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would be equal distance between the clavicular head as it's a midline structure, and any deviation will be due to changes in the rustic pressure. And the space between the trachea under the stone or cleidomastoideus on both sides should be equal. That's how we know it's a midline structure. So knowing this, does anyone know any causes of tricky a deviation away from a lesion? Tension hemothorax. Everyone loves that one. Me with Rx? No, always. So the tension attention, the important part here. Any of those apart from the funds over June. If it's if it's large enough and near the air packs, Yeah, cardiomegaly. No, not necessarily. We won't actually shift the trickier pleural effusion if it's extensive. Lovely. Everyone loves pleural effusion. A zoo well, So the main ones that I would classify like I'd say, extensive, clear effusion. Because if someone has a small pleural effusion, it's not going to be enough. Teo Increase impression to shift the trachea Attention pneumothorax so intentionally refer rocks are shown in this diagram. Here. This is a huge Rykiel d the action and what what difference? Yet it's tension pneumothorax. More regular pneumothorax. Is there a restroom upped in the pleural cavity could not scared. This excess air builds up and we eventually have such great pressure that we have this shift and we also have chest expansion. Not those major reason, but it's sometimes mentioned in literature. Essentially this volume expansion on one side, which these increased volume and pressure, the trachea is pushed away from the side of this mythology. It's an interesting thing on this actual X ray is that we have a mediastinal shift, not just a trick. Hield deviation at the top. The whole of the mediastinum is shifted. So the heart and everything is on a complete wrong side because of just this tension, the meth or ox. So we've looked at causes for tricky all deviation away from a lesion about deviation towards the side of a lesion. Put that in the chart. Probably That's the first one of my list of a low but collapse Pneumonectomy perfect. Anything else for me? Fibrosis? Perfect that my three. So this is where there is decreased pressure at the side of the lesion that pulls the truck here. So open the collapse. Forgive me first, pronounce this wrong, but Atelectasis is, isn't the professional number. It is where there's a volume loss in this deviation off the track. Here we have MRI fibrosis, which is where the lungs become scarred and stiff. We have reduced an air entry, which reduces pressure, and because of this could be something like TB and has just an extra of something, which is a right upper lobe collapse. And looking at where the arrows pointing here, This is quite a well defined line. That's how we can tell that this area off a pacification here at the right upper lobe. We know it's probably more of a collapse because of the well defined area. So we're thinking more collapse than something like a pneumonia. So palpations be us to assess just that expansion Unti really are posteriorly in our exams, and it should be approximately 4 to 5 centimeters. And while we're doing this, we've got to be the assessing, the symmetry, the synchrony and the volume of each breath, and we can have kind of a gross estimate by asking the patient to breathe I/O before we actually play several hundreds. Just to see the size of that breathing, get an idea in our mind before we actually assess without hunts physically, and with this, we're looking for any decrease in chest expansion. So is anyone able to tell me a cause off? A unilateral decrease in chest X function through in the shop? Your infusion perfect. There's plenty more. Going less is such a physical obstruction, I guess if it was dislodged in one side of the airway, but maybe if it was down the right man because she might have it reduced on the right side, I'm not too sure on that one. So pneumothorax perfect. So I'm pretty happy with those examples. So here we're just a few. And with unilateral decreased extension, it's such a useful examination finding, and the pathology is invariably on the sides of decreased chest expansion. That's why it's still useful. So things like our new authorities little effusions if we have collapse on consolidation also. So what about our symmetrical decrease and chest expansion? Can you think of any causes of that and throw it in the shop? Asthma Big one COPD. There there are two main ones that I definitely said. So the ones that I kind of think about asthma, COPD, fibrosis and have thrown in rib fracture is an M s care cause. So in actual fact, symmetrically reduced chest expansion is actually quite difficult to detect compared with the unilateral. And they restrict the obstructive lung conditions like asthma and COPD, reduce stress expansion, asthma that might be reducing months and do two aircraft thing, especially an acute asthma. And in COPD, the patients have quite high functional residual capacities, and therefore they have a limited capacity to expand their chest. Beyond this, so reduced