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thank you for signing. And everyone My name is cush on one of the radiology registrars at lest I I'm currently working plenty of hospital. Um, and I'm a cardiothoracic radio. Just eso Today, we're going to talk about mainly chest X rays, but we're also look at some CT imaging. You guys may have gone through the playlist from Radio Pedia on that, I sent out a swell. So what we'll do in the first half about hour or so is just, um, go through chest X rays and look at several examples. So I have about 25 test X rays, which will be very good for you guys who were just starting out in terms of making decisions. Now, based on your chest X ray interpretation on and the second half of the session, which will be much shorter, what we'll do is we will look at those really a pedia playlist on go through those cases as well. Okay, so, um, here's a normal just sex is it will start with something very simple, very basics that this just extreme front of you is completely normal on again. Going back to very basics. Yeah. Comes across that's black on a chest X ray or any X ray eso the lung surgeon really going to be black and thinks that have a little bit more of a density are going to be various shades of grey. Um, bones are going to be white or any metals. For example, the patient has an implant or a pacemaker or in kind of orthopedic prosthesis than those things are going to be a little bit more solid and appear as white. So a good quality chest X ray is when the patient is in a PA position, which is posture down teary er, that's just describing how the chest X ray the X ray beams were going through on. Basically, you want them to be in an erect position, have an adequate inspiration and the images not rotated. So how do we know if something is or a chest X ray has good inspiration. So what you're looking for is theanti earlier ribs. So I'm just gonna trace out the ribs here. You're not gonna see the ribs the most medial part of the anterior, because that's the cost of cartilage. That's when the rib is joining the sternum and that's going to be some cartilage around here, which does not have a lot of calcium. So you won't see very medial part of the anterior ribs on a chest X ray. Unless an older patients, in which case, the calcium, you know, the cartilage might have calcified, and they kind of become a bit more visible. But usually in a young patient such as this, you don't see the medial part, and then you start seeing a little bit laterally here and then as you go out last the first trip and similarly, the second rib and third rib. So this is the anterior parts of the rib, and then the lines that you see that are living more horizontal around here. Those are the positive your parts of the rib as they connect or join with the virtual body at the back, forming the cost of a triple joint yet So you can either count the posterior ribs, um, or you can come the anterior ribs. And generally I go by the anterior ribs on. You should see six anterior ribs, a midclavicular line. Um, this patient has taken a very good inspiration, which you do see it sometimes in young patients because they're they have generally don't have any breathing problems, so they're able to take a big breath in. But if you can see more than six onto your ribs at the midclavicular life, and then that has something that has adequate inspiration, um, rotation. So, um, what you do is you look at the media parts of the clavicle on Do you find the spinous process at the back, which is obviously the vertebral body and the distance between the spinous process and the medial ends of the clavicle. They have to be equal. And that's how you know it's not a rotated radiographs. I'll show you some examples off poor quality radiographs in the next lights. So this is kind of what you're looking for a year and in your quality assessment in the beginning as well. Okay, so this is, um, an AP projection. Generally, the clue will most almost always be on the radiographs. So here is clearly labeled that this is an AP erect, um, on the move, I'll radiograph so you can see the patient. You can tell the patients on well, without knowing anything, because the way it's being acquired. So if it's mobile than generally means that the patient is on well and therefore the radio prefer has bothered to go to the bedside and take that really wrecked Um, Andi. You can see loads of cables on, you know, easy he leads. And things like that around this patient with generally means patients on well, so sometimes we do. We do acquire a P projections, and that's that can be because of patients very unwell on the problem with a P projection is it makes the heart in the mediastinum the big, which she I'm sure by now you might have already known. You might have also read reports where it says the heart and the mediastinum cannot be assessed because it's an A P. It's a Navy acquisition. But the good thing about it is you can still make general comments about the lumps right. So here you can see that they long sir, looking generally Okay, maybe a little bit metallic changes down at the bottom on the on the left. All right, so why does film quality matters so much? Um, the reason for that is you're looking for a good inspiration, because if the lungs are not fully inflated than the bottom of the lungs. It looks a bit. It looks a bit congested or it looks a bit, you know, not very clear. So then you might think that always. Is this an infection, or is this taste this? Um, so it it doesn't give you the truth picture of the lungs. So that's why you want a good inspiration. And again, I'll show you examples of some of this on. And why is rotation matter? The rotation matters because if the images rotated and different things, it's things are not proportional, so it can simulate some masses in the heart, or the lungs just causes things to the bigger than they actually are. So So, here's an example off, you know, a patient with poor inspiration. So again the clues they're usually on the radiograph. It says Recess patient. You can see there been hooked up to see Geez on. There's something to be the structure here, which probably, you know, it's, um, oxygen, oxygen cabling. Um, Andi, just this mediastinum looks a bit wide. It's a supine, really grab a swell on. You can tell them not inspired because let's come down to your ribs. Here is the first street born to three and four, so there's only four anterior ribs if you're counting posterior ribs is 10, by the way. So posture, part of the first trip. 2nd, 3rd, 4th, 5th, 6th, 7th, 8th, and you're kind of getting nine ribs of the midclavicular line eso you want, you know? Yeah, you want 10 ribs, posterior or six trips on TV, so this is nothing to someone who's not taking a very good breath. Um, it's it's going to be a piece supine. It just looks. The lungs kind of look a little bit busy, especially on that left side. You know, it's there any infection there, this'd mediastinum is a big big, so it's not a great quality chest X ray, but, um, same patient. We then re image suspicion when they got a little bit better on Now you can see good inspirations there. 123456. The rib at the midclavicular line. Eso good inspiration and everything now looks so much better on. But it's normal. So that's why we kind of generally say, you know, if there is any doubt, repeat the radiograph in a pa position if the patient is able to and sometimes they're not able to because they're old and frail and they can't stand up or whatever. But generally the PD acquisition is your study standard. So here's an example. Off a port, poor quality, even because of rotation. Um, so the spinous processes here, and you might need to turn up your brightness on the device that you're looking at. Uh, science courses around here on the medial part of the clavicle was around here, so this distance is very close. But the media part of the other clavicle is here, and the spinous processes all the way up to there. So this is obviously, you know, the to distance. They're not equal. It's rotated radiograph. And it's giving that, um, appearance, that there may be like a mass around here on, and that the left lung looks generally a lot bigger than the right lung. Uh, is that right? Lung shrunken because of some reason, is the left lung hyper expanded? But actually, it's just destress. Normal is poor quality image because this is a portable really has. Well, you can see the table written right side. Um, it's a generally the clue is going to be with the X ray. Okay, Um, now just a disclaimer. I cannot make everybody an expert on chest X rays in one session or two sessions or three sessions. It's very hard. It's probably the hardest, hardest modality to master in radiology Onda. Because off, you know, we're doing so many more. CT's um, I think people are a little bit maybe losing that ability to make confident diagnosis from the chest X rays as well, which is fine. It's not necessarily a bad thing. You know, we needed to rely on chest X rays in the past because that's what we have. But now we have CT's and even the Chest X or has an important role. Maybe we don't maybe need to be the but that kind of, um, you know, like that jet I level off knowledge with chest X rays. Um, so some chest X rays, obviously easy to interpret some. Some are much harder. So what I'm trying to get through today is for you to be able to make some sensible comments when you, when a chest X rays in front to be whether that's not a ward round. When consultant, you know, just ask you. Okay, what's on that chest X ray? Or more importantly, when you're by yourself on the wars and there's a chest X ray that someone has asked for and you look at it on, but you're able to pick up something that is very important. You know, I don't want you guys to miss pneumonias because obviously sepsis, first hour of antibiotics very important on. But I don't want you to delay the diagnosis or delay treatment for patients, because if you work in your age, I'm sure you know that none of the chest X rays actually get reported on time. Generally, when we look at them when good around reporting them, it'll be for five days later, and you would have already made a decision about that patients management by then on. So those that kind of time crucial things are what what I will try to get across today So everybody has the same. When are the same? Everybody has a different method off interpreting chest radiographs, so I'm just going to talk through something that works quite well for me, and I'm not saying this is the best way. If you already follow a pattern, which is kind of working for you, then you buy all means, Father that Okay, so I'm just gonna talk through what I do. So I start at the trachea, and then I usually pick the left side and then go down the trick here, looking for any maybe enlarged lymph nodes around this area or any masses. I also checked the caliber of the trickier, sometimes particularly pediatric Tums. They they when they get laryngitis and stuff, but it can be narrowed. And then, um Then I get to the first bump, which is a card in younger patients. That bump is generally not that pronounced. In the older patients, you can sometimes