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And um welcome to the second session of basics of x-ray, basics of chest x-ray. Um Doctor Nain. Um it's going to continue from where we stopped last week. Um So for those that were not there, we had um a session on chest x-ray the first session last week and um we'll just continue from there. So, nothing. Hi, thanks. Um Good evening everybody. Everybody is doing fine. We're gonna start with our second session of the basics of the chest x-ray. The city is basically based um on an understanding of the basics of the chest x-ray because as a doctor especially, we are supposed to know even if you're not radiologist to, we are asked to interpret the chest x-rays. Um So far we have discussed until the cardiac silhouette and how the heart looks on the chest x-ray to take it further. Um We're gonna discuss from the mediastinum bit today, we did speak about medium when we were trying to make sense of things, how different structures look on a chest x-ray. Today, we will, we will just look into the detail. Um In me, the one thing that comes first is the hilum. Hi is basically a notch or depression right in the center of a chest x-ray and it's made up of each root of each lung produced by bronchi arteries. So I want to focus on arteries because those are the most important structures and we will talk about those in further detail. There are also veins and lymph nodes and you must be aware of some lymph node, adenopathies, um such as in sarcoidosis which appear in hilum. Then there are also some nerves and bronchial vessels. But as I said, we're going to focus on the arteries because the rest of the structures you can't really make out on a chest x-ray. As I said, um highly conveniently mix an h like structure in the um center of a chest xray, right? Um I said we will talk about the arteries. The first artery that we're going to talk about is um the left pulmonary artery. And um it, it could be surprising to some of you um that yes, we can see arteries on um on the chest x-ray and especially um the pulmonary arteries are a bit surprising. How would you know that, which is, which and how to interpret what's normal and what's not. We will take a deeper dive in this. So if I tell you that um this is the left pulmonary artery going there and this is the right pulmonary artery on electro x-ray. Uh This is, this looks like this. We will further dissect this. Um if you know the anatomy of what's going on in the chest, it becomes a lot easier to understand. We have removed lots and lots of structures from here. You got your heart and then you got your main stem and then both of your, your left pulmonary artery and your right pulmonary artery. You see from there, that the root comes from kind of a left side to the mid of the body, mid of it's, it's on the left side of the trachea. So the right pulmonary artery, it travels across the trachea and then divides into its further branches. And this is what I was just referring to on a chest x-ray that you, you, that you see this big, just remember that you've got your right heart border and it's just adjacent there and your left coronary artery, if you look on electoral view, what happens is it travels across the trach. Yup. And then it makes an kind of sort of arch with its tributary. We have removed the aortic arch from here. The aortic arch kind of makes an arch there like that. So there's a big arch there. And then there's a smaller arch which is, which is made by the left pulmonary artery there, the trachea, um and it's left bronchus we have removed, but it just arises from here underneath the left pulmonary artery. So you could say that the left pulmonary artery arches over the left main bronchus, we will see in a chest x-ray, how, how we can make sense of these things. If you remember this anatomy, it becomes a lot easier to see. So step by step, you can figure out where the left pulmonary artery is. Um First of all, have a look at your trachea. Um find out where your GNA is. We learned to do that in our last um session as well. So basically, you find any main bronchus left or right, the lower border, trace it to the v um with the meat and then you trace the upper border of the same bronchus on the left side. And just above you got your this shadow, the the which is basically your left pulmonary artery about that. You see a bit of depression, uh aortopulmonary notch, it's called and above there, you see the aortic aist could be curve there as well. How would you see the left pulmonary artery on a lateral view? Um What you do is you look for your trachea again, it's kind of rectangle with air inside. Um Then you see, as I, as I told you that your aorta makes an arch so it's visible there. It's upper border there, it's lower border there. This is the first arch you look for and then the second smaller arch is made by the left pulmonary artery. It's a bit whitish here as it's zoomed in, in this insect because your right pulmonary artery is just opposite on the other side there. So that's how you can have a look at the left pulmonary artery on A P A film and on a lateral film moving forward. And if you remember from the anatomy picture, I've shown you earlier, kind of so that your the left pulmonary artery crosses across the midline and then just goes adjacent to your right heart border. So looking