chest expansion will be noted bilaterally with fibrosis. The lung compliance is decreased. It's a restrictive lung condition, so there's decreased chest X function. And with our rib fracture, the pen on inspiration come depend on inspiration can prevent maximal chest expansion. The pen prevent you from breathing and with some abdominal pathology is this can happen as well, especially poor surgery. Patients avoid breathing and too deeply to avoid pain. But this has one side effects. It's a precaution we're now moving on to. You'll be asked because antirougeurs or posteriorly and all the healthy lung tissue, the sound should be no to be president loud on low pitched and with precaution, you're vibrates in the chest wall in the underlying tissues on this vibration produces sounds, and it helps us distinguish between tissues are filled with air fluid or solid material, so this sound is normal of a healthy lung tissue. It can also be normal to Hey, dullness, although the left anterior chest, due to the heart specific thing and over the right lower chest due to where the liver is, will have a dullness over the liver and hyperestrinism also quite normal over the left lower anterior chest if you going to start down to the stomach if it's a refilled, so pay for just a few. Allergy is well, you might, because ANTIROUGEURS Lee ideally, you actually want to, because asthma which of the longest possible to get the best examination findings. And my top tip is when you because pet each side like for like like for like is so important for all of your examinations that you'll be doing it gets sick of hearing it. But it allows much easier comparison, so everything should be done like for like and in a systematic manner. And although I'm not showing in this diagram, the axillary is so important in a respiratory exam. I believe in mark schemes for, like, Oscars and later years. The Exelon has its own special section. It should not be missed. You could do the Axler from an interior when you do, because you're antirougeurs or you could do it. Posterial. It's preference. Really? And when you pick up the chest until you really here a few hours, you can do this diagram doesn't show it that greatly. But this is this diagram is avoiding the scapular. There's a position we can us the patient to be in to get the scapular out of the way. Does anyone know what we might ask the patient to do to get the scapular out of the where lift downs you can grab and hands? So you can. You said I done of close your hands in front of the chest. Think like this? Um, a little lift? Yeah. Same. Yeah, but, uh, like Bendel were little, but exactly I think you look, you know, yet what we want the scapula to do is you want him to move up and out and to do that what we need to do is we can ask the patient to hug the knees. So essentially the arms are like this on the scalp. You out of the way. That means we could because more of the lungs. We don't want to be costing over the progressing over the door. Scapular. There might be pathology lying under there. Perfect. Well done. Simple question. When might we? Here, Hyper resident precautions owns. Uh, do you Brady COPD. Can you tell me why? Oh, inlaid the street is not in the initial status because of hyperventilation, and the l exit out. It is getting trapped inside, though agonizing that can happen is within not necessarily hyperventilation. We say, like the lungs are hyper hyper inflated. The lungs over time they become similar to return as they returned. All of those come down sides and that'll be your line is a lot of kind of dead specs. They have all of this guts just trapped Any other potential causes of hyper resident percussion pneumothorax. Great. And that's gonna be on the side of the pneumothorax. Obviously, it's, um, any cause of high president cushion. It's like hitting a drum. It's due to excess air or decreased tissue density, and we can distinguish between things like a pneumothorax versus COPD and asthma because with the pneumothorax is going to be unilateral and it's gonna be much more tympanic. It's gonna be louder and high pitched, whereas the hyper residents sound that we will hear in COPD and asthma is louder, but it's actually lower pitched and hyperinflated lungs in COPD in COPD, they're also airpark. It's due to all the all the damage that we call a bully. This is where we have these regions of emphysema, which dummies that all the oral I and we have these little lovely pockets. We'll have a look at the X rays later and in Asmara due to lung dissension and hollow bowels. It's not pathological. It's just an extra thing if you just end up causing over the over the balls. If we go far down enough that this Abalos so someone's put in the chart, collapsed Lung will be going on start one in a second. That's a tricky one. So we're all potential causes of high pull resident pushing this time New millennium and what isn't pneumonia an example of and any fluid? So what? I was getting out there with consolidation but perfect New Morning is an example of consolidation, but it was with, like puts all. Usually it's with a