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To start it. There you go. You can go for Jessica, right? Thank you. So, hi everyone. Like you said, I'm Jess and I'm in fourth year Imperial and I'm currently doing my respiratory BSC. So it only seems fitting that I'm doing the respiratory examination this evening. So this is going to be kind of a focused lecture. Okay, let me move my slides, a focus lecture on the structure of the examination kind of how imperial once you do it for your CPA. So the prompted examination year to some common pathological findings that are useful to know some anatomy, top tips for those questions at the end of the stations, some extra interpretation, which is always fun and then just some questions at the end to round up our knowledge. So I want this to be as interactive as possible. So um mute if you want to use the use the chat button just because I'll be asking questions throughout. And I don't fancy talking to myself. So the structure of the respiratory examination, the main examination. So cardio gastro and respiratory they involve kind of the Pippi pneumonic mostly that's a nice way to go about this. So you start with your kind of introduction before you position and expose the patient correctly. You then want to go onto inspection. How is the patient, how are they doing today? And then you will do a more focused one based on the examination that you're doing before you then go into palpations in the respiratory examination. This is going to be chest expansion and making sure the tricky is in the midline or seeing if there's any deviation before we then go on to percussion, percussion as much of the lungs as possible. Then our auscultation in and tactile, vocal free metis or tactile vocal resonance depending on your preference and rounding this up with a lymph node examination. So in the CPS, the examiner might turn around to you and say introduce yourself to the patient and again, adequate consent for the examination. So these are points in an exam where you can pick up easy marks. For example, things like washing your hands on this station. So washing your hands as soon as you enter the station, that's a mark. It's always good things to remember. Wash your hands before it. I think it's something that will kind of haunt you if you forget. So you then want to introduce yourself to the patient. Say something like hi. My name is Jessica. I'm one of the thornier medical students at Imperial. It's a nice way to end. People have their orange peel before you. Then confirm the patient's name and date of birth. You might want to give a brief explanation of the examination but not in too much detail that can kind of waste time in an examination scenario and you can end up rambling on and certain things might sound obscure to the patient. You then want to make sure you got adequate consent and make sure the patient's comfortable enough to proceed with the examination. So in the Imperial CPA for respiratory, the patient's likely sat in the correct position on the bed anywhere. So just sat 45 degrees and the correct exposure would be exposed from the waist of preferably okay. So, inspection inspection is actually incredibly valuable, especially for the respiratory examination and it shouldn't be underestimated. So when you speak to the patient, when they reply with their name or date of birth, you're actually checking that they're well enough to be examined. You're saying that you don't have to do an A two E because their airways patent, they've just spoke to you. So it's actually really important. So just open to the room, what potential signs of respiratory distress might you look for at the end of the bed? Yeah, definitely abnormal rising of the chest wall. Is it, is the patient breathing shallow? Are they breathing really deep? Is there kind of one side rising more than the other? That would be kind of really, really close looking? That's a really great example. Can anyone think of anything else. I saw someone was typing, I'll move on and give you a chance for the next questions. But basically there are so many things that you can look for in a respiratory examination, this tachypnea, there's cough cyanosis and these are really important. So with kind of cough, you want to take note of things like is the cough productive. You might look around the bed is a respule tinpot. These are classic things they can lay down in front of you. What color is that? Sputum, these kind of things that make you think, right? Is it an infection perhaps? Does this person have a pneumonia? And in that sense, it's always good practice to check around the bed and see if there's any devices, kind of those classic. See if there's oxygen, see if the person has a nebulizer. Is there an inhaler lying around? And what color is that inhaler? So use of accessory muscles is a big one too, especially in conditions like COPD. So using the like inspiratory accessory muscles like the trapezius and sternocleidomastoid, they're really, they're really quite prominent in patients with COPD because they're trying to get as much air in as possible as possible and they kind of just get these adaptations naturally. So here's an example of someone who's probably using their accessory muscles to breathe and they've adopted this position. So tripod, so this patient likely has COPD and the patient's generally tend to lean forward is it's thought to maximize their like inspiration ability. So they're trying to get in as much, much air as they possibly can. Okay. So in an exam kind of as part of inspection, you want to make sure you're measuring the patient's respiratory rate. And when we do this, we kind of categorize it. So is the patient really panic? Are they, is it normal the respiratory rate or they tachypnea kick? And these things aren't specific to respiratory examination. So someone could be tachypnea because of another pathology, but it's still very useful. And when you do it in an exam setting, it's important that you don't let the patient know that you're doing it because otherwise they're going to consciously alter their breathing. I might start breathing really fast or controlling it. So their breathing more slowly. So, a good way to avoid that is to tell the patient I'm just going to take your pulse right now. You'll take their pulse and you just look at their chest