on a P film, that's how the right pulmonary artery looks like. So your right pulmonary artery across the midline a bit higher, you see your left pulmonary artery. So they, they got them both. So it's important to know these arteries are there. Um not to mistake them with um thinking that this could be um patchy pneumonia if you know that, ok, this is the normal course or normal place. Um and this is how a normal right and left pulmonary artery looks like and you won't mistake it with something else. The other um significance of knowing what's normal is regarding these artery is pulmonary hypertension. When you got pulmonary hypertension, you kind of see that these are now enlarged and too big. So you can kind of assume we need to look into this further. As, as I said in our previous session, it's very important to know the um clinical history and exam findings. Um and only then you can relate with the chest x-ray findings to kind of sort to make up very good diagnosis of things. Next, as we discussed in the hilum, you got your lymph nodes and lymph nodes, usually you don't see them. I don't expect you to see them. Um But um when they're really, really thick and enlarged, then you can see those lymph nodes, especially the most famous example, being sarcoidosis. So here you see, the lymph nodes are really big and you can see them in the hilar. So how the normal um hilum looks. Um You got your normal there and your right pulmonary artery, left pulmonary artery going up, make an arch and then going down a pulmonary notch there and kind of curvature of the aorta there, enlarged. So you see enlarged arteries there and then you see completely distorted um hyaline with different lymphadenopathy. Next, I want to talk about is sin. Um Before we talk about radiological anatomy or try to dissect an x-ray, I just want to remember what kind, what do we have anatomically? What structures are there in Mediastinum? And how Mediastinum is further divided? Mediastinum is further divided into spi metin, middle meum, anterior metin and poster midst. If you look at the um how do you say, which is superior, which is an interior sterum, which is middle, middle a and posterior anatomically. Um You take a straight line from sternal angle and to the bottom of the T four, whatever up is your superior mediastinum, you get your heart, whatever is anterior to the heart and behind the, um, sternum is your anterior mediastinum, the yellow bit here behind the heart. You've got your metin and of course, the heart is the middle of the afternoon. So about sternum, the sternal angle. Uh what do we have in terms of arteries and veins? Um, you got your left, you've got your carotids, you got your subclavian right and left. You got your aortic arch and brachy in the vein, important ones. You've got your um is, I guess British pics and, and some small branches, you got some nerves there as well that you don't see on a, on a x-ray. You got your esophagus, you got your trachea that you do see in a chest x-ray, thus only in Children and it, it lies in the anterior mediastinum. We'll see. Um Then in the middle of the ask, you got your heart and tracheal bifurcation, basically. Um It doesn't, I mean to say that the trachea lies in the media mediastinum, but on a chest x-ray, you kind sort of see there. Um post the me ay, you've got important structures. You've got thoracic IDA, you've got Azy vein, you've got esophagus, accessory, hemizygous rain. So, radiologically, um the radio radiological anatomy, how mediastinum looks on a chest x-ray to delineate its borders on a pa view, kind of sort of looks like this and it's kind of a structure like a box. If you look at it from the front, it looks like just this much. But if you look at from the side, it it extends from the anterior to the posterior, almost all of entirety of the um chest x-ray. So um this classification is Felten classification. Um it's very easy to remember and it's very useful to classify where the lesions are. We can further discuss about these. Um Again, for the f in classification. Also we take straight line from the angle of sternum to the base of the T four, whatever above is superior. Then the anterior and the middle and posterior um medium is divided a bit differently. So what what you do, you take a line just interior to the anterior aspect of the trachea and all the way down, whatever there is counted as an interior with the ay, then you take another line which is one centimeter from the anterior edges of the vertebra and you just go through, connect all the dots, whatever you get behind this is your posterior mediastinum. Um And whatever is in between is, is counted as the middle medium. Now, um as we know from the anatomy that you've got different structures in the, in the mediastinum. Now, which structures you can see on chest x-ray easily. And how would you know which is which we're just gonna talk about those in, in bit detail. So uh as you know from anatomy, the aorta originates from the heart and then makes an arch then goes down. So which bits of the aorta. Can you see on a chest x-ray? Can you see the ascending arch very difficult but easily you can see this curvature of the arch and then the descending aorta on a chest x-ray on electoral. Uh we've seen that earlier while I was trying to uh tell you where the pulmonary artery is. Um It