Computer generated transcript

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

So, um hello, everyone. Thank you all for coming into our first online revision lecture today. Um, not really. How long can you hear me? Thanks. Um, I can see we've got many of you guys joining in. I know we still have others coming in, so we were just start now and just, um, except people as we go along. I can see we've got students here for many other parts of the country as well. So thank you for joining us today. Um, So, um, Sock is a brand new society on. We are impressed of producing many more events in the future, Um, including a conference with collaboration off Cambridge University and Anglia Ruskin as well, hopefully in may. Eso do let us know in the feedback at the end if there are any specific things you guys want us to cover because we are hoping to cover all aspects off acute medicine from your 12 year five. So today, Natalie will be giving you all a presentation. She's being qualified for almost four years now in diagnostic radiography, having studied or worked our hospitals across the south of England from Plymouth to Southampton, This included working at the major trauma University Hospital as well. Indoor set during the pandemic on experienced, many firsthand implications off the copay 19. So she is now a second year medical student at the, um A. And she's also my publicity's officer in the committee. So thank you so much. Not sleep for volunteering today on, um, you know, giving us a little talk. I know X ray. Something we all medics struggle with. So, um yeah, on hand over to, you know. Thanks, Eunice. Um, yes. So today will be covering, uh, lung collapsed. Problem fusions, pneumothorax, pulmonary edema, pneumonias, lung cancer. We'll touch on Kobe it. But there might be a few other things as we go along as well. So hopefully everything that all cover does have a relationship with emergency scenarios on Hopefully if you can detect things slightly faster on X ray and have, um, or accurate diagnosis um, it will help. You just were on your wards. And also, when your future doctors', if you have any questions, if you put them in the chat, I'll try to get them at the end on blank you or for giving me a time. So without further ado. Um, I just want to say a quick word on X rays because we're always taught how to order them. But we never really talked what they are. So it is. All it is is a type of electromagnetic, radiant energy on it's created when there's a periodic change of electrical magnetic field. Um so, well, that you really need to it, remember, is that X ray photons are emitted from June, um, photons being like a unit of energy on their omitted in a beam like fashion. So why this is important to know is if you imagine your X ray beam is a lamp and your detector is a war. If you put something in between a lamp in a war, it creates a shadow, which you take is your X ray image. And if you move that object closer towards the being that the sugar will get bigger, and then if you move it close towards the morning is more accurate, be sized. So that concept is kind of why you get magnification and distortion and X rays. And it's also the reason your heart is big on an AP chest X ray compared to a pa. Um, another thing to point out, just about X rays as well in slightly bigger patients. The reason that you don't get as good a quality of X ray is because there's more tissue on that photo has to travel through more tissue to get to the detector, and as a result, it's sometimes absorbed. It's sometimes skeptic. That's where on, that's why appears whiter. Usually when people have a bigger and b m I. Um so hopefully that gives you just some fundamentals of why you get magnification and distortion and X rays on for Mskube. That's really important, because in major traumatic, you very rarely can do the standard imaging and you will get distortion. So hopefully that helps. And you know that X rays. So with chest X rays, um, your standard imaging is just a pa. So that's posterosuperior anterior on, then, your AP anterior posterior. So obviously, there you can see on the AP. The heart is slightly further away from the detector, and that's again. Just want to get that magnification. Um, sometimes we do lateral chest X rays, but to be honest, he's a row only. I've only personally seen them used for, like foreign bodies, academic purposes. They're really good for pacemaker wiring checks. A swell that's regularly regularly done, Um, and sometimes used to check long cancers. But usually they just go for CT. Um, when it comes to chest X rays, always, always check your previous imaging on. Um, check your clinical history because you might find something on it might not match your clinical history at all. And then you have to ask yourself, Is it an incidental finding? In which case, good for you. But also is it maybe you just seeing the wrong thing or going down the wrong diagnosis path. Also, this is more something to know for the ward's, but you can actually add it. Ah, lot of imaging. Um, like doctors should have the option to window or invert the contrast, and it helps you to see certain structures better off certain pathologies just kind of enhance them so you can see the more clearly. If you do start playing around with the software tools on packs, though, just be careful that you can actually give the patient a pathology just by editing it. So so you increase your contrast. You are essentially just taking out the great pixels, replacing them with black or white ones. So you could essentially give someone like a false pneumothorax if you edited it, then didn't change it back on. Um, just be aware of that. So I think the main thing with interpretation is having structure. Um, I've come up. I know people like them new Monix. So I've come up with the little one. Um, I personally have my own way to do it, but I know most people like the AB CD approach. Um, especially with Oscar is it just means you don't miss anything. Um, I know a lot of reporters actually use their A B c D approaches. Well, um, again, because it just means that they don't miss anything, and they're seeing image after image, so it's easily done. Add also checking the quality of the image I've just put at the bottom. I think right is actually quite a good new monitor to remember, just like in an Oscar scenario or if you're on a ward. But hopefully the slides can get sent to you afterwards. So you have a lot of this, but we'll go through one or two images together on. Hopefully you can kind of get the checklist or the structure in your mind of it. Better just quickly will cover the anatomy of the thorax. I won't spend too long on this because hopefully most people should roughly no. So your trachea at the top classical your apex of the lungs that's your top belong the Carina. So that's why you're trickiest. Then splitting Um, right named Broncos left Main Bronchus Intermediate, I think, with knowing whether the bronchitis it's more just remember, it's a two D image of three D structure. So So you've got a foreign body lodged in your bronchus. It it's