wall and see how many times it goes up and down in 15 seconds and times that one by for. Can anyone tell me some respiratory causes of tachypnea have a guess, hypercapnia, hypercapnia. You definitely. So they're gonna try breathe it off. Hopefully, fever. Yeah. So if someone has infection, if they have a pneumonia, they're probably going to be breathing really fast. Thank you for a meeting. So, a really common one is if you have a patient that's kind of isolated. They've got usually like a young female patient. If they just got isolated tachypnea, that could be something like a pea. That's a really common thing cause of to keep neo and just acute asthma, things like that. So there's lots of things, but it's not, again, it's not just confined to respiratory pathology. So we want to pal patient. So we want to palpate the patient's takia. So we're looking to see if it's eco distant between the clavicular heads and the method on how to do that is shown there. And we think about trickle deviation in terms of unequal pressure in the thorax. So we think about cause is a tricky or deviation away from a lesion. So is anyone able to tell me causes of deviation away from a lesion? I made the tricky and move away from something. So uh I see someone typing, I'll give you a chance build up of fluid in alone. Definitely usually has to be quite a lot of fluid. Actually. Not quite pe good guess though, unless you mean thoroughly fusion it just fluid in the lung. Yeah, pleural effusion is a big one, but it's not the big one when we think about deviation away actually. So collect alone will come to that later actually. So with pleural effusion, it has to be extensive, you have to have an awful lot of fluid, literally kind of covering the whole size of the lung to get to keel deviation because obviously with the trachea being at the top. So pneumothorax is the big one, tension pneumothorax. And here's a picture of a rather large tension pneumothorax, a left sided tension pneumothorax. And you can see in this picture, there's so much pressure built up in there from air being trapped inside the pleura that the whole mediastinum is actually being shifted. So anything which is increasing pressure will push the Trek era where so that being fluid, that being I'm sorry that being air, whether it's trapped inside pneumothorax or even with chest expansion. So someone who might have one side that's hyper expanded, there's more oxygen trapped, there's sorry, there's more air trapped in there, more pressure that's going to push the tricky or away. Not to the extent of this tension pneumothorax there here. Okay. So we've done aware now about towards the lesion. So this is due to decreased pressure at the side of the lesion. What might lead to that decreased pressure? I think Nina might want to answer this. Yeah, collapse alone. Definitely. That's a big one that we've got here. Fibrosis as well. That's a really great answer. So we put my slides on. So upper lobe collapse, upper lobe fibrosis on pneumonectomy. So upper lobe collapse basically results in volume loss. There's no air entering there anymore. There's no air, there's less pressure which has caused deviation towards a lesion. Um upper lobe fibrosis, it might be caused by something like TB or aspergillosis iss or psycho doses perhaps. And it just means that the lungs are really scarred and they're stiff. So there's less air entry, less air, less pressure again. And here's an example of a lobe collapse. So right upper lobe collapse, and we can see that it's a collapsed lobe because it's quite well defined. I'm quite confident that this area at the bottom is well defined. An extra is compared with perhaps a consolidation pneumonia. This one's quite hard to see on the X ray though. So we're now onto palpations. Still, we're on the second part, we're on chest expansion. You might be prompted in the CPA examination to assess chest expansion anteriorly perhaps. And with chest expansion, what we're looking for is we're looking for symmetry, synchrony, and volume. These are the three categories we're looking for. Are your hands moving the same distance apart each side from the midline? Are that your hands taking off at the same time? And what is the volume of each breath like? So it should be approximately 4 to 5 centimeters, Johan should move apart. Well, at least. So with chest expansion, we think about pathology in terms of the unilateral decrease in chest expansion or a bilateral decrease in chest expansion. So unilaterals a very useful examination because the pathology is like it's always going to be on that side of the long weather's decreased chest expansion. So what type of things might lead to a decreased chest expansion, decrease unilateral chest X function. So they're all the conditions that we do for these, we just put the, they're just kind of the same. You could just guess one of the conditions you've already guessed before and it probably would come up in this. So things like pneumothorax, things like. And if you a pleural effusion, a collapsed lung consolidation, whichever side you have that pathology on that will be where you've got the decreased chest expansion. So now on two causes of symmetrical decrease interest expansion, this one's more difficult to detect and because of how people do chest expansion, it's not, it's quite hard to pick up. But would anyone like to give a guess at what pathology would lead to a symmetrical decrease in chest expansion? I, I guess palmy Dema was a good idea. I wouldn't necessarily lease I put that more on like a cardiac aside. Not one of the main ones, I'm thinking you've got a bit more complex. Any other guesses, things affect the whole lung. I'm just going to go on. But these are gonna be conditions like asthma, COPD fibrosis or even a rib fracture. So with asthma, the fact that it's an obstructive condition. So a COPD, chest expansion is usually reduced due to air trapping. So, lungs, especially with COPD, the patient's lungs are hyperinflated anywhere. They have this high functional residual um functional residual capacity. We've got lots of air trapped in their lungs, they can't seem to expand further. So that's why you would see that in COPD, especially in fibrosis, someone's lung compliance is decreased. So this restricts their chest expansion naturally. And with rib fracture, that's