post you to like the infection. So great examples here. Que mama fibrosis? I'm not certain, but consolidation. Yes, perfect consolidations. Quite a broad named, um, with Hypo all rested and percussion. It's just increased tissue density. I like to think if it is anything that feels the lungs that isn't there, and we consider divide this into dull and something called stony dull, which will have a look at in a second. Both the deal. Anything till over Born. It's quite dull. It's flat tumors, consolidation, consular duration, whether it's by with water, with fluid, with puss with blood and collapse, so collapses an unusual one. And I can. I can completely understand why a lot of people actually think it's part of hyper resident precaution. But in collapse, there's actually no other. There's no ad in the lungs, so it's actually more dense than it was before. That's how you should think about it. There's no air in it. So anything that those are mom's that isn't there, and it's normal to hear over the liver. So this anything that isn't air within the pleura or the long parent, kind of. So I mentioned we have stones. Little precaution. Is anyone able to tell me a condition where we might hear stony door precaution? Clear left usion perfects. You know, if you that's the man example ago with pleural effusion and human Thor X. Also, does anyone actually know what is meant by store needle? This is a difficult 12 types of anyone wants to one of you, Um, like when you are tap on a drug, the full of water, you get other type of resident. That is when you tap it on the wood or a branch off a tree, which is, Oh, not fluid, basically, and you feel them on both the same residents as it was in the jumbo for two. So it's quite hard to distinguish these different sounds. But the main distinguishing factor is actually that it's called Stone Needle because it's a type of absolute dullness. You're right because it's fluid this time instead, and it's Tony because it is if the examiner, when you are because in this patient it is if you're because things storm and it's quite painful, too, because that's where it got It's got it's name from although the sound itself can be a little bit harder to actually distinguish, it takes quite a professional you to distinguish the's. But from what I've read a partner, it's much more painful to because, although something like a pleural effusion and a hemothorax so auscultation, we'd be us to auscultation a chest antirougeurs and posteriorly. And we're basically just gonna auscultate where we put coast with a special use of the bell when we oscal take the adipex and when the auscultated. It's important to ask your patient to take deep breaths I/O through their mouth to increase the Jew a shin, the intensity of the breathing as well. And this will just kind of emphasize any abnormal breath sounds, and I'll be easier for us to pick them up. So we have two normal breath sounds. We have our bronchial breathing, which is lowers and a high pitched breathing, and it's hurt where there's very little surrounding tissue. Teo fill throughout sound. It's heard over the large airways, so the larynx, the track here, the bronchi and the main areas. We hear this our manubrium and I will write your protest until you really and posteriorly in the intercept alert area. A man thing is about bronchial breathing. There's actually a distinct pause between inspiration and expiration. And this is just you to the lack off alveola filtering. Second, just going to try get these sounds of you. I'm sick. Really Doesn't want me to do this. Ah ha. There we go. So just let me know if you can hear. But this is what bronchial breath sounds should hear. Sound like I don't think we can hear it. Just okay. No, no, it didn't worry about it. We'll put the legs apart. Peter. Yeah. Do you guys continue? Listen, I'll put that. Yeah, it's a good website. I'll put them all in a chair. All of the sounds will be discussing. We'll have it. So apart from that, just take my words. They're supposed between inspiration and expiration. Just have a listen after. So we also have a visa kill a breathing so physically breathing is literally hurt everywhere else. And this is because the lung parenchyma contends air, which muscles the sound. And it's heard of the remains of the lung fields. And it's more of a rustling quality, and it has a much longer inspiratory fairs. And this is due to the inspiration originating from our little bit segmental airways, whereas expiration comes from the more central airways. So the turbulence that you get from the exploration in the Central Airways moves away from the chest wall much more quickly and become spent. Er so. Expiration is shorter on auscultation, and it's actually no pause between inspiration and expiration here due to the muffling in the filtering. So now I went to some questions. When would bronchial breath sounds be pathological? Blown Kick dozens? Okay, Anything else? So I kind of have a general rule of thumb, a bronchial breath sound when it's heard out. If it's normal territory, that's when it's pathological. So if it's