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And interpret a chest X ray. Um And so yeah, you, you need it, you need to know how to identify common pathologies and maybe what you'd do as well um for those pathologies. So that's one thing. And then, yeah, obviously, like, you know, later in life when you're a doctor, chest X rays pop up all the time, sometimes there won't be like a, a radiologist around who's gonna necessarily help you uh to say what's going on. So you might need to do it and you know, patient safety, all of that and for you right now, you know, I don't know about you, but in year three, when I used to go on ward rounds, co also used to chuck me with all kinds of questions and they used to throw uh chest x rays, anything at me. Um And not looking like a complete fool is pretty decent. So after this talk, hopefully you won't look like a complete fool. Cool. OK. So let's start with the intro. So for any chest X ray, you can start like this. So you need to say whose chest x-ray this is and the date of birth or how old they are and the date and the time it was taken. So, for instance, I'll give you an example here. This is APA chest X ray of John Smith born on 25th of December, done today at 12:30 p.m. right? Um We will go into AP and PA in a second. But before that, it's just really important to identify who's it is. Um And the date and time is also important because, you know, you wanna compare um this chest X ray to previous ones, et cetera to see what the change is. That's how like, you know, fancy radiologists do it. But yeah, so when you start in your ACY talking about a chest X ray start by saying these two things. All right, cool. So I don't know if you've heard about this before, you might have. But when we're looking at, if a chest X ray is adequate enough for us to interpret, we start with ripe, so ripe stands for rotation, inspiration, projection and exposure. So just keep that in mind we'll go through every little bit bit by bit. Um Just so that you'll, you find it really easy to just reel off if this is a good chest X ray or not. All right. OK. So I know right starts with an R but I'm gonna start with projection because as you know, we already mentioned, pa api think it's kind of important to know um what is what? So I'm gonna start with what PA and AP means. So pa A means posterior anterior, meaning that the X ray source goes from behind the patient to the front, whereas AP is from the front to the back. So this kind of image shows that very well. Now, the point that I wanna make clear here is if you can tell one thing from the image that the heart size becomes a lot bigger on an AP than what it actually is compared to APA. So if there's one thing that you have to remember about projection, you can never say the heart is big. If it's an AP film, if it's a pa a film, by all means, say what you like about the heart. But for AP, you just can't say right? Cool. OK. So before I go into PA AP and, and this funny uh trick to help, I just wanna say that if it's not really mentioned in your osk and you'll find it difficult to tell if it's APA, it's more likely gonna be pa OK. Uh AP is sometimes done for patients if I go back. So you can see it's from the front to the back, it's sometimes done. Um when patients are really immobile, like let's say they're really, really unwell and you have to bring the X ray source to them. And so therefore you can imagine it would be hard to get them lying on the front and going from the back to the front if that makes sense. So you'd go from, you'd go from above them while they're lying down. So if you're unsure, go with pa, but this is just a little trick I saw somewhere which is actually pretty decent. Um So what you can see here is hangers on a rope. So the rope is the clavicles. Uh You can see those, those long bones, those are your clavicles. And if you see what the hangers are, the hangers are actually the spine of the scapula. So essentially, if you see clavicles that are more straight and spinal scapula, that's more angled looking like hangers hung on a rope, it's likely to be APA film. If it's not like that, it's more likely to be ap, right? So I'll show you this, I just wanna disclaim that it's not always true. So treat it with caution. If you're unsure, just say pa, I'm sure it'll be fine. But overall though, if you have a look at the picture on the left, you can see that the clavicles are a lot more oblique, they're pointed upwards, they're pointed away P film. Whereas the pa one is a lot more straight, that is classic, but it's not always true. And if you can see the spine of the scapula and the AP film is horizontal, whereas in the PA it's more upwards. So if you can see that hanger sign that really indicates that it's likely to be APA film. All right. OK. Yeah. And if at this point, any questions for anything just drop in the chat, happy to answer. Uh OK. Fine. So let's start with ripe. So rotation. So rotating essentially means is the patient kind of um flat on like are they, are they twisted when the X ray beam is being shr at them? And the way to tell is what I've done here is I've circled in blue, the medial ends of the clavicles. OK. So your collar bone and essentially, if you can see an orange, I've circled this little protruding bony bit that's called your spinus process. So the spinus process has to be equidistant between the medial end of the clavicles. If that's the case, you can say the patient is not rotated. If it's not the case, then the patient is rotated. And you should mention that when you start talking about your chest X ray. OK? OK. Let's move on to inspiration. So inspiration essentially means how good an inspiratory effort have they put in while the chest X ray is being taken. So I've put three things on the side that kind of tell you how good a chest X ray this is in terms of inspiration. So you should be able to see six anterior ribs. Alright. And now I used to always get quite confused about whether it's anterior or posterior, which one's which the kind of I've, I've numbered them So the curvy ones that go around the front, those are your anterior ribs. So if you count them from the top, if you count with me, cos it's 1234567. Meaning that this is a good inspiratory effort. It's good enough. You have to see at least 66 of these curvy ones that go around the front, not the ones at the back, the ones at the front, you have to see both lung apices. So the aps is like the top, the apex of the lung. So I've circled that and green at the top. And