just good to know, roughly weather. You're descending order so you can see the aortic knuckle, which will actually go through later. But if you follow, you're descending aorta kind of up your them. Find the A sounding aorta, which hopefully will point out just in a minute. Um, your Zytiga esophageal stripe that like that's just sometimes you might see a strike in the center of the heart, and we need to know about that. It's just an interface between your Zytiga Spain and, um, your right lung and It's not really a pathology. I've included a small picture, which kind of demonstrates this better. If you see a stroke in the middle of the heart, just maybe, Bill, where it's just those structures you go the shadow of the breast. Which again, if you see kind of a line going across your lungs, always just follow the structure around. Um, I know a lot of people like a common errors. To think that I clavicle is actually a pathology. But if you just follow the line round, you'll actually realize it's like a bony structure or a different structure in the chest. Die from XYZ. Quite important to know I think you're right. Diaphragm is higher usually than your left. Um, if it's the other way around, that could be something. A gastric bubble costophrenic angles. There's your aortic arch. So if you know, like follow that that, um, it was a coach down. Then you'll find you a descending, but you decide studier on left ventricle. Um, I think a really good thing for actually interpreting chests is just knowing where the lobes are so immediately. What if you're looking at a chest X ray and you see that your cost, a frantic angle, was filled with something. You know, the odds are if you look at that image on the left, it will be in the lower low. And then if you have anything on your right heart border, the reason they say, Always check. This is because that's essentially what you're middle lobe, ear's. And anything else will be up a lobes usually. So if you're I know that if you're not sure about the lobes, just say zones. So, like lower middle or upper zone. Um, but if you want to, I guess gets, um, bonus points. That's quite good today. Um, cardiothoracic ratio also quite important, especially in cardiology, So your heart size should be about 50% of your total long width. Um, if it's bigger, yeah, you've got cardiomegaly. And dextrocardia is a type of, um, I guess, conducting It's congenital abnormality where your heart can appear on the other side. So being on the right side instead of the left. And that is why markers are always, always, really important. Um, especially in next, rays on urinates a swell. It's really easy to retake thumb on gum. If there's no marker on it. It basically looks like they have dextrocardia when they don't. So, um, always make sure there's a mark on your X ray. Basically, uh, and yet sale sign. So this is usually what will appear in the left lower lobe collapse, But I hope that you can see if you compared, like, the left image with the right. Um, there's kind of a change in densities in the heart, and it it just looks like a sail kind of on top of your diaphragm. And if you see this while you're checking the heart, you know, straightway left lower lobe collapse, So check look out of your sail signs. So, um, now we're going to do one together. So what I'd like everyone to do. We'll do it my way, and then you can do it whichever way you like. But if you could take your like, little finger and just like, bring it to the top where my, uh, markers here you're just checking your airways. So is the trickiest straight yet it is. Then, if you follow it down, you're kind of checking your mediastinum. So having a look there isn't normal? Yes. Then you can check your highlighter. I got a Okay. Yeah, they look fine to me. Um, and then you can come down the right side and just look at that, right. Heartborn er the cardio front of Congo cost a frantic angle. And then just check the lung field Well, the way up and then going over to the other apex Just checking the lung field or the way down. Checking that left can cost a friend of angle and go to the left cardio phrenic angle, and then you're kind of back here in the center. So then just check the heart and then because you're around here, just check the dye from's. And while you check the lung fields, you should check. The fish is a swell, but you kind of see them as you go. Um, so, yeah, checking your diet from's checking the gastric bubble on the only thing left to check check then is your bones and soft tissue. So you conditionally just go up. I mean, if you're doing it in an Oscar scenarios quite hard to check. Really, Thor itty. But you can just kind of trace the ribs and just see if that looking normal. That's fine. Clavicle was finds of tissues once around five. So I like personally doing it that way because you're kind of going down structures, and then it kind of just makes sense to me to to almost do it like Central and then clockwise. But if you want to take a Navy C D approach, that's also so Oh, it gave you the differentials. But, um, this is a normal chest X ray, and it's really important to get to know or normal chest X ray. Looks like I don't They give you one in an all scapula. It's good to know one looks like. Okay, so this is a 21 year old female 36 weeks pregnant on she's having chest pain. Should this patient have an X ray and then think of some differentials in a diagnosis. So, um, she's 36 weeks pregnant and having chest pain. Um, you wouldn't want to do a CT on considering you don't know anything else about this patient. Whether she's got a raised, a dime a row and leg swelling. Um, we do do X rays on. So, like, ladies in the third trimester, if you're a doctor and you've got a woman in her first trimester. Maybe just think twice about giving her an X ray because the baby's most sensitive to ionizing radiation in the first trimester. Um, there's always a risk with X ray, but the risk is much higher to the fetus in the first trimester. Um, and the risks really should be explained. Um, especially if it's if that pregnant, just maybe try not to scare them too much. But it's like a risk versus benefit situation. Different shoes. I mean, chest pain. Could be P could be infection, maybe on diagnosis. If you want to. Again, just we can do a quick check. So the airway Central the highlights. Not particularly large, Um, then just going down to a costophrenic angles and cardio frantic and goes. That line there is just off the breast. That's nothing to worry about and again, like this woman has quite dense breast issue. So that's why that's appearing more hazy. Then, if you go up the lung field, you can see like all the lung marking is a kind of contingent on the same just checking the cost. A friend, a candle that call your friend can handle that? Um, checking the heart size normal die friends normal. Um, gastric bubble. That is one that It's just pretty things that he's around here on. Then again, just checking the bones. Soft tissue done no more. So this lady was normal. Um, even though this lady might have a normal X rays. Well, she