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Holla, geez, we'll be going through lots of different pathology is how to approach chest X rays when you're presenting them back to examiners on, we'll have some example presentations as well to help you with that, too. So I'll get straight into it before we go into any of the pathologies and cells. I just want to emphasize a couple of major things about X rays. Firstly, is knowing your left knee that's super important off, So you need to know where a pathology is and what structures it's affecting s. So I put a little labored diagram just over here on the left for you just to review on your own time as to what all of the exact structures are on a chest X ray. What I did want to say just before we begin relating, since some of the pathology is that we'll see later is just remember that surrounding the lungs is the pleura of which you have two layers. You have the visceral and the Pridol, with the visceral being in close contact with the lungs and the parietal on being more in close contact with the chest wall on do different pathologies, confederal the space between those two, um, laser pleura. Um, but you may not see it. You won't see if it's normal, it just x ray. But just remember, it's there, um, and also to look at the lung markings on a chest x ray. So the lung markings on a chest X ray are formed from both, like the lung tissue itself along prank um, A A Z well, as the vasculature that's supplying the alveolar eyes and the different parts of the lungs on that should be right up to the lateral chest wall. So just remember, that's there. That's really important. Then why I wanted to just say was about kind of how X rays were, because I think this could help a little bit with understanding the pathologies. So I'm sure you will know that X rays are formed by, um, an X ray source of point source on firing X ray radiation towards a patient. In this case, the chest on There are two main views that you see interesting phrase. You see either a P view or PA view. Um, so in a P in AP view, the X rays travel from antirougeurs posterior to the front of the patient's chest to the back on NPH. It's the opposite. So it goes from the back of the patient through to the front. Can anyone pop in the chapped for me? Why? Does it matter what way around the view is, um, logistics, right? Yeah. Amazing. Lots of great ideas come in cardio thrust ratio. Yeah. Brilliant. Yes. I mean, mainly it's mainly it's to do with the whole which I've tried to draw out on this diagram here. So in an AP view, it can force Lee increase the size off the heart on the other structures in the chest just because if the X rays were coming from a point source like singular point and then spreading out from there when it hits the patient and then the x ray film. If, um, you have an AP view, Obviously, with the heart being an interior structure, it's going to hit the heart. And then there's gonna be more time for those race to continue to reading upwards before it hits the X ray film, which I represented in the black and gray hair. Where is this? Someone, um, undergoing a PHS chest X ray because then the hall is closer to the film. There's less time for those X rays to continue to spread. So that's why that distortion happens. Um, as well. Just remember, in terms of like the different colors and different radiance you seeing a chest X ray. The chest X ray film is usually a white color before it undergoes exposure in a chest pain chest X rays performed on. Then, when you're viewing a chest X ray, there's mainly five different densities that you'll see that I've represented up the top. So you have, um, Airbnb, this kind of darker black color That's obviously your lowest density structure on these structures, like the lungs that filled with their they let X rays through on that turns the film black. Then you have fat, soft tissue and bone slowly and slowly, getting lighter to metal on which you might see if someone's got like a pacemaker in, or something like that. If it's got metal in there, any wires or anything, um, and bone is also obviously quite white as well. On these structures absorb the X rays, so when you're viewing a chest X ray, these appear white because the film hasn't changed color when it's been exposed to the chest X rays that make sense. Another point I just want to emphasize before we start is how you describe the different abnormalities that you might see on the test X ray. So the main things that you want to point out or it's density. So I've just gone through the five different densities you'll see. So if you pick out which one of those is on which one you think it is a Z well, a zip, it's uniform or not. So is all of the lesion, the same density to some of it, appear more dense than others. Then you want to talk about it's position s Oh, whereabouts. Is it on the chest X ray, is it? If it's in the lung fields in the upper the middle of the lower zones, etcetera on its size, how big is it on its borders? So is it related to the heart border? Is it is it in contact with the dye for, or anything like that? Um, so they're really important when you're describing different abnormalities that you see. So I know in the Oscars the we love our spot diagnoses. So I've picked out a few pathologies that you might. Comaneci's just X rays from a variety of different systems. So I'll give you the little vignette. And then if you guys type in the trap for me, what you think I'm alluding to? So we have a 24 year old man who presents with pleuritic chest pain during his broke the game. There was no trauma history on on examination. His right lung field has decreased vocal residence. The trachea is not deviated. What do we think the pathology is that I'm describing Pretty and lots of ounces coming in? Yeah. Amazing. Brilliant. Yes. So I think most of you got it s so it's a primary spontaneous pneumothorax. So the typical presentation of this is a young, tall, thin sport. A young male who's suddenly become really out of breath on has a kind of pleuritic chest pain where there's more chest pain when he breathes in. Oh, she breathing? Does anyone know? So this is a primary spontaneous. Does anyone know any of the other types of pneumothorax that you can get? Tension? Yep. Any other types? Secondary. Yeah. Well, do you What do you mean by secondary pneumothorax? What does that mean? Dramatic is, well, brilliant underlying lung disease, Pretty and yeah, that's great. So, yes, so there's, um, different types. So we have kind of are spontaneous, which can either be a primary, which suggests there's no underlying disease or anything like that in this case. Or it could be a secondary, which, as you guys said, is when there's underlying just diseases like COPD. One of the ballet could have ruptured, and that's released. A religious thing caused the pneumothorax. Um, so that's kind of your spontaneous type a Z you guys and they're due to. There's also a traumatic type. So if there's any kind of trauma to the chest, which in this case that wasn't that's another type of pneumothorax that can either be due to blunt, blunt trauma or like penetrating like a knife, stab wound or anything like that Or it could be something I actually can it cause you guys want to put in the chat. So something like a long biopsy may also be like a traumatic pneumothorax. Um, so I've alluded to some on here. Did they won't know the signs of a pneumothorax on examination. What would you expect to find hyper residents pretty and reduce our entry? Yeah. Amazing. Yeah. So there's those different ones you can get. You can get an asymmetrical chest expansion just simply because where the air is building up between the layers of the pleura, it means that the lungs can't expand as much as they normally would on do. Therefore, when you check the chest expansion and you're gonna have reduced chest expansion on the affected slight side, um on percussion is you guys said you can get hyper residence on. That's just because there's a below where your Percocet things. So there's a decreased decreased tissue density. That's what's making it like a higher resident. When you do that, um, he also is, in this case, you have decreased vocal residence or decreased tactile from a tous, Um, and you can also get absent breath sounds just because there's no long tissue directly below way, your auscultated and therefore you don't hear the breath sounds as well. Um, and you may also notice if it's something like a tension pneumothorax you might get like a displaced apex, the or something. Where there's been a whole mediastinal shift of the chest on the apex, but it may not be in the normal place. Um, one thing to know is on examination as well as the trachea. Yeah, people have mentioned it in the chat. Pretty. And what does that mean? Why is the tricky important? Yep, it can be deviated yet, and it's another. It's indicating. Yep, tension, pneumothorax. And that's something we really wouldn't worry about. Brilliant. Okay, I'll next one. So we have a 71 year old man he presents with a one day history of severe dyspnea. On examination, there's course crackles bilaterally of the lung basis, a raised JVP and peripheral pitting edema. A previous echocardiogram echocardiogram showed a reduced ejection. Fraction of the heart. So what we're thinking? Oh, lots of different ones. Pretty in so called pulmonale. A heart failure, congestive heart failure, hoping helpful. Yet, yet you guys got it pretty. And so I've said this is a cute decompensated heart failure, But you guys, that's have primary Deemer is completely right where they've got the course crackles. That's suggesting that some fluid is backing up into the lung tissue because he's got a reduced ejection fraction, so the heart isn't pumping out as much. So therefore, the fluid backs back into the lungs and causes this kind of flash Palmer gee, a Dema. The JVP is also raised because it's so bad that it's backing up into the venous system which can cause the JVP to raise. Um, I'll also the peripheral pretty edema for the same reason in that it's backing up even more and it's your causing fluid back up right down into the legs as well. Um, does anyone know what the classification of this heart failure would be based on the echo? What type of heart failure, if you like? Yeah, billion Have half a ref. Yeah, so in the old, in the old classic Asian for you, it would be like a systolic heart failure. But yeah, I'll tell you, with reduced ejection, fraction does they won't know the cut off for that in terms of ejection. Fraction 40 here pretty in weather, guys, it's amazing. So our next on a 62 year old man presents with dyspnea on a dry cough after a recent infection. On examination, he had stony dullness to percussion and reduce LDLs quotation of the right lung base. Radiant. Yeah, those of answers coming in for this. Really? Well, don't see that this is a purer A fusion s O where I spoke about recent infection That's hinting towards a pneumonia which can be a common cause for a pleural effusion. So short of breath has gotten, um, non productive dry cough. He's got chest pain, and they are really common. Presenting symptoms that you'll find with a pleural effusion on a stony dollars to percussion as well is really classic. That's just because where your Percocet there's fluid under where you're cutting on because the fluid is more dense than little tissue. That's what makes it sound