just from pain, secondary to pain. If someone's got a rib fracture, they feel a pain, they're going to stop inspiration, they can't reach that maximal chest expansion. So now moving on to percussion. So you'd be asked to because the chest anteriorly posteriorly in an exam and what percussion does is it causes the chest wall and like the structures underneath it to vibrate, producing sound. And this helps us determine whether the structure below is filled with air fluid or a more solid material. And over healthy lung tissue, the sound should be resonant loud and it should be low pitched. So of a healthy lung tissue, healthy peripheral tissue, but it is still normal to hear kind of model findings over born in an in an examination. So when you're per cussing, if we're per cussing anteriorly, what we want to do is we want to percuss, I think I should use a pen and it might help me. There's a point. There we go. When we percuss, we want to do things like for like so if we're percuss ng as we percuss in an exam, we want to percuss the air pieces one after each other before we then go to per cussing near the superior lobes. And if we do things in a like for like manor, it's nice. It's systematic and that allows for comparison. So we're able to compare the right APC to the left a pissy. These in my opinion are a bare minimum. So I'd because as much of the long as possible, why not, you've got all this area to percuss. And I want to stress that actually, although not shown in this diagram, the axilla is one of the most important areas in the respiratory examination. So when we, because posteriorly, we go in a similar systematic manner. But what I'd suggest is if you've got patient sat in the bed, what you might ask them to do is bend their knees, bring their knees to their chest and bring their arms up on their knees like this. And what this will do is this will move their scapula out of the where. And it just means you've got more lung tissue too because without the bone being in the way, which is a nice way to because as much as possible. So now we're on to pathology that might alter the cushion. So hyper resonant percussion. So it can sound kind of sounds like hitting a drum. It's caused by decreased tissue density. So what conditions might lead to a decreased tissue density? COPD? Definitely, that's a big one. So COPD, it might do it bilaterally, actually, it might do it across the whole lung in general, just because there's so much air trapped that it sounds kind of sorting panic or it could be in small areas. So there's usually kind of where, um, where there's bully. So there's this, these small regions of emphysema where the alveoli saw damage, we just have these kind of air pockets in the lungs. I'll keep going. But the big ones again, pneumothorax, that's a big one. So if someone's got a right sided hyper resonance, it's likely going to be a pneumothorax there. It's quite tympanic, it's loud, it's high pitch. The pleur is filled with air, you can really hear it. And so your P D N A Q asthma, like we said, so we also have hyper resonant percussion. We can split this into dull and stony dull. So can anyone hazard a guess what type of pathology might lead to a hyper or resident percussion? The things that have led to increased tissue density, what type of things could do that in alone like new mania or a pleural effusion? Definitely. So you gave me both categories there actually. So you give me a consolidation pneumonia, which is something that we'd classify as a kind of classic dull sound. And we're gonna look at stony dull because pleural effusion comes under that category. So basically, we get hyper resident when there's something in the lungs that just is an air anything else. So, bone makes stony, dull, dull noise anywhere. A tumour consolidation collapse even so when the lungs collapse is not airing it, it sounds dull and it's actually normal to hear over liver and bone. So now on to stony, dull. So stony dull. That's something like pleural effusion and hemothorax. And this is hard to hear. You have to be kind of, you must have a really fine tuned ear, but this is kind of flat, much flatter than the other. And it's where there's a type of dullness that when you're percuss ing, it's almost painful. It's like per cussing over stone. I believe that's where it came from. The origin. I can't say I've ever felt it. So we're getting closer to the end of the exam run a of our Pippy pneumonic and we're thinking about auscultation in. So you would get asked to auscultate the chest, anterior lobe anteriorly or posteriorly and you're just going to percuss in the areas. So you're going to auscultate over the areas you percussed in the same like for like manor. So the write a policy for the right a pussy going in that systematic man. So the right embassy of the left embassy in a systematic manner. So when you're asking a patient to do this in an examination, what you want to do is you want them to take deep breaths I/O through their mouth because that increases the duration and increases the intensity of their breathing as well. And it just makes it much easier for you to be able to detect abnormalities and make a comment on something. So when someone just breathing through the nose, it's really quiet and then you'll have to really focus and have very, very good hearing. So we're just going to cover some normal breath sounds. So there are two types of breath sounds, usually bronchial and vesicular. So bronchial is normal when it is heard over the tricky, you're in the large airways. So kind of more centrally, it's really loud. It's high pitched inspiration. Expiration are equal. And there's a distinct pause between inspiration and expiration. And this is because there's no Al Viola. I know lung tissue filtering out this noise. So that's where we get bronchial breathing over the large airways. So we also have our vesicular breath sounds and these are what we should be hearing over the rest of the lung where any lung tissue is in much lower pitch, the more rustling because there's that lung tissue that's there to filter out that noise. And what we have here is we have a longer inspiratory fares. There's no pause between inspiration and expiration. Like there's no distinct pause and it should be heard everywhere of a healthy lung tissue. So, bronchial breath sounds can be