still has chest pain. And she's still, um, you know, doesn't have a definitive diagnosis. Like, just because of this is more x ray, it doesn't mean, um um, I think we've got question hilum lymph node on the right. This is a normal x ray for this lady. Um, I see what you mean. Like, you can see them. But if we compare it to the last slide again, this is normal, and you should be able to see, um, the Highlander is It's quite a blood filled structure. So I have that one. This is your question. Um, so, yeah, it's no more to see the hilar. When they're enlarged. Will see some examples later on. Um, when it's really notched. Okay. So we can get some more exciting stuff. Is this pushed or pulled? What? Where and how so, um, we can do are A B, C D or my way. Um, so checking the airways you can obviously straightaway see it's deviated to the right. We don't actually know it's the right facial because there's no marker on this X ray. So if this was in practice, you'd have to get a repeat X ray and get them to put on a marker. Because if you go doing anything to that left lung, well left lung and it turns out the image was flip door, the radiography did something with it. You could be essentially taking out there any working long, so always, always check the marker. Um, so, yeah, you can see that trachea's is deviated to the right. We'll say it's the right at this. Left lung is full of something that's a lot a same density, so this is likely to be is fluid basically because it's a little same density. It's no, um, collapse, because if it was, if you got a full long and it's collapsed, your turkey, it's more likely to be pulled towards that collapsed lung. Well, actually, this is like a fluid in there fluid in the flora flora is in the pleura, which is essentially like taking out that long and pushing not your key the other way. So it's plural effusion. It's in the left lung, and it's a very large. So now if we compare it to this image again, just checking the airway and you can see it's moving towards the left side again. There's no marker, which is annoying, but left side. We'll say so with this one, you can kind of see this hazing us, Um, around this up his own. I hope everyone can see that. And if you can see your tricky is kind of deviating towards that haziness, you're more likely to be considering a low collapse. We'll go over collapse on consolidation a bit later, but this is just kind of introducing how to look at the airways and what immediately, if it's deviated, it could be. So this has left upper lobe. It's quite severe. It's pulled towards the collapse. Lobe is essentially, it's just you've got inflated long and it's closing and you've just got spaced that tricare to move towards it, Um, and also something to know is that the right hemidiaphragm is actually it sort of the right one should be higher than the left. And here you can see this is being pulled up on this bit of space between the gastric bubble, um, and die from Okay, we're going. No, the scenario. So you've got a 20 year old male he presents with sudden shortness of breath. Pleuritic chest pain doesn't smoke. Um, again, if you want to do it along with me at home, just going down there. Airways, that pretty central, the hilar nothing really to note there. Nothing in the mediastinum checking the then right heart border, right? Cost of cardio friend can go right costophrenic angle then looking up the lung field. And then you get to about here, and I hope everyone could see this at home. But there's a change in this right up a zone. Um, Onda, I don't know if you can see that there is essentially just a change in density. Um, you should really be able to see a line just kind of running along here on, but I think most hopefully you'll know what this is. Is just the pneumothorax to have kind of try to big it up here, and there's you can see that the lung markings kind of extend out. And you've got this kind of light gray, and then it turns into this. I know this black of the same color. Um, some common mistakes. Sometimes people can have a cycle slopes. You don't know what this is. Just google it in your in time. It's just some people can have an extra lobe and you get a fissure. And people mistake this fisher for a pneumothorax. Well, people can also think that the one of the anti first ribs creates a new math or ex. So you have your first rib kind of hear the structure here, and then it kind of makes love heart around the other side. Um, this space, obviously not in the right, but on the left. You can see like this type of gray is the same as this type of grey. Like there's no new mouth or X there. And that shape it's just your anterior rib. Um, helpful. Here, you can see there is and you with works. But that one we gave that one straight. We gave away straight away. I can't see the market point. I'm not sure if it's just me, okay? I'm I'm trying. Put that on, um, new before X. Um, this is in your left lung, okay? And you can see, actually. Connect. Can you see the point of canIs? Okay, good. So if you're looking, you can do airways. You can, um, checking me to style. Um, check your Hyler, but it straight away, You're seeing a pathology. Maybe just look closer at the pathology and do the rest of the screen. Um, so, yeah, the only bit of actually that's not really touched by this pneumothorax, I hope you can see is you follow this around. That's the remainder of your lung, and then the rest is just air in your pure space. Um, and then we'll go over what to do in a tension pneumothorax situation. But you'd be looking at an urgent needle decompression. Okay, so we're gonna move onto pleural effusions now. Um, there are different types of pleural effusion. I don't think you need to know them in detail, but it's good to be aware of thumb if they do come up. Um, I'd say the most commonest subpulmonary, but we'll go through it. So insisted is kind of where you get tracking both the pleural effusion along the fissure. Um, so we've described this has insisted, and you can see the plot. The fluid is just kind of tracking in between the lobes of the long. This patient actually has quite a big heart, is well and has had heart surgery. So you can see some artifact there, maybe some staples not too sure what that is, but, um, And if you remember the cardiothoracic ratio as well, um, if you actually take your pinky finger on your index and put either side of the heart and then move that to the size off to the to Acosta frantic angle, you can see it's just over 50%. So this patient will have maybe some heart issues going on as well. So pulmonary. So you get pooling off the floor in the fluid in your usually in the basis of your long, um, this is in the left side, um, so you can see that left diaphragm is much higher than the right and the right should always be higher. Um, and you can see I think there's a like a little gastric bubble there, and usually your gastric bubble should just sit right under your diet from because that's where your stomach is. But actually this one's this gastric bubble was quite fall from the heavy foot Die from. So again, just, you