heard over the normal lung fields where you should be hearing vesicular breath sounds, that's not right. That is when it is pathological, and it would you be due to anything that will increase the transmission of sound to the surface of the chest. So whether that's fluid off a solid decision as they transmit the sound waves much more efficiently done at sitting consist our consultation, our pleural effusions are pulmonary fibrosis aches another collapsed lung. So we also have many other breath sounds. These are just added breath sounds. Can anyone list in a child or just on mute and tell me some added breath sounds in pathological added breath? Sounds be is. Is increpitus long chi wheezes wrong? Can you elaborate on that last one? Uh, wrong key? Wrong way we discussed. Yes. So we discussed how bronchial breathing when it's know, heard over it's normal territory. That's when it's pathological. So we we'd is always a favorite one. Crepitus strider. Lovely. Love that one as well. Someone's given me calls. Crackles to 11 crackles. These are all great examples. No, we want to have a look at whether actually are so. We start with our ways. We use is a high pitch sound due to airway narrowing on so obstructive causes usually and it's loudest on expiration and we have two types of ways. Does anyone know what they all we can classify other types of lease. So it it is kind of a difficult one and the starting lot at the end of the like phase off inspiration and expiration. So that's a good way to describe a ways we can describe when we hear it. That's really good practice to do that. I'm thinking no one's mentioned it so well. So we subdivided into polyphonic on Monofonal. Cui's is on D. Polyphonic is more musical, lots of different notes. Monofonal is just a one, not wheeze, and we find polyphonic in conditions such as asthma and COPD. That's when we hear a polyp on a quiz on Monofonal is when know that's the other is a fixed airway obstruction. So we have our strider, strider and wheeze very similar, However, the Strider is a high pitch sound that occurs due to airway obstruction in the upper airway. And another distinguishing feature between Strider and Wheeze is that Strider is loudest on inspiration and it is loudest over the neck compared with wheeze, which is depending on the cause. So crackles crackles are kind of like sharp, high pitched, discontinuous popping sounds, kind of like Rice Krispies kind of makes nto and the result from AARP be forced through really natural or collapsed airways that might be filled with fluid posts on mucus on d. They might be heard when is delayed opening of our overall I So someone gave in the chat that that we have cause crackles. What are the type of crackles Do we have? Fine. Perfect. Oh, lovely, fine crackles. So it's really important to be able to distinguish our types of crackles and it's useful. Listen, look going to website and listen and start fine tuning it years to them. So fine crackles. Stunned it. Everyone says it's on my belt Crew on their heard. They're produced in smaller airways, and conditions like pneumonia and pulmonary fibrosis will cause the's so fine crackles will continue until quite lift an inspiration as they're in the smaller airways. They could start quite early an inspiration, but they usually do continue until let inspiration. We don't have other calls, crackles our calls, crackles or heard earlier. Inspiration compared to are fine, and they're from the large airways. We might hear our calls, crackles and things such as COPD to tip mucus filled bronchioles and the crackles that we hear in COPD in early inspiration, and they usually end about mid inspiration. Cities isn't good distinguishing factors, but my favorite one when you hear fine crackles, you know, it definitely is like Velcro the people. All right, Tell Bokel pharmacist going towards the end of the exam here will be asked to assess it until you really or posse really and refuting of the palpable vibrations would be asking the patient to say, 99 in a continuous tone. And we're seeing if there's any changes in intensity of these Bible Asians that we palpate on the chest wall created by spoken words and in healthy lung tissue, we should know that the vibration should be symmetrical and even throughout the lungs. What are the potential causes of increased tattle vocal from it? Holiday shins and pleural effusion consolidation? I love pleural effusion and pneumothorax. Not quite. We'll have a look into that in a sec. There they actually decreased a little bit local from a tous. So when we think about title Benical from a Tous, it's all about density again. So increased sucked elbow cough remedies is due to increased density. So with our consolidations, so the consolidation, whether it's post blood, anything like that, it's many consolidation pneumonias, tumors and lord collapse, So no air in the lungs increased entity decrease tattle walker from a tous. This is when we started to think about our actual things, such as our pneumothorax and clear effusion. So we can think of decreased hotel vocal from a test in two