you should be able to see both costophrenic angles that pointy bit at the bottom. If you can see all of this, this is a pretty good chest X ray. You can, you can, you can see a lot and you can tell a lot from it. All right. OK. Fine. And then, so we've moved on from rotation inspiration and now we're on to exposure. And I know this is like quite a dramatic example, but the tip here is that you have to be able to see if you can see the vertebrae. So that's the bony part of your spine. You should be able to see the discs in between and you can see that on the left picture. That's a good picture. And I know this is quite dramatic. The one on the right. But yeah, you can't, you definitely can't even see the vertebrae, you can't see the discs in between them. So yeah, so that is whistle stop tour through rotation, inspiration, projection and exposure. If there's any questions at this point, let me know, right? Um Fine, let's talk on to presenting. So putting this all together, remember, we have to say the patient's name, their date of birth when the chest X ray was done and then you can move on to just walking through it. So in the first line itself, we will mention whether it's a PPA et cetera. So you can say this is APA chest X ray of John Smith, born on 25th of December, 1899 done today at 12 p.m. Then you go through your right. So the patient has not rotated, has adequate inspiration and exposure of the film. So cool. OK. Um So now it's time formenty. So if you guys can log in and then we can try try some of these, sorry, sorry. Uh And then we can try some of these um and see how you guys go, right? Are you guys logged in? Ok. So we got two people. I'll just wait maybe a couple of minutes to see if anyone else is is here. OK. Code is on the chart as well if um you can't find it. Sorry. There are some questions in the chat and I was, I was just saying that the mental codes also in the chat. Oh OK. Yeah, yeah, if you guys need to get it from the chat as well, please do. Cool. Um I'll probably just make a start then. Ok. So, so which of these types of images can you comment on cardiomegaly? You got 15 seconds? All right. OK. So um good, most of you got that. It's a pa a chest X ray. So um just to remember that with AP if we go back to uh this, let me just quickly go to this. So if we go back to this, if you can see this. Um So if you have a look here, if you look at AP, it goes, the, the rays go from the front to the back and essentially the rays end up going outwards from the heart, making the heart look bigger on the actual film than what it is. So you can't really comment with an AP but you can comment on PA but having said that I'm glad no one put on like hip ultrasound. So that's decent. That's not too bad. Um So yeah, so PPH s actually good for the uh you guys who put that. All right. So I'll give you guys a second to look at this. Don't ignore the arrow. Um But having had a look at this chest X ray, what projection do you think it is? I'll give you maybe 1015 seconds to have a look at this one. All right, cool. So, uh 00 we got four people decent. OK, cool. So you've had a look at that. Let's see. Um What projection do you think this x-ray is? OK. Everyone's very, let's have a look. OK. Very good. So, um if I can just go back to the print, I'll show you why it is a pa x-ray. All right. So let's have a look at this. So what I said that would be good to look for Is this hangers on a uh on a rope sign? Yeah. So you wanna look at the clavicles? Do these clavicles look mostly flat to you or do they look mostly kind of oblique and going upwards? They look mostly flat, right? And this is a spino scapula. Does it look mostly flat or going up and hooking on like a hanger on to a rope? Because this does have this hanger on a rope sign. This is most likely gonna be a PA a film. This is APA film like it's not most likely it is and I'll just show you what I mean again by the hanger sign one more time. Um So just to remind anyone who forgot, it looks like this. If you see something like this, it's most likely APA film. And if you are guessing, guess pa there there's more, more time than not, it's gonna be APA film. Alright. But OK, good. Most of you got it. So that, that's good to see. All right. So next one Ok, we've got we've got Puffy in the lead. No, we got no bug bugs in the lead. Ok, good stuff where a bug is. Alright cool. Now having had a look at this chest X ray uh tell me what projection do you think it is? Uh I'll give you guys again 1015 seconds to just have a look and then after that we'll open the voting. Ok cool let's open the voting. Three players have we got number four? Yes, cool. Let's do it. Oh OK. Everyone's really quick with this one. OK. OK, fine. So this one people are a bit more confused about and I actually do get why you're more confused with this one but having said that, OK, so this one if you are more confused because the clavicles look a bit more oblique. That is actually fair. That's fair enough. But again, if you have a look at the spine of the scapular, it's hooking on to the clavicles like hangers on a rope. If you see a sign like that, it's just gonna be pa uh and this is APA film. All right. Any questions about that, please drop in the chat unmute. I mean I'm sorry you can't unmute but yeah, drop in the chart if there's any questions about that one. Cool. OK. There's a lead the board off to every single one. OK. Bargain vote go did good on this one. So bug still in the lead. All Right? Cool. OK. OK. This isn't the best image ever but have a look. Look for a little bit and then tell me what you think. This is a bit more challenging, to be honest. But um I'll give you again 1015 seconds. OK? Cool. Let's have a look. OK, we've got four players ready to go. Let's see. What, what do you guys think? OK, let's see what everyone put. Brilliant. Perfect. OK, great. So if we just go back to the picture, there's no hangers on the rope, the spine and the scapulae are here and they're absolutely flat. And even though these aren't oblique clavicles, everyone knows there's no hangers on a rope sign. Really good. Awesome, cool. You guys did really well with that um that season in the lead did not give you guys a chance to like put your name or something like bug goat, Puffy. OK. Whatever. OK, cool. Uh I'll give you guys a little bit of time to look at this one. Sorry, there was a fat sign over there. But um have a look at it and tell me, do you think this chest X ray is adequate or not? And think about why cos that will be what