makes the aorta makes an arch on a lateral side as well, which is very easy to delineate the, it's, it's up upper border and the lower border. Both next spi Veneva, we can see this later border of the spi Veneva on a chest x-ray very, very easily because it makes an interface with the lungs on um on electoral aspect. Um So you got your, you see here, your arch of your dates very clear, it's superior margin, it's inferior margin. Then you see your right pulmonary artery, its arch and the origin of the right pulmonary artery there. And you can imagine the left pulmonary artery is just behind this. So where is your spi Vena Cava on the electoral um x-ray, it's kind of like a straight line just adjacent there. Why it's important to know where this spor Vena cava should be um anatomically. It's because you got lines and divi lines, um tubes inserted in the sphere, Vena Cava. So if you know where the, where the normal position of the spi Veneva is, you will know where the tube is inserted. So what I would do is look for the arch of the pulmonary artery left one and then just adjacent to the straight line there, it should be the spi vena cava esophagus. And it's very easy to um appreciate the esophagus, making an interface with the azygos and making something called um a Zygo esophageal recess lymph nodes. Um You got lymph nodes usually don't see and I don't expect you to see, but it kind of sort of looks like this in, in, in a media. So um making a sense of um the structures in the mediastinum and what you can see in a chest x-ray, we will start with this. Um As I said, the Niva should be there. So you can know that that border is made by the sp Veneva. Of course, the right atrium border and just adjacent to there, you got your left pulmon, right, pulmonary artery, left subclavian artery makes this interface, the aortic arch as we saw earlier, makes this bit of um bulge there, aortopulmonary window there. And then you've got your auricle of the left atrium, you've got your left ventricle again, if you look from the lateral, so that your heart inferior goes there, aortic arch again, we've seen earlier. So um appreciating different structures in medstar and a chest x-ray. So you start with the trachea, then you go next, look for your Spio Vena cava border there. I hope all you can appreciate this this interface right there. That's your Spio vena cava. You move on next to your hilum. Um, in the hilum, you look for your right left pulmonary artery, right pulmonary artery, you look at the lymph uh, at the lymph nodes. Are they visible? Are they thickened? Is there any lymphadenopathy or not? Are these two, blood vessels of normal size? Are they too big? You move on next to your right atrium. We saw the double sign in our last last um session where we said if there's a hypertrophy of the right atrium, you could see double sign there, look for your aorta, um normal aorta makes a very small bulge, then aorta the there not the hy descending aorta you sometimes also see in, in here we've talked about just now, right? So we talked about um dividing the metin according to the Felson classification, inter superior, anterior middle and posterior Medin. Why is it important um to divide this into different classification into different parts? What benefit can be gained from this? It's very practical classification. For example, if you see this mass there, um just looking at a pe a view, you can't say um where exactly in the chest, this masses. So you will need your electoral view um and your p classification to kind of make an initial differential diagnosis what this could be. So, and um for example, in a pa view, you see mass there and then you get electoral view and, and you get, you see that this kind of lies this mass in the interior sp sp region of your meds Asar F's classification. What are the things which could be there? So you, you've got to remember these, that the structure of that line as we discussed from the anatomy thymus, mainly in children's. You've got some blood vessels but to remember which masses could be in the anterior mein are the five DS um thyroid goiter thyroid tumor from kind of from the neck in the line interiorly. And they can have extensions down into the interior metin on a chest x-ray thymoma, um testicular mats could be found there in the Indian mediastinum. So if you look up here, they will be scattered all over. But when you do electro, they're mainly located in the um anterior metin and lymphoma. Sometimes. Also, I've got the masses in there localizing to the middle, mid. Um When you do a pa view, you see a big mass in there. But how would you know that it's exactly in the middle, a very good example. And common example is um hiatal hernia. So you see you do a pa view, you get distorted um images there and then you do the lacter view, you see the visa there with the air bubbles and, and you kind of know, OK, where does this lie? So if this is the interior, if it's behind it's the posterior. So it lies in the medial me asym and again, the hiatal hernia presents in various shapes and sizes, but it's one of the pathologies or with the middle mediastinum, you see distorted Mestinon, you do the lateral, you see that this distortion lies in the, in the middle of metin, not posterior, not an interior just there. So you kind of sort of would say, OK, this, this is