pathological. Can you think about when we might hear bronchial breath sounds in conditions like asthma where you got a lot of mucus that causes like whistling that cause like the high pitched whistling noise. So that's a, that's a different thing. That's not bronchial breathing. That's a good example though. It's a good guess. That's like kind of a wheeze, that's slightly different. Well, come on to those added breath sounds. So that's, that's what we use. That's an added sound. You guys are good. You're giving me the hardest stuff, you're giving me the kind of extra sounds. So we'll get onto that soon. But Bronchial breathing is kind of when you hear the bronchial breathing outside of where it shouldn't be. So the underlying periphery and it's due to the increased transmission of sound. That's because fluid and kind of consolidation, they conduct soundwaves much more efficiently than air. So you get this bronchial breathing, you don't get the filtering that you would get if healthy Alvey Oliwa, they're healthy lung tissue. Like that job is kind of filter the sound and give you vesicular breath sounds. So things like consolidation, pleural effusion, it's what kind of transitions, the healthy physical er, sounds to bronchial in these conditions. So I just wanted to show some examples of added breath sounds you guys have already said to, to me. So I've had, we've described to me and I've had crackles. So I'd like to get on looking at these. So we's, it's very high pitched. It's due to the narrowing. Like one of you said it's due to kind of mucus, perhaps being plugged in their preventing is creating an obstruction. And this is kind of loudest on expiration. We can split weeds into polyphonic and mon a phonic. So polyphonic when it sounds all different musical notes and that is things like asthma and COPD is a bit of a variable obstruction going on. Whereas monofonal pick is due to a fixed obstruction, likely upper. Our, we also have stridor very similar to ease, but it's high pitch and it's due to upper airway obstruction, it's also loudest on inspiration, whereas the wheezes loudest on expiration. So in an examination, if you heard any of these added sounds is a really good practice to say when you heard it, did you hear it at the start of inspiration? Did you hear it late inspiration or was an expiration? It's just nice, good habits to get into. So we then have crackles which were mentioned in the chat and these are like discontinuous popping, like sounds, you might hit the pulmonary fibrosis ones. You hear that kind of sound like Velcro sometimes that's what people say, people have different examples of them. So the velcro pommery fibrosis crackles, we call them fine and they're usually heard in kind of late inspiration because they originate from the small airways. So if it's something like fibrosis, if it's perhaps a pneumonia and the small airways, so continue into very late inspiration, we then have a category, of course, crackles. So these are heard much earlier on in inspiration and they're from the larger airways that might be something relating to COPD. So if there's kind of too much mucus in the larger airways, some mucus filled bronchioles perhaps. So you guys will get the slides after I believe that there's a link for some audio, which might be interesting for you guys to look at. If not, I believe it's on the kind of Littman website, the stethoscope website, they have some good lung sounds. So now moving on to kind of our last part of auscultation, we group these together. Sometimes you'd be asked to assess the tactile vocal free metis anteriorly and posteriorly. So the tactile one vial fremitus is where you use your hands and resonance. Some people use their stethoscope to listen. What you would do is you would ask your patient to say 99 in a continuous tone every time you place your hands on their chest essentially. And what you're doing is you're comparing the left left lung to the right lung. Is there a change in intensity that you can feel in your hands in this spoken word? Is there a change in the strength of these vibrations that might indicate lung pathology? So again, it's all to do with sound, transmitting through lungs and with looking for symmetry in this. So causes of increased tactile vocal fry metis. Anyone has it a guess at what conditions might increase focal parameters like a pleural effusion. That's actually in the other category that's actually in decrease good guess COPD is also in decreased. So I'll give, I'll give us guys a way to think about it. So basically, it's due to any increase in density and I know it seems like pleural effusion increases entity, it does, but sometimes it falls into a different category. So with increased entity, things like consolidation, pneumonias, tumor's lobe collapse, these are going to increase tactile vocal parameters will be able to feel it and a decrease is due to things like COPD. So there's hyperinflation is more air present. So we've got hyperdensity or anything that will actually increase the distance between the lung itself and the chest wall. So that could be a pleural effusion, a pneumothorax or even kind of in general, something else like your distance from your hands, your to the lungs, obesity, you won't notice a difference in symmetry, but it might be a bit harder to assess it on a patient. Perhaps here's a diagram just showing um a pleural effusion and a CT sorry, showing a pleural effusion. And then you can see it kind of posteriorly, you would feel decreased tactile vocal parameters. Okay. So we're now into lymph node examination, you might be asked to palpate the patient's lymph node. And it's a great idea to know the names of the lymph node groups. You might be asked to talk through it as you're doing your palpitation routine. It's great to get in a nice routine. So when you're palpating lymph nodes, you want to be doing nice circular motions. You want to be like using the pads of your fingers, using them? Oh. So do you mean, so like density of the lung? Like how much? So air is less dense? There's less density if there's fluid or solid that makes it more dense. So with increased density, if you've got a solid in there, instead of air, it makes the vibrations travel faster or travel more strongly from the lung. Like you can feel the track the vibrations further if that makes sense. So