know it's more likely to be a plural effusion. That onda matter is a is a really hard one. It's more than if you're ever just like junior doctors and you see this. It's quite a bizarre thing to see. It's pleural fluid, like tracking up vertically, Um, like a up the chest wall. Um, I've personally not seen it too often, but it does happen. It was really hard to find a picture of, but I guess it's just got to be a web. So, um, I'm gonna move on from Florida fusions. Onda, Um, I think something that's really good to know is what the difference is between Albury lover versus into start your disease so you can figure it out kind of easily if you think about it logically that you're over here and just lots of air sacs and if they start filling up with gunk. So whether that's fluid, um, or anything effective, that's gonna create more density on an X ray because you're photons gonna have to work harder to get through. So it's going to create more like of fluffy appearance. Um, because each of those air sacs might have a different amount off. That's a dog in it on. That's why there's more fluffy. Well, you're interest. Ocean is essentially a collection of support issues within the lung that includes the outfield, uh, epithelium, your endothelial and basement membranes. Um, and these kind of surround the LDL I. So if you've got something wrong there, it's going to look at it more linear. Um, all right, take your, um I'll show you some examples in a minute, but you're quite good, in my opinion. Um, with alveolus changes as well, we will talk about a bronchogram a bit later, but you should get the appearance of a nap. Bronchogram. Um, usually with alveolar changes on. That's just because you have, um, kind of density from the pathology on, then. Obviously, like in your bronco, your bronchioles you still have going through, and then they're No, I'll explain it. I didn't explain that very well. I'll come back, um, interstitial opacities. So there are some examples of X rays here. Um, and I hope you can see that it's more of a linear appearance there. But I think the CT's just show it so much better that you can see he's kind of white with bright white lines throughout the chest. Um, it shouldn't really be the so That's your interstitial disease because it's not there. I'll be real a sock itself. It's they tissue between it. Now, if you keep that CT image in your mind and then look at this CT, you can see that those white lines aren't there anymore. It's within the actual tissue itself. It's all fluffy in gray, like this whole long should hopefully be black, full of air. But plus, so that's why it appears more fluffy, um, on the x ray. So why is this useful is that if you can recognize interstitial a disease from Algeria, lung disease or now or down your differentials very quickly on, um can make you means that you can treat the patient of it faster, So usually alveolar long disease could be from the pneumonia. Um, but you can also have such sometimes that interstitial pneumonia, which is good to be aware of okay? I know recovering a lot today. I have I'm not going to quickly but kind of conscious of time. So pulmonary edema. I won't speak too much about this, but it's good to know it's just an abnormal more accumulation in the extra packs. Vascular component of the lung. Um, it's a demon. So the question for you guys now is this alveola or interstitial interstitial cystis. Okay, I hope everyone's got haven't answer in the minds, so this is actually mixed. So where the white areas are are the areas off? I'll be real changes, which is kind of more fluffy. Um, it's kind of around here. It's kind of quite diffuse and then near the bottom. It is quite hard to see on this X ray, but I hope you can see, like, here is some white lines just kind of tracking down. And that's more interstitial disease. So you can have a mixed picture with this is well, again, you kind of have to correlate it with your physical findings. Um, and the patient's history as well. Okay, moving on. So we'll just do a quick talk through of this. So you're going to do. Your airway is normal. Higher regions go Boom, right. Heart border. Um, your ankles up the rights along to your apex. Always double check the apex left and then coming down. Checking your cost burning candle there called your friend of angle That and then just looking at the halt. Onda it's of a normal size. There is something else going on with the halt. I hope everyone has had a moment to just try and figure it out for themselves. So there is actually a soldier tree. Pulmonary natural. Um, just that. So it's in your left lower zone. Um, and it's quite small. So, um, it is always good to when talking about a solitary pulmonary nodule really sort of nodule in the lung. Don't say it's behind the heart in front of the heart because you don't know it's the three D. It's a two D image of a three D thing on. There are many. Different was for pulmonary nodule, so it could be actually something on the skin. It could be a cyst. It could be new class. Um, it could just be an artifact on the chest. So if you say left lower his own. You kind of during people's attention to that error error, and hopefully they should find it for themselves. Um, and there's actually a tiny PCG sticker here talking about a fact. Okay, so we're going to the next image again. Airways normal, Tyler region Normal, right heart border normal angle normal. Um, goes normal. And then you come to here and there is actually a little salt. So that report memory nodule here have it for control your attention to the left lung. It's also very similar looking one here you can get just dance nipple shadows on X rays on. If you do get this, you will need to repeat the chest X ray on nickel markers aren't the most lavish things in the world. We usually just use paper clips, which in unfolded we make a triangle, stick them some tape on them and give them to the patient and explain what to do. And then you get another image with essentially like an outline of wet showing whether the Cozaar and then if they and then you know if it's your nodule or not like if you still have a nodule there and so you had a nodule here. You know, it's not the nipples. You also can get unilateral density. Uh, it could also be a nodule on the skin. A swell. Um, So for people who like neurofibromatosis, it's also worth considering. Okay, Um, so if you're going down your airway, um, it is It is slightly deviated on this one, but I hope everyone can see straight away, like if you are in a Noski. I understand that there is like a structure to it. But if you can see a pathology straight away while you're checking the airway is right next to the outrageous comment like areas central. But it's deviating slightly towards the pathology. There's a passage in the There's no marker, but right upper zone. You know, it takes one thing off the books. So this is a pancoast tumor. It's in the right apex, and it's quite large. So this patient will be having symptoms. Usually it's I think it's hoarseness of voice. Um, I think Horner's syndrome is also thinks to Apex. Choose. So