more dull. Um, you might, um, as it says here, you might want to get reduced entry on that's months again because there's fluid between where you're listening to on auscultation on the chest wall on where the lung tissue is on their four. You won't hear the air entry as well assay you as you might might do if it wasn't there. Um, and you might also get a reduced chest expansion for the same ruthless and pneumothorax in that the the lungs of being compressed by the fluid. They can't expand as much, and therefore you get reduced chest expansion on on that side. Does anyone know? So I've alluded to a pneumonia here, and that's kind of the most common exudate ivo form cause of a pleural effusion so they won't know the most common transit Ativan cause of a pleural effusion mixture. Okay, yeah, there's there's different ones on. Yeah, the one I think that's coming up the most in the chat is heart failure, which is correct, although those that suggested malignancy, that's that's good as well. So on next one. So a 56 year old woman presents with gradually worsening dyspnea have BP is 97/68 millimeters of mercury notice the vessel in her neck is raised on our support. A shin you struggle to hear heart Sounds clearly past medical Straight was an Emily two months ago. You see, GI shows altering heights of the curious complexes. Any ideas what this is? Oh, yes. Sorry. Malignancies. Exit dated. Apologies. That's a common cause of accidentally off the menu. Yeah, pretty. It wasn't everybody. So cardiac template. So does. Then we'll know what triad. I'm alluding to in that, um, vignette. Becks tried fabulous. And can anyone put in the trap? What extra it is, But what's it made up off? Yeah, pretty and muffled heart sounds price. JVP on hypertension? Well done, everyone. So yeah, you get the It's a in cardiac temporal. The there is kind of a fluid or blood or something like that That's surrounding the heart, Which means that it's kind of compressing on the heart it can fill as well. It can't contract as well. So you get your low BP because you're getting where the heart's being constricted. You get less cardiac output. Um, you get a raise you JVP? Because where the heart can't pump a swell blood fax up into the venous system on. That's what causes the JVP to raise, which is what I alluded to with the vessel in her neck being raised and then the muffled heart sounds is quite senator before where you've got the fluid surrounding the heart. You can't hear the sounds of the heart as well auscultation does. They will know why the past medical history of an MRI is significant. Yeah, brilliant. Yeah, is simply that so um, sometimes after an MRI, you can get pericarditis on. Then that paragard diet is coming cause fluid just gradually accumulate in the pericardial space on which can then lead to Cali. Attempt on. Does anyone know what the easy GI finding was? The addresses bottle guys, A Melo that's cool turns here pretty. And so this is where the amplitude of the curious complexes basically changes. When you get any CDs of one might be taller and the next one might be shorter on. That's just because where the heart is in this kind of fluid fluid, it can sometimes swing, um, in that fluid where the heart is suspended. So when that happens, the electrical signal that you get on an ETD depends on how close the heart is to your E C D leads on the chest wall on. That's where you can get the different um, amplitudes in the curious. Brilliant. So next 16 year old man presents with severe abdominal pain. On examination, there is rebound and percussion, tenderness, guarding and rigidity. Previous to this, his abdominal pain was less severe, but he had not past freighters or story in five days past medical history of colorectal carcinoma. Any ideas? Yeah, lots of ideas here. Yeah, lots of ideas on the chest. X ray funding is all pretty. And yes. So this is about perforation, which in this case is secondary to a large bowel obstruction. So the rebound on the percussion tenderness and the guardian, the rigidity, they're all signs of peritus. Um, which is basically where you got the information of power paratonia, um, on the part about lot passing flatus. That's suggesting that there was a balance structure on. Therefore, the reason for the parrot is, um, is because of a bowel perforation. Do they won't know the significance of the colorectal carcinoma. Why? Is that significant? Yeah, pretty. And someone's got it. That's amazing. Yes. So a colorectal cast normal correct answer is the most common cause of the large bowel obstruction. And I think some of you guys have beat me to it in the trap. But what's the name of the chest x ray finding that we'd be looking for brilliant? Yeah, pneumoperitoneum, which is basically when you just get a run, the the diaphragm on what type of chest x ray do you need to assess that erect. Yep. Super quick. Amazing. So that's when uh, yes, I never had chest rates. X ray. Let me is the patient needs to be standing up, and that's just so that the air gradually rises to the top of the peritoneal cavity. Well done. So our last one. So we got a 26 year old man he presents to any by ambulance after a road traffic accident. He describes a severe, sharp, right sided pain. Um, in his trust, you noticed that when he inspires a part of his chest, more moves in words. What do you think this is? Yeah, pretty. And loads of correct ounces in the chart. Good job. So, yeah, this is a suggestive of rib fractures. A Z guys will said, like a flail chest. Is the flow test for those of you that haven't heard of? It is basically when you get these paradox school movements of the chest, when you have multiple rib fractures on gun, you have those ribs, fractures. What happens is a bit of the chest wall kind of unattached from the rest of it, because of where the rib fractures are. And that means the normally, when you inspire your thoracic pressure. The pressure inside your chest cavity goes down in order for you to have a sucked into your lungs if you like. Whereas if you've got a flail, just a bit of your trust that isn't attached to the wall. What happens is normally when your chest more your chest wall moves out words as you inspire as you try to increase your thoracic volume. But because you've got a bit of flailed segment that isn't attached, doesn't working with the ribs to do that. It's pulled in words because of that. Decrease in in pressure in the chest, so you'll see a difference in how the chest wall moves. So brilliant wasn't guys so know that we've gone through some spot diagnoses? Let's get on to chest X rays and presenting them. So I'm sure you guys have heard. But when we present a chest X ray, we want to take an A B C D E approach. So that's airway breathing, cardiac die from and everything else. And then after that, we look at our review areas and we summarize our findings. So in today's session, what I'm going to be doing is working through these different areas. Some of the pathology is that come under each of them. Um, on do if I ask you any point in the session to present a chest X ray will be going through some examples, and this is the structure of the A B C D. Structure that I'd like you to use. But before we do any of that, what do we need to say before we even look at the chest X ray before we even start looking for pathologies? Yes. You guys have being to a lot of our skis. Actions, you know? Brilliant. Yes, sir. Patient details. Yeah, everything that the name date of birth, age, anything you'll give him. Like the sex. Yep. Hostile number data scan. And you guys have got it in. And you'd also offer to compare to any previous imaging that they've had. Um, that's pretty good. Swelled. Um, anything else you do specifically for a chest X ray? Some of you have alluded to it already. Yeah, the quality of the chest x ray Do they will know on acronym that we tend to use for, um Okay. The image quality, right. Brilliant. Yep. So we're gonna quit. You go through right for assessing image quality on this stands for rotation, inspiration, picture area and type A nexpo jher. So let's start off with voter a shin. So the first thing that you need to know about rotation is that the medial borders of the capital need to be equity equity stint from the spinous processes of the vertebrae on. That's to basically ensure that the position of the chest X ray is central to me that your left or your right sides of turned forward in any way. Um Andi do they will know why That's important. Why? Why do we care about rotation? Yeah, pretty it. Yes. So it congested or the size and position of certain structures. So we talked about like the problem with heart size with our picture types. It's a similar type of thing. It can distort structures and where they are, like if your trachea is deviated, things like that, you can't assess it properly. Yeah, brilliant. Um, it may also affect the density of certain structure that as well, because of where tissues overlap eso you could wrongly interpret that as a long pathology, which obviously we wouldn't be very good at all. Um, another thing that we need to check for in rotation is that these finest processes are vertical within the vertebral bodies once again just to make sure that the spinal column is aligned. And it's not going all over the place. Um, brilliant. So our next one is inspiration. So when you're looking a chest X ray, you need to appreciate that. We see the ribs in one of to waves. We have the anterior ribs, which are the ribs curving downward and forwards of it. If you think if you asked me the other ones coming forward on that's represented by the yellow on this diagram, and then we have our posterior ribs, which are the ones that are more horizontal, is have shown inbred here, and they tend to be the ones that are probably easier to see. Does anyone know how many ribs there should be if someone has adequate inspiration on the chest X ray? Yeah, pretty. And there's there's always a bit of a debate, and it's quite hard sometimes to remember the numbers. I tend to go with about 5 to 6 anterior ribs on 8 10 posterior ribs above the diaphragm. A swell in inspiration. What? We need to look for us to make sure that, um, different parts of the lungs, uh, visible to make sure that we've got enough inspiration in that way as well. So we need to make sure that we need to see the lung apes sees. We need to see both Cost a phrenic angles at the basis. Um, and we need to be able to see a electrolyte parts of the ribs as well, just to make sure that we've got enough in our picture to be able to see um, and the same one know why it's important. What do we need? Adequate inspiration. Why is that important? Yeah, brilliant. I've had some a message. Me. That's right. So if you've got someone with, like, a bigger inspiration, um, that generally results in better images just because it shows more of the lungs and there's more to say also as well. It can be a bit less hazy. A swell, a little long basis is well, brilliant. So then we have our picture Aaron pitch tight. So we said we need to state whether the film is a a pea or PA, and we've said why? That's important. If there's no label, then you assume it's a p A film. Just cause they're the ones that are more commonly done on a PPI tends to be more in patients that are unable to mobilize. And they're in bed and they're using, like a portable X ray machine. One way to check is well, which I have marked on here. So