like with COPD like conditions that we've seen that's hyper dense. So you've got less density because there's so much air there. Great. So back to lymph nodes, it's a great idea to know the groups. You want to use the pads of your fingers and you want to use a circular motion, none of that like tapping, none of that tapping stuff because you can miss lymph nodes and it feels a bit weird on patient is a bit more of a missile massage if you kind of use circular motions with your fingers and we want to do all of the groups. So get a nice routine to maybe start with your submandibular, go through to your submental and people do them in different orders, just do one in a way that you can remember. That's my, that's my advice. Definitely. And the things that we want to think about a size mobility tenderness and consistency So usually they should be less than 10 millimeters mobility. Um That's something to consider pender nous, usually if it's painful, um, it's less likely to be more serious pathology with pain sometimes. Um, do we stand? So I definitely stand behind it just, it's just much nicer to stand behind them. What you would do if they're in the bed, if they're fit in, if you could just ask them to swing the legs off the bed and come behind them, but you can just ask them to lean forward. The beds aren't too high and then practice on your friends. That's a very good question. Yeah. So let's think about causes of lymphadenopathy. This is another part of the examination which is really not specific to rest up. It's like other pathology could lead to cervical lymphadenopathy. So for example, um certain cancers, um think colon cancers associated with a lymph node in the neck, a specific lymph node, any other causes of lymphadenopathy, perhaps when you might feel it on yourself like colds. Yeah. Any infection really, it doesn't usually it's upper respiratory tract infections. But then again, it's kind of, it doesn't have to be respiratory. You might have a might have an ear infection, something that something like that. So infection, any kind of inflammation, it could be more sinister could be, could be a malignancy, which is obviously some something to consider in certain groups. But an isolated lymph node, you wouldn't be too worried medication can even cause this or it could just be benign. So a common kind of question they can ask you at the end of an earlier Czarsky slash CPS style examination is to describe the surface markings of something. It's an easy question for them to throw out. So the common ones that I would say two, take it alone and learn kind of the lungs in general. So the markings are left and the right lung, the pleural pleural borders as well. And also the markings of the horizontal and oblique fissures were back when, when I did my C P S, I think I had the horizontal fissure, the kind of generic questions I can ask. So I don't want to dwell on this too much. But these diagrams can be used to learn this type of thing whether you want to kind of flash card it. So the whole lung just following and these, they're red star here, these daggone so great things to learn for an exam. So I want to spend my time now looking at chest X rays. This is where I kind of the I say the more fun, the more fun things are. So the most important thing when it comes to chest X rayer like assessing your chest X ray and reporting it is a systematic approach. So we want to use kind of a set protocol that means that we don't miss anything. So before we even properly start looking at the X ray. I think it's important to identify the patient's correct. Check that the name and date of birth matches with the patient you're after, you don't want to be kind of assessing wrong chest X ra perhaps this would happen in our ski scenario. But just when you're an F one, I guess you don't want the wrong X ray. And before again, before we even get into the X ray itself, we want to think is it good quality? Because if the extra is bad quality, we're not going to get much from it. We're not going to, we might actually miss things on a really bad chest X ray. So the way that we see if a chest X ray is good quality is we use the kind of acronym ripe. So rotation, we want to see if the patient is the patient rotated at all because that can kind of mess up the perspective of everything and to see if the patient's rotated. What we do is we check that the clavicular heads on both sides Ecuador distant to the spinous processes here. So on this, on this chest X ray, the patient's not rotated, it can be kind of obvious and the clavicle might be a little bit further on a patient just means it's a bad angle. So if they're kind of to rotated, it might obscure things, you might miss things on the overseas, perhaps you might not be able to make a comment on the heart. So that's are we then have I, we have inspiration. So you want to make sure that you can at least see 5 to 7 anterior ribs, otherwise you're not breathing enough and you're not going to see the whole lung things will be hidden. So this one has at least that you can count the anterior ribs, the ones kind of sloping down and then we have projection. So most chest X rays are going to be pa films. So it means they're kind of shot from the back and the P unless stated otherwise, the scenarios where you see A P R usually in kind of like an emergency department when the patient's in, in a trolley in a bed. So you'll do like a rapid chest X ray there. That would be an A P because they'd be laid down. But if, if they find out it's likely peer, we then have E for exposure. So you want to see that the X rays are penetrating well enough. So the way that we see this is we see, can you see the vertebral vertebral bodies behind the heart? And here we can see them, we can see them quite clearly. So we know that the exposure is good enough. So we know this X ray is good enough quality. So we can start assessing it. And the approach that we take two, that is an air to e approach it's a nice way to remember. So we start with air which is airway. So with the way we're thinking about the Shakya again, is the Shakira in the midline, is there any deviation? And we want to look at the carina, we want to look at the bronchi where they kind of the bifurcation here and we want to look at the hilar areas. So is there any lymphadenopathy here perhaps? So that's our