moving onto this one again, Airways, look for the mediastinum. Yes, fine. The heart is that I have to say like a funny shape. I know we don't go straight to heart, but and it's a funny shaped this one. Um And actually, when you go to the higher the region to say you're coming down your right bronchus and then looking at the right hilum, you can see you've got these nodular like, Oh, then no chills. But they're not just at the hilar. They are kind of throughout the long. And then if you have a quick glance to the left, you can see there are also a couple of that. So, um, what is this likely to be? Yeah, right. Common every metastases. So multiple pulmonary nodules, Um, usually from the breast colorectal, A renal conscious. And you can also get cannonball minutes used to quite late stage. But these are much bigger. Now, if you compare it to this, you can see there are multiple pulmonary nodules throughout both lungs, and this is a type of memory metastasizing, um, so you can actually get, um, memory metastases with no only from cancers, but from things like TV. If you think of miliary TV, um, you can also get it from infections, sarcoidosis, new, makin any assis, uh, some sources said. It's like the most common one to come from a thyroid, that common metastases to come from a thyroid cancer. But I don't know if this is always the case, Okay, I said I'd come back to it. So collapsing consolidation so normally if you've got collapsed, you'll have production in volume. Um, it could be caused by numerous things. Um, always check the diet from's check. Um, the size of the entire long check. The Highlander mediastinal shift is your biggest give away. And then with consolidation, you've got, um, it's long tissue that's filled with something that just isn't there, and it's usually the out here left socket. So I did say I had come back to a broken grams. So they're essentially your aspace consolidates around the bronchial tree. Um, so you have your bronchial tree, and it's the consolidation happening around it and the air in the bronch. You, um, stays black on the X ray because the photons can pass through that, but it can't pass through that density either side of the bronchus or at the end of it. So that's why you can see the Broncos more clearly because the tissue around it becomes more dense. Normally it should be black because it should just be a run around the bronchus, so you wouldn't see it. But if this tissue around the bronchus is filled with gunk, then that's why there's a change in Don't sitting. You can then visualize him. I think that explanation was much better than I lost one. Okay, it's no, they've away. Um, so this, um, if you do that's good. Okay, that airways, then you check their you just sign them in the highly region, going to the right heart border, and you can see straight away that that right heart border you can no longer really distinguish from the lung. So, you know, it's the middle lobe. Um oh, it's just right up alert. I'd say that's meadow, because the right you've got this still working. Well, um, but I would say that's middle. I don't know about you, but that kind of is the shape of the middle lobe is Well, if you remember those images at the beginning, then again, they all my slides. Um, yeah. Thank you. Hey. Thanks, Units. Um and it's a low birth. Consulted a shin. So if you can see that the whole lobe is It's only one lobe that's affected. You could call it low, but consolidation. I know if you're ever not sure what to say. In a Noski scenario, I know they love the world. Word infiltrates. You can see something like this, and you're not sure whether to call it consolidation. Um, the modulate was say infiltrates. So if you have a 21 year old female, two months of cough chest pain just high being my you can see this from the soft tissue and the fact that so you know, more photons being attenuated can't reach the detector. Um, so let's go down the airways highly region normal right Heart border. Yes, your angles. So you can't see the cost of frantic and very well. But because of this patient's being my you could have Well, it's more likely to be her be in my than a pathology because you can see the lung markings are still coming out to the bottom. Just checking the right lung. Check the apex, move across to the left apex, checking the left lung and again, you can't really see that angle. Great, but you can see it. So it's It's just a matter of, um, be in my, um So then you've got the called. You're finding hankel normal. You have the silhouette sign, which I haven't really discussed. But it just means that if you have an absence off the cilia, um, it's more. It's more likely to indicate a pathology. So it can everyone see that just where the hot the border of the heart is, there's almost there's this black line. Um, so that should be there because it's just the difference off the dense heart against the blackness of the lung. Um, and it just creates the shot in like, effect is when you have an absence of this, that it means that the longest a similar density to the heart and that there's some sort of solid a shin or pathology going on. Oh, it didn't actually tell you what this one was, but, um, we didn't really finish going over it. So the heart normal sized guy friends no more. The right is higher than the left, which is normal gastric bubble. You can't see because it's patients. Be in mind. You can check her bones. Normal clavicle was normal. This is a normal chest X ray. And again, I get used to seeing them. Because you could say all the patients got consolidation in the lower zones. It's No, it's just if you think of, um, you know, how am I? And, you know, that could be a a multitude of other things. The cough could be from something. Um, and how prosperity tract, um, chest pains could be anxieties. So, um, just to keep in mind, um, I won't go through this one. It was well, like fully. Um, but this is a patient with COPD, and they do have some lung changes, so the heart is in enlarged. You can see that. They've got They're called the thoracic pressure. Um, this is more than 50%. Um, the hilum vessels do look more prominent here, so I know there was a question earlier about you know what? When they're prominent when they're not, you can see they're kind of you can follow the lung markings a way out in this kind of this white blob here. It's very different from, you know, just having, like, a light gray hair. It is quite white. Um, so yeah, this patient does have changes, but it is normal for them, so patients might come in with you might have a look at this X ray and when you look at their previous X ray from three weeks ago is exactly the same. So it's always something to keep in mind that, um, you know, you will have changes on the person's X ray, but it might not change really help your diagnosis if it's exactly the same as an X ray you had fairly recently. Okay, I just wanted to show you this one as well, because it's a lateral chest X ray, and you can see quite nicely the left upper lobe collapse. So when we want to collapse now, But, um, you can see that really