this this image is an AP view. If you look for the scapula, they in a pa view won't be visible over the long over the very lateral aspect of the lung filled on, but in in a a pea, you may be out to see them check for that. And then finally our exposure. So our exposure is basically a measure of penetration. So how much the X rays are passing through the body? Basically, um, on the key role with this is that the vertebral body should be just about visible through the lower part of the shadow of the heart through the cardiac said, Oh, um, is if we look at these images here in the left image, you can't really tell the difference between the heart and the vertebral bodies. Very well. Um, you can't. It's a bit hard to differentiate, whereas in the right image, you can almost see them too Well, it's a bit of a balancing act, Um, but you want to hit the sweet spot where you can just about see them through the lower part of the cardiac center. It's a good I hope that makes sense. So now I'm going to be going on to a our first bit of our ABCDE approach on some of the things that we need to look at for under the category of airway esos you guys have already talked about in some of our pathologies, it's really important to look for the trachea. Um, this should be central, shouldn't be deviated. It's sometimes it could be slightly positioned towards the right lung just because of where the aortic arch is. But generally it should be fairly central on defense deviated. It suggests that some pathology is pushing or pulling it sideways. Does anyone know any pathology? Is that pull the trickier to its side? So if there's a party on one side, but which of those villages positive care towards up collapse. Brilliant. Yeah. Brilliant. Yeah, things like collapse words. Yet consolidation is well, brilliant. Yes. If you have quite a big consolidation or pneumonia or anything like that, I will pull the trickier that way. Can anyone think of any pathology? Is that do the opposite and push the Tracleer towards the other side of the chest? Yep. Tension, pneumothorax. Anything else for a fusion? Yeah. Brilliant. Those are probably the main two. Um, on Get anyone think when the Kia may look deviated on a chest X ray, but it might be straight in real life. What? What problem have we got there? We just talked about it. Any ideas? Yeah. Rotation. Fabulous. So, yeah, if the you might have a trick here, that looks deviated, but because of the rotation of the patient, they are fine. So just make sure to check the medial end of the kava calls against the spinous processes to check for that great job. Then we need to look at the carina. So the carina is basically the cartilage found at the point where that you cared divides into the two left and right main bronchitis. And it should be visible if the chest X ray has enough exposure. So have a look for that. Then we should look for the like, the left and the right main broke. I just check their okay on then. Finally is well, the Hylira eso The hilum is basically the main kind of pulmonary vasculature. The bronchiolitis codes. They're going into the lungs. Um, and usually it's no very visible. The left hilum. If they are visible, the left column. It's slightly higher than the right. Um, but usually they're size. They look pretty symmetrical if you are able to see them. Does anyone know any pathology? Is that cause the highlight to, um, in large sarcoidosis pretty and yeah, lechon C is well, brilliant modern. Okay, so let's start going through symptomologies. So can anyone tell me just spot diagnosis of you? Like looking at this test X ray? What are we thinking? Could anyone spot the abnormality? Okay. I can see why people put COPD because the, um the, uh, die from that quite flat. Anything burning when we're thinking about airway? Brilliant. Yes. I was picked out a deviated pretty and yeah, yes. Well done. Yep. You guys have got it. So it's a pneumothorax. And because of the tricky or deviation, what can you be? A bit more specific? Tension? Pretty it yet. But I'm guys see how this is a tension you month oryx and so attention. Pneumothorax is basically the presence of within the floor space as we said it, beginning between the two layers of the pleura separating be lungs in the chest wall and the important bit for attention pneumothorax is that there must be signs of mediastinal shift. Um, so how does it happens? It's usually caused by a thoracic drama. What generally happens is that when you have that trauma to the chest, it creates a one way valve that let's into the pleural space during inspiration. But then, um, when you expire, that valve is color. Snapshot on the air is trapped in the floor space on there for each time you breathe in, more and more accumulates in the pros base with each breath and it can escape, and eventually that creates lots of pressure. I've done this diagram here, so like your oranges, like your chest cavity. If you like, your blue is your lungs, and if you saw it slowly, shrunk is more and more air was accumulating in in the chest cavity. On what happens is more pressure builds up in the thorax. It pushes the mediastinum away. It can kind of cause big problems like causing kinks and let the big vessels and causing cardiorespiratory arrested things that that's not good. Um, does anyone know any signs and symptoms of attention? Um, it works. What things would we think? Oh, this is This could be attention when you're Yeah, pretty insurance of breath. Any examination findings as well? Tricky and deviation yet just just yet. Just extension on the affected side. Hypertension. Yet you guys have got a good long list. Pretty in Onda. Obviously I've shown your test Chest X ray here. Attention, Pneumothorax. Broadly speaking. Should we have this? Should I have been showing you a chest X ray? Attention? You with the legs? No, her like that. Big capital Know why? No. Yet isn't emergency. Don't wait for a chest X ray. If you're suspecting it clinically, then you need to start the management. Don't don't wait for a chest X ray on. Do you guys have already spoken about some of the findings on the chest? X ray as well. So we've got this mediastinal shift so you can see kind of the heart is moving towards the right side of the chest. Here we got the tray here that I have outlined that's become deep. Deviated the Hemi die from can be depressed. I can see why a lot of you thought it was so pretty. You can also get that in a pneumothorax. Attention pneumothorax on something. You got a swell pointed out the blue line that I put him in the started line as well. Brilliant. So what is the immediate management of attention? Pneumothorax say Well, no after you, like, don't you write a Yeah, brilliant. Yet so decompression. Brilliant second intercostal space midclavicular line. Brilliant. So you need to insert a large ball like 14 gauge Kanye into the second intercostal space midclavicular line. That, as you say, is like urgent needle decompression. It quickly relieves the pressure short term, but it's no no definitive way of fixing the problem. You need to then go into a definitive management which does Then we'll know what the definitive management is. Yeah, brilliant. Well, don't guys yet? Tester chest pain which will then remove the, um, because if you just did the, uh, decompression, it would just refill pretty well done, everyone. So this is in comparison to a, um like a non tension in the thorax, which I grabbed a picture of here S O is You can see there's no trick. Your deviation here. There's no mediastinal shift. The heart is in the right place. Um, but you still have some of the similar chest X ray findings in that the lung markings, if I put on the floor line, is where the lung markings don't extend to the peripheries on. You'll see this blue lines. If I go back, you kind of see this blue line here which shows you at the edge of the pleura and the lungs. So make sure to keep your eyes out for that. And we mentioned it is well in our finals. Easy sessions. But men remember for the management when you're measuring the size of a pneumothorax, measure it at the level of the highlight. That's like the normal way to do it pretty in on. This is kind of a summary of how we manage a spontaneous pneumothorax. I went go with right now, but basically in a nutshell, Uh, so if it's a primary pneumothorax on the patient has a remember that you've measured at the level of the highlights of less than two centimeters on they're not short of breath. Then you can discharge and see them in outpatients in about 2 to 4 weeks, whereas if they have, um, greater than two centimeters, remember or they're short of breath, then you should aspirate, Um, And if that fails, chest chest rain. If it's a secondary cause, then if it's less than one centimeter oxygen and admit for 24 hours, want to aspirate on? Also, admit for 24 hours, and if that fails, months can do a chest. It just rain. And if the rim of air is greater than two centimeters or the patient is short of breath and then you go straight for a chest rain, admit them is wealth 24 hours. Brilliant. So carrying on with our airways, all these policies are related to airway. Can anyone spot the abnormality with this one? Quite a snake. You, um, so if anyone's fault, say, I'll be very impressed. But we're thinking about a way not to do with the highlight. This one? Yes. Some people have got it Well done. Yes. Something in the hour. Yep. That will do. Brilliant. Yeah, it's a foreign body. It's quite a sneaky one. You can just about see it here. So this checks a chest X ray issuing a, uh, it's actually a needle like sewing needle in the kind of right lower zone, eh? So this is an inhaled form. Body is common in young kids because we know what your kids do. They put things in their mouths, and sometimes that can cause them to inhale of foreign body. And does anyone know any signs of symptoms of a foreign body? What might someone present with a Maybe it's a child, and they can't explain what's happened. Yeah, pretty. It's dried. Uh, Anything else? Dyspnea? Yep. Yet they might be coughing. Yeah. Yeah, Pretty. In those days, Yes. They, as you say, they might be coughing them. I've strider. It might be like choking if it's further up. Uh, I have no my have voice changes. They might be, like breathing. Quite have any, like, technique on. Did you say they might be short breath as well. And why is the fact that it's in the right right side of the chest in that done is going down the right bronchus? Is that important? Do you think that's significant? And asked me, Yeah, what do we know about the less me of the right focus? Yeah, yeah, brilliant. So it's It's wider, it's shorter and it's more vertical than the left. So if foreign body is coming down and it's coming down to the pre no, it's about to go down one. The bronch I The right one is wider, so it can be more easily get down there on gets shorter and it's more vertical, so it objects more more commonly and go down that side. Eso particularly look on the right hand side. Um so, obviously is a alluded to the signs and symptoms depending where the foreign object is s o. Can anyone tell me what the management would be if someone was choking in emergency? There's been a foreign body that they've inhaled on. It's like further up. So, like your first aid management, what you gonna do? Some ones from choking yet pretty in Austin to cough. Ready? Good. Yeah, lot of you guys are saying like