Hiatal hernia. How would you um know which pathologies aren't there? So, the pathology is related to esophagus. Um trachea, foot vessels, I dash we see, we see lymph nodes could be there. Um from lymph nodes, lymphadenopathy, sarcoidosis, lymphoma infection could be in the could be found in the, in the, in the middle mein bronchi, bronchogenic ca carcinoid esophagus, lem myomas cancer and hiatal hernia will be found in the middle of mediastinum, aortic aneurysm could be seen there. Um and great vessel aneurysms too. OK. Again, um P A view, you see a mass there. Uh just from a peer view, you can't say if this is an an an anterior dey, it is in the middle of the posterior one. But when you see at the lateral view, um you kind of see that, OK, this is invading the middle, mid as well. But if you trace this border back, they kind of come from the in from there. So, you know, it has its origin from the posterior mediastinum and then it sort of is so enlarged that it, it's invading the other mesna as well. What structures to think of uh when there is a mass in the posterior, basically, nerves think nerves, um neuroma, schwannoma, ganglioneuroma, lymphadenopathies could be there as well. Aortic aneurysm could be so big that it's going back. Uh bash one abnormalities. We'll be talking re the ay sometimes because of trauma, esophageal rupture, vomiting those melly was tears. Um asthma and the rupture of the lungs, post neck or chest surgery or bare trauma diving could result. You could see some air in the mediastinum. Whenever you see air in the mediastinum, then you need to rule out all of these. Um what's the cause symptom is up just present with this and that's the only thing that you get in a trauma patient. And then you have to get your swallows to see if there's any leak next. Um In our UB CD E, we will talk about diaphragm. Um So normally they should be um smooth and they appear dot control on the both sides. Um The right is a bit higher because the big liver is just sitting under it on the left side. You see stomach bubble and spleen is just under it and you should um be seeing the con of an eye shop edges on both sides sometimes. Um something happens which is called diaphragm eventration. Um the elevation of the diaphragm. And so you see this diaphragm is really low. We know at the right diaphragm is a bit higher, but it shouldn't be this much higher. Um So when can that happen? It, it can happen when there are diminished lung volumes. So there's nothing there. So the abdominal content push up uh in atelectasis, for example, um, nerve palsy which basically supplies the diaphragm. Um could cause this subic abscess could cause the eventration of the diaphragm and hepatomegaly. If the liver is so enlarged or spin me on the, on the left side, you could push from down under there. Uh We are, we are all um aware of this and the air under the diaphragm and perforation in the abdominal sca the air tends to go up and you kind of see the air end of the diaphragm. This is the double go sign. So it could also happen postoperatively. Um when you could get a pneumoperitoneum and some areas left in there and it could happen after trauma. Um And it's usually normal after peritoneal dialysis to have some air under the diaphragm. When do you see flattened um diaphragm. We talked about this in our previous session when you've got emphysema and the barrel chest. Um So the diaphragm is also also becomes flat. Um If there's a tension in the s there's so much air in the chest, it just flattens the diaphragm. Next. Uh We're gonna talk about pleura and the pathologies of related to it. Uh The first one and the biggest one that we see is uh the pneumothorax and pneumothorax could be just pneumothorax or tension pneumothorax. So basically you got your lung and the air just surrounds it. If, if there's a, if you like, you see there's a small rupture in the integrity of blue right here. So it will come in and then it will start compressing on the lung and then making it smaller, very nice. Um pneumothorax. You hear you, you can differentiate the lung very free here and, and it's, it's all there in here. You see it just on the top, some on the bottom, but mainly it tear and, and you don't see any lung markings beyond there. Does um anybody see anything in this chest x-ray? Um I, I'll give you a spoiler that it's um related to pneumothorax. Does anybody appreciate a pneumothorax in this um chest x-ray? If yes, which side do you see? I will look from the um periphery of the um chest x-ray and see, try and see the lung markings. The lung mar are not there for almost one centimeter. Um But after that, you should see some lung markings, but if you don't, and if it's all clear, there's no lung vasculature seen. And then you suspect there's a, a pneumothorax. So you see a pneumothorax here, there's, there's, there's no lung respirator from here to here and then you kind of sort of have no lung escalated here and you see clear border of the, of the lung there. The um technical point here is sometimes what happens if you get. So this is the same x-ray that I've, I've shown you in a previous slide. If you ask the patient to um expire fully and get an expiratory film, um the lung completely collapses and the pneumothorax becomes very, very visible. So if you're in doubt or if it's really small, um you can ask the