseases really get revealed during pregnancy. So I, you know, she's had two Children of her own. So I asked, I was like, hey, is pregnancy? Ok. And she said, yep, no breathing issues. So this is, really, is a 52 year old who actually is involved in the medical system. She sees her PC P about once a year but never really put on any true medications. All only like a vitamin here and there. Um But no past medical history except three months ago with a toothache and now this all right now just so all three of you, any other questions you guys want to collectively ask if not, if you're ready for the x-ray. Let me know go. Did she took any kind of medicine or any kind of medications related to while she was on the tooth ache or? Yup, she took antibiotics. She took what's called Augmentin. Augmentin is a two for one medication cause it's the clain acid is meant to augment the amoxicillin, which is a beta lactam, meaning that's what it impairs in the bacteria um uh out of the family of the penicillins. So she took that for 10 days and that was it. Oh, I think we lost ana. She will join us, Deanie. Let me know if we can bring Ana back on to stage. All right, with that said Ryan, anything else on your end uh or anything else on your end before we go ahead and go to the x-ray? I think I'm ready to leave. Sorry, I had a problem with my internet. Um No worries, no worries. Uh I just wanted to ask concerning the tooth ache. Um I know that you said that the tooth was fine, but I wanted to ask maybe if she had an abscess. Yeah, so three months ago it was not fine. She kept putting it off, putting it off, putting it off. It was an abscess that the dentist ended up draining and uh giving her 10 days of antibiotics. Yup. Great question. Anything else? No. Uh No, that's it. Thank you. All right. All party animals. Let's do it. Let's dive into the x-ray, Brian. You're gonna tell me about the spinal process and then you're gonna tell me about the trachea. Actually. Hold on, let me share my screen. I'm gonna put you Ryan Amna and Kusa. You guys have seen several normal films up until now, right? What I want you guys to do when the x-ray comes up, I want you guys to just say normal or not normal. That's it. It's not a race. I don't care when you guys say it. But what I'm looking for you guys to begin to train yourselves is to something tingle something, go off that says this is not a normal x-ray. OK. All right. I'm gonna start sharing the screen, take your time and let me, once I share it, I won't be able to see you guys. So over to you guys, what do you think normal or not normal? Go ahead and unmute whenever you guys want. Mhm. And you're going with normal. OK. I would, I'm sorry. Or, or do you go ahead? Uh I think that there might be a problem with the um left atrium. OK. Cause I don't see um the two slip system. OK. Good, good. Anything else? So we're going, we have one normal, one abnormal which is fine guys. Again, we're amongst friends. Um Ryan, anything you wanna uh share from your standpoint, any spider sense tingling. Um I'm a little bit concerned about what's happening on the lower left side here sort of down by the diaphragm. OK. We'll talk about that. Yes. All right. I love it. So what you guys are going through is, have you seen enough normal where you feel like this is abnormal? And at the same time, there's some discrepancies happening and you want to weigh in on that. You're like, hey, I haven't seen these abnormalities before. Is that pathological or not? Right. And I, I think I know where you're hinting at. So let's dive in Ryan. You get first pass. Well, let me find the markers over here. All right, we got our pen Ryan. I'm highlighting you the spinal process. What do you think is the patient rotated or not? Uh I inclination is not rotated. You are awesome. My friend. Next, I'm gonna draw you out the RNA here and the trachea, of course. So would you agree that the corona seems to fall in between the two boundaries of the vertebrae? Yes, I would. And this angle, I think it looks rather acute. Are you fine with this angle? Uh Yeah, I go ahead. I, I think I would be fine with that. OK. Yeah, I know uh Ryan, you, you've been one who's been with me for a while. Uh So saying the splay uh is new where I'm adding this lingo to, to more and more. Um So thank you for diving in with that with me. All right, Ryan, take a breath. You, you went through the Mediastinum. You also mentioned that patients not rotated. So how we interpret it will not be impacting your judgment. I love it. Not, you're up next, my friend. You ready? Yes, I am awesome. Ana where are you coming from? Are you in Baltimore too? Cause the internet connection tends to be shoddy usually in the housing units of Baltimore, but where are you coming from? My friend? Uh No, not as of the current I'm still in right now. Ah All right. Fair enough. Sorry about that. All right. Um Now let's go through the plural space and thank you for reminding me. Um, you're all the way. Uh, sorry about the time zones. No, it's ok. Tell me costophrenic gangs on the right and left. What's your impression of that? Yeah, they seem to be normal. Ok. Yeah. And what about the A PC up here? Air or no air? Nowhere. Meaning is it of the grayish? Nowhere? All right, perfect. All right. You, are, you, you correct. I, from the apex, I will, I will tell Ana Ryan and Kusum, this one is a little tricky. So I'm