get a big jump from the aortic knuckle, and then you end up in the AP window on. This is where things can get missed so carefully looking for any enlarged lymph nodes or any lumpy, bumpy controls that can arise from mediastinal structures being enlarged. Um, you'll be able to see the normal pulmonary arteries around here, and then I go along the border of the heart, Um, looking for any meeting? Um pericardium or any evidence of pericardial effusion pregnant. It is very difficult to diagnose on the chest X ray, but you still have to look for it. And then I go around following the corner of the heart. The cardio phrenic angles. Athm on the border of the dye from the board of the diaphragm should always be quite clear. Um, there cost a frantic angle looking for any blunting. And then I go up along the pleura looking for any areas of pleural, thickening or pneumothorax, a plural effusions that someone's are showing those of examples of this. But this is a method that I generally follow. And then once I get to the top and go around and do the same on the other side, look for the same things and you don't be. Don't be contours, um, the normal mediastinal structures that mean with the pulmonary arteries and then go around the heart and same on the other side. And then I compare the lungs on either side so divided into zones, I'm sure you just noticed by now. So, uh, presents medicines and lowers arms who usually don't tend to comment on the loops. And let's just x ray. But sometimes you can do, um and I'll show you examples of that as well shortly. So that's my method of looking at just extra start in the middle. Go around the heart, go around the lungs, sing on the other side on D. Then you need to look at the boats any soft tissue. So if you end up doing radiology as I know some of you want to, the breast is usually a very tricky kind of radiograph. In this example, Britta's well, usually they'll be a patient of the mastectomy, and you're supposed to pick that up. Um, but generally, you know, you don't end up looking at soft tissue. Just focus so much on the long side, you don't notice that the patients have a mastectomy, and at the age of the building there might be a sclerotic bone lesion. And then you're supposed to put together that this is a patient who's had a recurrence or metastatic disease from a breast cancer. Okay, so what will be due next next? I'll talk about their space pacification. Onda, uh, show you lots of pneumonias. Um, but that's what you mainly see. You see lung infections. You would please to know that there are no code cases. I'm sure everyone's sick of Kobe by now. Um, Altri. Then what? Interstitial opacities a shin looks like. So indecision. Pacification institution is whatever. Whatever is in the lung, that's not an air spaces in decision. I sure, some pictures as well, which will hopefully be able to clarify that further for you. Um, and then we'll see the lows of cases. Right. So this is the first case. Um, if you see an abnormality, just start typing on the chapter books on. Then we'll see what what level everyone is at. And hopefully they'll give me an idea about what you guys already know and don't know. So stock on the chat box. If you see any abnormality, just start typing, right? So that's I mean, everyone thinks this is normal Or is it not working or what's going on? Oh, yes. Okay. Something's going out. Right? Lowers on a pacification. I mean, seven prosecution. Okay. Um, fine. So it's this is right. Lowers and pacification. We divide that into upper, middle and lower the abnormalities here, So let's let's follow the method, and then we'll start yet. So like I said, we'll start the trickier. Come down, make sure there's nothing. You're a technical normal. This area heart is normal week around, that's normal. And then you go around and that's normal. And then when you comparing both sides, this side is a little bit more dense compared to that side. So, um, you would say this is write letters and pacification, but this is more air space, a pacification rather than interstitial pacification. And I'll explain that a little bit more. You can actually localized this to the middle of lobe on the way you can do that is just by a little bit focusing a little bit on anatomy. So, um, in the lungs, the right lower lobe will contact will make contact with the right heavy diaphragm. So if this a pacification waas in the right lower lobe, you would lose that crystal clear outline that you're seeing off the right hemidiaphragm. But what you're losing is the border of the right heart on. We know from anatomy that the right heart border is just adjacent to the middle of. So that's how you can say that this is a middle of consolidation. But that is, you know, taking a little bit further. It's perfectly fine to look at this chest X ray and call it a racket Lorzone airspace pacification. So when you know something, someone conference you with this chest x ray that you say that there is abnormal, there's there's a possibility in in the right lower is, um and this is most likely due to infection. Okay, so write letters on a respect fascination, right? Heart border is lost, that the right hemidiaphragm is preserved. And therefore, this is the right middle lobe pneumonia. And you don't you don't really need to say right middle lobe because there's only one middle of insulin which is on the right. The left doesn't have a middle. Yeah, right. So I said, airspace, the pacification. And what does that actually mean? So in the lungs, you have your bronch I, which divided bronchioles and then they divide into these alveolar alveolar is where the gas exchange ACOs. And then you have dividing the alveolar. You have these soft tissue structures of cancer tissue structures which are the interstitial off the lungs. And when we say airspace pacification, what we're saying is the abnormality is in these, I'll be a life. So if you look at the picture on the right, which is where pneumonias um, the patient has pneumonia. The bronch I on the air spaces are filled with abnormal inflammatory substance on that is in response to the in response to the infection so that pneumonia is actually a pacification off puss or inflammatory exhibit material into the LDL. Um, and just to clarify a couple of terminologies as well, when we say consolidation in the lungs, it just means that there's something they'll hear. It doesn't necessarily mean that there's infection. Um, out. It may be that the patient has had trauma. And then there is confusion in the lungs, and there is blood building. Those are your spaces that would still be consolidation, Um, or if they have pulmonary edema and the albuterol every field with fluid, that is still consolidation. So just be careful that it doesn't necessarily mean infection. As you know, you might think so. Air space of pacification is what was abnormal in the last chest X ray, and I'll show you cases of interstitial abnormalities. A swell so interstitial. Um, I'll repeat, is these structures that are in between now the away and those form of different kinds of a Pass it easy as you'll see shortly eso how to distinguish between the two airspace. Pacification looks cloudy a little bit fluffy. So if you think back to what that's just extra look like like according ball kind of a positive. Whereas interstitial pacification is when these these lines become thick, for example, and fibrosis or in union pulmonary edema before the fluid goes in value lie, it actually goes into the interstitial. So there is, um you can get ridiculous. Pass it easy with your with pulmonary edema as well. So generally interstitial lung disease is when you when you see this, cause that's where the fibrosis happens because obviously fibrosis can't happen in the alveolar, which is, you know, where it's just at. And here's more examples. So this is a really bad case of pneumonia. So if you look at these apostasies here, they're quite fluffy. Cotton ball kind of cloudy a pass it ease. Um, this is what it looks like in the CT kind of again. Loudy fluffy a pass it e um and actually everyone knows who co Caries. So this is K stupid. Um, again. So it's just type away. What? You can see any any abnormality. Try and describe it if you want. Um, don't Don't forget to mention which side that normality is. Ryan is correct. It is right Lower zona pacification again. But I'm just put this here because so if you remember in the last one the right heart border was lost, suggesting that the infection was in the middle of Where is here? If you follow the right hand, he die from this side looks okay, But then there is kind of a positive. Here is some kind of tendon going on, and then you see the rest again. So the right hard borders have preserved which reason it's not in the middle of and you can say that confidently that this is in the right lower. But again, it's perfectly fine to say this is right. Lorzone airspace pacification because you're seeing fluffy carby stuff rather than lines, which is ridiculous, possibly a shin. So next time you you you guys describe a chest X ray trying trans to, you know, try and decide whether this looks like a cloud score. It looks like particular stuff, which is lots of lines in there. Um okay, so we'll move on. I know that normality. Okay, so I'll just I'll just talk through this because I hope that everyone can see fairly, obviously, that there is left sided abnormality here. Left, uh, presume, um, airspace. A possiblity. A shin again Because we're seeing more dense, kind of, Um, there's dense, cloudy, fluffy. A passage. The rather than ridiculous. It is possible to get both, but with infection generally, you know, you get this kind of rapacity Onda. Rest of the lungs are clear. So, um yeah, hopefully that wasn't too hard. So left upper zone airspace of aspiration in the left upper lobe on This is a case of, um I think this is a case of TB, Actually, TV mostly tensed happen in the upper the mid sounds, um, and same again, in case for where you're getting fluffy. A pass it ease, um, in the mid zones as well as the left to lower zone. Okay, um, the reason I put this case here is because it's, um It's not always that, you know, you're seeing meeting and lowers. Um expressive asphyxiation, but it doesn't always correlate with the load. So that's kind of why I put it here. You may think that this is in the left lower lobe, but this is actually left upper lobe pneumonia. And, um, it's it's the same kind of logic as before. So if if this wasn't, you know, definitely lower love, you would have you lost this outline of you actually die from, um But what you're losing is made with a little bit of the left heart border, which is in the lingular because and then, you know, is affected. But that's fine. You don't You don't necessarily need Teo. Think that much about which low there and everything is in because at the end of the day, once you're dying is pneumonia. It doesn't matter. What would you look? It's affecting you treated the same way, which is with fluids and particles and someone. And this is kind of the point that I was trying to make. So this is the left lower lobe left. Hemidiaphragm is down here. If the left lateral are had a response to