airway, we then want to go on to be, which is breathing. So, breathing is kind of the whole lung tissue and the pleura. And what we want to do is you want to kind of trace down the whole lung comparing each side. So comparing the right to the left and we don't want to miss a single part, it's quite easy to miss areas. So even if you have an extra in front of you, kind of use your hands to kind of move across or use a mouse on the screen if you're on sona or a system just to be able to look. And what we want to do is make sure that all the lung markings, it's hard to see. Honest diagram will see better on the examples that all the lung markings are going right to the edges because you shouldn't be able to see a pleura on a healthy individual. You shouldn't be able to see it. The lung markings should be going all the way to the edges. And if they're not, that person has a pleural effusion, a pleural effusion. I'm sorry, they have a pneumothorax. Sorry. So it's really important to see these kind of little lines going the whole way, the lung markings, we then want circulation. So we're thinking about heart. So it's circulation or cardiac. We want to think about the heart size and its borders were going to take a closer look at that in a minute and see which chambers form the um the borders of the heart. And then we want to think about diaphragm. When we're thinking about the diaphragm, we want to think, is there any flattening is one side a bit too higher than the other? So usually the right hemi diaphragm is a bit higher. It's not shown that excessively here. It should kind of look like a lobster sided m essentially, but that is normal and we want to look at things like the cost of a phrenic angle. So, is there any blunting in this angle here? A blunting would suggest a pleural effusion could even be a really small one. So any fluid here, any blunting of this angle, these angles suggests pleural effusion. We then would do e for everything else. Literally, everything else we want to kind of go check over the areas that we've just looked at. Did we perhaps skim over something we want to review the bones is a re fracture that might have caused this patient to have a pneumothorax. Is there something odd with soft tissue? We don't really get taught that much in detail, but these are things that you'll start picking up. Does the patient have a heart valve, peacemaker? Things like this? These are all things you have to comment on. Okay. And just to touch on what the colors on an extra, I mean, so x rays either go straight through the body, they freely pass other attenuated. So, X rays are most attenuated in more dense things. So like metal, that's why if you see metal on an X ray appears really white, well then have bone which appears kind of a dark gray hair because the X rays are attenuated but not as much as metal. And then we have which appears black. Okay. So the heart, let's go through the board. What kind of web pointing out on this diagram here? What structure my pen is not working? My. Oh there it is. We're structurally pointing to here. Which part of the altar exactly. That's the aortic arch right there. So you might be able to see an aneurysm on now in the aortic aneurysm. So these are type type of things that we look at. In this specific part, we kind of call it the Arctic knuckle. You might also hear it referred to as that. So if there's an aneurysm, the border becomes a bit less well defined, it obviously depends on how big as well what structures have been pointing out next is that the wall of the atrium. Not quite, that's the next one. These ones are quite hard to see and something that's what I struggle with sometimes. So let me show you. So these are the pulmonary arteries, okay. And you can kind of, you can see it branching a little here. It sometimes looks a bit blurry but the structures that are branching quite close to the mediastinum on both sides of the pulmonary arteries. So you can see them there. We don't have the left atrium, which is just here at the top. Therefore, what do we have at the bottom? We have the apex right at the point. But what forms this, what's being farmed here? What makes this wall exactly? That is indeed our left ventricle. So the left border is made up of our left atrium and left ventricle. So another thing we want to take into consideration with the heart is cardio thoracic ratio. So this heart is normal sized and a normal heart should be kind of between not 0.4 and not 0.5 of the distance of the like the whole width of the thorax any more than half the hearts are getting on the big side. This can only be measured on a PPI air film. So the usual chest x rays, you shouldn't really be doing this on an air p film, it's less reliable. Okay. So then we have the the other side. So we have the right heart borders. So what is our first label up here? Is that the subclavian artery bit before that the larger vessel for an artery trunk. Not quite, it's hard to see the Vida Carver. Yeah, we got there. Yeah, it's so we've got the superior Vena cava on this side and we can see the inferior kind of just here seeing vessels is an art on extra. Sometimes it is really hard to distinguish, but we were kind of pointing in a general area. So then what makes the power right heart border, not quite the right ventricle, almost the atrium. So that's actually part of my questions. So okay, let me move on. So that's the right atrium. So the you can see the superior Munich over the inferior, the right heart border is made up solely of the right atrium. And the thing is we actually, we can't see the right ventricle. It doesn't have a border on this chest film and I'll show you why. And that's because the right ventricle, if we look at it, it's it's anteriorly. So it doesn't make up the borders of the heart. So we can't necessarily comment on it. Okay. Now, some fun. Now we can guess the pathologies we've had a whistle stop tour of things that we can look at. So here's our first chest X ray. What pathology can you see? Is that a, what is that a neuro NYA, you got that little pretty pits. So those are, those are quite fine, that looks kind of normal, in my opinion, like the highlight area, sometimes it does look a bit more defined. These are the kind of vessels branching out. So you know what we mentioned about the arteries, et cetera. Okay. Yeah. Uh it