Heimlich. Yeah. So you would be doing your like You don't yet. Your five back blows And five after little fast, brilliant and the same one. Know, if it's like in this case, it's gone further down. Do we know? Does anyone know how you manage that? What? We'll be doing this case to get the needle. Yeah. Amazing. Yeah. So, yes, we would secure the airway first. We want to, like, make sure the patients okay without a PCG. Definitely, but yeah, it's so it would be a bronchoscopy. So that's basically where you a thin tube into the trachea down the relevant bronch I with the camera. And it also has a tool to pick up any tissue or objects is going down there pretty well done, everyone. Sir, On this next chest x ray. So this time I don't want you to look for a pathology, but I specifically want to focus on tubing on tubes that you might see the chest X ray. So can anyone pop in the chat? Any of the names of the tubes that you can see on this chest X ray? Yeah. Brilliant. So we can see. We can see some STD dates. Yep. Chest drain. Fabulous. And J and et tube is Well, yeah, brilliant. So I'm gonna start off going to kind of work through these different troops because I found it initially very confusing. Um, so to start off with, you have, like, a nasogastric tube eso the nasogastric tube. I've just marched the division of the to bronchitis in this kind of a V shaped just See, you can see it. Um, that's obviously where the carina is s. So the nasogastric tube is this tube here that I've marked in the yellow on. But it's basically a flexible rubber plastic troop that's passed through the nose down the esophagus into the stomach on diets usually temporarily place there just to deliver substances such as, like any medications or anything like that, or to remove them for from the stomach. So if some of the difficulty swallowing, then you could deliver things that way, Or if someone's got stomach contents that you need to remove, say, someone has like an intestinal obstruction, you want to decompress it, Then you would insert the treatment, get out that way. But the important thing for us to remember a chest X rays is that they usually order to check that you've got the N G tube in the right place because you don't want to start using the tube until you know you put it in the right in the is in the stomach. Basically. So I've marked the Carina on here for a reason, so they won't know why the Carina is important for MG to placement. Yes, it's enduring proper placement. Yes, so brilliant people put it in the check. Amazing. So, yeah, the energy to should travel past the Carina If it's in the G, I tracked a zit needs to be in stomach needs to be below the diaphragm because you guys have said we don't want it being in the respiratory system. We don't want to start putting any like, um, like like foods like bike medications or anything like that in the respiratory system, that would be very, very bad. So, yeah, we need to make sure that it's below the Carina and below the diaphragm to confirm that it's in the right place. Um, let's say that can cause lots of issues if it's if it's not so great. So on next to Does anyone know what the name of this truth is? You mentioned it before, but I've just popped a different up. Yeah. Brilliant. Eat each tube. Fabulous. Is it placed in the right place? No, no. Lots of notes. Why is it not placed in the right place? What's wrong with it? Needs to be higher up. Okay. Too low. Yeah. Brilliant. It's below the Carina. Fantastic. Yeah. So can anyone tell me where the truth is? Now was the tip of the tube, right? Main bronchus. Fabulous. Yeah. So, um, endotracheal tube is once again it's like a plastic tube on diets. Usually place kind of, but, like, below the vocal chords into the Kia in order to provide oxygen to both lungs prevent, like, other contents getting down into the lungs, like from aspiration or anything like that. As you guys said, it needs to be placed above the Carina. Does anyone know roughly how many centimeters it needs to be above the Carina? Like how? Yeah, brilliant. Five. Yeah. Brilliant. So yet we aim for about 5 to 7 is what they say centimeters above the carina, just to make sure that, Um Well, you guys tell me what? What would the issue be if it was below the Carina? It was only going into, um, say in this case, the right main bronchus. What's what's the issue? Or two intercostal spaces? Thank you. Thank you for that, guys. Yeah, So you'd only be ventilating. You'd only only one long but be getting ventilator because there will only be traveling into one bronchus a Z. I said it can also cause a collapse of the other Long as well. If it's not perceiving oxygen, which would be very bad on Is the bright main bronchus significant again? Why? Why is this why I send you picture over the right main bronchus? Incorrect in session thing that's relevant. Is it more likely to go on one or the other? Yeah. Brilliant. Yeah. Is more anatomy? Yes. Is more like it's going the right for exactly the same reasons as it was that before, with the foreign body Fabulous. Well done. So on next one, what tube have we got here? Does anyone know? Yeah, we got the EKG leads. Any ideas on the tube? Yeah, There is an N g. I've been a bit sneaky. There's another one that had mentioned that we mentioned before. Yeah, test during fabulous um, So for chest rain, it's function is usually either to drain a pneumothorax or pleural effusion. Do they will know someone to put in the chart earlier? I did see. Where do we insert Just rain? Yes, Safety triangle. Trying of safety, Pretty and say, one of the borders of it. Fifth intercostal space. Brilliant midaxillary line. Yeah, the other border is three. Yeah, so you can either do it, um, by the but the lines, or you could do it based on the muscles. So it's either the if intercostal space midaxillary line on anterior axillary line. Or it's the inferior nipple line, the lateral edge of lettuce, mist, or C, or the lateral edge of pectoralis major. So but on guys on, where is the needle inserted in relation to the ribs? Is it just above just below, above, above, above pretty And and why do we set inside it just above? Yeah, pretty, it's We want to avoid the neurovascular bundle, but it's running just below the lips, the ribs Sorry so free instead of just above. We're not gonna damage those at all, said once again, a bit like before. Once we've inserted Chester and we want to check by chest X ray that's been positioned properly as a general rule is a very general rule if you're draining a new math or it's typically, the tip of the N G tube is aimed more superior early in the lungs. Where is when it's straining? A pleural effusion? The tip is usually located towards the lower part of the floor cavity, just simply because when you're draining a fusion, you're draining fluid, which because of garbage, the falls to the bottom. And so in this case, they're draining a pleural effusion because the tip of the test range is in the medial costophrenic angle. So and that's it for a pneumothorax is where you can see it's a bit higher up. Amazing. So our last pathology that I wanted to pick up airway did they won't know, see any abnormalities with this one? Yeah, something to do with the mediastinum. Yeah, pretty. An enlarged Tyler. Brilliant. And someone's already put the diagnosis really well done. So, um, there is highly, uh, enlargement high lymphadenopathy on this case. It's bilateral, which is a drug alluding to is often seen in sarcoidosis. Eso sarcoidosis is a disease, Um, made me characterized by gross of these granulomas, which is basically like the collections of inflammatory cells containing lots of macrophages and things like that on did happen anywhere in the body bit quite often affects the lungs and the lymph nodes, and people get loads of different symptoms all over their body because it's a effects anywhere. But in the respiratory system, it can cause the shortness of breath and non productive cough eso we said bilateral hilum lymph adenopathy that is the most common chest actually finding you will see. You may also see primary fibrosis, and you may also see a pulmonary nodule. Um and so But you have that wanted where the, um, highly lymphadenopathy is have shown the upper lobes. Fibrosis is well, there's also stage it staging for this checks X ray that you can know, but this is probably a bit too high yield. Uh, probably two detailed, but it's there if you guys, if you want to read it in your in time. So we've kind of gone through some airway pathology. So now I wanted to let us have a go kind of presenting and interpreting it. Just X ray s o. I mean, you want us to follow the structure that we've gone through Severinsen prompts there. Could you guys start itself? So start to interpret on this chest X ray for May for me from the beginning, using those prompts on the left hand side. So what, we're going to start off by saying, Yeah, pretty insulins give him something. Yep. Chest X ray. Mr Peter Pan on a 21 year old male. Great. That's pretty good. Yeah, And then you guys have gone into airway. Is there anything else you want to say? You've introducers introduce the chest X ray? Anything about right? Anything. You just comment. Any comments? Yeah. Describe right. The airway. What were you saying about airway So that your kids deviated to the right? Yep. Yeah, yeah. Brilliant about on guys. Yeah, right. That's fine. Tomorrow I was just suggesting that you should talk about right. That's fine. And you guys, the counter diagnosis Really good. So this is an example. One. I'll quickly read through the main point. So as you go, I said This is a chest X ray, Mr Peter Pan, a 21 year old male. Same when it when it's taken at this point of like compared to any previous imaging, then you need to talk through Ripe. I appreciate it a lot to do in the chat, so I don't worry, but talk a little sentence on each one's like there's no rotation or there's minimal rotation cause of this. Um, because there are consistent. There's enough inspiration because it's how many ribs I can see. What a projection is, is the exposure okay, in this case, yes. Is, um, and then what I've done here is I have highlighted in yellow all the kind of pathological things that I've seen with this chest X ray. So you guys smashed it. You said the tricky is deviated to the right. Um, there's a Then if we look at the lung fields, there's a pleural line marking the edge of the long left lung, and the lung markings don't extend to the lateral chest wall in all the lungs owns and then proceed. The main allergy that we picked out is the card actually isn't very well defined. It's been displaced to the right as well. On the left, Hemidiaphragm is depressed under D on Go under. Either is everything else the mediastinal shift towards the right side of the chest cavity. And as as you can say in white, I've just include all the normal things. You'd say those as well. I think they were there in yellow. They were the main things that you guys picked out really well done. And then you just summarize. So I reviewed this chest X ray, um of Mr Peter Pan, a 21 year old male taken on the 21st of April. My positive findings are trade your deviation and mediastinal shift to the right based on the patient's presenting a plate of shortness of breath. My top different diagnosis is attention. You with Oryx. This is the structure I would juice for interpreting a chest X ray, and hopefully that