ways. So do to decrease density because might be COPD. And this will be just the hyperinflation. A small, uh, has decreased decreased density that all we could think about us. There's an increase in distance between the lungs on the chest wall. And this is where our clear effusions you know what new math or issues come in because they're feeling the flora. They're increasing the distance between the lungs and the chest wall. We can also mention hemothorax. He, um there's a CT example showing a let's me point to the laser pen. Here's an example off a pleural effusion showing an X ray, and you can really appreciate the increased distance between the lungs on the chest wall and, I don't know, put on the slides. Another factor is actually things such as obesity and increased muscle mass can actually decrease total vehicle from a tous because that increasing the thickness of the chest wall, we can break this down. As a final part of our examination. We're going to need help in the lymph nodes. As with anything, it's really important to do this in a systematic manner. On learn the names of the lymph nodes. They will ask you in a Nexium to name them as you go as you as your palpating, which group you palpating over. It's good to practice people feel for them in different ways. Get your routine, see what you like. Make it and stick with it. I've still doing the same one I did in second year. And when we feeling these in floors were coming to think about size were thinking other more bile. Are they tender? Is a patient wincing when you're touching them? And what what do they feel like? If their heart could potentially be metastases? Is it robbery? Maybe we're thinking them foma, and is it soft, potentially just reactive. Is anyone able to tell me potential causes off cervical lymphadenopathy infection men, one. Any others Sarcoidosis on human Potassium is all perfect, so these are very broad. Cervical Lymphadenopathy does not mean a respiratory cause we're kind of using a surgical sit here with an infection. Inflammation malignancy medications were benign, but in a respiratory context open respiratory tract infections the most common cause, so speed up a little here. We've been through the exams in their findings and my advice for exams. For the questions at the end of the exams, learn the surface markings of the looks. Learn the surface markings off the pleura on learn the surface markings of the horizontal and oblique fissures. The final one is one that can easily get mixed up, and that was a common complaint for a lot of students that sure, they just got them mixed up in that a believer mark. People just got them the wrong way around, so it's an easy mistake to make. Get to learn them early, get you to them. Then you don't have to spend the week before your exam worrying about them. So you'll have this here just, um, diagrams that I feel like a lot of students, especially imperial students. Well, it came across and they're really quite useful, showing the borders of the lungs, the pleura, it's easy to just break them down. So if I were to describe the whole the whole right loan, the air packs is at the one inch medial third book the clavicle I've got down over the stone A clinic in a joint sound sternal border to the difference if external joints approximately a rib sex but then still be going along rib six at the midclavicular line and be a rib eight at the Midaxillary line before we then go posteriorly to approximately t 10 at the medial scapula border, and then we go up to our t one quite a systematic. We're just learning with flash cards as my That's my biggest advice. Get used to them to know probably the bit most of you looking forward to X rays. Expert interpretation. You probably second saying, But a systematic approach is vital, especially for extras. But before we start jumping into things we did identify the patient is this right patient we're talking about? Is this actually good quality? And to determine whether the X rays good quality, we use a new monitor called right where are stands for rotation. So we want to make sure that the patient isn't rotated. That's to be equal space between the medial aspect off. The Chronicles on the spinous processes know in this case, the patients not rotated here. Great inspiration Can you see at least 5 to 7 anterior ropes? Then it's a good film projection. We want to know what type of film is this year is a p A film, and most chest X rays of probably 90% of them will be P A. Films it's not labeled will assume probably Pierre, because they're the most common. And he for explosion. Can you see the vertebral bodies behind the heart? Yes, we can. And this is a good enough quality X ray. If you see the way the I approach things. If I see anything obvious that point out first before following my systematic pathway. If you see something, said something really obvious jumping out of the page, mention it first. We then want to go through the ABCDE approach. No, The reason is one but the X ray one, Where and where means we're looking at the truck here. Is it Central is in this case we want to look at