pacification, you would lose that hard for left. Sorry. Let me die from here. Um, whereas if the pacification is the left upper lobe, you will see the outline. You lose outline off the heart, but the Hemi diaphragm will be clear. Okay, More air space of sedation. So I did say to you that I should lose. Sure. You guys lots of examples off pneumonia, because that's the most common thing. Um, and in this patient that left hemidiaphragm has lost. So, like, I was saying, this is going to be a left lower lobe pneumonia. Okay, Um, I'm just gonna go back a slight before I talk to you. Sorry. Right. So just going to summarize a little bit. Chest X rays. Um, looking at the chest X ray is what you would normally stories. You start in the middle, come down, uh, around the heart. Hopefully, you know, these kind of positive. It just it just catches your eye straight away, and then you can if you can, you could go to these apostasies directly and then start describing it. But if you don't see it, you would follow that pattern off your normal practice off, searching around valentines and just sex race coming down here and then you need it. You'll start to see that the left heart border. Um, you know, you can see a little bit. A little bit of that is lost. I left Hemidiaphragm is completely lost on on. Then there's no pleural effusion. There's no new Clorox and the right side is clear. Okay, so we will. Now I think we're going to more ridiculous pasties. Um right, So have a thing off. What? This radiographs, shires, Onda. Start typing if you kind of know what it is, or even if you don't know what it is, Maybe trying. Just describe what you're seeing because that's that's quite important as well. Even if you don't know, um, you know, the final diagnosis using terminal The correcting medical terminology is to describe abnormalities that you're seeing eyes that you to develop interstitial lung disease, diffuse the past mention bilaterally. So I think I would more agree with diffuse a pacification bilaterally. Um, is this a respite suppositories or, you know, Are you seeing any other abnormalities? Are you seeing a mixture of two? Yeah, so make sure is right. So Okay, now, let's, uh let's look at this chest x ray in with a bit of patients and, you know, let's look at everything. Yeah, Sam has raised his hand. Was that on purpose? Do you ever read? Ask a question or type your question? Okay. Why don't you type if you did actually have a question, and then I'll just carry on. Okay, So All right. So we've seen that this is a mobile radiograph. So that was the first clue. Patients unwell. Um, it's erect, and we start of the trachea just on the left. As we come down, there's no lumpy, bumpy contours. Your fault. You're seeing that your teeth are fine. There's nothing abnormal in the hilum as you come down the left heart border. Um oh, I've given over the answer as you come the come around like heart. Border left heart border is clear, but the left hemidiaphragm is lost. Um, there's no clearly fusion here. There is no pneumothorax. I'm on the same on the other side. Uh, you know, abnormal condors around the hilum or the mediastinum and mediastinal borders, right? Heart border is here, and you can see it left me there. Right? Honey dot This buying. There's no abnormalities, but in the long parents I mean, they're definitely abnormal. You can see Espace a passive These these cloud like a pacifier presence in the upper lips bilaterally, the middle lobes and in the background. Um, you You can also see these lines here. So these are several lines or curly be lines on. You see this in in pulmonary edema? So that's this is what this case is peri mean It Perry higher distribution off there. Space a passage. So there's the hilum. Yeah, there's nothing that much in the apex, but most of it is around this middle zoom. There's not that much of the basis on what you're seeing also is theseventies lines and the loss of the left hemidiaphragm could be because there is some atelectasis there. Or maybe some super added infection on this patient has a nasogastric tube, so probably very well may be difficult to interpret, but it's going down the right place. It's going down around the midline, and then down here is very difficult to see because it gets it disappears almost with this high density here, Um so area yes, you get a lot more so you can get they can look very similar. Onda in areas. What you normally see is diffuse airspace a passage e um you don't maybe get the second line. Is that much? Unless there is ah, super out in infective element. But you do get diffuse there space a pass, It E s Oh, this is someone with Florida pulmonary edema. Um, and it's very unusual to get this degree of anemia, so it'd be fair to put this put a radius of the differential diagnosis for this. But I think the presence of the septal lines, you know, is a clear indication that this this patient has pulmonary edema in a radius is well, there is There is an element of problem you demon going on is because the systemic thing that is happening that affects the lungs on you get non college and pulmonary edema with a really is about. So there is definitely a degree of overlap, right? So, heart failure. When we were in medical school, we used to learn this ABCDE thing. Um, aces for alveolar Dema Carly be lines cardiomegaly divers enough the blood vessels towards the upper lobes. And then there's a cute in. This is This is indeed Are you seeing a congestive heart failure. But this is no the right order of things. It's just in the morning to help you remember the You know, I remember everything but no in the right sequence. But it's it's very easy to understand this. So what happens essentially in um, C CF is first thing that you'll see. It's upper little diversion and upper lobe diversion if you haven't been able to appreciate it, or if you're not sure, it's perfectly fine, because there is even within radiologist. There's a huge degree off in terms or enter observer variability on whether or not something is up a little diversion. The best method off making sure it is upper lobe diversion is to compare with previous and if it looks definitely different from previous than that is probably more helpful than making, um, an actual subjective kind of assessment based on that current radiograph. But generally see, see a patient that cardiomegaly, which is, um, which should be apparent on the chest X rays. And you just measure the cardio thoracic Gracia. So what you do is you measure the, uh, maximum diamond dropped the heart on the maximum diameter off the lungs and the ratio should be about 50%. If it's more than 50% it's cardiomegaly on. Do some people use 55% as a cut off the first stages? Cardiomegaly. The heart is big. And then, as you start getting decompensation of heart failure, the pressure in the venous system rises, and then the blood starts going back into the pulmonary veins. So that's what you're seeing. You're seeing couple of diversion off blood vessels, and then as the pressure rises further, you'll start getting interstitial edema. And then that's what, um, manifests us Curly, be like So they're curly and curly see lines. But, um, it's not that important to know about them. To be honest, I'm not exactly sure either. And, um, I don't think that it has that much clinical relevance. So which spokes on TV lights on the current guidelines are also called sector lines and Davy, they're showing, or what? What they're representing is a demon, the interstitial, and as the pressure pressure builds further, then you start getting secret off the fluid in the decision into the albuterol, and you get the albuterol redeem Onda next stages pleural effusion that comes later on. So this is, um, what you could get with heart failure. Enlarged heart. That's the first step. And then blood vessels start. Um, they start getting dilated, so you get a couple of diversion on D sector lines and then pulmonary edema. So this is kind of what the chest X ray that we saw earlier about showed it showed that very high. They're experts participation with sparing of the embassies and the extreme basis on sector lines on the pulmonary. Okay, so, um, has the case again. The heart is not that much enlarged in this patient. Um, but if you probably measure it, you probably find that it's kind of borderline or borderline enlarged, but there's definite Perry high there space a pacification, Um, a couple of divers. A little bit difficult. Appreciated. Like I said, um, you know, it's it's not. It's not a highly sensitive or a specific Suppose it's sensitive, but it's not very specific. And there's a lot of in terms of variability, so let's leave that one alone. But once you start seeing sector lights, um, that that is quite clearly pulmonary edema, and you get these spaces last vacation. Okay, Um, so curly, be less. I hope everyone can see it. Here's a picture off a zoomed in chest X ray on, but it usually be like these lines that are perpendicular to the pleural margin. Um, and just keep it. You have to look for it, so sometimes you might not be able Teo it. It may not catch your eye because there's a lot going on, but if you look for it, you'll start seeing them as well. Okay, so here's another chest radiograph where things are, you know, abnormal. Obviously abnormal on D on this one, mainly the a pass it Either you're seeing is not a respects a pass it because it's not cloudy or it's not fluffy that we saw in the previous chest X rays. These are particular abnormalities on there. Quite diffuse. They're bilateral. Yeah, So this is actually interstitial lung disease. Um, widespread reticular a pass it ease on because of these regular pasties, you kind of get the shaggy appearance of the heart border. Uh, seemed that the dye from you lose that very clear outline of the m E died from a swell because, you know, the interfaces now messed up because off these abnormal interstitial thickening, which is what interstitial lung disease is pulmonary fibrosis can occur for a variety of reasons. And I hated running about these when I was in medical school because I just couldn't make sense of them because there were so many. But generally what you need to remember is most of it is idiopathic pulmonary critical and fibrosis. Then there are a bunch that are related to connective tissue disease. And then you have these occupational diseases, like asbestos related or silicosis. Our coworkers new can use is another. On be big group is drug religious. Well, so, people, um, who were on methotrexate or nitrofurantoin which is not that helps people are because of their UTI is they tend to get it a swell. So hopefully this light is beginning to make a lot more sense. Now, in terms of differentiating the airspace classifications versus ridiculous pacification ask Mr Pacification infection in the alveolitis become a floppy and cloud like And you can imagine why. You know, if you started feeling these alveolar I with stuff you can imagine What kind of a pass itty you'll get You get these. What were you what we see. Where, as you can imagine if these lines were thickened on became abnormal. You start seeing a network. Here's another example. So if the airspace classifications a