will make sense. So well done. You got through Airways. Let's take a little bit of a breather, and then we'll go on to the B and C parts of our, um, chest X ray interpretation. So our next bit of presenting our chest X ray is breathing eso the main things that you need to look for in breathing are the lung fields on the look out for any allergies to do with the pleura eso. When looking at the long fields, I tend to divide this into three zones, occupy about a third of the height of the lungs. What I want to emphasize is this is not the same as lobe. So you can see on this image here the different loads of college in different colors. And as you can see, if I labeled the zones, they're not the same. It'll, um so just remember that the right lung, um, has three lobes have the superior, the middle of the inferior, and the left has to be superior in the inferior. On a chest X ray of the looking at the right lung on a chest X ray, you maybe see the superior in the middle lobes. You don't really see a lot of the imperial on once again. Look at the left side that you made me see the superior low. You don't see a lot of the in fear one a tall so you can either described by lobes but often zones easier um, the main thing for this is just comparing for symmetry. That's my biggest tip. So, obviously in the chest there's some natural asymmetry anyway, for example, with the heart. But generally when you look at the lung fields, compare, like, for like on each side. And then that can help you pick out, um, simple pathologies. But as we just shown for boys sarcoidosis, sometimes you get pathologies that bilateral. So it's not a 100% working technique, But generally, if you compare side, side beside, that's pretty good. Eso Comey brainstorm in the trap. Any pathologies or findings that you might see in lung fields? What would you be looking for when you look in the lung fields? Consolidation? Yeah, Brilliant. Which could be a sign of pneumonia. But in absent markings. Yes. We told you about pneumothorax yet? Brilliant. Me know Jo's yet? They can say yet would also be seen in consolidation. Yeah, yeah, really good. Two guys. So yeah, Generally, I look for things that consolidation, which could be a sign of pneumonia or malignancy. Um, look for any fluid on looking the cost of carrying angles. Are there any kind of infusions? Check the lung markings, especially on the lateral aspect of the chest cavity. Once again, looking for pneumothorax, check for any other masses or lesions or anything like that. I think that cancer on and check the size that long codes as well are they hyperinflated which, as you guys have said before, could be a sign of COPD. Then, as I said here, we want to check the pleura. So, as I've said before, the PLEUR aren't usually visible in normal, healthy individuals, but do they wouldn't know if the pleura peer thickened and they appear visible. What's that common sign? Sign off. What could that pathologies could that be suggesting? Yeah, he's a teeny over. He's a big one. Yeah, it's also saying yet and things like TB I'm seem a hemothorax. But yeah, I'd say means that the number is the big one. Pretty in while done. So can anyone tell me what pathology you see here? Yeah. Brilliant. People were already doing really well. Yeah. So this is a right up his own consolidation on down, Uh, what's the most common cause of consolidation because of already said it? Yeah. Brilliant. Pneumonia. Well done. Um, so I said. This is a consolidation of just outlined in yellow there for you. So consolidation basically occurs when the air spaces but in the alveolitis come filled with, like a dense of material than airbase ically. So, in a pneumonia, this could be like a X. I dated a posse. Kind of fluid contains lots of inflammatory cells, but you can you can get other causes of consolidation. They won't know any other causes of consolidation that you might get consolidation for any other ideas. New Mayor is the big one. Any other reasons why you might get a consolidation? Yep. Tenses one pretty in yet other infections. Brilliant. Yeah, great. So you might get it because of, like, a pulmonary edema, In which case you're getting like a watery fluid filling up the albuterol. I you might get it in like a kind of, ah pulmonary hemorrhage. So if one of the blood vessels and supplying different parts of the lungs first and you get blood, fill the Advair and I, you guys said, then you close to get a bone cancer appearing like consolidation on. That's when you get like cancer cells, filling up the lvot I or various other materials that might cause a consolidation. Um, generally for pneumonia when it's like a infected cause, the consolidation generally stays in one lobe. Does anyone know why? Why does it tend to stay in one, though? Yep. It is to do with and ask me any advances on the next May. Yeah. Brilliant. Yes, sir. Um, your pathogen, whatever is causing this infection, it spreads through the different pause in the alveola, which can cause it to spread from alveolus. Salvio this But you guys have said there's a pleura covering the outer surface of each of the lobes on drum Ember. The pleura kind of covers round each load. It doesn't just come around the whole lungs itself, so it prevent it from spreading from adjacent loves. Um, another classic sign that we see in consolidation is something called airbrush Grams does. They will know what they are. Have marked one on there. That helps. Yeah. Brilliant. Yeah, well, don't. So it's It's the within an area of the lung that's consolidated. The lung tissue, as I said, has become more dense on by as it fills up with material inside the albuterol. I But as you guys, I said There's conducting airways that spared eso. They still remain that low density, that dark color so you can get these kind of black markings within the white whiter consideration to look out for those because that could be a classic sign of a consolidation of the checks. That's right, Onda. Um, I've talked about this before how we can either use owns or lobes to describe the site of consolidation. So, as I said, you can only use the lobes three only right side and the two on the left. But, um, you can also use the zones as well. So I just put on here kind of what structures each low borders. Just see. You can identify the load if you did want Teo describe the lobes when describing the site of consolidation or any other pathology. So in this example, the patient did have a pneumonia. So just to quickly chap through, because you might get lost in your skis about the investigations in the management on does they won't know any bedside investigations that we would do for a pneumonia. Yet speaking coaches, oxygen levels. Brilliant. If someone came in really, um, well, in the last five. If you if, um, had it for, like a day also not. Not for a long time. Yeah, I'm getting lots of observations. That's really good. 80 Fabulous. That's always looking for brilliant. So yeah. 8. 80. Yeah. I think you guys have got the most of them. So 80 assessment If they're coming and acutely say that for any acute presentation, get loads of those basic labs that you had talked about. Your respect to examination generally in the CD is also used to offer patients with pneumonia on initiate the sepsis. Six. But you guys have talked about I know you guys have talked about a BG's. Any other bloods that you'd like to do on patient presented with pneumonia for suspected pneumonia? Fbc his knees. See all pay coaches. Yeah, pretty. And all of those are really good on. But also check that curb 65 schools while using those results. Um, I'm finally imaging special tests. Anything that you'd like to do Chest X ray. Brilliant. I'm glad that's been said. Yeah, yet Pretty and so Sutent, um, cultures. Brilliant. Yet, Cove, it is well, really good thing to check on you as we said a chest x ray. So I've written here and kind of the management of new Only I'll let you guys go through that in your own time as to how to calculate carbs. 65 where we manage patients based on nice timelines on DA the specific medical therapies that we give them. Great job. So our next pathology can anyone spot what's going on here? Yeah. Brilliant. Yeah. Brilliant. So bilateral pleural effusion. Really well done. Eso pleural effusion. Being abnormal. Collection of fluid between the two layers of the pleura between the prior to on the visceral. Any examination findings that you guys would expect to see with the pleural effusion. Start me donuts. Fabulous. Would you say run tree? Great decrease. Focal resonance. Yet you guys have definitely got it s I've listed them here. So you have trick your deviation away from the infusion. It's usually only seen in larger effusions on, But that's basically because, um, there's kind of mediastinal shift. Um, and so the trick here is kind of pushed away from the infusion where it's filling up like a volume filling up in space in the chest cavity and you get the displaced a prick feet for the same reason, once again produced chest expansion exactly the same as before. Lungs of kind of being compressed by the fluids. They can't expand as much. Stoney Donuts. Yep, so as he said, increased tissue density off the fluid competitive lungs that makes him sound more dull to percussion. Let's Custody described was like a stony don't nurse decreased October okra, Metis and vocal residents. Yep, just because the fluid isn't transmitting the sound as well. So it's decreased. A low dose breath sounds because there's less air entry. Um, brilliant. Any signs on the chest X ray? I saw one already in the chapped. Um what signs of a chest X ray suggests it's a floor effusion. Meniscus sollume. Brilliant, blunt e blunted costophrenic angles. Yep. Amazing. Yet the whiteness, the a plastic a shin. Pretty Yeah, pretty. I think you guys got the main ones I've listed for here. So looking for as you guys said the meniscus sign. So this is kind of like the sloping that you see do to the fluid where if you have kind of any fluid, that it kind of goes up the sides where there's a bit of occasion to the the storage container. If you like these in sushi a meniscus sign, you might also see fluid in the lung fishers, which I pointed out using these arrows. A said. I said Costophrenic blunting. So the cost for a week I was at the Boston of the chest cavity won't be a sharp on If it's large and unilateral. You may also get a mediastinal deviation. That's pretty in Do they want, uh, the two main types? How we cast by floor effusions? That's pretty. That's pretty good. Yeah, transit Ativan next state of brilliant. And so what I've done here is I've listed the common causes of each. So, as he said, before, heart failures, the main transit date. Of course, sir, I think of transit. Ativan is like more watery on then, in terms of exit Ativan. Most common causes pneumonia, but you might get other infections, malignancies, things like that. And as a general rule, transit Ativan are more likely to be bilateral and equal on a chest X ray on exudate it more likely to be union actual unequal on a chest X ray. So I know these aren't exactly equal. But this would be a transit a two because it's bilateral on there. Almost equal. Sorry, this theoretically, this chest X ray is most likely to be due to something like heart failure. And then I probably slide in for you guys to read in your own time just about the things you might need to know for finals or