the question is. So I'll give you guys a little bit longer to look at this one because uh you know, go through the process that we went through and see what you think. OK, cool. Uh Let's have a look at this one then. So we got three players ready? Is car here or that car? Cool. Let's do it. OK. What does everyone think? OK. So two thing, yes and two correctly say no, it's rotated. OK. Let's go back and let's talk about it. All right. So let's go through our right. OK. So first thing we gotta do is we gotta look at these spinus processes. All right. One end of the clavicle is here and the other end is here. This is a lot closer. If you can see this to this end than the other. Don't look at the black thing. The black thing is not what you should be looking at. You should be looking at this little bumpy diamond type thing. That's the, that's the bony bit, that's the spinus process and that if that's a lot closer to one end of the clavicle than not, it means that it's rotated. But having said that let's go through it all. Yeah. So inspiration is the next thing. Let's count how many ribs you can see. So it can you can you just confirm, can you see my arrow? Uh Maybe she's not there? OK. Sorry, that's just not nice for you guys. OK. Um OK. But hopefully you can see my arrow, but essentially this is rib one, rib, 234. You can see I'm looking at the curvy one. Yeah, 567. We can see seven and we can see the costophrenic angle here and the apex. So therefore, the inspiration is a OK. We're happy with that projection, clear hangers on a rope sign here, meaning it's APA film. All right. And one last thing is the exposure. Let's have a look here. You can just about make out the introvert disc, you make out the bone here and the disc in between. All right. Fine, fine. Yeah, but I get it. That was a bit more of a challenging one. But as you keep looking at chest x rays, you'll get it. No worries. Cool. Well, on to goat and puffy, but is anyone gonna catch a bug? Not yet? It's very, it's very tight up there. S you keep going, you keep going. OK. OK. Let's have a look at this one. So again, I'll, I'll give you um however long, I'll give you a certain amount of time and then we'll, I'll put the question in. OK, let's, let's give it a go nice. Everyone's ready. OK. What does everyone think of this one? Good? It is, it is very much adequate just gonna go back and, and just show that so very quickly. So these are the medial ends of the clavicles. This is pretty in the middle of those, the spinus processes. You can see 1234567, maybe even eight anterior ribs. Very good. You can see both of the apexes. You can see both of the costophrenic angles. Very good there. And you can make out the ribs at the back projection wise hangers on a, on a rope. Again, you can see that in um, that kind of look here. So that is APA film. All right, cool. I think that is probably all for now, I think. And then we're gonna come back to Mentee in a sec, but everyone got that right. So I'm very, very happy with that. Um No, not this one. OK, we'll, we'll leave that one. So let's go back to the presentation. So, yeah, we've done that. Yeah. OK, fine. So luckily for you guys, chest x rays have um fun pneumonics to for everything like adequacy and now we're gonna actually interpret it and it has a really, really nice fun pneumonic ABCD E. So, um it's kind of like your ABCD E, you know, the acute emergencies thing. So the A is airway, the B is breathing or whatever breathing fields, C is cardiac. So heart stuff D is the diaphragm and E is everything else. So what we're gonna do is we're gonna work through every single little bit and yeah, just, just, I'm gonna try and make it as easy as possible for you guys so you can just quickly rattle it off in your ay cool. So let's start with airway. So there's three things that I want you to look at with airway. All the three things are the tia, the bronchi and the carina and the hilar structures. Now, that might sound a bit crazy right now to you guys. But hopefully as we go through it, it won't, it, it shouldn't. Ok. So let's start with the tia. So as you know, the trachea is um the windpipe, right? So I just wanna show you because this one obviously shows a very abnormal trachea. I wanna show you guys what a normal trachea does look like. So if you look back here, if you look on the er, one with a tick, if you can see the black thing coming down, remember your trachea does have gas, right? So it will look black if you can see that coming down, that is in the midline, that is in line with the spinus processes. We're very happy that that is in the midline and um there's no deviation. All right. In this one, particularly, there is some deviation. You can see, I know they've colored it in blue but it would actually be black and it's crazy how deviated that is. Now, the cause of tracheal deviation are good to know. So they can either be push or pull. All right. So the things that can push your trachea away is if there's extra stuff on one side of the lung and you gotta think, is that fluid or is it air if it's air pushing the trachea away, we call that tension pneumothorax. All right. So, as you guys might know, pneumothorax is when there's air in the pleural space, tension is when air can come in, but it can't go out and eventually the air pushes the trea away from the midline. So that's an emergency. Hopefully, you haven't got to a chest X ray by then you've already stabbed them in the second intercostal space or something like that. The other thing is fluid on one side of the lungs that pushes the trachea away. Um Now that fluid on one side of the lungs in the, in the pleura is called pleural effusion. And we'll go into it later how we can identify that on a chest X ray. All right. So that's your push. Push is gonna be two things. It can be air or it can be fluid pull is when the lung collapses. Now, that could be because of some obstruction like a cancer, that's really the most common cause. So if the trachea is pulled towards something, it's probably because of some obstruction. Um And here I think that might be the case is you can see this patchy thing that might be a lung cancer that's caused collapse and is now pulling the trachea. Alright. So the first thing on airway that you're gonna look at is you're gonna follow that black line and you're gonna see, are we in line with the spinus process or not? The midline is shown here. It's the red line. Alright. So if we're in line, we don't need to worry if we aren't, then we need to think then