looks quite sometimes you kind of trick yourself into pathology sometimes Aha Nina's got it. So COPD and hyperinflation. So this one, this one is only just I would say, but there is some hyperinflation here and that's because we can see the diaphragm is a good way to see if someone's, if someone's hyperinflated, if it's a bit more flattened, then you think it's hyper expansion and it's COPD in this case, it's likely to be okay. So previously earlier I mentioned about hyper residents in COPD, it can be just to kind of lots of air being in being inside the lungs. So being overfilled, but it can also be due to bully and these bully are the areas of emphysema, al Veolia sore damage that you just get these collections of air. It's kind of really emphasised emus hour and these are really resonant. You can sometimes see them on x rays and that's because you can't really see the lung markings as well and it appears kind of darker. So the air more dark, it is the more air okay. We now have number two is that hemothorax, not quite uh huh. There we go. Got it. Pleural effusion, left, sided. Great. That's something that we like reporting about side. So we're all on the right lines with some sort of fluid. But here we have a pleural effusion and the way that we would talk about this is when you report an X ray, you can report in the 80 where that we just spoke about, but it seems kind of silly not to go with the obvious first. So start off by saying like there's an obvious pacification and the left lower zone that on this one, we describe effusions as having a meniscus. So let's see this. So in this one, the left lower zone is uniformly white, there's a uniform area of pacification and the meniscus sign tells us that there's fluid. If we were to kind of go throughout 80 we couldn't really make any comments about the heart. This patient might have cardiomegaly. We have no idea we can't see. So we can't make kind of question distinctions on this also tiny bit here like you can barely see, but basically, they have a little bit of a right sided diffusion about to happen as well because like there's this slight blunting of the costophrenic angle, you can see like a tiny bit of a pacification there. But that would be a bit mean for me to see. Yeah. So and he missed them. You don't really get asked to see him Rotarix on an extra, I guess because it's in between the pleura, like it's in the pleural space. So you might actually see it. We'll see him. I thought um we'll see pneumothorax and then that might help straighten that out. But this one is more common, I would say, hopefully I answer your question when we see pneumothorax. Okay. So we're on number three, you might want to definitely turn up your brightness for this one. Look very carefully. That's not, that's not our main one. It does look at, it does look hyperinflated, but I said they've got a bigger issue. Is it Tokyo deviation? So that's your keys in the midline. It's almost a little bit slanted. That's what I thought someone's close. It's a, it does kind of look like a bully, but it's not a bully. There's something to do with. It's just because of the way that it is because they look slightly rotated their clavicles. So someone said bully and I'm assuming they're looking at this area here. So I'm just gonna pass it on. And this is why it's so important to look at those lung markings because these are so easy to miss. But this is actually a left sided pneumothorax and it's not tension because the tricky is central. This person's, I think they've got, they've got a rib fracture actually in this. But basically, I can, I can see the pleural edge and it's because if we go back, it might be easier on this one. The lung markings don't spread beyond here. And that's telling us that the kind of that makes you think there must be a new math Arax because you can't see any lung markings in this whole area because air in there taking the nun a bit smaller. So, yeah, check those areas. It's common to, what did you mean by lung markings? So, like the, the best way I can describe it are like the little fuzzy lines. So kind of the fuzzy lines. Can you see the difference between the lines? It's kind of vessels and we just call it lung markings from here to there or even if you compare the right Apis um the left Embassy to the writer Pissy. Can you see how it looks a bit grainier? The grainy a white is telling us this something there's tissue there, whereas kind of the darker is telling us it's just air there. Does that make a little bit more sense? Yeah, that makes a lot of sense. Yeah. Yeah. So these are really small things to look at and Embassy's make sure to look that's a commonly missed area because that is so easy to have a look. Okay. So now this one, what is going on here, what, what you see what looks different, what looks off. Um This one, it's not quite fluid. So with fluid back with our effusion with fluid, you can see like a fluid level so we could see this aware that you can kind of get around. Um, I wouldn't go straight to Tuma. Good thought though. But what I'd kind of say about this in general if I didn't have an idea what this was, I just say what I see. So I see in here the kind of middle zone of the left lung, there's a bit of a pacification there, there's a bit of a kind of fuzzy a pacification. You might say a heterogeneous pacification mean that it's not quite uniformly white. And that's, that's a good observation. And so there's an a pacification, it could be tumour, it could be could be a consolidation, pneumonia. We could have all of these differentials, but usually when you're in a clinical scenario, you take all of these things into context. So it be made much easier if I told you this patient had a fever and a productive cough, you look at the X ray black. Oh, that's so that's obviously have they have a pneumonia, they have a left middle zone pneumonia and pneumonia's look kind of like fluffy. That's how I would describe them. The opacifications a bit of a mess essentially. And it is really hard to see, but we, I can see something called Air Bronchogram seems these are some things that can be mentioned. And the Air Bronchogram Czar like these lines here, these kind of darker lines and they're essentially Airfield Bronchi and they're just made to look darker because the area around them is white. That's all just