the Carina. So the cartilage before the tricky of bifurcate it's You want to look at the bronchi. We could see the right man bronchus here, and we want to be looking at the highlights structures. If there's any Hyler enlargement that's indicative of pathology, it unilateral those it by electoral. So that's what I wear breathing. This is where we want to look at the lungs and the blue room. We want to be systematic. So we want to go from the embassies, comparing like for like and go all the way down the lungs, looking all over the whole area. And something important here is that we want to make sure that all the lung markings extend to the periphery, and that's really part of the lung. Marking should be gone all the way to the periphery, and the apex is a commonly missed our area, so good a good practice to start with it, so you don't miss anything. We then go on to its its circulation here. But I think I'm in cardiac, so we want to be looking at the heart when I know its size is and launched. We want to look at its bodice before we then look at the diet from we want to look at the diaphragm. Is there any flattening? The diet from is usually raised. It's a normal variant to have a raised. I from on the right hand side is usually quite a nice M sort of ship, and we want to be looking at the cost of chronic angles. He cost a frantic angles. Any blunting here indicates might be fluid present. So we were thinking maybe a pleural effusion. You can see tiny effusions by blunting of these ankles. Before we didn't look at a three thing else. We have literally we want to look at the bones there, any fractures? Are there any devices that we want to mention? You could see the exact pairs America's and evolves Any tubes? Can you see an NGO tube? They're important things to point out. So just a quick reminder of what color things should look like on X rays. The modern is the tissue. The more X rays are attenuated, so messed up. Here's the most white therapy Is block bonus pretty close to a white on the spectrum? These are what we should be looking up. So, taking a closer look at the hall, what is the first are at the top pointing to is that you don't Well, is that sorry? Uh, no, actually. Alter and perfect. We call it something else. When we look at the X ray because we actually got perfect, someone's got it in their chop. We're not actually look at the whole of the Arctic arch here. It's a special little portion called the aortic nickel, and it's the first structure we see when we trace down at the left. Mediastinum. What is the next trip to a point to go up? Left started school. What was that? Sorry. No, quite the Bronchioles left atrial article. Not quite a slightly higher A plan now, So here it's up. Someone's almost didn't write, reportedly veins. But it's actually our primary arteries that were pointing out here, and they could be seen brunching throughout the lung. So the pulmonary vessels I'd probably give you half a lot for that one, that's all. We then move down. What is the next one point to go right? You guys be more complex. You're saying left atrial appendage when I'm being a little easier on you. It's just the left atrium. You guys have been moving more complex, but it's our left ear drum that were pointing out here before we then go to our left ventricle. So our left heart border is made up of the left ear drum and our left ventricle. Important to know a swell that on an X ray our cardiothoracic ratio on a phx directory. So the maximal horizontal cardiac diameter versus the maximal total thoracic diameter. It's usually about no point for 22, not quite five any more than that, we're sinking cardiomegaly. So I'm aware of time to respond a little bit that I would right mediastinum is made of superior mean it vehicle over at the top, and we have our right atrium forming our right heart border here. The inferior vena cava can be seen inferior Lee here. But the main question that I have is why does the right ventricle not have a border on this chest film? Yeah, it's ah, actually lose a tingling the Diastat Um so in that unlikely does not exposed when and we see you don't know next. So people are actually saying that is prosteva, but actually on our pa phone when we look at it, the right ventricle sits unti really? So it doesn't actually have a bottle on this film on this pa chest film. If we look at the Heart Institute. You didn't form our borders and this diagrams of grocer of that. After that, you had a good explanation that about it was just above the dye from, But it's the fact that it's it's until really so. Now we want to quickly go through some of samples. I'm keeping you for a while. So that stopped these. What is the most obvious tablet Maliti on this chest X ray? Not quite June. I think that's just the aortic arch. This one's a little bit of a mean or is your heart doctor does look a little bit small. It's not know, excessively small. It's pretty Okay, it just looks more like that. So just in not quite see everyone. Someone's got it. So someone's got that. It's hyper inflation. So although you can see the high levels