that's something to know like what could it be? Alright. Fine. Next thing is your bronchi and Carina. Now this is pretty, pretty easy stuff in the fact that there's like there's not much abnormalities that could be with this. So what you gotta do is you've gotta look for the black thing coming down the airway, you can uh it's highlighted in blue here. It's not easy to see. But if you keep looking for it, you might be able to see it on the very left photo, follow it. And if you can clearly see the carina, which is the bifurcation of the trea. So where the tria splits into the left and right bronchus, if you can see that and there's nothing in the airway obscuring it, then we're happy. The main abnormality they could bring up is a foreign body that has been inhaled like on the picture on the right. OK. So, so far airway, you look, you look at the Jaia, are, are we in the midline and then follow the airway until the Koreana? And is there any foreign bodies? Ok. There's nothing great chest X ray is looking good. So far, the third thing that I said it is important to look for is the hilar regions. Now, the hilar regions are confusing to be fair. II definitely don't think I knew what the hilar are in are in third year and you guys might fair enough to you guys. But um I'm not like now I do, which is good because I'm giving the talk. So, um essentially a hila are these regions. Um It's highlighted on the, on the right on the very, very right picture. It's highlighted in blue, but it's those kind of really patchy areas just next to the to the spine. Essentially. What it is is it's where the main lymph nodes in the, in the lungs are and the most of your pulmonary vasculature. So, looking at it is pretty important because hilar enlargement um can be all right. So I first I just wanna show you what bilateral hilar enlargement looks like. So where both hilar become bigger than usual. So if you look at the one on the very, very left, the photo on the very left, that's what normal looks like. That's what normal looks like on the right. You can see it looks like a big clump on both sides that's high by actually. And if you are to remember two causes, you might already know it. Uh I wish you could drop it in the chat. But um if you, you know what, drop it in the chat if you can. Um but essentially the two causes to remember are t and sarcoidosis now, uh you might or might not know what sarcoidosis is by now, but essentially, it's uh um an inflammatory condition uh which can affect a bunch of places in your body. It can affect your lungs, it can affect your heart, it can affect your liver, it can affect your bones, your joints, it can affect everything pretty much. Um But yeah, so if bilateral hilar enlargement comes up, if you can drop the differentials of TB and sarcoidosis, you're doing really, really, really well. All right, cool. So that's bilateral hilar enlargement. Uh Again, if there's any questions, I hope Angel will point it out for me. Um Yeah, but then moving on, just wanna show you what one sided hilar enlargement looks like. So if you look at the image on the left, the, the right side of the lungs, which is the left of the image because everything you're looking at it flat on the hilum is, is very much enlarged. You can see that there's, there's some kind of consolidation type thing there. Um And one sided hilar enlargement is very suspicious for malignancy or lymphoma. So, what you wanna do with Hila is you wanna look at both sides of the hilum and you wanna assess whether there is any asymmetry, if there's an asymmetry that's very suspicious for malignancy if they're both big TB and sarcoidosis. All right. Cool. So, just to recap airway, we're gonna look at the tria. Are we in the midline? We're gonna look at the bronchi. So your main kind of airways in the lungs, you're gonna look if there's any foreign bodies there and then you're gonna look at the hila compare one side to another or are they both big? And that's it with airway? If anything is unclear again, just drop in the chat for me. Uh Let me just check the chart really quickly. Just to check there's nothing in there. Uh Oh, there is something, men code. Yes. Ok. Not really cool. All right. So moving on from airway now we come on to breathing. So breathing is how we're gonna look at the lung fields. O overall. All right. So I hope airway was clear enough, but breathing essentially, you wanna split the lung fields into three zones or however many zones you like, but you wanna just be looking for asymmetry, you wanna look, is there something different on that side compared to the other grossly different? Um and just a tip for your Aussies, the main thing that they could be bringing up in terms of something that's different from one side to another is consolidation. So that, well, I'll show you what that looks like if you don't know already, but it's essentially like fluffy patchiness on one side or reduced lung markings, which I don't know if again, we'll go through it, but if you see reduced lung markings on one side, it really does indicate um a pneumothorax. Alright. So breathing the main tip break up into zones and just look from one side to another. Do they both look the same or not. If they both look the same, we're happy. Probably. Uh, if they don't, then you gotta think, what is it that's different as a consumed consolidation or is there less lung markings on that side? Great. Ok, cool. Let's move on. So, just to show you what it looks like. Uh, so first consolidation, so if you, if we split that into zones, right, the top zones mostly look the same, the middle zones roughly look the same as well. But if you compare the bottom zones of both lungs, um there is a lot more patchiness on the right. So that is very suggestive of right, lower lobe pneumonia. So, consolidation is essentially fluid, right? It's a, it's a, it's essentially fluid. Um That's what we think it is at least, but it can also be cancer. So, um if you do see consolidation in your os cy, make sure that you do drop to redo a chest X ray in six weeks. Cos after you treat a pneumonia, it should have gone in six weeks. If it's not, then you probably have to be investigated further for cancer. All right. So that's consolidation. So that's, we're happy with that in terms of a pneumothorax, this might be a very, very obvious image. They might not be as obvious. But if you look at the left lobe, er the left lobe of the lung, what you can see is um there's a lot of little pulmonary vessels, et cetera coming out from the