patient to get another film called Expiratory Film where they expire to the max and then you snap the x-ray, the lung collapses further the air rushes in. And then you see it very, very clearly that, that, that this person has got a pneumothorax. There's another trick. Um So uh the people who use Sara, there's a very good function um of in investing the image. Um Sometimes you can inverse the film. So you can appreciate some pneumo here on, on, on the right side. But if you ener the film, it also becomes very, very clear that you see your lung markings and then the lung markings, as I said, are basically these are blood vessels. So blood vessels you don't see in blood vessels is one centimeter from the lung margin and then the vasculature starts. So this is where the vasculature ends, nothing in one centimeter. So it's all clear, then you see the margin of the lung and then you see this empty space uh to the end of the, of the chest cavity there. So this bit is here. It's all clear. You, you can trace it up. So sometimes in sing the image also helps you. Um see uh pneumothorax, we all know um if a pneumo is too big. Um So you see that checked a black air there and then um if it's too great, um the pressure, it it, it can become tension, pneumothorax and the tension pneumothorax would just kind of sort of push the um the lung to the other side and all of the mediastinum to the other side, it's an emergency, it needs to be treated ASAP. So you basically look for your medstar structures. If they're being, they're being pushed to the other side or not. So, um how do you classify pneumothorax is um uh if it's less than two centimeters, a small pneumothorax, if it's greater than two centimeters, then it's a, it's a large pneumothorax. So basically just sometimes um pneumothorax present um in a way which is which we call deep sulcus sign. You see this, the gastro angle is like a very, very deep sulcus. This is also pneumothorax. We listed some causes of pneumothorax from primary spontaneous pneumothorax, skin retro and and COPD. Um cystic fibrosis, pneumonia, pleural as we all know could be exudative because of the inflammation or lymphatic obstruction or transudation due to the imbalance of the hydrostatic pressures. The important bit to um to notice or to learn here are sometimes you get a P A film and you say, oh, I see a very good um costophrenic angle, they're nice sharp edges. Um I don't see anything and there's no pleural effusion. So just looking at a pa film, you should not say that this patient does not have got any pleural effusion. If you want to go into a pleural effusion, you need both pa and electro views. The reason being when you get um when the fluid level is too low, you don't see a distortion of these costophrenic angles in a pa a film. But when you get a electral view, you see that there is some fluid build up there, how much fluid um can be accumulated in there before you see it on a pleural effusion. Does anybody know how much fluid be there before it appears on A P A film? We will come back to that. Um Sometimes the um pleural effusion could be free flowing. Um And sometimes it could be within a cavity like a loculated. How do you differentiate between the two if you are doubtful? Um if it's a free fluid or, or loculated in here, you know, it's kind of loculated if it's just um is contained in this bit, if it was not all loculated, all of this would have gone out here and would have made a very straight um angle there. So what we do is we get um lateral decubitus view. Is it um Hi. Oh Yeah. Just an answer. On the chart. Um Taha said 200 me, she's right and she's absolutely right. Uh I will come back to that later again. Um So, uh when we get the electoral decubitus view, um what becomes is if it's free flowing, you kind of see that it also becomes horizontal, it loculated, it stays in its place and it doesn't become, it doesn't flow. Um An important thing to remember is that when you get um x-rays in critically ill patients, uh or again, we will remember from the first session that we said the x-ray quality should be good. Um If it's not a good quality x-ray or if the x-ray beams are not directed in a good way, you can get um picture of the fluid in a way which does not give you accurate idea of how much fluid is there. And it if the patient is lying down like at, at an angle, so what becomes the blood meniscus mace comparison more difficult? You won't know how much fluid is there. Sometimes it's difficult to just obtain those views. So yeah, um uh 200 mils, 50 to 200 mils is the right answer. Uh So you see if 250 mils, you can still have your angles quite sharp, quite visible. But when you see electro, you see there's something in there. So when it just barely becomes visible, like here, you see some blunting of the angle, um then it could be 200 to 500 mils. And of course, if it's more than 500 mils, it's quite obvious on a, on a e looks like something like that. So, pleural effusion could be due to the inflammation or infection, as we said. So, um you've got um a pneumonia there. Um and then you see some blunting there as well. It could be due to the mass, uh a big mass. Uh the pleural effusion, sometimes the pleural effusion is um so big that it causes the, uh you see the heart is being pushed to the other side can cause mia sometimes you get hydropic, you, you