interpretations in Oscars for pleural effusions as to the values that you need to know pretty and so on. Expectolerance Any ideas on what this might be? Yeah, pretty. And there's a great answer is coming in. Yes, it could be. I think this could be one of two things s so it could either be a low low collapse, or it could be a a new, uh, a new Mexico. So starting off with the low bar collapse, this is basically the collapse of an entire lobe of the lung as names. Yes. Um, and it's often caused by an obstruction off the bronchitis applying that lobe. So if the lung is receiving any air, it's not being inflated. So it collapses. Basically, Does anyone know any causes of why I am? While there might be low bar collapse and it causes you might know foreign body. Yeah, fabulous. He talked about that earlier. That's really good malignancy. Really Big one. Yet regards. Yeah, I say. Those in the main two got a couple other ones tone in mucus, plugging fabulous. Yeah, So I'd say the main ones are lung malignancy, because your umbilicus, you might compress on the bronch eye on That's the most common cause off low bar collapse in older adults. You might get an asthma issue, I said, because of mucus plugging of the bronchitis that gets blocked visible the mucus that's produced thing that can cause a collapse. Um, foreign material, foreign bodies. As he said before. If that blocks the bronchitis and that because a collapsed And as you said before with the endotracheal tube, if that goes into the one of the bronchi, I, the contralateral, the other lung make lap because it's not receiving any oxygen. Pretty in. Um then, as he said before, the other one is a new tomato. This is the surgical removal off. A lung is commonly used in a primary lung. Malignancies where they're quite localized, have metastasized on the other. Long is doing okay and hasn't got any issues. Um, that's another differential that you might have. So you guys got to lowball collapse and pneumonectomy quite quickly. Um, what signs on a chest X ray suggests that it's one of those, too. What did you notice in the chest X ray that made you think it was one of those whites out yet? Okay, a deviation towards that white out. Brilliant. Pretty. And, yeah, lots of good answers coming in to see. Yeah, I'd say the main ones are you said the tricky deviation towards the, uh, collapsed lobe or the collapsed lung or the pneumonectomy outside. But that's occurred on just because there's less volume in that side of the chest. Eso that here naturally goes to fill that space basically on a similar reasoning for the mediastinal shift. There's less volume there, So the mediastinum shifts that way and allows the other lung to expand more. Um, you may also c elevation of the hemidiaphragm, um and sometimes know in the case of new elect to me where the lung has been removed. But if there's been a low bar collapse, you might be able to see the actual lobe itself is usually like triangular pyramidal shapes. And keep an eye Look out. Look out for that. Um, And if it's been a pneumonectomy is no Look out for the bronchitis where it's been cut off during the surgery. You might see that, but there signs that you might see on a chest X ray. Really Good job. So our next with ology. Any ideas on this one? What can you see? The top image was taken first on the bottom image was taken a a few months later. Any ideas? What, 30 am losing too? Yeah, pretty. And you guys have got the bottom one? Yeah. Brilliant. So malignancy perfect. So, um, on the top, we're looking at like a primary lung cancer. It's a bit hard to say. You won't be at ST just from this one image. I want to show you the one underneath, but you can see a new area of increased density here, which, in this case, was a primary lung cancer on gets kind of at the top of the hilar on the right hand side. Um, several. And here's some of the signs and symptoms that you might get with, um, primary lung cancer lung cancer so you can get him up to cysts. If the tumor starts to invade the airway, you get chest pain, shortness breaths. Be symptoms that we always check for in our histories. Could anyone tell me why they might get swollen face in lung cancer? What's that leading to? Yeah, brilliance, even superior vena a cave obstruction. So if you have an apical right sided tumor that compress on the superior vena Kaveh, and you might have heard of something called Pemberton's test, which is when you get the patients to raise their arms on, that causes flushing and swelling of the face. Um, why would they get wholeness syndrome or what could they get a hold of syndrome? What's happening to the malignancy there? Yep. Pankos Tremor. Yeah, What's it? What's it pressing on? What's what's irritating? That's causing Horner's Yeah, brilliant, sympathetic ganglion. Yeah, really well done. That's it. Yes, and then that can cause our prior to fullness in Germany. My roses on hydro cysts and Tosis brilliant on the horse voice. What's what's, um being affected there? Recurrent angina? No recurrent laryngeal nerve. Brilliant wasn't and they were low. The three, like main types of lung cancer that we commonly get tested on. There's quite a few different types, but the main ones that we don't normally get to some Yes, most yes. It's more so Non A non small cell, pretty. And then within the non small, small cell. Brilliant. Yeah, There's squamous cell on adeno carcinoma. Really? Well done. Um, so looking at this, uh, topic church here based on location, Obviously, we can't say for sure until any histology has been done. But has anyone got any guesses as to what type of monkey answer that would be squamous. So yeah, pretty. Why do we think it's squamous? So Yeah. Brilliant. So squamous cell carcinoma is tend to affect the large Central Airways in this case is near. The highlight is near the airways. That could be a squamous cell carcinoma, as it cost Normal. Went to that. You tend to present peripheries pretty in small, so yeah, they tend to be sent to a swell, but no as associated with the airways. Really Well done on, then. If we look at our bottom image here, you guys got it straight away. So these are lung metastases. Does they won't know what this Sinus called. You might see it in your finals or something like that. Cannibal. Yeah, Brilliant. So this is when you have multiple bilateral kind of severity, well defined lesions, varying sizes, mainly locating the pro freeze, that kind of across both lung fields. It's commonly seen in renal cell carcinoma, but it can be seen in other types of well, so make sure to look out for those. And these are some other cancers that commonly more tests I still love. But classically, if you see this, think renal cell carcinoma brilliant. And then this is just a summary side of the three main carcinoma of the lung that you might get in your exams, and I'll let you review this in your in time. And what I've done here is well, is I've just made a kind of, um, compare comparison off our differentials of kind of white pathologies that you might see it on the chest X ray. So we said you could see Palmer erythema. You could see a collapse when we have that white out before a consolidation on effusion or a mass on D. You need to know kind of the main features of each, which I have put in yellow for you on. But I think one of the easiest ways to different she ate is to look for those main features, but also look based on the trachea deviation. So I've written here Which ones, eh? So we have when we have our lung collapse or a pneumonectomy. As we said before, because of the loss of volume, little here deviates towards the white out towards the white lesion. Um, whereas if you have a pure blur, a fusion or a large mass that goes away from the white out on. But if you have a consolidation that's of an average size or ah Palmer erythema or a small mass that tends to know affect the trick, you know it, it stays pretty central. I think sometimes it's quite easy to, um, confused or collapse on diffusion because they're both uniform soft tissue kind of white densities that you might see. But use this trick, your deviation role to a different rate. The two cool. So our next pathology. Any ideas? What you can see here? No. Okay. Lots of different ideas. This is quite a hard one. I must have met. Yeah, there's a couple of correct answers in the chat. Ready? Well done. Well, don't have anyone that said, Palmer Fibrosis. That is correct in this case. So primary fibrosis is when you have lots of fibrotic tissue in the interstitial um, which is basically tissues that support the lungs of the valve, your liability a member capillaries and vascular lymphatic structures. Things that that another X ray, What you find is this ground glass appearance. I can see why people put prominent idea because it does look quite similar. But this is like the shadowing of the interstitial. So it looks. It gives like a ground glass appearance. So have a look at a few more chest X rays that have primary fibrosis, a diagnosis, and try and look for this ground glass appearance because it can be quite prominent exams on. There are different causes of primary fibrosis on. We tend to differentiate these into whether it causes fibrosis of the opposite owns or the lower zones. So, does anyone know the pneumonic that we use for the fibrosis affecting the opposite owns? You might have paid off, So it's okay. Chaos. Okay, I've had lots of different ones, but it's the one I use his charts so they won't know any of the answers to charts. As to what Those stand for TB. Yeah, Coworkers long at brilliant. Yeah. Brilliant. Yeah, I was on guys. Really good. So c stands for coworkers. Pneumoconiosis is This is basically when if people have been working cold minds and things on the inhale lots of, like, the dust that can cause fibrosis, as you say generally of the opposition's on. But it's because of the cold and the silica and things like that. But they inhale. Um, Then you have history cytosis. So this is when you have lots of history sites which are a type of white blood cell buildup in the tissues. And once again, it causes up his own, uh, fibrosis. Yeah, I'm I'm closing frontal itis radiation TB on either silicosis or stark white doses. Brilliant on then, for the Lorzone vibrates is I tend to use the new Monica acid on this stands for asbestosis. So exposure to asbestos, connective tissue diseases, things like sle. So no, I explained that causes up a zone, But other connective tissue diseases generally cause low is I'm by price is then we have idiopathic pulmonary fibrosis. Where? When? It's a progressive condition. We don't really know the cause on drug induced. Does anyone only drugs that cause fibrosis? Yeah. Amiodarone. Brilliant. Yeah. Brilliant. I think you guys got the main ones. Really well dot So amiodarone. Methotrexate's on. Uh uh. Blowing my sense of amiodarone is our potassium channel blocker. Methotrexate's being a dimard. Clear. My son is an antibiotic. Great job. So any ideas what this chest X ray is showing? Yeah, pretty. And keep few correct ounces in the trap. Pretty well done. So yet this is a special It's exposure, and somebody said it in the chart as well. It causes these plaques, which I've I've highlighted in yellow for you just so you can see them. So these are called pleural plaques. They're asymptomatic. They're basically calcify plaque, so they kind of they appear more of a white color compared to the air in the lungs