hilum. Er, and there's a lot of little markings but on the right, there's really nothing, there's like a big bit of blackness because that's air, that's air in the pleural space. So, these are two very common um abnormalities that may come up when you're looking at chest x rays. So, yeah, so split. So just a recap on breathing, split the lung into zones. Look for asymmetry, look for your consolidation. Look for your pneumothorax. If you're not seen any of that, we're happy we can move on to C and C is for cardiac. OK. So with cardiac cardiac is probably in terms of the borders, at least it's the most sophisticated part of the chest X ray interpretation I would say. But um heart size is, is fairly obvious uh sometimes. So um with cardiac, the main things you gotta look for is how big is the heart and are the borders well defined or not? All right. So let's start with the heart size. So your heart is this. I hope hopefully everyone knows it's the white thing in the middle and it shouldn't be more than 50% of the cardiothoracic window. So the cardiothoracic window is all the way across pretty much of the chest X ray from one end of the of a lung to another. Your heart should occupy less than 50% of it. Now, you might be asking me, how do you know if it's 50 or 52% et cetera. I don't think they'd be mean enough in your osk to give you something that's like, that's not obvious. The heart will either be massive or it will be normal. All right. So just remember that and also remember, you can only comment on pa films and I just want you guys to have a look here. You can see your um hangers on a rope sign. So there's APA film, we can comment on the heart size. If it's an AP film, you cannot comment. That is some that is a key learning point to take away. All right. So in terms of the the heart size, it can't be more than 50% of the of the entire width of everything. All right, next borders, OK. So borders are really important actually. Um because they can show you some sneaky, sneaky things in a, in a chest X ray. So the main things that is important to look at. I know there's a lot of lines here. I want you to look at the yellow line, which is your right heart border that should be nice and smooth and nice and distinct. And I want you to look at the orange line which is your left heart border that also should be smooth and distinct. I'm just gonna go back to one which isn't annotated. This one. There's a very clear right heart border and a very clear left heart border, we're happy with the borders and we're happy with the size. All right now, I'm gonna show you what it means that if they uh what it means if the borders are not distinct. So let's start with the image on the left. Alright, let's try and look at the left heart border first on the image. So it's nice and smooth on the image on the left. Alright. But where the orange arrow is pointing, there's not much of a clear right heart border at all. Right. Can can everyone see that it's quite hazy. You can't tell at all what distinctly where the right heart border is. Now, if that, if you see a loss of a right heart border, it's pathic, which means it definitely means it's a right middle lobe consolidation and I think that's really handy only because if you have a look here, a lot of people might look at that and say that's a lower lobe because it's, it looks like it's in the lower zones. But no, this is, this is a middle lobe consolidation because the right heart border is not distinct. OK. Fair enough. Fine. Now, conversely, let's look at the image on the right. If you look at the right heart border on the image on the right, you can see that it's pretty clear, we can, we can draw it and it's quite continuous. We can definitely tell where it starts and where it ends but if we look at the left, it's not clear at all. Actually, the left is really, really hazy. It almost hazes out if you have a loss of the left heart border, what it means is there's consolidation which we talked about which is most likely pneumonia. Uh, there's consolidation in the lingula. Now, the lingula, you might be thinking what is the lingula like? What is the lingula? So I've got a picture. Do I, I've got a picture here. So it's not the best quality, apologies for that. But let's just talk about the lung anatomy. Yeah, don't ever say there's three lobes on the left, there's two. So there's two on the left and three on the right. So you've got your superior and inferior lobe on the left and you've got this little bit this notch. Um just to let the heart fit in there, that is called the lingula if that bit. So essentially the left superior lobe, if the end of it gets infected or consolidation, that um is the lingula, OK. And then you lose the left heart border on uh a chest X ray on the right, you've got your superior, middle and inferior and just remember your fissures. OK. So, um the just have a look at this and, and so on the left, what separates the superior lobe and the inferior is your oblique fissure. And on the right, the one on top is the horizontal one and the one below is an oblique one. This is just something I guess that you're gonna have to learn. Um But I just wanted to show you this image just to show you what the lingula actually does look like because to be fair, I'll be honest, I didn't really know what that was at the year for sure. So you guys by coming to this talk, you're well ahead. All right, fine. I had to add this in because um heart failure or cardiac failure is a very, very popular chest X ray to, to bring up in acies um because there's such um distinct features. And again, there's a fun pneumonic. Why do the pneumonics end? There's a ABCD E for this one as well. So essentially the ABCD E are these things alveolar edema B lines, curly bee lines, cardiomegaly, dilatation of the upper lobe vessels and effusions. Don't worry, I will go through every single one and explain what they mean. But if you start to see like this, very likely what they're getting you to look at is heart failure. Um Now, before I go through every bit, I just wanna explain what heart failure actually is just in case quickly, I'm sure you guys do know what it is, but just to in uh just explain just in case. So heart failure essentially where your heart can't pump to meet the demands of the body. All right. Um And if it can't pump effectively fluid stays in your heart and it goes backwards. So, as you know, from the left ventricle, it'll go back into the left atrium, into the left atrium and then it'll go back into the lungs. And