see the air fluid level there where you've got both. Next. Um We will talk about um the equipment and lines, um especially, um sometimes you get asked to comment if the line is in the right place. Um How would you know what's the normal, where should the line be? And how can you say? And when can you say, OK, this line is safe to use? We'll talk about that. So basically, um the line could come either from sub mien, um could come from your internal ejaculate or could come from your picc line from peripheral veins as well. So where is, is it normal and OK for it to use. So, left internal jugular vein and left Bron brachy and SVC. So internal jugular phallic and then it rests in S we C comes from the right internal Jura phallic and then rests in s we see. So an example of subliming could come from either side. What's the great position? So, um to go through with you, um, look at the crier. So that's very important. But ideal CBC position, if it's coming from your right side, it either has to stay in the seabed, right, which is brackish malic or it needs to be in, in the zone a delineated here. It's just at the level or below the groin. It's coming from your right, then it should be in zone A and away from the um SVC border. So now if you remember, we said that your heart border is there, you got your right pulmonary artery there and then from the mediastinum, you kind of trace where your SVCS lateral border is. So you look for your lateral border and then you see if, if this is touching that lateral border or not, it shouldn't touch the lateral border if you're giving medication through it. And if it's constantly touching the sp it just can make a hole through it. And, and that would be a disaster. These are some wrongly placed lines. Uh This patient has got different attachments to him and different lines in there. We we're interested in this one. So this is coming from his left side. So internal jugular brachy phallic and then where do you think is this touching? So this is touching the lateral um margin or lateral border of wall of the SP And I get this is wrong. This has the potential to rupture through the um S PC. So this is a picc line coming from the left side and it, it has to go down and into the S WE C so you look at your CNA, it should be somewhere there. But what happens is it, it has gone up. So this is wrong. You shouldn't use this one then um you got this one coming from the right, your groin is there. So it should be like somewhere there away from the lateral border of the SVC, somewhere there. But what happens is to it once it, it's in your right atrium giving you the risks of arrhythmias and whatnot. So this is ST it once it needs to come back a little maybe to here and away from the wall of the SVC Angie. Um You must, you may know about the Angie position. This is wrong. You look at your CNA should bisect, the crier, should bisect the diaphragm. Um and sit in the stomach, bicyclic groin, uh bicycle diaphragm should be in the stomach like this is the correct position. Summarize tube and whatnot. And they come with a, with a tip which is radio quick uh to make it easier for us to see wrong es um So obviously it comes from here. You, yeah. So this is the one I'm talking about they've got with the radio, big tips, um, easy, easier for you to know where the tip is. So this tip is in the right Bronchus. Um, this tip is almost at the level of the diaphragm. Uh, it is a crossing, I will be sure to you that it needs to go further down. This one, just go on its own and goes back up. Correct. T if you, if you are looking after a patient who's incubated, what's the correct position with the neck in neutral position? Like you would sit up in a chair, uh It's five centimeter plus minus two above the corer. And if the neck is extended, it's seven centimeter plus minus two above the. Now, there should be your, that's the correct position, extension of the neck and under to the normal position as well. And with the flexion, it's three plus minus two. Next, um We will talk about uh ABC DEF. We are at a, the fields uh by fields in lung, you've got your different lobes. So, and another point is that the lung actually extends below the diaphragm. So you see the diaphragm domes there on, on a chest x-ray, the actual lung extends lower than that. Just, just remember that bit. The uh I I've told you this one already. Uh But you need to remember this um the vasculature marking in the lung stop about one centimeter from the pleura. So if you take your blood up one centimeter. The vascular mar marking just stop about right there and the on the lateral, posteriorly, the lungs get blacker more inferiorly. That's another point to remember what are the white lesions on a, on a chest x-ray. In on, in the lung field? You see some focal white lesions may be patchy, may be diffused. You may see segmental or lobar white lesions, perihilar, peripheral or entire lung, unilateral bilateral white lesions. Before I get to um further, what I want to discuss is some terminologies that um that, that are used while interpreting the um chest x-ray is what's a nodule. And a no basically is a is is could be mass is, is a white area surrounded by the gray area. It's mostly has very de marketed borders. So the nodules could be solitary and there could be multiple, multiple, as we said, um testicular