cloud in fluffy on Ben, these reticularis abnormalities are like cobwebs. So this is another patient with pulmonary fibrosis on your seeing these lots of lines, particular abnormality. So what you'd say is diffuse bilateral particular abnormalities suggested open underlying interstitial lung disease. And you're getting that shaggy outline the heart borders, draggy outline of hemidiaphragm as well. Okay, so, um, this is slightly more subtle. So just to make, you know, show you guys that obviously there's going to be a spectrum, depending on early stages of the disease to the later stages of the disease. So this is also someone if you focus around here, there are these abnormal, uh, reticularis abnormalities here, and that's the first place you'll get it. So most of the time or not most of the time, I suppose. But for the most common pulmonary fibrosis, which is idiopathic pulmonary fibrosis, that pattern is it's a lower, low, predominant disease, and therefore you start seeing around the basis first and then as it is these progresses, it will affect the upper lips as well. But generally that's going to be a Grady int on be a pickle to basil greedy in or a pickup Oscillo Greedy in, um, which is what you schedule your pathic pulmonary fibrosis in, um, in pneumoconiosis, which is cool workers and, uh, coworkers Pneumocolon Unisys, Or what's the other one? Cilic. Silicosis. You get upper loop, predominant disease or in chronic hypersensitivity pneumonitis. So what? What Chronic hypersensitive pneumonitis is a reaction in your lungs, too? Um, organic antigens. So your bird pounds your lungs. People who keep pictures and stuff like that if your lungs get if the If your lungs develop a hypersensitivity reaction to, um, organic antigens, it's hypersensitivity pneumonitis. If it's in organic, like coal or silicon, then it's pneumoconiosis. And he's The reason I'm talking about these is because because these are related to you actually inspiring the thing that's making you and, well, they generally tend to affect the upper lobes. So if you get an upper lobe predominant fibrosis, then it's going to be generally either pneumoconiosis is, um or you chronic hypersensitivity pneumonitis type of picture, because oxygen you can imagine that you're breathing in your air. Upper upper zones are the ones that do most of the ventilation because gravity on, um, those are the ones that I get that will get affected. Whereas in idiopathic pulmonary fibrosis and stuff like that, you will get lower some predominant. Hopefully, that makes sense. And it's the same with smoking as well. And the semen is always worse. Know always, but generally were worse in the, uh, presents because it's smoking because it's inhaled a sh independent. Okay, this is another case where you get up a zone predominant fibrosis. But there's no five versus at this stage. Um, can you see what the abnormality is on this right, and start typing. If you do, I'll give it about 15 seconds with Okay, a couple people have got it right. And so this is actually bilateral inviting opathy. So if we follow our system, come down from the top erotic knuckle. Um, but remembering the previous ones, you could see their clinical fine. And then, you know, you could tell where the vessels were, but it it just takes a little bit getting used to that. There is a little bit abnormal condor going on here, and hopefully it's a lot more obvious around here as we come down the hilum. Sorry. Right. Come down. The tricky on the mediastinum on this right side. Sure, some of these these are vessels, but then you're getting these bumps, which we definitely didn't seem last one. So let's just go back to some of your previous ones for for you to appreciate this a lot more. So if you compare this highland, um, these a pulmonary vessels normal versus the hilum. Yeah, definite abnormal soft tissue. So this is sarcoidosis on Sarcoidosis is a, um you know, one of those. What if you kind of conditions and noncaseating granuloma? It's formed throughout the body on most commonly on it, manifest in the lungs as bilateral symmetrical highlighting number the ondas. The disease progresses. It kind of then leaves the hilum. It starts chrome going into the lungs. And it is also along with the new vehicle. News is, um, hypersensitive pneumonitis and upper zone predominant disease. So it'll start going in and then causes interstitial lung disease up with the president's something else that causes, uh, presented by process. I guess you don't need to know this. I'm just saying that's our interest. Is ankylosing spondylitis is well, right. So this this radiograph has a very subtle abnormality. And my wife's a med ridge, and she struggled with this is Well, so I was practicing on her before, you know, on and this talks that if you do see that normality are they do you let me know? So again, I'll give it another 15 seconds. Okay, so we'll start from the right side, because that's where the abnormality is. We come down the tricky and mediastinum, um, along the right heart border. No abnormal lumps or bumps. Condo and the island. Meaning that there's no enlarged lymph nodes. Blood vessels are looking okay, but as we come along, it looks like someone's taking a bite out of the right heart border. Um, you're not seeing you kind of immediately lose the right heart border in this region. Um, and then you can't see anything. And then you see that right? Heavy guy from fine. Remember Lear? I was saying that the right heart border is directly adjacent to the middle lobe of the lung on So this is a patient who has middle of collapse. And because that right middle lobe is collapsed, it doesn't have that normal interface with the right heart border. And therefore you lose that clarity of the great heart border. Okay, so this will be at this point also clarify the difference between collapsed in atelectasis. Um, they're kind of the same issue after, like, taste is is the term that we give. So if you go back, if you think about that picture of the alveolar that I was showing you if you imagine that some of those alveolar now not filled with air or anything, there's kind of collapsed. Um, so the albuterol a collapsed is what we call a flat tastes. And I'm not talking about a single of your life, you know, group a bunch of all the others are not inflated with air they collapse on. Then you can imagine that they're they're start forming ridiculous abnormalities, right? Because the airspace, it's not a space of asphyxiation that shuts such. It's more of an airspace obliteration. So you start forming, um, particular passage. These, um, thick kind of particular passage ease. And that's what we call atelectasis. And I'm sure they're the examples of this they're quite common on. I'll show you if there's another test 60. With that, I'm sure you have a comment on. It collapses the word that we use when it's it's at a higher level. So if you imagine that the middle of bronchospasm now obstructed with, um you Kosor, you know a cancer is growing around it and obstructing it on the whole little bits collapsed. That's that's when we use the word collapse. So collapses like at a low bar, or at least a segmental levels within the lungs. We have different segments as well. You know, some division off there on the lobes are the segments of the lungs. And so, at least at a subsegmental segmental type of level on if the bronch bronch I or all the alveolar in one segment or one loop or collapsed on gets collapsed, whether but if there's only, um, a few group of alveolar at a subsegmental ever level are collapsed, were obliterated, then we call it at all it takes is hopefully, that's it. That kind of makes sense on this is the same patient with a lateral X ray. We don't electoral is anymore and naturally they're very good for to thinks, one identifying which was collapsed on to identifying If, where are masses So again a favorite and radiology exams is to first recognize that there's a mediastinal mass on, then decide whether or something is in the interior mediastinum middle mediastinum or in the posterior mediastinum and lateral. You got admitted really easy, but they're kind of now going at a fashion and in uhl, we don't really do this anymore. Okay, Um obviously the abnormalities on the right side. So this is, um, against likely at a higher level. So I just talked to it's and that's like normal. But as you start following this right, um, you know, there is something here, Probably something around there is. Well, this is not a contour that we're expecting. We're expecting to just slide down the trickier get to the mediastinum. And then the only bump that you should get is the pulmonary vascular bump, like in this level. So we come down here, we slide on the aortic arch. In this case, there's no, you know, she caution the contralateral side. Obviously, on you start getting the vessels and then the hard borders. That's what you should be saying. But here you're seeing Dennis a positive. So this is a new terminology, I suppose, For you guys. So we talked about particular pasties, airspace, policies. But these air a little bit more intense to be simple. Airspace A passy, these ones. Yes, maybe. But here is quite dense on. And then more dance a pass. It eased down here. You completely not saying the right heart border completely. Not seeing that right. Hemidiaphragm more dense a pass it as we go up along the pleura. So give it 10 seconds for someone to write the diagnosis for this if they know it. Okay, 10 seconds or up? I think so. This is me so measly. Um, so this is a pleural based malignancy. That's why you're seeing, um so obviously the pleura extends to the mediastinum and that the abnormal bumpiness are you getting are not lymph nodes in the mediastinum are as waas in the sacral doses case that this is abnormal contours of the pleura where you're getting chloral thickening, uh, on your getting chloral effusion down here. So when the pleural effusion is huge, I guess this is the used to call this kind of small to moderate volume, but if it's you know, if it's any, if it's off any significant volume, it kind of forms this dense, white out pacification. Yeah, so this is pleural effusion in the context stuff. Musically, the your mouth is a pleural based malignancy which occurs as a result, a specialist exposure. Um, the other thing I want you to focus or trying note is if you compare the volume of this right lung versus the volume of the left lung. So this left lung is normal and it's properly inflated. Whereas can you appreciate that This right side has lost volume on. And also look at the rib spaces between these two ribs and if you compare it outside, the gap is wider. Why gap? Narrow got. And that's because the nature of the disease is such that it in cases, the whole of the right woman not hold the right lung. Great. It starts in case in this case, it doesn't taste hold the right line. Or so it doesn't start this way. But this in this case where the disease is fairly advanced, it doesn't case pretty much the whole of the right lung on. It's not letting that lung expand as well. In addition to having some probably pulmonary infiltrates as well as a pleural effusion. So this is, um, dance a