when fluid accumulates in the lungs, you might see something like this. All right. So let's start with alveolar edema, alveolar edema on a chest X ray sometimes looks like what they call bat wings. If you just have a look around the heart and around kind of the hilum, it's very patchy. It's, it's spreading out almost like a on both sides. I wish I could uh could highlight that for you. But um if you just have a look, you can see that almost on both sides. It's like wings of the heart. The heart has wings, it patchy kind of um thing. It, it's like a patchy appearance to the lungs. That's alveolar edema. So if you see consolidation like this on both sides, just patchy throughout the lungs, it's most likely alveolar edema. So fluid building up in the alveoli and you know, the alveolar all throughout the lungs. So therefore, it wouldn't be in one spot. It would be all throughout like it is here. You can see it's very patchy and very spread out bee lines, curly bee lines. So what this is, this is fluid in um the horizontal fissure or just any fissures. So the key tip with curly bee lines is to separate them from everything else is they are directly horizontal white lines. Uh The best one is the one on the right lobe here, you can see that that's a directly horizontal white line because that's directly in a fissure. So that's a curly bee line. You can see that this heart is pretty big, right? It's more than 50% of the whole width of the um thorax. So this is gonna be cardiomegaly. So that's your CD is one of these upper lobe vessels. So if you can see uh the bit where it says ca cephalisation of the vessels, they're more prominent than they usually are. And I just wanna show you a normal chest X ray just so you can compare that. So this is a normal chest X ray on, on the uh well, I at the top it's it's normal. Uh just look at either one. You can't see much in terms of the upper lobe vessels. You can see the hilum, but you can't see that much else in this one here. They're very prominent. Er and that is another feature of heart failure. So that's your D and E is the effusions. Um This isn't the best image ever um for effusions, but we will cover them later actually. So uh we'll cover what they look like again, any questions so far, drop it in the chart. I'm just gonna quickly have a look. OK, I can see there. Could you please click on the height. Ok. Uh Where is it? Oh, sorry, my bad. Ok. Uh Fine, cool. Ok, let's move on from heart failure. Um So just to go back to, to heart overall, you just gotta look at the size and then you have to look at the borders and then we're good to go. So just to clarify for everything we've been through just really quickly. Look, is it in the midline? Great. Look at the bronchi. Is there any foreign bodies? Look at the hilum? Are they big? Is it one side or the other or is it both cool? That's airway done breathing. Let's split the lung zones up and let's look for any asymmetry. Let's look for any consolidation. And let's look for any pneumothorax. Heart, let's look at the size is the heart particularly big are the borders defined and if not, we've talked about what it could be and these are just the ABCD E of heart failure, which uh is important to recognize. All right, cool. Now we're gonna move on to d the diaphragm. So the diaphragm as you know, is at the bottom of the lungs, it's a muscle which er, contracts and relax to help us breathe. Yeah. But uh in a chest X ray, there's two important things that you gotta look out for. One is the costa. So remember I said that we couldn't talk about effusion before I'm gonna show you in a second. Why it's important to look at these angles. And you also have to look for something called pneumoperitoneum. All right. Ok. So let's start with the costophrenic angle. So the cost of running angle is what's highlighted in green is the sharp angle between the um costal region and the diaphragm. And anything related to the diaphragm is called phrenic or like for instance, the nerve that supplies it called the phrenic nerve. So, um this, these are the costophrenic angles. So on the left, we can very clearly see them and they look very sharp. If they're sharp like that, we can be pretty confident. There's no effusion. Now on the right, if you have a look at this image, well, this is again an extreme example, but you can't really make out the costophrenic angle in the right lobe. And the reason is because there's a massive pleural effusion or fluid building up in the pleural space. All right. So that's the first thing that we've gotta look at. We've gotta first look at the costa front angles and we've gotta think, are we happy er about them being sharp? So if you have a look in the picture, which I've said has an effusion, if you look in the left lobe that is pretty sharp, there's no effusion there. It's only on one side, it's only on the right lobe. All right. The next thing is pneumoperitoneum. Alright. Um If this was, if I could get you guys some mute, I would ask you what this actually means, but essentially it's air under the diaphragm. So what it looks like is what is shown in the right lobe here. You can see the white line showing the diaphragm and you can clearly see a black air bubble beneath it. Yeah, that is pneumoperitoneum fairly careful is the there's always gonna be a gastric bubble below the left hemidiaphragm. So the left diaphragm, there's always gonna be a a gastric air bubble there, which sometimes people can think is pneumoperitoneum, but it's just normal. So if I was you, I would always look at the right, the right is more likely to be a reliable source in pneumoperitoneum. But if you are looking at the left, if you see something quite circular, then it's more likely to be an air bubble. If it's something more crescent shaped, like what's shown in this image, it's more likely to be pneumoperitoneum. So pneumoperitoneum means air and the diaphragm, it's a very, very important thing in medicine. Um And the reason that it's that important is because what it signifies is that something in the gut has perforated. Now, that's an emergency. So if you see someone for like I'm just saying this writtens et cetera. If someone has pneumoperitoneum in your writtens, the next answer, like what's the next best step is emergency surgery? They need to emergency, have a laparotomy where the surgeons can open them up, have a look and sort out whatever the problem is all right. So, for instance, it could be an ulcer that's perforated. It could be a diverticula that's perforated. It