and as I told you, you will get a lateral view and see they will be in the that they usually are found. And so this is what a nodule, solitary or multiple nodules will look like big points. Um What's a cavi dating lesion? Um A cavi dating lesion is basically looks like this and you can find it here, you can find it here and then uh so cavitation lesions could be caused by cavitation tumors or cavitation pneumonia, Cavite pneumonia, we will discuss further. So these are many, many cavitation lesions. Um So these are usually found. Um consistent with multiple septic lesions in IV D hemocytic lesions. These are next. Um I want to talk about air broncho branch. Um You will come across this term. Definitely air bronchogram, as somebody will say, they see air bronchogram. Um What is an air bronchogram? You got your bronchioles. Um And then you've got your alveoli around it if there's any fluid or blood or anything in, in the or mucus in the alveoli and it's gathered there. What happens is that normally you don't see bronchioles. Normally you don't see bronchioles or air in them. But if there's some fluid collection, blood pus or whatever surrounding them, what happens is that these, the air inside the bronchioles become accentuated, you can easily see them. For example, when you get a lung consolidation, you see a consolidation here and what you see if you focus there, you've got your bronchioles inside. Now, you can see the bronchioles and air inside them apart from the vasculature. So this is what we call an air bronchogram when you can see the air within the bronchogram, when they are surrounded by blood pus, water mucus or tumor while talking about the interstitium. Um What um lesions of inter are seen on a chest x-ray, you could see reticular, too many lines spread like these nodular small miliary dots. Um radicular reticular nodular where, where you, you see a mix of both. You see examples of both of these. So reticular, too many lines. That's how they look. You see too many lines right and left in every direction. Nodular. You see very small millie it's called miliary because mill seeds small one millimeter. So lesions reticular nodular, you see the mix of both the linear patterns. As I said that the lung markings there and one centimeter from the edge of the lung. But if you see these linear lines, it's not normal, we'll talk about these further particular pattern looks like this, you know, the lung. Um Next, we will talk about pulmonary edema. Um pulmonary edema, we will come back to pneumonia and discuss about the broncho cramps and whatnot. We will take a deeper dive in the pulmonary edema. Now, um what are the features that you see uh in the pulmonary edema is usually bilateral. You see curly B lines, we will talk about those um very bronchial coughing, very high haze, mild cardiomegaly ankle like history and one by one, you see um many lines in there. Um So usually pa which are taken for the pulmonary edema are the B lines. These are these straight lines that you see here if you go back and these white arrowheads and basically these straight lines coming from the side. As I said, there shouldn't be any lines there one centimeter where the lungs end. So if you see these straight lines there, these are the curly B lines, this is one of the signs. Um Staal is basically when the edema and lots of fluid down there, it just constricts, the blood vessels down the blood vessels on the, on the cord end, but the cephalic and becomes um too thick and too prominent. This is called um cat also happens in pulmonary edema because pulmonary edema tends to settle in the, in the bases. One other thing I forgot to tell you that the currently B line is basically um is the thickening of the interceptor, very bronchial coughing, uh very bronch, um coughing is the area on the bronchoscope. You and more prominent on an, you sometimes see these lesions and pulmonary edema as well. So if you see these lesions, it's, it's also one of the signs of the um pulmonary edema, sometimes um thickening of the fissures uh because it's a fissure thickening, it looks like a mass, but it's not a mass increased vasculature. So, if you remember, um so this vasculature is really, really no, this um right pulmonary artery also looks really thick. The bad sign is basically um bilateral, very hilar shadowing. So you see all of this shadowing there, we see you probably be line ization of the uh coughing and you correlate your history, you a bit of cardiomegaly there as well. So you've got your pulmon edema. So getting back to the um to the uh reticular pattern, we saw it usually is in um pulmonary fibrosis, mostly in all ways it's spine. You see the reticular bacter and you see that just radicular batter. So you think of um, pulmonary fibrosis and then you go over the history. Next, next, we're gonna talk about pneumonia. Um, pneumonia could be low with the whole low is, is consolidated and, and in there, if you focus, you see the, um, both of problems in there, very subtle but very clearly seen. Ok, bronchopneumonia, uh you notice the patchy consolidations, um, that's how the bronchial pneumonia presents. So, interstitial uh pneumonia is characterized by interstitial nodules or Ticar densities, nodules and reticular densities that you see all over TB. Uh TB presents in, in many many ways. Um Miliary TB presents