here, that I wouldn't be too worried about anything going on here. Hyperinflation. Although it's not excessive in this scenario, quite a reliable indicator of hyper inflation is actually that the diaphragm is quite flattened. So the green line here shows kind of what we'd expect. So the wrists and hyperinflation going on here and I have been kind of mean with the first one, but you do always kind of think you used to see a lot more than you kind of put things on your mind but get used to looking at normal extras. Well, that's a good example. So another feature that we might actually see into your ppd thing is called fully. I mentioned these before, and this is when emphysema. So we have damage to the albuterol I when we have these collections of air and the damage, all they all are the kind of a good cumulation like pockets, and they appear as darker areas because their collections of air like bully and these are the things that make the COPD mosque susceptible to pneumothorax is. So what's going on in the sex right now? Perfect. I always think someone's be more specific. Perfect love, the left sided always see which side's. That's a good example. Suicides that I will left sided pleural effusion. And we know this because the left lower zone is uniformly white. That's how we describe it. If we were describing an X ray and at the top of this area is a bit of the fluid level going on there's a meniscus. That's how we can tell that it's a pleural effusion and you can't actually see you see the heart and neck so we can't make any conclusions about the heart. And I went into the approach and on the right side also, this a slight blunting off the cost, a frantic angle. So it's telling us that might be a little little effusion going on that side as well. But I'd always be happy to see a pleural effusion exam. What about this one, Uh, follow the air to a systematic approach. My hunch is look really, really close. There's a reflect, too, so to think about what the fracture might have actually cause. So we think we're not think about RMS care pathology here. So there is a tricky your deviation going on here. Yes, there isn't the reason to repeal deviation, but to think about would be think about lung markings. And what might the rib fracture have have caused spatial squints to prove it being so the hyper they tend to Oh, lovely, not quite, although we did mention that someone's got it. So it's we've got a pneumothorax. The rib fracture here, which we would have picked up about. The assessment is probably caused a pneumothorax. And although this is very hard to see and I've been quite mean with this, But beyond this line there's actually no Norland markings present. We can't see any of the nice long markings present, so we know that this is the pleura and in the pleural cavity is being filling with, um, needs A Really, these are really easy to miss, especially in the ethical areas. So we have out visible pleural edge and great scenery fracture. But this the rib fracture probably caused this. And what about this extra? So good question. I'll go back. So this is just a pneumothorax. We would not call this attention pneumothorax because there's a nor triple deviation. This is just plain old pneumothorax. If it was attention pneumothorax, a tricky it will be deviated, but it is not is nice under central good question. That's how we distinguish between tension and just on average, in the middle, rocks like to x ray awful what we're looking at here. Let's give you a hint with the compare the middle zones. I love the word on that use use that does my own so left sided, a pacification. So with any kind of a pacification, we can't really make any too too solid of a conclusion. We could see that this the left middle zone is a lot more pacified. But to be able to do the pneumonia diagnosis, we take into consideration the clinical picture, usually because it might not actually be a new morning. It might be something else causing the consolidation. So our new morning. So it's a left middle zone consolidation, and we know that this patient's feeble olive how to cough so we're able to come with. Perhaps it's a pneumonia. From of clinical findings, we have an area of a positive. We can still see things in the a positive way we can have these things called bronchogram so and these are slightly dark areas on in the area of a pass it e. And that's because the bronchial filled with air and being made visible by just the a positive patient around it to you because the area around it's much lighter. You are now able to see the bronchus so you can see the bronchogram is kind of around here. That's probably the man, one that we'd see great, well done and the final X ray before we come into some concluding questions. What's going on here? Everyone loves this one. I kind of love this one as well. Yeah, but, well, good. Like where you going of the laws are, I guess those are not natural walls. So we've heard. So he had some kind of female patient. That's not necessarily an identification, but great. You've identified. It's a woman we like, but the there's something in the