positive. He's pleural effusion. Okay, um, 10 seconds for the diagnosis. That is correct. So these air polluted plaques, calcified pleura plaques to be little more specific on this is another manifestation off. It's best us exposure. So just to clarify against, um, terminologies we don't use the term asbestosis. Um, when their pleural plaques asbestosis is when you get by, bro sis in the lungs as a result of asbestos exposure. So remember, I went out of saying earlier that exposure related things are usually upper lobe. Um, asbestosis is the expert. Sex is the exception, because a specialist particles are heavy on the tend to settle in the lower lobes. So you do breathe it in, but they kind of then start going down into your lives and you get five process in the lower lower zones of the lungs on that Saphris doses. Where is here? You're getting calcified pleural plaques, and hopefully everyone did notice the's a pass it ease When the passages. I'm a clear outline like this, you know that this is not going to do the LDL. Why? Because know Alveolar Is this straight or this? You know, this kind of it doesn't alveolitis don't have this kind of structure. So you know that this is not in the air space. Obviously, this is not an interstitial abnormality. Um, and then further clues is that this is dense. You may not be able to appreciate that here. These are dense, but look elsewhere. If you look at these, um, the pleura here along the diaphragmatic aspect, you can tell that this is a high density is even denser than the bones. So these air calcified fluid plaques, Same on the contract. Outside is well, council right. Pleural plaques along the diaphragmatic pleura on and probably around here is well, and these air fluid backs and these air favorites for the consultants to shook because they look quite catching. I catching. And, you know, you can clearly tell that this is abnormal. But if you haven't seen this before, then you don't know what it is. Um, these are not. These are usually not have any clinical significance by the way, So it's not going to make the patient on. Well, um, asbestos can lead to clear a fusion. And that could cause indirect breathing difficulties in the patient. Um, obviously, musically, um, it's bad on do. That's essentially cancer, but, um, blue plaques usually are the night. Okay, um, abnormality in the right upper zone. Hopefully, that's clear. Um, this is you can then start thinking once you see the a pacification, then you can then think about whether this is a spacer pacification or where this is reticular or whether this is not even in the lungs. So I would say this is kind of a response of ascitic a shin. Um, but the the thing that you need to bear in mind is generally infection 10 generally doesn't tend to affect the upper lobe that much? Um, he usually be in the millions of the results, and something about this looks a little bit more dense. Hopefully with experience, you should start noticing, you know, when it doesn't look like a simple infection. So this is actually a pancoast tumor on diets. You know, sometimes it's fine to say that it's Estrace pacification on it could be infection because that's the most likely thing with the most common thing that's happening. But if this patient is from GP, um you know, has hemoptysis does not have reason for memory markers has been coughing. Um, but there is no productive sputum. Doesn't have any teachers consistent pneumonia on. Then you need to stop thinking sometimes on our reports, you might have seen we right repeat radiographs in 4 to 6 weeks or 6 to 8 weeks or whatever. And the reason for that is just to make sure that the initial abnormality has healed particularly, you know, if they've been treated, which hopefully they have been and then on the repeat radiographs, they're getting better than you can confidently say that bastard's infection and it's responding to treatment, but it is getting bigger than it needs further investigation with CT on. So this is a pancoast tumor. Anchor steam is actually country associated with Horner's syndrome. Um, this is the name on it that I used to use in medical school. Um, Tosis and I grosses meiosis. Okay, next case, eh? So this is also a subtle abnormality, Onda. This is the importance off having review areas to look at in the lungs. Um, so again, I'll just give it 10, 15 seconds if someone sees the abnormality. Um, just just type it down. Oh, so in this radiographs, if we follow our systems, there is nothing abnormal in the mediastinum. You do see the aortic knuckle AP window. Fine. Right Left. Sorry. Left our borders spine heavy. That runs. Okay. Pleural space is a row. Okay. Same on the other side. One of the review areas is behind the heart. Now, if you look at the density off this heart well, this part of the heart compared with density of this part of the heart this size little more dense. And there is a line through it, which you shouldn't be. So I'll go back to a previous just extra, and you can notice this. Perfect. So Okay, full of his heart is of the same density behind it. We're seeing the vessels on the bones are abnormal. Office. I'm no abnormal, but the bones are They're making it not very margin it's and seeing on this side. Um, but here this is likely little insert. This is high density. So this is called a sale sign and this is a sign that we get in left lower lobe collapse. This is quite quite a good one to pick up. If the patient has infectious features, then it could be that the bronchus is obstructed on the holes. The left lower lobe is collapsed and emitted to this triangular region. But if again, the patient has weight loss and obvious is it could be a bronchogenic carcinoma which is obstructing the level of broncos and causing this collapse. Here's ah bit more exaggerated version of that. So MetroCard area should be one of your review areas. The other of your is generally for people are the embassies handful of the diaphragm because the heart, the lungs to continue below the diaphragm as well. I mean, no, no anatomically speaking. But on the radiograph. If you if you look at this level left over this right hemidiaphragm, you can see that there are lung markings going behind. There is well, so if there's a lung cancer down here, you might miss it if you're not looking actively for it. Um, so, in addition to following your method off interpreting chest radiographs, you should have your review areas as Well, okay, Um, so this one 15 seconds to see at the abnormalities, and hopefully you should be able to pick this up. If you follow the system, It's on the left side. We come down aortic knuckle, and then through the vessels. Yes, but in addition to that, there is a left sided, um, masses. Well, it's an AP recreation graft on. Do you know if this was a pa, hopefully would be able to see it a little more a little bit clearly. Um, but this is a patient with left hilar mass, which is the lung cancer. So this will need a CT for further assessment. This is very obviously of the cancer. Um, so hopefully no one's gonna miss that. Okay, um, there are lots of things to wrong with this chest X ray. Uh, have a look and type. What? Um, um, allergies. You can see in Ms Patient. Okay. Uh, yes. The heart is enlarged. That is correct. There is a right shoulder dislocation. That is correct. So if the heart is enlarged, what should be your next thinking process? Um, the heart is enlarged, meaning that there is underlying cardiac dysfunction. So the next thing you should be thinking is does this patient have? Yeah. Okay, people. Got it. Um, so All right, let's start from the beginning. Patient is unwell. There's a mask up here. There is a auction tubing going around Easter GI stickers. Heart is enlarged. Would pick that up. Uh, and then this patient does have a degree of upper lobe diversion. And again, like I said, this is going to subjective, and it doesn't really matter. But Perry Hyler airspace a pass it easy, like this kind of white fluffiness, which shouldn't really be present in a normal chest X ray. In addition, this is difficult to sleep slightly, But you do see some sector lines around here. There's a little bit of fluid in the fissure, which is basically pulmonary edema on. Not parents are a pleural effusion, but not quite in the classic place where you see, because pleural effusions essentially few it and it depends If the patient has been lying down, it's gonna settle. Not down here, but probably higher. Up on discredits is which is the fish is, um, bit of atelectasis. So this is, um what I was talking about barrier. So these lines down here. I'm not so much down here are because when the patients lying down there not taking deep breaths, seen. And obviously this is not a fully properly inspired radiograph. You get these abnormalities on there is right shoulder dislocation. But also there is a left shoulder dislocation. So this is the green oId, um, that had is nine joint. And there's some reproductive PSAs well, which I think are around here. But they're quite difficult to see the image quality. So this is to show that don't just look at the lungs. Um, look at the lungs. Look at heart. Yes, but remember, in addition to looking at the heart and lungs, you're also looking at bones, soft tissue structures. Sometimes you'll pick up in large lymph nodes and you pick up broken broken joints or even destructive bone lesions on cancers and things like that as well. Yeah. Okay. Um, so this is I'm normal. The abnormalities on the right side. What is it? Yeah, right sided. Pleural effusion. Um, so it's not a rescue. It's a passive the It's not radicular a passive the obviously. It's a dense a pass. It e on this isn't a pleural space. You can see the and the meniscus of the fluid. And because of the size of it, you're losing the right heart Border. You're losing the right hand. He die from this. Oh, sorry. Found I was gonna talk about exhibiting transit date. Right. Pleural effusion can be because of multiple reasons. Um, I'm sure you know, for medical school that you can classify it into exited in transit. Basically speaking, exudates is when you have a pleural fluid off a little bit more protein content compared to transit eight. So things you get things that cause exhilarated pleural effusion are your infections cancer? Because it's changing the permeability off the pleura because off the local inflammatory processes or whatever whereas translate, is simple fluid with low protein content content, and that is accumulating because of changes in the actual hydrostatic pressure's that are that are occurring around the chlor. So you get that with C cf or they were cirrhosis because the albumin is low or because off renal failure, because, you know, you're not peeing out the fluid and it's all accumulating in the body. Okay, Um, can you think what has happened in this patient. So we're going up to I think case 25. So not that much left. So let's just do these next few cases and we can have a break. Um, what's going on in this patient is this electoral fusion, and if not, why not? So youngest correct that this this is a left lung collapse. I striking a few people have got it now, and it's this is no pleural effusion because this is