could be anything. But, um, essentially that is, that's the importance of it. And if you do suspect that something might have perforated, just going backwards, you have to ask them to do an erect chest X ray. Now, it would be really good to get you guys to think about why that is. But what, uh if you think about what is underneath the diaphragm, it's gas, right? It's gas. If you're lying down, that gas might not rise up to the chest in your, in. So it's in your tummy, it might not rise up to the chest if you're doing erect chest X ray where you're standing up, that gas up to your chest and er, will be able to see it. Ring alarm bells, get that patient to surgery and save them essentially. All right, cool. So that is, um, that's the diaphragm stuff. So just look at the Costa Fron angles and look for pneumoperitoneum. All right, we're happy with that. Ok. So we've done ABCD E is pretty much everything else. So you've gotta look for bone stuff. So I just wanna show you what rib fractures look like. So just so you can recognize it if you do see in your Aus, but it's like a clear break in bone. Uh, so bone fractures lines. So this is an NG tube. And if I, if you do know, so tubes are tubes which are put from your nose that are supposed to go down to your tummy. They can either be used to feed. So some people have like an unsafe swallow so they can't take food through their mouth. So we feed them directly through the tube or their bowels obstructed and kind of acid and, and stomach stuff is building up. It can be used to drain that and make the patient feel not so nauseous. So in a, in a normally placed NG tube, it shouldn't be finishing, finishing up in the lungs, it should be finishing up just below the left hemidiaphragm where that gastric air bubble is. All right. If we, if this is the case and you start feeding into the lungs, it can cause aspiration pneumonia, which is pretty dangerous. Um and sometimes can be fatal. So that's why after an end tube is put in a chest x-ray is always done to check that it's in the right place. And in this case, it isn't. All right cool. So that is your ABCD E just a quick recap on the ABCD E. And then we'll talk about presenting quick mentee to finish and then I will leave you be ok airway. So Rekia is in the middle. Is it not Bronchi? You wanna follow it down? Can you see the carina? And can you see any foreign bodies? Hilar regions? Are they big. Are they asymmetrical? Cool, done breathing? Let's split the lung zones up. Look on either side. Is it the same? Is it not, is there any consolidation? Is there any pneumothorax? Cool heart? So, when we want to see is the heart big? And are the borders clear? Fine, then let's move on to d diaphragm. So can we see the costophrenic angles? Can we see the, can we see any pneumoperitoneum and then everything else? Look at the bones, look for any lines, look for anything else that's outstanding to you. Yeah, don't just, just have a good look up and down the chest X ray. Anything else that stands out? And then you're done then, then obviously, it's a very important, you can notice everything, but if you can't present it, then there's no point. So let's add it all up. All right. So the first thing that I said, it is important to say is name, date of birth, time and date. Yeah. So we, we have started with that P HS x-ray John Smith, born on 25th of December 1899. It was done today at 12 p.m. Then we need to talk about adequacy, right? We've already talked about P So we just r ie the patient is not rotated. There's adequate inspiration and exposure of the film. Done. Great line. You're sounding great. Now, we need to go through our ABCD E. So remember with airway when you first talk about the JIA, the JIA is central. Then you talk about your uh bronchi you could do, but I don't think it's essential. So for airway, the line I would use is the central. There's no hilar enlargement. Happy then breathing. There's no visible consolidation or pneumothorax. Happy. S remember for heart, you have to talk about the size of the heart and the borders. So the heart is of normal size where the borders distinct. Great d you're looking at the cost of running angles and you're looking at pneumoperitoneum costa angles are not blunted. There's no evidence of newer peritoneum. Now, for e which is everything else. If there is something to comment on, comment on it at this point, otherwise, just leave it there and say in summary, this is a normal chest X ray. Now, uh you might be thinking what if there is some sort of abnormality. So I'll uh say, let's say there's a right lower lobe pneumonia. I'll skip the first paragraph, I'll skip, I'll and I'll just say from otherwise what you'd say. So you say the trir is central, there's no higher enlargement, there is visible consolidation in the right lower lobe and then everything else is the same. In summary, this is consistent with pneumonia done. You're sounding great. You're gonna, you're gonna fly for your osk. All right, cool. I'll have a look at the chat in a second if there's any questions, but if we can hop back onto ment. Um and then we are nearly there. OK, perfect. All right. So I'm gonna leave you guys to look at this for maybe 1015 seconds and then after that um we can answer this. Yeah, so don't just look at what is the abnormality also have a look at what could the abnormality be due to? Ok. Fine. OK. I got two. OK. Wonderful. Good to see you guys still with me. OK. So, so let me know what you think. OK. What does everyone think? OK, great. So most of you guys got this bang on, well done. So um let us go back. So you can see my arrow, which is great. So if we go through our ABC, you can see the TIA here. It's, it's a little bit uh off the midline but nothing crazy, which is OK, you can just about see the, the bifurcation and there's no foreign bodies. So happy with that. The next thing that we have to look for is um the hila. So this is the hilum here that looks pretty big to me and this is it on the other side, they look equally big. This is bilateral hilar enlargement. All right. So that is the main abnormality I was getting at and as I said, if you might have forgot by now, but um bilateral hilar enlargement is such a buzzword. It means TB or it means sarcoidosis and well done to three of you who got that. It is sarcoidosis indeed. But whoever put lung cancer fair enough, it's not impossible, but it would be more likely if it's on one side. And if you thought that this one wasn't enlarged, I can get that, but they are both