middle, it's not a pacemaker. What is that? The valve replacement? Someone. Someone's got it. There's a valve replacement that's going on here. And if we can, if we're going to be specific, anyone tell me which balls I Oh, Dick. So the aortic would be somewhat Yeah, I don't know. Actually, I don't think it's aorta. This is where do you mean of me? But make sure someone's got it right, buddy. Perfect. It's mitral. We'd be here arguing older, but it is a mitral valve replacement in the center, and you can see that there were quite a few surgical clips along along here. There's been quite a lot done to this heart. We don't have a clinical picture. We can come up with a diagnosis, but we can comment on what we see. Yeah, massive cardiomegaly and the surgical clips can be seen. So I was quite low from looking at the X rays. No one's a questions. I have three kind of exam style questions that we ask the end off our CP examination. So, firstly, we have an 18 year old female 18 year old male. Sorry presents to any with dyspnea right side of pleuritic chest pen. The symptoms started two hours prior while the patient was playing football. On examination, the patient has reduced chest six months in on the right hyper resident percussion note on the right. Decreased breath sounds on the right on decreased from a tous on the right. What is the most likely diagnosis? Tension New. So you say that again. I think it's stent in Imitrex. Maybe Bunch of I don't know. As useful as you disclosed, it did that before X ray. Yeah, so with the X ray, it great with the new math or rocks from our examination findings that we've got here, we actually can't We can't tell if it's tension or not, because if it was tension, I would have put about the tricky Leave the action. Yes. So maybe that's a bullet up. Cause diarrhea. Yeah, so we can only conclude if it's tension. If the chuck E is being Devia is all. That's when we score from pneumothorax to know all my all my gosh, it's tension, tension the big, um urgency. Yeah, it's a right sided you, majority of perfect. And with football, it could be due to rib fracture. This is quite a common presentation, and I've seen it quite a few times in SPS. So I stole it and put it here. So it's usually kind of people people doing spot. Someone's asked a really great question. What's the difference between consolidation? Onda pacification? So when I say a pacification, I mean anything that looks more white, anything that's more dense on an X ray, that's just a general description and that a pacification could be due to a consultation. It could be due to clear left fusion and pacification is very broad. So with pleural effusion, we have quite a come a uniform, a pacification so uniformly right out. Where is with a consolidation pneumonia. It's kind of like a hazy, hazy white. Oh, I hope that extends a bit more on to our next question. But a 72 year old woman presents with slowly increasing dyspnea over the past two months and left sided chest pain. Her dyspnea is exacerbated when she lies flat on examination. This reduced chest expansion on the left. Stoney don't the question of the left lower lung field, bronchial breath sounds off the lower left lung field and decreased tattle vocal parameters over the lower left lung fields. What is our most likely diagnosis? See your good you had this time. So you had this time when we read about the question to think about it. Perfect. And this is why it's so important to kind of have a clinical picture because with pleural effusions, the hidden that I gave here. So it's got they're wrong. Details on the slides. I'll go back to this one that with this, the fact that it's the left side of your life. Usually it's slowly increasing dyspnea. That's a typical kind of history. Again, with pleural effusion, it's slowly happening rather than it being a cute They're a little hints and especially with the edge. You going all of these that you just put in an exacerbation when lying flat. It's almost like a buzz word should be going off in your in your head so and onto our final question before we wrap up. What are the surface markings off the horizontal? Fisher. Yeah, it's a long one to type out. You know, one brave in there, I'll give more normal, and then and then we'll just go through the answer. You can just write it down and keep it to yourself. If you don't feel the bottom of this cough, okay, I'll just take or three down, some too keen. So, looking at the diagram, we go from the level of the right both into fourth costal cartilage along the along, the actual card along the actual rib to the junction off the oblique fissure at the Midaxillary line in the fifth intercostal space over here, and it just basically devised the right lung above the oblique figure oblique Fisher into the right superior and middle loves nice and easy one. So that's all of my content covered today. Thank you for having me do this respiratory lecture today. And if you have any questions, my email address is here. Feel free to email me or I'll take any questions that you have right now been passed. It definitely also.