gonna go over that with you guys because it's gonna train your eyes. I promise you. All right. Last thing for you and then you're good to go as we pass it on to coom to go over the heart and all go over the lungs together. All right, Ana tell me about the hilum. So the hilum over here to some extent, there's a little bit of this and I know you might say, well, that looks like it might have been greater than the um left atrium. But, and you're right compared to the prior one. But I would ask you this. Can you on the left side of the hilum? Can you still does? It still seem rather translucent? Yes. Yeah. Um And by the way, if you're noticing these kind of holes here, these are normal. This is just the airway coming right at you. So it's kind of sliced. So this patient may be 52. But I can tell you her heart, you know, we'll go over the heart in a second but still rather young looking because I would have expected the heart to be a little bit further out where it would bulge the hilum amount. But, you know, so the hilum is normal and I can tell you this is usually how the hilum looks when young people because the heart is usually right behind the sternum, but the left hilum is normal on the the right hilum. What are you're thinking? Does this look like a kidney shape as I outline it here? Uh Generally speaking. Yes, but I don't know if there seems to be some protrusion coming out protrusion. Yes. Yes. Yes. Yes. Well, in the world of in the world of reading x-rays, you can do the hey, parts of it look normal and parts of it. Don't the second your spider, this is what's great. The second your spider senses are tingling, saying something seems off. Just mention it. You're like, hey, that's for treating time out. Good. Awesome. Own it. Love it. Next coom nice job. Nice job. Ryan Kusum. You're up, they're doing great. You gotta, you gotta bring it home. Now. You ready, Kusum. Yes. All right. First things first, the heart does the left ventricle go all the way to the border. No, it looks still has a space. Perfect. Perfect. Now, I know Ahmad was discussing the two slip system looks like it may have been lost and maybe I, you know, I would say sure, I think I would agree with that. And I, again, I think there's something driving that, but I would agree the left atrium doesn't look like it. There's a two slope system per s here. So, you know, when my residence, if they mentioned it or not falls in a great territory where I would agree, the left atrium looks like it's a little bit plump. So I'm taking that to uh agree with Omna. So no worries from your end cous to answer it. But now let me ask you this coom, are you ok with the right atrium? Does it look? OK. Right. The hilum is always the extended over here. The right atrium doesn't seem to be extending beyond that. Would you agree to that? I mean, yeah, cause it, it is, it is looks right to me. OK when it compares to the cup art. So we're OK with the heart, the left atrium, maybe there's something going on there with some excess pressure. So we gotta get to the, you know, is the heart the culprit or is it just an innocent bystander being impacted? Let's go below the diaphragm. This is the one thing I wanna point out, right? This is the liver over here. So I'm writing an L not to confuse you guys with left. But let me see if I can write in liver and then All right, Ryan. This is what you were mentioning like, whoa whoa I've never seen this before. Correct Ryan. Good, sir. Yes, sorry, I was muted. No worries. No worries, man. No worries. All right. So I can tell you this is a normal finding, not one that will always be there, but it is a normal finding. This is the patient's stomach. So she might just have some gas in the stomach. So we will allow this kind of gas finding in the stomach and usually just write it off as a gas bubble. That's it. So you're right to point it out. I love it. I want you guys to point out abnormalities. What you'll come to appreciate are some abnormalities are uh still part of a normal variation. Others are not if I saw this on the right side, call a surgeon, something's wrong. Air is in the abdominal cavity. All right. Now, let's go finally into the actual lungs. So right off the bat, what you guys have identified is abnormalities to the left atrium that, you know, maybe the two slip system isn't properly there. We've identified an abnormality to the, you know, finding a gastric bubble, which as I mentioned falls more in line with kind of a normal variation and um found a protruding uh right hilum, something's off with it but Kusum Amna and Ryan, as you zig zag through this, do the lungs look? Ok. Um As you guys zigzag up and down just go ahead and unmute and let me know if anything stands out or you guys are happy with it. What do you think? Who would like to go first? Co some on mute. What are your initial thoughts? My friend for me, it looks just, it, it just, it looks, say that again. It looks distributed. The air looks distributed from right, from right lungs to left lungs. So I believe it's a normal, you believe it? OK. That's fine. Completely. So the lungs look OK. All right. No worries. Ab and Ryan, anything else to add or take away? I'm not trying to lead you guys one way or the other. I want you guys to train yourselves to be able to identify normal or not. Uh To me, I would agree but I feel like there's a really small opacity at the left uh at