made to look because of the contrast. So, yeah, just remember that if you see some sort of a pacification, just do a pacification then while you think about everything else and think what it possibly could be, the tumor is usually a bit more well defined. This is not that well defined. Okay. Now, we have a final one, final extra. Is that a cardiomegaly? Are you sure? Definitely. Yeah, it is. It's that heart is huge. So there's cardiomegaly here if we, that's probably the most obvious pathology here. But is there anything else you can see that you might want to comment on when reporting this chest X ray? It would come under our e for everything category. I know you can see it. Perhaps you don't know what this is. Can you see what I'm circling? Can anyone has it? I guess that what that is a random objects stuck in the esophagus. Good. Guess it's actually a medical object. So these, I can see a few things here. So this person has a mitral valve repair. And when you think about the heart anatomy, it sits in the correct place. And also you may have some kind of like clippings I can see here here here. These are just I think metal clippings, metal wires perhaps. So that would be something that you'd want to comment on because if you were asked to present this and you miss them out, you consult and be like, well, what are those things? Why haven't you mentioned them but not something you can ignore. And if you don't know, you can just say, uh, there seems to be some sort of object, inquire about two, I guess. Okay. So we're just gonna round up with a few questions that could be asked at the end of, um, like the Imperial CPA exam. If my computer let me move forward. Okay. So this is might be something that you'd get at the Aussie style station. So an 18 year old male presents to any with dyspnea and right sided pleuritic chest pain. The symptoms started two hours prior while the patient was playing football on examination. The patient has reduced chest expansion on the right hyper resident percussion note on the right deep decreased breath sounds on the right and decreased free metis on the right. What do you think? How most likely diagnosis is here? Asthma attack? Not quite good guess though, because of the age group, I'm thinking more on the with an asthma attack. What would happen is they'd be hyper resident on both sides. This patient has unilateral hyper residents. So just on the right side. So there's a rare, there's more air somewhere. What else could this be? We've seen one of them on an X ray. Was it pneumothorax? Yeah, this is. So I hate to be the one to say, like, learn your buzz words. It's a, it's a great way to introduce. It's more probably important in third year, etcetera. But it's quite classic. This is a, with pneumothorax, usually get a patient with COPD who tends to be quite older but, and it's usually kind of a young, young male with the pneumothorax. They're usually the cohorts that get them, I guess. And that's exactly what it is. It's a right side in pneumothorax because of the investigations that we've been given. So that's what we'd answer with. And it always tends to be playing football as well in kind of SPS. I throw that one in there. So here we now have a 72 year old woman presents a slowly increasing dyspnea over the past two months and left sided chest pain, her dyspnea is exacerbated when she lies flat. So when we examine her, we've got reduced chest expansion on the left stony, dull percussion of the left lower lung field. We've got bronchial breath, sounds of the left lower lung. We've got decreased tactile vocal fremitus in that area too. What's our top differential for this lady? It's like a pleural effusion or like a hemothorax. Yeah. So this one I'm going to assume it's plural effusion because of like the context that it's been given. So it's a left sided pleural effusion and the buzz words and the question of the fact that the Disney is getting worse, kind of slowly, this is how it can commonly present in people. And actually the lying flat is 12. That's a buzz word for a pleural effusion but can tend to be so, yeah, exactly. That the stony dull is how people do describe pleural effusion too, so well done. And then I know we didn't go into this in detail, but it's fun to throw this one out. But does anyone know what the surface markings are for the horizontal fissure? It's probably going to have to be an unmoved one. It's quite long to type. That's quite mean of me to do. I'm sorry, but I'll show you guys, I'd recommend you learning them. Like I said earlier, my top tips to learn the horizontal, the oblique fishers learn the surface anatomy of the, the pleura in the lungs. They're great questions they can ask you and they do get asked, you've probably been asked the past few years. So it's great to know that. So with our horizontal fisher, so it's from the level of the right fourth costal cartilage along the fourth rib, along the fourth rib to a junction with the oblique figure fisher, approximately the midaxillary line. And this is more on the fifth intercostal space and what it does, it um divides the right lung above the oblique fissure and it divides the superior in the middle lobe been in. So that's all the questions that I have to do. So if you have any questions for me. Um Feel free to um you type them in the chat now, I can stay on this call and also my email address is here. So if you can think of anything after the lecture that you'd like to get in touch with me about, I'd be more than happy to answer and also feedback. This is the feedback you are would really appreciate if you, you guys filled that out. So I'll just stay on the coal for a few minutes if you guys have anything that you want to ask. Yeah, thank you so much, Jessica. I'm sure that was really helpful for everyone. Please, please please do fill in the feedback form. It's a great way to show gratitude and obviously the only form of evidence that you is get for this and I can see your question, Nina and chat. I will upload the uh the slides as well as the recordings with a bit of a summary onto medal. All you have to do is just fill in the feedback and you'll receive all of them, the slides and the summary should already be up there once you fill in the feedback and then I'll get this recording up as soon as I can today and I'm just gonna stop recording nozze.