well that and you can't really see it as well in this one, so that that's when, like a a lateral X ray would be quite useful. So I'll give you a moment to get this one. So if you're checking the airways straight away, you can see there's a pathology on the right looks slightly different from the pathology. So earlier, though um, is kind of the same color fluid usually accumulates in the bottom. So you're more likely to put this down to it being a collapse. So it's a write up a load collapse. Well, you could say collapse in the right upper zone if you want 100%. Sure. I did want to draw your attention to this one is the golden sign. So, um, when you have right upper lobe collapse, you get an s like appearance. Um, with the lung. If I go back just a moment. Our ship, this one is not very pronounced, But you can kind of see an inverted s. Yeah, that's golden Sign. And, um, if you see this shape is probably up alot collapse opposed to panko stream up, for instance. Um, make some. It's unlikely it would go like that. This one was actually discussed earlier. But if we go down to the trachea, does look slightened deviated the Pyla. Quite normal, right? Heart border. The heart murmurs looks shifted. So, you know, usually you see the heart kind of sticking out hit somewhat, But on this one, it shifted towards the left side immediately. You're thinking Okay. Why would it shift? And then you have a closer look at the heart and it's quite bright on my screen. I'm not sure about your was, but there's actually this change in density throughout the heart where you've got most like this bright sale sign And if you don't, if you remember from earlier. But a sale sign is a lower load collapse were left lower, though, So with this one, you can see straight away. It's not normal. Your airway is very deviated. You have of the pulling of your trickier to the right to remember if you've got a pass, it e on. But it's pushing it. You mean the tricky would be going the other way, So that would be more likely to be pleural effusion. But this is being pulled towards that. Pass it e. There's almost like, please white out here. So, um, you've got your left lung, which is kind of hyper expanding, a swell and that trickier. And then that bronchoscopies toe a hole so that if you can see here, this is almost what I meant about bronchogram. This is that the air is still tracking down through here, and you can follow that one quite far. But in this right main bronchus. It just stops, but no more air is kind of coming through here. And this is due to an obstruction in this right main bronchus, and that's led to the load collapse. So it's always worth kind of following those structures down. Okay, this is, um, more of a cardiac pathology. Um, but if I said you call increased bilateral shadowing over, like the peri highland regions to your highly region is very, very, um, dense. The you can't really assess the outweighs. This patient was probably really, really poorly. I'll come back to that in a minute. Um, so with this one, um, was so you go, like, enhanced on Haider regions. And this is from an acute cardiogenic pulmonary edema. So pulmonary edema can be caused by, um, you know, have cardiac causes on the typical appearance off pulmonary edema. Is is usually this kind of like bilateral shadowing over the peri highly region. Okay, um, I did have a question. Just I'm not lost image about whether they had attention your mouth or ex. Um, so it is quite hard to see. Um, and this is where kind of the editing of images becomes really important. Um, because I can see how it might look like that longest. Maybe darker. Um, but you can see that the the lung vessels or the thumb should say lung markings do track all the way out to the purpose of the long and it just looks black. Er because of I think the way this has been edited because I don't think usually this would appear so white. Um, but if you're ever not sure with pneumothorax is just always like, see if the lung markings go to the periphery. Um, and this year, this is an amazing image to be sure. Um, but usually as well. With a pneumothorax, you'd have mediastinal shift is well, toe, um, I think it's usually towards side. Okay, so this is another cardiac. Um, example. So you can't really assess the airways again? This this is a really white image again. I think it's being, um, edited in a way, she's not very helpful. Or maybe the explosion went very good. Um, there are the markings, but I can see that says mobile. So this I think this patient have been really poorly on wouldn't be able to come to the apartment, you can throw it away. See, the mediastinum is really wide. Um, you can't really assess the higher regions just because of the width of the mediastinum. And the heart is obviously very large as well. I've included a CT here. Um, so you've got you able to and what's happening here is usually if you get this mediastinal biden and it's a rupturing of your aorta and your mediastinal hemotomas. So you've actually just got blood. Kind of like pulling, um, in your mediastinum. Um, so this is quite a serious, um, pathology. Okay, so I've not got much more to cover. If anyone needs a break, just stretch your legs. Oh, Mr. I'm just gonna take a 70. Okay, um, pneumonias. We love him. No, this this a few more. So, um, alveolar pneumonia. I wouldn't go through all of these in great detail, but it's just good to know that. Does this different tires? Um, so this one you get more consolidation in your loving parent. Comma is unlikely to effect your airways. You won't get volume loss on this. And when we say homogeneous a pass it e. We just mean it's a passage of the same color throughout the long. This one's more Broncho Broncho Pneumonia is more pap tree consolidation more scattered, separated by AARP containing tissue. So you can see here around a piece of airconditioning tissue and then you've got a consolidation. And then again, you've got a containing tissue up here. Going to change is again down here, it's a bit more random, and you're likely to get long abscesses with this is Well, um, pneumonias are usually will have consulted it. So what consolidation means, essentially, is that you have, um, something that's no air in your air sacs or when you're out of your life. Um, so that's what the meaning of consolidation is. I think pneumonia essentially causes consolidation. Um, so it's very likely with the pneumonia you would get consolidation. I hope that helps. Okay, um, interstitial pneumonia. So it's more linear because it's again affecting your interstitial. So it's tracking up in the white lines Instead of being like randomly patchy in flow, you can see it's more my white lines through the long. Obviously, it's quite diffuse here, but at the top, this is really prominent lung markings. Okay, and you can have the appearance of like small nodular densities, which almost at the basis of the long as you can see a bit better. Oh, come on on aspiration pneumonia, you'll get multiple alveolar density is why distributed through both lungs but usually affected by gravity. Um, and you're very often