the right um, upper lobe uh near the chest wall. Yeah, I, I was also gonna say, I can't tell if it's vasculature or airways, but I would expect the sort of top of the lungs to be or to have a lot less of that sort of networking, I guess for lack of, no, I actually, I might still the word networking. I love it. So you guys, are you guys kind of discussing like up here? Yeah, that's what I'm looking at. OK. All right. Yeah. Go ahead and know I was gonna say if you like uh parallel to that near the chest wall. That's the, um, opacity that I see like this thing right here with my Yeah. None. Nonetheless, nonetheless. All right, let me take you guys through this. So you guys are thinking about this correctly to some extent. Now, I'm gonna add to your thinking. So, what you guys picked up with the hilum is actually what we're gonna just focus on right here. This, this is by far the abnormality right there and to some extent it is in the lung. The challenge of its anatomical placement around the hilum makes it hard to interpret. So when you guys are telling me the lungs look fine, I agree with you because part of me made you guys exclude this from the interpretation because it's in the hilum. So don't worry there, but there's some things happening to this that you're right are creating some level of increased vasculature or networking up your RNA like it. But there's other subtle symptom it's causing down here. And the left atrium, I think the elevated pressures are because the heart is finding some difficulty in pumping blood out, not that it's causing any heart failure, but it's working a little bit harder. So pulling this all together, what this is this uh circle. I want you guys all to try to make a mental note of it because look how it's shaped. You see kind of this circle right here surrounded by or kind of darker space around it. Ryan Kusum and Amna. Do you appreciate that? Yup. Yeah. Yes. All right. This is a cavity. This is a cavity. This means something is in the lungs, closing itself off from everything else. However, it's not a perfect closure because it is still leaking fluid and right here. So this is what I love. Look the way Ryan Kusum and ahmed, the way you guys have answered. It's the same way my 8:30 a.m. interns answered this morning. So I'm already promoting you guys to first year residence because you guys answer just like they did. So you should be proud of that as an attending. I will introduce new things to you guys. So take a look at this costophrenic angle here. Nice and sharp. It comes down. This one is very subtle. The only people that I would expect picking it up. Maybe my pulmonary fellows the attending. Should your radiologist 100% should but look at this subtle, subtle. So this isn't as sharp and looks like something kind of goes up right here. Do you appreciate this kind of extension going up a little bit? Because take a look at this, I'm gonna erase it in a second and compare your eyes to that versus here like you don't see that on the left side, there isn't something kind of going up with the same kind and not, I'm not talking about a rib, a rib, look at the ribs, right they have a very specific color to them. This isn't rib, this little uptake right here is not rib, right? This is where I'm like trying to draw you guys, Kom Amna and Ryan. Do you appreciate that? Yes. So that is a pleural fusion of the world's slightest. I promise you if I put an ultrasound on this patient, that's I told you guys, you need about 300 mL to blunt the costa for any gangle to completely take them out. This is easily somewhere between 100 mL. If not less around that, you probably may get a radiologist here and there that may miss it. Not often, you know, a seasoned pulmonary doctor will probably miss it more than a radiologist, but we should get it more than half the time. I don't think really this is an incredibly subtle thing, but this can be life saving because when I see a cavity in the lungs and I see fluid in the pleural space. So what can form cavities? Let me get everything away. I want you guys to take a look at it for a second and then let's bring he home for some teaching. So take a second to digest all of this. Let's go ahead and stop sharing. All right, let me teach you guys a little bit. So cavities in the lungs, many things can create them. Cancers, cancers are notorious for creating them squamous cell cancer specifically. So, cancers in the lungs tend to be named for the type of cell that went haywire. Squamous cell is a normal cell in the body also in the lungs. Um, oftentimes associated with smokers, if there's a squamous cell cancer, squamous cell cancers love forming cavities. It's frustrating, autoimmune processes form cavities. There's an autoimmune process, I'll throw it in the chat box called ACA Anchors for the antibody. Uh So an aa associated vasculitis can do it. Oftentimes one of them called GPA uh GPA for those of you. Um Coming across this acronym for the um first time uh has an interesting story. So it stands for, I'm putting it in there for you guys right now, typing it in sending it OK. It stands for, I guess the rheumatologists love long names, they love long names. But the rheumatologist I will tell you are my favorite doctors because they have an equal laziness as lung doctors do. But they're just fancier cause they just use their long names. Granulomatosis just implies the type of