obviously, you know, you would describe it as there is density ascitic a shin off the left, uh, long, and there is compensating hyper expansion off the right lung with the mediastinum, which is shifted towards the left. So if this was pleural effusion, pleural effusion is, um, you know something that is something space occupying in the left side. So if there was something space occupying, then it would push the mediastinum towards the right. It makes sense for this to be collapsed because it's collapsed. It's kind of sucking down, um, that mediastinum along with it on because this patient not struggling to green that right lung now has to hyper expand or do a little more work. So it's showing compensated hyper expansion. The other cause for this appearance is if someone has had the whole left lung resected and that can happen if you know there is a cancer. And for that treatment didn't have taken up the whole of the left lung. And you'll get a very similar picture because it's for the same reasons. It's not something space occupying instead of negative pressure, right? So the next few cases will have something which will need quick action on D. This is particular important. When you're moving, I think most of your bones may be, But when you start being F to use and you then suddenly are the S H O P. And you're expected to then make herget decisions. Obviously, you can call for help, but which is not always possible. So it's important to have you know, your own knowledge that you can rely on, rather than relying on the knowledge, others. So this is the kind of stuff that will be important. Okay, what's wrong? On the straight a graph, they're more. They're more than one abnormality. So let's say, um, you know, you put in energy tube on someone and then you can't get an aspirate they do a chest X ray, um, left collapse. So engine to position is abnormal. That is correct. But I don't think there is a left collapse. There is something that is, uh, urgent yet kinds of corners. Right? So tension is so so let's talk about the radiator. Okay, so first of all, we'll talk about energy to the engine tube. Uh, is abnormal. It's going down the midline. But then instead of continuing down the midline, which is as it should do it, it's in the esophagus or it's going through the esophagus. It should continue down the midline or roughly around midnight, and then start deviating. Once injury reaches the level of the diaphragm sits and usually go to us is left eye. But this is clearly deviating around on the mid thoracic level, following the theater city off and not the passages. Sorry that following the left main bronchus here and going all the way down into the lung And remember earlier I was saying that the lung does continue below the level of the pretended I refer to see, you know, if we're saying that letter a guy from is in a comparable position. See how far the lung can actually extend them below the left. So this is obviously, you know, gone through the diaphragm in into the abdomen. It's still in the lung, but this gives you an indication of how much longer can be below the diaphragm. Um, next, there is new with Rx on the right here. So as you're comparing both sides, you'll notice that this is a lot more Lucent than this side. There are no long markings, and you can see the pleural edge here. So there is a right sided new Rx. Now, tension is not a radiological diagnosis. You can say that there is new math or ex with mediastinal shift. Um, the tensioning is when the patient is hemodynamically unstable. Um, so usually, I think usually happens is the same with massive Pia's. Well, just because there's a lot of PSVT skin doesn't mean that it's a massive pee as respiratory clinicians like to remind us off. So two things I'm normal, and this is not a collapse, because eh? So if there was a left lateral collapse, so obviously the left long haul off the net long is not collapsed. You can see aeration present in the upper and the medicines. You are not seeing the left hemidiaphragm. And that may be because there is, um, a flick tastes or consolidation at that left places that I would have expected accepted that as another answer. There is no left lower class because that produces a sale sign on. We're not seeing the flipside we're seeing lost the left any background, which can be because of infection in the lower lobe. Maybe there's a little clear infusion that we're not seeing. Obviously, this side is a pacified. We're not seeing that cost for any Gangel on the right as well on that can be because there is a little a fusion around here. It's dense, a pass, itty. So there is most likely some pleural effusion here on Presently. There's pleural effusion on this side as well, which is causing the loss of the left and the guy friend. So many things wrong. Wrong inject. You're going down the broncos, um, bilateral pleural effusions. New authorites on this not not this really rough. Exactly. But one of my ms is happy. There was ah, nasogastric tube, which is obviously in the wrong place. I looked at it and then I was like Shit, this is in the wrong place. So then I phoned the clinical team on day reported as really grabbing the wrong place. And then I moved on to the next case. And I didn't fall in my system because I was too distracted by something that is obviously abnormal, Uh, which I phoned in and then there was a pneumothorax on on the other side of Seems like I remember now, but thankfully, it wasn't a big pneumothorax. It was only a small pneumothorax. Even if I had picked it up, they wouldn't have done anything. I knew they wouldn't put a drainage or anything like that. So in the end, it didn't matter that much. But, uh, what we see, you know, I should have picked up the new math or it's a swell so really ologist to miss things as well. Which is why it is important for you to be able to recognize these clinically version things. Um, especially in your HDL. Sure, you can call your Reg? Um, who might miss thinks? Or you might call us who could also this things, but diffuse if you see something abnormal on do you can rely on your own basic knowledge than that would be a lot more helpful. It's like the Swiss cheese things in. It cools the right side of me with the racks and bilateral pleural effusions on these Augusta to be abnormal. Um, okay. Have a look at this. Onda. See what abnormality you can find. So again, same history, uh, newscaster to cannot get aspirate. All right, so in the interest of time, I want well, on this too much. There is a nasogastric tube coil at the top here. Yeah, so again can commonly happen. So this is what a perfect music extra tube looks like. Um, it goes down, the midline keeps going down the line and then only starts deviating at the level of the diaphragm on, but usually goes to the left hemidiaphragm sometimes a little bit more complicated when they have high discerning is and then, you know, they're kind of coiled here. Um, but generally, this is what they were. Quite okay. What's that? Normal on this history? Shortness of breath, if you're lucky. Yeah, right side. And you with oryx. Um, so you come down here. And then as you're coming down, you come down here as you're going down, appearing. Hopefully then you start noticing girl there. No lung markings here. Um, hyperinflation. 123456 to 6. Anterior ribs at the midclavicular line. So that's a normal degree of inflation. Um, if you see more than six and here is, um, more than 10, then that's when I called it hyperinflation. But I see your point that that right hemidiaphragm is maybe a little bit more kind of in volume. Then that left side, but essentially pneumothorax, right? This Disney's a chest drink because it's quite big and the patient's gonna be unwell. A swell, Um, So this is another patient with a pneumothorax. So there is the pleural edge. But in addition, this patient also has a dense capacity in the right lower zone, which is right sided pleural effusion. And when pleural effusion occurs together with new authorites, we use the term hydropneumothorax. And that can occur a Xultophy, you know, trauma or, um, patients with Bill, you and Billy ruptures your commonly get fluid accumulating in the early as well, right? Another complete white out off the lung. But compared to the previous one where the whole lungs collapsed, there is now a mass effect because the mediastinum is shifted towards the other side. So this is a space like confined thing. Um, this is a large pleural effusion, then suppository involving mainly the middle lower zones with mass effect causing shifting off the mediastinum tourists. The left on this is a very dense or very large pleural effusion which will need a drink. So I don't know if this is the same patient that that dream has been put in. Um, but unfortunately, this patient also has another pneumothorax. Um, and there is fluid as well. So hydropneumothorax on day, Sometimes you can get loosened, sees on one side, come back to the other, but always look for the lung markings and the pleural edge if you can't see the pleural edge, and if you can't. If you think that the lung markings are definitely present, it's not going to be the pneumothorax. Um, one of the common reasons where you kind of see a line. But then the the lung markings continual. The way to the periphery is skinfold when the pages are obviously big then you can get like a a pseudo pleural edge forming. But always check for the lung markings. And what? I mean, my lung markings are kind of like these branching vessel lines as you're seeing here on on the left side, it continues all the way to the pleural edge, whereas on the right, it doesn't. It obviously stops here. Who doesn't go beyond the chloral edge. So this is attention. You look, uh, this was a case of attention you authorized because of mediastinal ship. Um, okay, this is a CT and not a chest x ray. Hopefully, you'll know that by now. Um, and this is a CT pa. So just some anatomy is sending ureter decently. Urata main pulmonary artery sec. And this is contrast in the main pulmonary artery on D. There is filling defect. That's a term that we use when we're expecting something to fill, but it doesn't feel so. We're expecting this to feel with contrast, but it's not. It's filled with clot to this is p. So will she will see some peas when you go through the radio. P A cases. Um, you know, in a minute. So this is I just want you to, you know, see what he looks like. And then we'll go through those cases. Um, final case, interstitial opacities with pulmonary fibrosis. So particular pasties. Not a responsible cities on do. Um, there's a fluid level here. Okay, Everyone can see that on if I kind of draw around it. And there is a structure that's still with fluid behind the heart. So always review behind the heart. And this is high Dishan. You're in a patient. No normal finding, but you know nothing, but you need to fact virginity on, so start in the middle. Aortic arch. Sorry. Uh, pretty good. Arch. Looks big because probably a p radiograph. Um, heart hemidiaphragm should be clear. Pleura know chloral effusion on your mouth or ex. Same on the other side of the lung. Parent time. A particular passage. These look behind the heart, I discern