get aspiration. Pneumonia in bed ridden or debilitating patients are also patients with pumps like innards and throat things going on or who find it hard to eat. Um, sometimes he often told people, though, the elderly will get aspiration pneumonia from like coughing on toast or Casati. It sounds stupid, but it actually it will cause a lot of problems for them. And they do get really bad infections from something simple as that. Okay, so I'm just I'm not going to go into great detail about Cove it, but I just wanted to show you because it's quite no current with Covic. What they found is that it's a lot of consolidation in the periphery of the long, for some reason, so you'd expect, like if you think of the common route of most infections, it's like three the trachea through the bronchus and through all of the LDL really? But for some reason, with cove it it seems to affect the peripheries of the lungs more than it does centrally on. This is quite a severe case. I'm just to compare. So it's more in your left and right upper zones, especially in the right. You gave it away. Um, so again, this one you can straightway see when you're checking you out That way, you've got something going on in that right apex. It looks a bit different from the pankos tumor. It's a bit different from the right upper lobe collapse because it doesn't have the s sign. So this is actually the appearance of TB. It's kind of consolidation. Cavitation on something you will often get with TV is a girl lesion. I think that's how you pronounce it on this kind of, I think, the easiest way to describe it. It's like a yeah above on your X ray with an area of a positive way around it. We could bless the Roman ist, uh, keeps getting in the way. Um, this one you can see while the lung itself might all of the chest itself might be okay. You can straightway see in your soft tissue. There's a lot going on, and this is why the lung itself might seem a bit strange. Um, and this patient does have a long pathology. I thought they had extra card here for a minute, but they don't. But the main thing that's going on here is a subcutaneous emphysema. So that's where you get gas within your subcutaneous tissues on. You can get this from penetrating traumas. Um, perforations. So it's good to be aware of Pick this excavatum. This is just how it appears on X ray. Um, and I think this did come up in a few off skis for those at least angina. Okay, time for some audience participation. So if you'd like to put what you think in the chat, so but he is. The 75 year old female was born into E. D. By the nursing home. She's having a hard time breathing on clinical exam. Better short breath for four cyanosis. She's tachycardia clo 02 SATs and she has a low BP. You order a chest X ray and take some blood and sputum cultures. What should you write on on X ray request. So I don't know if most people have actually been taught this year, but anything that's something that's really covered till you're F one F two. Um, but if you want to ask the radiographers, um, usually you need to just put your why you want the X ray just from this patient's history. What is indicating that they need a chest X ray And he wanted in the chapped. We look at the X ray, just her hum history. Okay? Sepsis. So you don't know if she's got sepsis yet? You've just taken some bloods, but she potentially could have sepsis. So us to be Sinuses. Yeah, perfect. So she's got short of breath. She's got purpose. I know. He says she's not perfusing great. She needs to probably needs an extra just to check what's going on on a chest. Um, X ray form was pretty much to say. The clinical indications on make sure it makes sense because if you write a request that doesn't make sense, then we'll be rejected. And it means that the patient has to sit for an hour or two more. And eDiets can literally be like that sometimes, just because someone put the wrong thing on form, and obviously with this patient's history, that would be great for them. The big thing is, well, with requesting No, I shouldn't say never because of hospitals, A different but pretty much most hospitals won't accept rib fractures as an indication for a chest X ray, because it doesn't change the management of the patient if you find out they have a rib fracture on the X ray like management's the same as if they didn't have the X ray. If you are worried that, however have bleeding or have some other pathology is you need to write those pathology is now but right, right, fracture because it will be sent back to um And I've seen a lot of June your doctors to rip up on that, Um on what are the main findings off this X ray so you could do the always highly region right heart border. So I think maybe going on here can't even describe it as a zone. If you want. It is like maybe let me have a quick look. Any guesses to the pathology or shall I give it away? I think the tricky it could be slightly deviates is yes. Uh, pneumonia. Well, you don't know for sure if it's a new more in the topics you haven't got that blood and sputum cultures back. But they do have extensive consolidation throughout here. Um, and you can see, actually a small air bronchogram just here. So you've got the trickier it splits, and then you've got the broncos there, and you can see that much. Nothing. You shouldn't really be able to see this. Um, so they've also you can't really assess their right hand. You die from a swell, so it's very likely they have a right lower lobe pneumonia. So you have that pneumonia. That's pretty pretty good. You got the coaches back. They have streptococcus and my name. You put her on some oxygen. Um, describe her the correct antibiotics, but she continues to worsen. And should you admit her to hospital, I would. Should you discharged her. And what kind of school? Like you used to help you decide that Cup 65. Perfect. So if I told you, she wasn't, actually Yeah, Let's make her confused. If I told you she was confused if I told you, I mean, you know her BP from that. You got low SATs. I didn't give you her respirator. Her respirator is eight. Um, and we don't know how you really yet? Just from that. Do you think she should be admitted? Probably. Yes. Yeah. So this patient's X ray, um, it's not better blue boat, but whoever this X ray waas, they actually didn't need Teo be admitted and they got moved to I see you in the end. Um, so even once you've admitted the patient will move thumb to aim you wherever they go. If you're looking at this on the chest X ray and that much of their long is full of essentially infection, um, you might want to consider ventilating them. So pursued. It is a 50 year old male comes into, uh, any with sudden onset of shortness of breath and worsening chest pain. His COPD, his medication was recently reviewed, but he has the 20 pack year history on examination. His truck you was deviated. There was hyper resonance over. The apex is long on. His SATs are 85 in this heart rate is 140. You order an X ray so immediately just picking up on. Maybe the shortness of breath wasn't Just pay the fact he has COPD, um, was a previous smoker