thing that you find under the microscope or granuloma with polyangiitis, poly, many angiitis, many inflamed blood vessels. G P's older name used to be wegener's Wegner was though a doctor for the Nazis. So anything that uh had names associated with Nazi physicians, we have taken out of the medical vocabulary. Now, it is just known as GPA. By the way past, I'm realizing I'm saying this, these initials to you guys are like probably having some anxiety but like grades is not that. So, granulomatosis with polyangiitis, that's the most common type of autoimmune disease that form cavities in the lungs. However, this cavity, this cavity had a slight pleural effusion associated with it. Why I'm saying that? Because if that's all I saw was just this chest x-ray, that cavity with a slight pleural fusion. My money is on an infection and that's what she had, right? And you guys know like that she had other symptoms too. She had fevers. Yeah. But autoimmune diseases can cause fevers. So we can't technically rule it out. Cancers can also cause fevers. Actually, all the symptoms she had could either easily be in cancer, autoimmune or infection. But the key thing here, what happened to her three months ago, some what happened three months ago that I told you guys about to, to um wisdom tooth infection. Yeah. One that finding that an American dentist takes time, put it off, put it off, put it off. Finally went to it on the made a case. Hey, was that an abscess? It was they drained it. They gave her antibiotics. Your mouth is flooded with bacteria. An abscess is a great way where some of the bacteria can actually get into the bloodstream and get to your body. Oftentimes majority of the times, if not all the times right to the lungs. So the type of bacteria she had in here was an uh bacteria that's oftentimes found commonly in the mouth, one of the streptococci. So in our mouth, we have a lot of gram positive. So, streptococcus was the type of bacteria she had and one of its species. So what you end up doing for a lung cavity in this case, is technically, would be a lung abscess. So I'm not asked if there was an abscess in the mouth for my future surgeons out there. What we do for a lung, what we do for an abscess, what we do for an abscess other than the antibiotics, we drain it. Oh man, we love putting some scalpel in there. It oozes out like a eighth grade, eighth grader's volcano at a science fair. It oozes out. Oh By the way, when you guys are in med school, right? When you're a third year med school student, you're with your surgical colleagues. You will know if you wanna be in surgery, the second you put in a scalpel into the abscess and it drains out. If you're in love with that feeling and even the smell doesn't gross you out. You're gonna be a surgeon. If you're like me, you're like uh I'm rather more interested in antibiotics. We're gonna give the patient internal medicine. Um However, lung abscesses, you don't wanna do that. The reason for it. I mean, we reserve a surgical intervention as a last resort. The reason why you don't wanna do that is because if this pus comes out, it's gonna come out into the rest of the lung. Right. You can't really maintain sterility for that. Like, if it's on the skin, yeah, you can make the, it will ooze out. Right. If it's in the abdomen, your surgical team will tackle that appropriately. Or often times they'll put in a catheter. This is tough. So, what we end up doing is the antibiotics for a long duration. You know, she was on it for a little over eight weeks. So we extended it. So because our suspicion was she got treated, drained up here, antibiotics did her fine, but they were stopped. And then this abscess slowly grew. So whenever you see a cavity in the lungs, you try to see if it's infection, cancer or autoimmune. If it's infection, then, you know, you're walking down the lines of it being an abscess. And um the way we ended up identifying the culture is because we went back to the dental records where they drained it and we're like what species overgrow there. I know Streptococcus. So we geared all our antibiotics to that. All right. Was this a good case? Ryan Amna Kusum? I wasn't trying to trick you guys, what I'm trying to do every time it's not tricking. It's, I want you guys to identify what, you know, and I'm proud of you guys, you guys knocked it out of the park and then I'm layering on a little bit more to that. Like the subtle of the costophrenic angle. The formation of the abnormality around the hilum that threw you off, not threw you off. You guys perfectly mentioned, you're like, hey, it's protruding out, loved it. And by the way, left atrium as I was alluding to you from Ada. Yeah, it's probably struggling a little bit just because it's gotta push blood against the cavity that's around the vasculature there. So innocent bystander and Ryan, you saw the gastric bubbles. You guys did. Amazing, nicely done. Seriously. You guys are doing better than my interns and not a not to my interns. I love them. They're doing great too, but any last minute questions before we move on to. All right, awesome. All right guys in two weeks, we will regroup, take the 19th off. We'll be back for the 26th. Watch this again if you guys like learning about abscesses and lung cavities. But thank you guys so much, Ryan. Congratulations again. Good sir. Bye guys. Take care. Bye. Thank you. Thank you. Bye.