you. So, um, the main things is chest X rays are hard, but some are easier than others. And at your level, which is foundation your doctor level, um, you should be able to recognize the most common abnormalities or things that make a difference immediately, such as pneumothorax. Wrong injure tubes. The large pleural effusions infections which urgent antibiotics on to make sure that you find something. Um, don't wait for something to catch your eye. Follow your system. So either follow what I do. Or if you have something that works full of that. If you see in a pacifique, ask yourself. Is this cloudy, or is it like a reticular cobweb? The A pass it e um cloudy A passages air like a respite. A Pass it easy Carb wraps are going to be your interstitial opacities interstitial opacities occur in interstitial lung disease, but as we've seen, they can also occur with all the stuff like plural effusions pollen. Your demon are important to know, especially if you do a cardiology job when they have a chest X rays and you need to miss about with diarrhetics. It's important to recognize or even in a surgical job, actually, because you see very often that 60 70 year old patients with heart failure end up having surgeries on as you do. Everyone gets fluid in a surgical ward, and then you just pump them with fluids and fluids and fluids until suddenly they become short of breath. and then they have a chest X ray. Um and then it's important to recognize that you're giving them too much fluid on they are in coronary Dema, um, or pleural effusion and always look behind the heart on around the disease. All right, so a lot of cases are from Radio Pedia. What we'll do now is will take about 10 minutes break, and, um, we will quickly go over that. Playlists will only spend about 20 minutes, and that's it. It's no longer. All right. So I will see you in about 10 minutes. Okay, we'll go through. These are really a p A cases. Now there's 30 cases, but some from you know, it's kind of building on the same thing that used already seen. So we'll start on day. It won't take that long. So 20 minutes, and then we'll start at eight o'clock. Um, so the league that actually just shoots send to you If you click findings in this corner, it will tell you what the abnormality is so you can go through this latest in your own time as well. So on this, if people the system as we go along, the flora There is a little bit of blunting going on here which is not present there. And this area looks a lot more loose and as well. And as you go up, you start noticing Hopefully that you know, there is no pulmonary markings adjacent to this pleural edge. Definitely no markings around here. You can see a pleural line on. That's how that's what you're looking for to make confident diagnosis of pneumothorax and at foundation level of what you could do is then, you know, you start calling your seniors to start making treatment decision on this patient. But if you didn't spot this on a chest X ray and you just hung around for about 15 2030 45 minutes until the patient was deteriorating on both or it was getting bigger, then that would be problematic. Yeah. Um okay, so we'll go on to the next case to give you a couple of seconds to read the history. Okay. Good. So we'll be lucky if we got history as extensive as this. But this is Norco. Bit huge pneumothorax. Definite abnormal on asymmetry between the two long feels lung markings seen normally all throughout the right lung, but the left lung appears completely. Lucent. So air is obviously black on. Do you get in a lot of, um, black stuff, which is gas. All the lung is scrunched up into this little ball here on this is a huge pneumothorax with a little bit of blunted costophrenic angle. So hopefully you're seeing a pattern. Now here that if you see high, if you see a new with or access and usually maybe a little bit of fluid, uh, which makes it hydropneumothorax. But when the component off the air is so big, it's okay to just call it in English largemouth oryx managed for the chest rain. This is a value off looking at not just the immediate clinical question. So this is a part of a pulmonary pediatric radiograph. And you can tell that because the offices have not used to these are not fractures. If you worked in pizza are peace any you'll notice that you know these unfazed epiphysis are quite common in pediatric population. Staying here. This tip of the crew Muniz not fractured. It's just a, uh I see a line. Same here. But if I see a line new fracture but there is a name with Rx and no pulmonary markings up here. Uh, the pleura Let's share is a little bit difficult to see, but it is. It's a few. Increase the brightness on your screens Awful. If you're going through this another time, you'll be able to see that there is actually a pleural edge just where I'm drawing it around here. And then it kind of disappears around. But this is probably where he spotted the you most. He's a li is around here. Yeah, so that pleural edge and the loss of lung markings is quite important. Confident. It's a It's a pneumovax, jaundice and breath. Poor historian. No such thing as a poor historian, only a port history taker. Um, large pleural effusion, dense a pass it e in the mid and the lower zones little bit of a mass effect. Mediastinum is shifting on. Click here to see what the findings are. So this is you know, when you're going through the cases yourselves, a large pleural effusion mediastinum the shifting on very nauseous. Um, and mastectomy. So this is what I was talking about. This would be a classic radiology examination. X ray where there is left breast present right breast is missing and you're getting pulmonary nodule on pleural effusion. So this is going to be an executive pleural effusion associated with, um, presumably going to do the breast breast cancer recurring or progressing, depending on whether what the status of the patient is few emotions here on here, maybe years. Well, so then this patient has a CT. It's a good thing about radio P A is you can scroll through the cases on D. These are axial slices, large pleural effusions, that this is what fluid looks like on a on a CT. Um, this is fact. Subcutaneous fat. Yeah, um, and fluid is kind of in the middle. Looks great issue. This is contrast in the aortic arch. So that's the UTI Carson. And it's visit a piece of your PSA pulmonary vessels. And if we put it in the lung window, I want you to focus on the right side now, and there are lots of little nauseous, so we'll go to the top. No juice here, there. And as I scroll down there actually in numeral modules a lot more Then what we initially saw on the chest X ray. And that's one of the limitations. Just X rays, that you can actually see some of these time modules. And that's why why I was saying, you know, that's why we prefer CT a lot more. Um, these days So that's a a patient with breast cancer who has had a mastectomy and has now large pleural effusion with lung. It's clearly fusion again. Compete whites out. Onda Positive mass effect Mediastinal shift. Uh huh. Right Lung is fine. So you would describe this as you can call it a complete white out or density ostium holding the whole long either spine. Probably the latter is a little more. I'm kind of medically acceptable. Linger road dosing One town I normally go with dense, a passive a shin. This is a different kind of pleural effusion. Um, so normally pleural effusion will have a, uh, kind of meniscus. This is more loculated. So if you look at the shape, um, this's not following gravity. Basically, if if it was following gravity, most of it would be down here. So this is up here, and that's because in trapped, it's a block. You later pleural effusion. Um, can occur in the setting of empyema. So if you click empyema here, what it does is it takes you to the radio Pediapred different times. You could do that as well when you go through it, uh, on. And what environment employment will do is it'll form like a fiber optic capsule around it, which is why it becomes a loculated and therefore it doesn't follow that usual simple pleural effusion. Kind of, um, gravity based appearance. So shortness of breath due to malignant pleural effusion of unknown etiology. Infusion was grain. Chest X ray showed pneumothorax and the chest ring was inserted. So this I catching appearances that off subcutaneous emphysema or surgical embassy. The air is black and it's everywhere in the soft tissue. Yeah, on D. This is our Tradjenta. So they had a pneumothorax, and then, you know, they put a chest ring in. But if the whole of the drain and know the whole of the drinkers in the opening or the whole Angela Ellie hold the drain is not in the pleural space, but it's in the subcutaneous tissue than the gas from outside can go into the subcutaneous tissue and it can go everywhere on disk, kind of. If you touch the skin, it sounds like when you step on a dry leaf. Crunchy sound. So this is what the CT of this patient looks like. Gas everywhere in the soft tissue clue effusion down here sex thing, but also a pneumothorax. So hydrin arcs. So we'll go to the top and pneumothorax pleural edge. And that's when you that's why you see that the lung marking doesn't go all the way to the floor on the chest X ray. So that's what you're seeing on. Then there's a hydrothorax and lives guests and subcutaneous tissue. That's subq doing a sample. See me? You too, Mr Place. Chest you. So if the chest tube just you is, you can see the chest tube here. Okay, there's a chest. You? Yeah, going along. Basically, what would have happened is you see these gaps? These are to drain the air. If some of these gaps are here, which would have been for this patient, then you get this huge. This is a simple plural fusion as a person and not related pleural effusion that we saw. This is this could be a simple chloral a fusion in terms of, you know, it's just a next day. Tradition infection, um, or heart failure related. Right. So clearly, plaques calcified here. Calcified pleural packs, high densities. Always look at the diaphragmatic plural of pleural plaques. Um, and some leafy clear across here as well. So I think that's all the Hollies appearance, Um, documenting stones. Yeah. This is what it looks like on a CT. Police is just still images, not screw little, but you can speed that. They have calcium with same density has bone on. This is the coronal plane where you're seeing same thing issue with the mild cough little box again. Remember, um, when you see a pacification from it to ask yourself Is this area spacer? Is this ridiculous? On when they have sharp border, that's not going to be our space. And then ask yourself, Are these pleural plaques are the high density? Can I see them elsewhere? Look at the diaphragmatic aspect. And usually that's when you can see that they're in the maybe of high density and calcified. So the the counseling stuff starts redeploy class of the holy for parents. Same more bizarre appearances off pleural plaques again Like I said, these are benign. They don't necessarily cause any symptoms. And it's not asbestosis. They don't call it asbestosis. Anesi c five process on. This patient does not have any particular life's down here, So this is