normally on. But they get really severe. They can almost appear the same. Density is boom because they're castle wide. You're looking out for a really irregular shape with a well defined border. But usually as you can see here by these yellow lines that really irregular in shape. Um, and remember, there's no risk of that turning into, like, a malignancy or anything like that. You just see these really irregular shapes. Um, in the lung fields, you cannot see Also see pleural thickening, which I pointed out in the with the other. I rose. You can kind of see the pleura becomes visible. It becomes a bit thicker. A swell. Um And then you may also see a specialist is so that is the fibrosis caused by yes, best office that's been inhaled into the lung on. But what, Based on our previous slide, is that an upper or lower zone fibrosis level? Oh, brilliant. Well done. Yes, I remember that. Acid new Monix. It's a level one. Brilliant. Um, and then you may also see music video mama on, but, um, that's a malignant tumor off the pleura when that has sadly, already, poor prognosis on gets also risk factor for lung cancer. So don't forget that as well. But if you if you see any irregular world defined lesions in the lung fields that look of it like this, then think asbestos exposure. Brilliant. So I'm gonna give us another chest X ray to interpret. So using our structure before can anyone starts talking through his tests? X ray starting right from the beginning? Yep. Brilliance. Start off with patient details. Fabulous. Yeah, looking at the trachea Looks a bit deviated, I degree yet and we talked for a ripe A Z. Well, brilliant. Really good. So we talked for a patient details to talk for. Right? We said that your keys deviated. Anything you want to say about the low fields going on to all breathing. And don't worry if you don't know the pathology, just describe what you say. Yeah. Brilliant. Brilliant. Yeah. And anything else you want to talk through on CD any Any other pathology is that you notice? Don't know if you don't, but if you do anything that you notice, what do you think? They look normal. Yeah, but And I had someone Message may. Brilliant. That's great. So here's my example. I won't talk through all of it, but it's very similar to fall. So patient details, remember? You're right. Eso Yeah. You guys got it so that you're here is deviated to remember to say what side is deviated to do. In this case, it's the right side on. Then how I describe this abnormality in the lung fields is that it's a non uniform, um, soft tissue density containing a broker, guns indicative of an area of consolidation in the right upper lobe. Or I think you said that the right middle zone as well. I I would agree with that. That's also very valid. And then you'd work through CD, in which case there aren't really any pathologies to see. Um and then to conclude, you just say your findings based on they're presenting complaint of shortness of breath fever and a productive cough with green sputum. Top differential is a community acquired pneumonia. Great job, guys. So on to see so, uh, see sounds for cardiac. So things you want to look out for here, our heart sides and hop borders. So anyone tell me what is the normal heart size? A Matilda notes to your question. The trachea can be sent. Drawer can be deviated in a consolidation. Depends on the size. Yeah, brilliant. So it's less than 50% of the parasitic width really were good. So looking at the ratio between the greatest with across the chest cavity, um, against the greatest width of the heart as well. Um, and it must be in a p a radiograph because, as we said before, we don't want a heart to be abnormally enlarged and greater than 50% would be indicative of cardiomegaly. Can't even think of any conditions that cools cardiomegaly heart failure. Yet that's a big one. Brilliant valvular pathologies. Yeah, brilliant. See anything that heart failure valve pathologies call your mother? Mild disease might cause cardiomegaly If there's any lung pathologies that causes you, say, like congestive heart failure, those things that you might want to look out for, or if there's any pericardial effusion is worth. There's fluid surrounding the heart as well that can make it look enlarged as well. Then we want to look at the hot borders, said I should be really well defined, right? Heart Border is mainly showing all right. Atrium on our left hot water is mainly are left ventricle, so it's really important when you're looking at um, the heart looking at the lung tissue around it because that can give you a clue as to where things are brilliant. So moving on to our next slide. Brilliant. So if I got get you guys to look at this chest X ray, any ideas as to what you think it might be? Yeah, I would say this cardiomegaly brilliant is p A. Yeah, but in some people got it as pretty good. So this chest X ray is indicative of heart failure as well as kind of pulmonary edema that's being caused by a difficult compensated heart failure. So where the heart is failing to produce enough cardiac output, you're getting fluid. That's backing up into the lungs and causing this kind of flash pulmonary edema. Um, did they won't know the kind of five main features of heart failure that usually go into an ABC Teo? Yeah, ABCDE pneumonic. Does anyone know what they stand for? Yeah, we had a demon the back way. Winging perfect curly be lines cardiomegaly. Yep. Deanie delighted upper airway vessels. Brilliant me effusion. Amazing world of guys. Yes. So I have your low Dema. So as I said, that's where fluid is backing up into the albuterol I spaces. And that's causing these kind of whiter sections off the lung fields to be seen. Generally, they start of it closer to the Hylira. And so that's why you get this kind of battling your appearance out from the highlight where you see kind of more increased density, weather is a demon in the outfield. I, uh Then we have really be lines. So I popped up a little picture of it here. They're very hard to see, and you might only see if you know exactly what you're looking out for. But it's basically when fluid builds up in the interstitial. So the tissue surrounding the lungs because of the heart failing and the pressure in the capillaries and you get these little I don't If you see these little white lines, that kind of transversally is coming out from the lap chole sides of the chest. And so those you can be lines. Uh then, as you guys said, cardiomegaly, and I've explained how we, um, look at the cardiothoracic um, Braciole. So just remember that the heart is failing, then. Usually there's hypertrophy I put free in the name of increasing the cardiac output and cells get bigger, more cells, a kind of lay down in order to generate more force to improve that cardiac output. Then, as you said with diluted up alot, vessels are up alot diversions, which is basically because if the heart is failing, the pressure inside the atria goes up in the left atrium because there's left called Your help Put from the left ventricle on Do that causes increased blood flow up to the top of the lungs, basically, whether it's better mentally. And then finally we have floor effusions where the fluid collects in the cost for any samples. Brilliant. And then I just got here The m I hate a cast occasion of heart failure if you guys to review in your in thymus Well, really, in so clean one. Tell me what this pathology is. What sign you can see. Drop your heart. Brilliant. Yeah, And what's that? A sign off. Brilliant. Yeah, pericardial effusion. Really good. Like I say, it's the pericardial effusion. And this is, um, either alone a Z. You guys said as, um, globular heart based, also known as a water bottle sign, eh? So it's based off these old water bottles that used to be used on a kind of thing, kind of decide you. It looks a bit like that on. That seems very large. Pericardial effusion. Often pericardial effusion can be asymptomatic. You don't notice them. Um, and they can accumulate over many, many weeks. Onda pericardium kind of gradually stretches, but if you do a chest X ray, this is what you'll see. It's caused by pericarditis. So where the pericardium is in being irritated, it causes release more pericardial fluid, which can then build up, um, post cardiac surgery. Do trauma or malignancy as well. This look out for the water bottle sign as a sign of pericardial effusion. Onda a long A similar. It's fine. Any ideas what this pathology is or what? The Sinus you can see? Yeah, brilliant. So there's pericardial calcification yet which, if you got a few of you guys have put in the chart, ready was done. So this is due to constrictive pericarditis, So constricted paragraph JIC pericarditis is basically when there's protic inflammation of the paragard in which makes it thick, makes it Fibro's makes it really noncompliant. So what that can cause is this calcification of pericardium, which you can kind of see here by this, um, more white, more dense line here at the base of the heart. Um so people can present with shortness of breath they can present with signs of right sided heart failure where the heart isn't pumping as well. So they're right. Heart tries to, um uh, like tries to compensate where it's being constricted. It's not feeling as well so you can get lots of different signs such as elevated JVP for for Dema ascites things like that. Um design will know any particular sign that we see in constrictive um pericarditis. And yes, there's all clips in the midline. Is that Yeah, brilliant. Cruz will sign. Does anyone know what kids will? Sinus? Yes. So the JVP um it varies of breathing in that Usually when we, um inspire where we take in a breath or JVP it falls because usually when we breathing this kind of this sucking motion where blood from the venous system is drawn into Atria a Z lungs expand whereas in constricted pericarditis because you've got this impaired feeling of the right side of the heart because the pericardium is poorly compliant, quite stiff, it causes a backup of your venous blow blood into a JVP as you inspire So you're JVP actually gets more prominent or it becomes more descended when you inspire. That's cool, cause more sign. So I've got a little video and hopefully you can see that when this person is inspiring, the JVP becomes a bit more prominent. That's cute. Small sign um, you might might also here on something called a pericardial lock, which I hope we got. I would you get the work. That's basically a high pitch sound that's made by the heart just after us to on. But it's because the heart valves become less elastic because of this calcification of the pericardium. Um, so it makes the valves kind of shocked prematurely. So you get this knocked up again just sitting here, and that's called a pericardial look. I'm just drawing a little diagram. It's a bit easier to visualize where that sound is. It's quite hard to hear, but you can listen to that in your in time when you get the recording on. All management is a pair called Pericardiectomy. So basically surgical removal of the pericardium where has become ready constrictive great job. So our last pathology for cardiac does they won't notice any abnormalities with this chest X ray. Yeah, brilliant. Well done. Yeah. So a wider mediastinum. So generally medias item is passes widened. If it's greater than, uh, like 6 to 8 centimeters, which is usually what it's no more, it's if it's greater than 6 to 8, then