with small millets. Um You could have ver and cystic changes as well. Like here, Ticar changes and mi you see both pneumonia sometimes, um could also come with a bronchogram and infusion. You see you do, ok, handle there, there's a consultation there. Pneumonia can also come with cavitation lesions. Uh So this is cavitation lesion and you see a fusion in there and there's a, a fluid level. So you see the fluid here and then air above it. So, cavity lesion within the lesion, you see a fluid level. So this is an abscess as associated with the pneumonia, fungal pneumonia. How do you diagnose a fungal pneumonia on a chest x-ray? If you look very closely, you see a, a very characteristic, it looks like a cavitation lesion but like fungating margins. Uh in in the center and and on the outside as well. So this is also called a fungal ball. Again, you will take the history um atypical pneumonias and then um look at the chest x-ray closely all of the page on this. So nodule, we all know the nodule um could grow. And so what, what we usually recommend is serial chest x-rays to see if it's growing and then further work out. So serial x-ray is very small, later on, becomes bigger, becomes more bigger. So it's called total growth. Sometimes the uh you can diagnose a malignant lesion right away. So you see a mass there and we don't know um if it's in as procedure which one, but then you see that it's eroding through the ros and the structures are just point. So if you see erosions of the structure, then from this, you can tell that it could be malignant. Next. Uh We're gonna talk about um the vessels, that's the end of our ABC D, the vessels, as I said that you usually see AORTA. Um So you see aortic knuckle, sometimes they call that they call it just aortic bulge. And then you see your pulmonary artery, um notary artery, your left main bronchus. And as we discussed earlier from the media, you can kind of trace back your descending order there. Sometimes what happens is the aortic arch just looks big and the descending aorta is also big. So that's an aortic aneurysm. So, so you look at the aorta and it just continues to there. So there's an aortic um aneurysm there um home. So go and check your heart small um neurovascular radical like a knot and then increased vasculature all over. So that's DD I, so um that's uh all of our ABC D. So going through ones like as estimation of what we discussed so far we can do is just talk through all of the ABC D and then we will finish. And then if you got any questions, we will go through those. So in a um of our ABC D approach, we had assessment and quality, we saw three excess movement of the x-ray and then um if the, it it's penetrating a lot, um do we see all of the structures? Then we saw the airway, we saw the trachea, then we saw the bones, bones included the shoulder bones, clavicle, um scapula, ribs, correlate the history. Look at the body walls. Do we see any, any masses or anything going on there? Then we see the cardiac sleet. Do we see if there's any right atrial enlargement, if there's any um what's the ratio? And then we had to look at the sin and we looked at the hilum first and then after the hilum, we looked at the left and right in the artery, the side, the side, the S PC um then uh beside the esophagus. Um if in the mediastinum you find any mass or anything, then you compare with your electro and then based on it's, it fits into you. It could be thymoma, it could be thyroid. It could be um a testicular c and then you look at the middle one, if it's an hiatal hernia or the other, then you look at the posterior if, if it's um coming from a nerve region. So um you, you try to make your differential list, um, correlate with your history, then you look at the diaphragm is the diaphragm at its normal position, right? A bit higher. Is it even tra it, is it too low? Is it flat? Then you look at the pleura, can you see the pleura or is the pleura, is there any air in there? And is there any pneumo? And when you're looking there, look for effusion. Is there any fusion? Look at the claus angle, the blunting of them in a pa and in a electro don't comment on an infusion if you're just looking at the and you can't see anything. And then you talk about the equipment and what equipment we talk about central lines. Um, we've talked about um, pic lines in a normal position. We've talked about E TT, we've talked about um, lung fields. Um, you look for pneumonia, type of pneumonia, um, in the lung fields, we found nodules, cavity lesions, fungal ball, um, local pneumonia, patchy, pneumonia, interstitial pneumonia. And um, of course, then um any nodules and then the vessels if you can catch. Um or if you always look at the aorta what its main cause is and if you do all of this assessment and, and I don't think um you will miss out on anything major. Um So, um any questions or anything that you want to ask me? I'm happy to answer. I thank you. Nothing for discussion. I'm just looking if there's any on the chart book. No, I don't think there is anything in the check box. Thank you so much guys for listening and thank you so much for your time. See you again at some point. Yeah, thank you so much, please. Um Everyone if we can just um fill up the feedback, um It would be very helpful. Thank you once again. See you soon. No worries. See you guys soon. Bye bye.