just it's testosterone related pleural plaques. The expiration, however, does have interstitial lung disease because you can now see these comp wet type of particular pasties. Um, and earlier I was saying that the most common type idiopathic interstitial lung disease Are you having pulmonary fibrosis? Whatever you call it generally is no result predominant. So I hope you can appreciate that the upper lobes are rather to be, well, a return without any significant rigidity. Rapacity ease where it's down here, the passages become a lot more. Um, sit here. So the glass of water on my table. But that's fine. Um okay, So what was the saying? Yes, sir. Reticular pass it. Ease down on the bottoms of this is just a little fibrosis. And this is the CT appearance, so cast by pleural black cast. If I'd floor a black and, um, particular changes Lorzone predominant. These are some honey coming as well. So these are kind of you know, the terrorist that we used to describe for you. It's not. It's not essential that you know exactly what they mean, But hopefully it's something that you come across before. And if someone doesn't mention it, even now, I understand what they're talking about. So this patient has asbestosis because we've got asbestos related pleural blacks on the got fibrosis. So this is asbestosis, and the patient would then get a compensation from the government. Week is off, you know, Um, obviously they use as Mister's throughout the construction or should building industry, and they didn't know that it could lead to cancer. And now people who get asbestosis or musically, a young man because off asbestos exposure are compensated for that reason. Pleural effusion. Quite big tense, a positive in the Lorzone. Well, yeah, fluid meniscus. And that's what it looks like on the CT. So this beautiful long is, um, so can you. Hopefully, you can appreciate that this density is slightly different to the extensive, and that's because this is the pleural fluid. But this is lung on. This bit of lung is atelectasis, and the reason for that it's being compressed by the pleural effusions. And this is what we call passing that like basis or, um, compressive athletic senses the large pleural effusion not pulling gravity a lot related pleural effusion. So clearly fusions are generally homogeneous. Onda, um, you know, not a respite or ridicule her so that could be in pain because it's encased. So that's how you could tell a pure collections and by and this is what I'm buying my looks like on a CT. So remember I was saying that they can't. They're loculated and they have a capsule around it. So this is the capsule around the flora, and that's why they don't follow rabbity and they become loculated and get in tract. Uh, and they become They have that kind of appearance, which is different to a normal chloral effusion. So lots of things going on here almost complete a pacification. Um, mediastinal structure shifted that way because of a pure of fluid collection. Again, clearly fusion, homogeneous density. I'm sure your ct for this patient. Um and this is again and I'm a because the, uh, pleura surrounding the truth, Louise, Think. And then you see a compressive. I like Texas here. A swell isn't that awful. Okay, well, so this is what Atelectasis looks like. So just that bit of whole. This is linear atelectasis. So this bit of lung is not inflating. Um, so it's not collapsed collectively called Low to just to give you an idea for three dimensions. What athletics? This looks like and the rest of the lungs are finally inspection. So this is a patient with lung cancer. Large mass, um, with a bit of castigation as well. And below that Castaic Castaic Master getting some collapsed lung and some infection and bullet as well. Hello, Mary. Fibrosis. Um, just subtle reticular pass it. Ease down at the bottom. Um, not Espace particular. No resemblance. So this is for your pulmonary fibrosis, as opposed to some really established pulmonary fibrosis. Dietician, do you guys earlier. And this is an example. Office severe. Call me by versus so they can progress over over years from what we're seeing before to this kind of overall diffuse reticular a pass it ease. So this patient has long people be contour here. So this is the aortic arch. But if you look here, this is abnormal soft tissue in the mediastinum and upper zone airspace. PacifiCare's in. So this is sarcoidosis with pulmonary infiltration. So here we saw sarcoidosis. Um, this is more clear, Really. Restore Sokratis is with just little body. Not Cathy bilateral symmetrical, inviting opathy but no coronary infiltration. So in this station, you're getting the next stage, which is a present predominant. Call me infiltrates. Eventually they will have these linear passages with five versus the fibrosis hasn't yet occurred in this patient. It's the same patient, Gan Lumpy, bumpy contours. Now there's bilateral infiltration Another in interstitial lung disease, ground glass appearance. So you may have seen that term, you know, throwing about a lot Lorzone predominant. Our prisons are fine. This is a different type of fiber. So this is not your path. Think this patient house and standing sclerosis. So this is, uh, different kind of fibrosis called ns i P, which is non specific interstitial fibrosis, another psychotic along with large bully. So this may be a combination of emphysema and long fibrosis. So these are the reticular lines that you end up seeing on chest X rays. Uh huh. Look, so hopefully you can appreciate that these are bilateral. Perry Hyler, especially pass it e So this is classic off pulmonary edema. So this is established or, you know, diffused beer in this patient, um, operative diversion will be present. You can tell that the heart is big. No, there's a pleural effusion on the left side. For sure there is, you know, blunting off angle. You can't see the left hemidiaphragm. So there's pleural effusion. Um, with alveolar a dina when I think this is the same again problem Redina Prisons are fine. Very highly distribution off their space. A pass It is bilateral usually infection, Pneumonia. Bacterial pneumonia is usually unilateral so and whenever you see bilateral airspace pass, a patient could use their space pacification. We should be considering what, um, sector lines. So if you see a pacemaker, the paid the patient has kind of background. How about his big, um, here you've known established proper Common area team, as in aerospace, a positive alveolar edema. But you're getting a lot of sector lines, these occurring feelings, right? Cardio the lights. There's a C. T s. So the patient has been treated. And then that has resolved curly be lines or bending killer to the pleural edge. I said this is what I was trying to get at. Uh, this is the CT equivalent off. So, you know, if you just compare the x ray that we saw earlier with the CT So this is what you're seeing These air interstitial lines which are thickened. Um, and this is what curly be lines look like on CT. All right, so this is the last case. Um, this is a screw little piece, So I showed you a sorry a scrotal ct stack. And I showed you earlier a case of pee on. So you have a lot of CT peas and then your HDL the turnover time for reporting in patients is actually four hours, so we might not get around to reporting. CTP is very quickly for you guys, In which case that you can, you know, by all means, open the CT, study yourself on D. Um, look at the pulmonary vessel. Ideally, you would window is slightly on the vascular renew, but you don't necessarily have to do. And these are filling defects in the left and the right main pulmonary artery and extends all the way that these should all be a pass it by with contrast, but they're not a pacifier. With contrast, they have sufficient material in it, which is thrown this crap so you can if you can, you know, recognize a P. That means that your patient could get really from a little better at this anticoagulation right from the license exposed. But you could start them on therapy to keppra on. You know, pretty and usually peas are not always that massive sided. So it was the last case for actually, I think it's the second last case. Sometimes, I think very subtle. So I just want you to, uh, focus on. So actually, this is an abdominal, uh, abdominal ct. Um, so if we lined the top, if you just follow this vessel, see there, instead of having contrast as it was here, you're getting a little bit off killing defect, so please can be a such a little slap. It doesn't always look that huge as in the last six. Okay, um, so we'll stop here. So hopefully you guys now have a system in your mind about how to look at chest X rays. Chest X rays are great studies, and they're the first line for investigating loads of respiratory conditions. It's very important for you guys to be able to recognize what infection is worked. Home Demon looks like pneumothorax. Wrong injure tubes. These are things that have immediate impact on patients. Management. Uh, so don't always rely on your seniors. Um uh, you know, it's not possible to just learn everything about Chest six and one go. But go through that power point again. Goes to really a pedia. If you just look for other place, it doesn't have to be this one. If you just Google Radio Pedia chest X ray playlist, you'll find place from other people. And you can look through these on your own times. Well, like on findings that will tell you what the abnormality is. Start looking at CT is a swell so that you can appreciate what you're actually seeing on a chest X ray on on a three dimensional study as well. Um, start looking at C GPS. It's not hard people's, you know, even at ST one level. That's one of the first things that people start reporting when we're first of learning about CT's. All you're looking for is trying to find this kind of filling defect in the public factory so and comically as long as you recognize upon the arteries. And if you're confused, just look at the right ventricle and just follow the track that comes out of the right ventricle. And that's gonna be the pulmonary artery, right? So just follow that problem reactor E and try and look at its branches and then see any of it is blocked. And that's gonna be pee. And if you spotted give us a ring and then say I think that's part of the PT Can you make sure And then we're very well. Be very happy to then start reporting that more urgently rather than reporting the countless normal CD has that we get from all right. So hopefully that's being a good session. Um, we will send the slice over, Um, in this Siris. I think we're going to give you a little bit more now on other kinds of other aspects of radiology rather than the chest. It will probably not be me doing it will be some of my other colleagues. So just for you guys to get a flavor of different speakers and, uh, you know, different, different, perceptive perceptions. Cool. Um, all right, Moderator. Guys, is there anything else that we need to tell them? Hi there. Yeah. If you could just fill the feedback link out that be really appreciate it because it's useful for Let's get you back. All right. Have a good night. Thank you for spending your Sunday. You're thinking with us. Thank you.