we're thinking that the Mediastinum is widened. Does a one of the most common cause of the mediastinum widening on a chest X ray? Any ideas? It's a bit of a trick question. I'll give you that. Yeah, brilliant. Someone's got it. Yes, it's actually, it's a bit of a shock. It's actually X ray technical problems. So things that rotation positioning, um, things like that. That's the most common cause of a wider mediastinum. But I was being a bit sneaky. Does anyone know some actual kind of true causes of mediastinal whitening yet? Aortic aneurysm. Aortic dissection? Yeah. Brilliant. So I've listed a few, um, here, So thoracic aortic aneurysm, aortic dissection. I'll let you guys read through the rest of look into the rest in your in time, but the size that you're looking for the chest X ray are the wider mediastinum and also a loss of the aortic knuckles. So usually there's kind of a and not if you like, here after whether thorough, uh, I take a water passes over the left main bronchus and their primary vessels on. But if that's lost, that could be a Sinus. Well, of white, immediate side of brilliant. So another chest X ray to interpret. So how are we going to stop patient details? Very well done. Then what we're going to say, right? Brilliant. Well done. A B, c d. Okay. Brilliance to start your ab CD working down any issues with the airway. Tricky, essential. Brilliant. Central. Brilliant. You guys is doing really well. Abnormalities on the lung fields going on to our breathing. Don't worry. If you don't know the exact pathology, just say what you say. Yeah. Brilliant. Yep. Right. Look, so good suggestions. Yeah, but I think some of you guys can't. Well, the pathology is, but get ready. Get anything you want to say now about cardiac cardiomegaly. Brilliant. I think you guys have picked out the main pathologies Well done, so I won't go through all of this once again. But this is just kind of how you present it. So you guys go right Intro, right. Okay of essential. Really good for starting without a Don't just jump to the pathologies on dust. Say what you see so you can see that it's, um a plastic, a shin of the lung tissue. I'm if you're really looking just about, see some curly be lines on because somebody said the upper lobe vessels are more prominent on as someone else. That is, well, the cardiac threat. Cardiothoracic ratio is greater than 50%. There is cardiomegaly on. Um, there is very mild blunting of the cost Rennick angle on the right hand side, but it's very mild. Um, so overall, when you summarize, you say that because the presenting to play your shortness of breath on exertion top differential is heart failure. It's really well done. Says take another breather. You guys have done the majority of the session. We have to go much more to go take a little breathe and then we'll do die from and everything else. So our last couple of section now. So we've got, um, the moving onto D, which stands for the diaphragm. So when you're looking at the diaphragm, you want to look at the shape of the dye from what's under the diaphragm and look at those costophrenic angles. So look at the shape of the diaphragm. The right Hemi die from is generally higher than the left just because of the liver on the left. Hemidiaphragm has thesis meq underneath that which you might see as a gas bubble as well. Um, they may be flattened, which, as we said before, could be a sign of COPD as well. So that's something to the cat for, um, looking under the diagram diaphragm, usually the underside of the diaphragm on the viscera, the organs below it on there isn't like a distinguishable difference. You shouldn't be out to notice the diaphragm, really? So the main thing that you want to look for is free gas or pneumoperitoneum that we spoke about before, which maybe this boiler on erectus sticks right where throats in the top off the peritoneal cavity on Ben causes the liver or the stomach and the dye from two separate, and you can see underneath on Then, as you said before, I want to look for blunting of cost frank angles, which could be a sign of a fluid accumulating in them in, like, plural fusion. So it's move on to some pathologies and yeah, it is what we consider in this chest X ray. Flattened diaphragm is brilliant. Hyperinflation. Yeah. You guys getting the diagnosis? Really good. So, yes, this chest X ray is quite is has signs which suggests that it's COPD. Does anyone know what to conditions are under the umbrella of COPD? Yeah, pretty. And so we have chronic bronchitis and emphysema. Eso I've listed What? Those are here. So chronic bronchitis is an inflammation of the mucus membranes in the bronchioles and that can cause mucus production, coughing, bronchospasm things that that and then the emphysema is the breakdown or damage to the albuterol I, which can cause them to enlarge for the delay that we spoke about earlier, which a large air pockets basically form inside the lung. Um, and you guys have already picked out all the signs of COPD or a chest X ray. So I've written some of them here. So look for hyperinflation. Remember to count the number of anterior ribs. So if it's over eight, then you're thinking it's probably a hyper inflation. Look, those frat him, he die from? I'm look for decreased lung markings because that could be a sign of ballet on for prominent Hyler as well. That can also be seen in COPD next pathology. And yeah, just what you can see here. What's the sign that you can see? Brilliant. Yeah, Free guess. Pneumoperitoneum. Well done. So, yes, this is pneumoperitoneum so appointed with the hours where you can see it. So that's when the free games s is outside the limit of the bell that's collecting under the helmet. Hemidiaphragm is on on erections. Sex Ray do they will know how long you need a patient to sit upright for before they haven't erector set Ray to allow the ads rise up? Yeah, pretty. And so tends to be somewhere between 10 to 20 minutes before Yeah, 10 to 20 minutes before you have the image taken because that allows allows enough time for the air to come up to the top of the cavity pretty well done. This is a really good way to look for, like about perforation or anything that's causing a parenting a cavity because there's a very high sensitivity in that you don't need to have too much gas present. Oh, too much air present before you notice it so you can pick up when there's only, like few millimeters are of of gas. So it's a really sensitive test, which is really good and ever in here. Some of the differentials that may cause a pneumoperitoneum, um, that you should be thinking off when you see a pneumoperitoneum on a chest X ray. Brilliant. So because of time and you guys probably want to get on with the rest of your evening, I'm going to skip over this one. But this is how I would interpret this checks chest X ray. I've pointed out all the abnormalities with the airways, thie lung fields and the diaphragm on this was indicative of COPD. So I'll let you guys read through that in your own time. And finally we're onto everything else. Basically, So you want to check the bones, check all of them, take your ribs, crackles check your scapula A on a a pea view because you want to make sure there's no fractures. What you want to do is you want a trace trace around all of those bones just to make sure that there's no discrepancies in the autumn allergies. That's all continuous. On that way, your best be able to pick up if there's any fractures or breaks. Um, look for any tough soft tissue abnormalities, things like swelling, hemotomas. Anything like that might occur. Say after trauma. Um, look at the mediastinum. Is it wind? And we've gone through some of the reasons why it might be a widened on. See if the aortic knuckle is an abnormal shape on. Finally, just look for any devices. So we've talked about some of the tubes and things you might see. You see GI came with you guys picked up on earlier, but for heart balls, pacemakers, things that back. So let's look at couple more tests secretaries. So can anyone spot the abnormality in this chest X ray? Bear in mind, we're covering everything else that's likely pregnancy. Where you put that focus on the thoracic part of the cavity. It's not to do with the heart, so someone's close. It is to do with the bones. Yes, yes, people got it pretty well done. Yes, and this this is a bony fracture. Very, very sneaky is that it's quite hard to see it's a clavicle fracture on does they won't know where. The most common site of the clavicular factories, like on the on the clavicle. Where on the carpet was the most likely side of fracture? Middle furred, brilliant common causes of clavicular fractures. Any ideas? Brilliant trauma is a major one. Yeah, pretty and fish Pretty. And that was the other one I was looking for. Yeah, the trauma or a fall or an outstretched hand. Common causes of convicted of factors and our last chest X ray off the night. Now, I know everyone's gonna come out with the cannibal lesions that we saw earlier, but I want you to think about more outside of the box. And can you think of any reason why that might be, um, cannibal lesions? Are there any other soft tissue things? Maybe that you can spot on this X ray? It's not to do with the lesions. It's not to do with the lesions. It's to do with something else, not to do it close to the romance. So these are These are, um how many Mets Any idea is what's causing the Is there a clue elsewhere about the polar e mets yes. Breast cancer. Your little right lines. Yeah, brilliant. Someone's got it. Well done is a mastectomy. So it's quite a hard thing to spot. But remember to look for things like the lines of the breast tissue so you can see that this patient's had a mastectomy. So this patient, in fact, I had a mastectomy because of her breast cancer on, But, uh, sadly, it wasn't removed. So it's become metastatic, um, which is called the Lesions in the back. But remember to look for things like sex, maze and soft tissue things as well. That's important or not. Forget brilliant. So well done. You guys are really, really well to finish off presenting a chest X rays. Just remember to look over our review areas of these areas of the chest X ray that are commonly missed. Eso things like your along apes sees Make sure to look symmetry between your too long, able to seize that behind the heart. It's really it can be quite common for there to be villages behind the heart like cancers. Oh, consolidations and things. So look at the density of the heart shadow. Is it uniforms it more dense in certain areas. Does that suggest there's something behind it? Um, look for the pro Freeze that for your lung thickening your loss of lung well, kings and check your hilar. It's well, check. There's no don't be there. And then finally to finish, just summarize your findings what your overall impressions are on. Explain that you'd like to look at previous films if you haven't done, is already on related back to any clinical history that you've been given. So what I've done here is is well, as I've put together a little table for you all, just with some of the common people A. Geez, we talked about tonight on about how they present symptoms wise as well as how they might present on chest X ray. And then what I've also done it is like popped in a couple of other tests X rays for you to test your sounds on in your in time. Thank you so much for staying on. It's been a very long session on you guys.