enlarged. All right. Cool. Good stuff. Um Fine. All right. Um Let's, let's go to the next question then. OK. So have a, have a look, see what you think. OK. fine. Um Yeah, let me know what you think. Great. OK. What does everyone put? OK. OK. This is a very, very tricky question and um I actually get why most people have been tripped up on this one. But let, let's look back. Let's go back and look why it's not pleuro fusion and it's lingular consolidation. Alright. So let's go through it step wise. All the black, the black um Airway, which is the trachea is following the spinus processes. We're happy with that. If we follow it down to where it bifurcates, there's no foreign bodies. We're happy. The hilum on both sides look normal, they look normal size and they look symmetrical. We're happy with that. Now, let's split the zones up. Alright. Um There's no difference between these two. There is obviously some consolidation here and there is some consolidation over here, right? All right. So there's some consolidation all across here slash some something like a, a white out essentially. Now, I'll tell you why this is not a pleural effusion because if you look at the costophrenic angles, they're pretty sharp. Even here, it's quite sharp. It's, there's, there's no blunting of the costophrenic angle there is. However, now let's move on to the heart. You can't really tell where the heart ends, loss of the left heart border, which if you remember that means that there is lingular consolidation. All right. So the reason this is the pleura fusion is because of the, the, the um costophrenic angles. So angles are nice and sharp. Therefore, it can't be, but you've lost the left heart border here, which means that it is a lingular consolidation, but a very, very tricky one. So don't uh don't worry too much if you've got that one wrong but well done. Toe, got it right. All right. Um Fine. So the next question, I'm gonna leave you guys um, like maybe 1015 seconds to have a look at this, see what you think. And then, um let me know what is needed for this patient. OK. Fine, great. Let me know what you think. OK. Let's see what everyone's put. Oh, wonderful, brilliant. OK, great. So this patient has pneumoperitoneum. Look on the left. It's not too easy to tell because as I said, there's some gastric air bubble, it's not the easiest, but you can clearly see the diaphragms here. There's a big fat black cresentic air underneath the diaphragm, pneumoperitoneum means emergency surgery is needed and you guys smashed it. Good. Fantastic, cool. Um I think there is another question perhaps. Um votes goat, fair enough, vote goat's doing their thing. All right. OK. Fine. Um Sorry, this is not the best chest X ray ever to look at. Um But let me know what you guys think is the main abnormality here. I'll give you guys maybe 10 seconds to look at it. All right. Let me know what you think. Just waiting for one more. OK. Pneumothorax. All right. OK. Um I do actually sympathize because this could well look like a pneumothorax and to be honest, mm it could be, but the, the deal is that the, the X ray is not very well exposed, the foreign bodies are here. So I thought those were, were by far the main kind of thing, whoever managed to swallow a a nail, er fair play to them. So, but you know what? I think there might be two right answers here that this does look a lot more black than the other. Uh There is a significant loss of lung marking. So I'm happy with new if you put pneumothorax as well, my biopsy that's also correct. I just forgot about that one. OK. And then last one uh is this question here? Have a good look at it, go A two E style. Uh And let me know what you think is the most important step in management of this patient. It needs a little bit of uh further knowledge, but let's let's have a look. Ok, ready. Ok. Lovely. Ok, everyone's voted. Let's have a look. All right. Big spread, big, big spread. Ok. No, no, some of the options are correct. Sorry, this is my bad. All right. So the correct answer here is needle in the second intercostal space. Ok. Now let's let's look at what this is. Let's let's have a look together. Alright, so let's start with the tia. Is the tia deviated off the midline or not? It is this is, this is deviated away from this black thing. Ok. Fine. So the trachea is deviated. Is there anything in the bronchi? No, we're happy with that. The hi limb on both sides look roughly equal. And if we compare side to side this, there's a clear like you can see this like blackness, lack of lung markings. There are some lung markings here. There's nothing here, ok. So we know it's a pneumothorax but a pneumothorax plus a tracheal deviation means it's a tension pneumothorax. Now, the deal with a tension pneumothorax, the management of it is needle decompression. So what you have to do is you have to stick a needle where I set. So the second intercostal space and you have to essentially decompress it as fast as you can. It's an emergency or o the patient, what will happen is it's air will push on blood vessels and essentially cause your heart to stop beating, push you into cardiac arrest. All right. So, um, chest drain insertion is likely they would put chest drain in afterwards. But I put most important step because I'm being really mean. Um, and IV, calm and Clarithromycin. Yes. Uh, that, that would be the treatment for a pneumonia, but I can't see any consolidation here. This is actually just the lungs. It's been compressed and this is all air in the pleural space. All right. Ok. perfect. So, um I'm pretty sure that's all there is from me. Um Just to summarize what we've covered, we've covered this right ABCD E system for a chest X ray, recognizing common pathology. So we talked about quite a few pneumonias. So consolidation which can be cancer and pneumonia. We've covered what? Um pneumothorax looks like tension, pneumothorax. We've covered sarcoidosis TB we've covered a bunch of things, heart failure, pleural effusion. So I'm very, very happy with what we've covered. II, hope you guys are as well and how to present as well. Um Yeah, so that is everything. Thank you guys so much for coming and taking out your time to listen to this presentation. I hope that you found it helpful and yeah, good luck for, for your Aussies. Uh If you would please fill in the feedback form, I would really, really appreciate it. Thank you so much. Uh I'll leave that up there for maybe just a minute or so. And then after that, I'll just have a look in the chat, if there's any questions.