on the tricky of creation. So you see this? So looking at the airways pretty deviate it. In fact, you have the whole of the media sign and shifting to the left because the heart you can't even assess that right heart order it hidden behind this well should say behind it's hidden buds. Fine. So you know, probably is gonna be something going on with the right lung. You take a look at the right lung court. Do you think it could be? Yes. Um, And what kind of pneumothorax do you think it's to be? Yeah, it's a big one, literally the only bit of his lung, which is still no, that's that's how big this new with or X is. You could consider a second because he's got COPD. Yes, perfect intention with drugs and x ray. So, uh, so it depends on how big the pneumothorax is. There are different ways of measuring it. I think how we're taught at least, is you measure from the highland, the level of the hilar. And if it's more than two centimeters. I believe it's, um some think you will have to. Oh, that's when you put in a chest ring. But with tension in your thorax is not just the x ray findings. It's your clinical findings. So it's, um, high heart rate over 135. Usually really low saps. Yeah. I'm sorry. Um, yes. I hope that answers your question of my no means an expert on pneumothorax is, But I believe, like, with attention pneumothorax, if you're getting mediastinal shift is tension. Um, you shouldn't I don't think all pneumothorax is called me cause mediastinum shift, But this this is a big one like that. That is literally that right? Lung? I have helped. Thanks. Um, So what would this pain? What's the next step in the management? You know, they want attention. Pneumothorax was the next thing you need to do. Oh, two you need Oh, yes. Perfect. You don't. Decompression set. Second intercostal space. Middle medical. Particular line. Yes. Perfect on. What? So it all goes well? You save him suit. Um, what do you want to tell him when he's recovered? And you know you're letting him go from hospital? What you need to tell him to do or not to do. Don't go on a plane. Thank you. My first time. I think that's forceful. Don't go diving. Ever. Yeah, correct. He's also got the 20 pack. Your history? Um, I think, Yeah. Stop smoking. I mean, he might tell you he stopped, but I just really like you have COPD. You just had a massive pneumothorax. Have you thought about not smoking? Okay, last one, Daphne, 23 year old female is brought in by ambulance. She presents with experience three stride or confusion and significant respiratory effort. I should be raised. How respect to rate is raised. Oxygen SATs in less than 92%. She has signed off. She has sinosis and tachycardia and hypertension. You order the X ray. What are your differentials at this point before even getting the x ray? This is again, like clinical history. History. Big, big. So she's quite young. Um, you got experience tree stride or what kind of things could cause expectorate stride or may upper s truck obstruction. Yes. Yes, that's what? Yes. So yeah. Inhaling a foreign object. Three overproduction of phlegm. Um, allergic reactions. Asthma. Could definitely be one. I broke your question. Construction. Um, cancer of the vocal cords. She is quite young. Could be pregnant. We don't know. So maybe being or even like, oral contraceptive pills could lead to peas. So, um yeah, really good. So we've discussed differentials. You get this, Um, and then you look a definite records and you realize she's called cystic fibrosis. So if I told you, you see if I told you that this is a right lobe collapse, I mean, like, you've got your tricky a deviated towards the side of the pathology is likely to be a collapse. She's got complete white out. It's the right lower right lobe collapse. She's got cystic fibrosis with what do you think might, of course, the collapse we did kind of mention Yes. Yeah, really good. I can't see on it. And it is mucus plugging. Um, yes. So very often with sister corpora. Sis, you're out of obstruction musicals like the thick mucus. And it, um, obstructs the airway, and then it leads to the collapse. Really good. How much you treat it? Don't overthink it. She's got, like, a booked. Like an airway that's blocked from you, Cas. That's led to the collapse. Breast busier. Yeah, really good. Even before that. Something say, you're all in the bay with her on D You look around. What's the first thing you might see? Oh, two's definitely worth considering. We collect IX even simpler. Mucolytic. Really good. Um, it's something that should be aspiration. Oh, she could. Okay. Positioning? Yeah. Is it changing her position? Could help. Nose bronchodilators. That's very good. If, um, on a crash stroller, usually what is there to help with unlocked airways? Up to help on broke. Always suction. Yes. Really good. Perfect. Everyone's got it. Um, yeah. So suction is the simplest. The first thing you might want to consider doing, considering it's an emergency scenario. Just see what you can get out while you're sorting out drugs or, you know, changing her position like your main concern is unblocking. And as much as you can, um, from her that way on, just, um, again, thinking about differentials, especially with X rays. What else could cause a white out like this on the next day? Ignore the trick, you deviation. But from what we discussed And, um So what are your thoughts that could cause a white out. It's just a pass. It e Claritin fusion. Great. You know. Yes. You menactra? Yes. Compute lobe collapse. Massive pleural effusion. Yes. Yeah, pretty much anything. That's that's a mass I Recently I was literally studying, especially today. And I realized I found that, uh, Charlie transfusion related acute long injuries can cause white out as well. Um, so that is the end of my presentation. I hope that it helped, um, and that you at least got to see some different pathologies on X ray. Um, practice interpreting them. That's me. I'll try and answer any questions. Great. Very frankly, so much monthly. You have any questions for not anyone. So if anyone pop some questions on, we'll just green them. But meanwhile, thank you so much. Not city for your accident. Talk on the X rays. Many things, lots of them cover today can come up in. Oscar is as bad diagnoses. Just remember that in the beginning, off the lecture, she talked through anatomical landmarks. Um, I know at this for you, yet they love at least asking, like, five questions on different parts of the anatomy off the chest. X Rays that I was very, very well covered. Natalie. Thank you. I know there was a lot you did in a short space of time. So we have recorded the lecture on. We will upload this on medal and hopefully on blackboard as well for you guys to review. Just remember to use the link to fill in a quick five second feedback on how not really did, um to also receive a certificate off attendance. Um and yeah. I thank you all at once again for joining us today. We hope to see you all again very soon on Yeah, we talked to We hope you enjoy the rest of your day. Thank you so much for coming. Thank you. Thanks so much. Thanks.