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My name is Vincent. I'm a clinical research fellow in Interventional Radiology at University. So um just a quick um a review of chest X ray interpretation. Um I kind of want to take this small bit of a clinical or as a foundation doctor point of view. Um but I will quickly go through the basics and um jump into some cases. Um So kind of some basics. So just go through kind of um a structure that I use and trying to focus on how to actually do well and nosy um with uh the with, with in chest x rays. Um So I'm sure you all know there are many indications for chest X ray. I think a lot of people miss out the fact that you want to do a chest X ray on all chest pain patients. Um just because they could have pneumo pneumothorax or any other causes for chest pain. It's always good to have a um chest X ray for chest pain patients for septic screen, short of breath and also sometimes for pre op management as well. But I will delve into these because I'm sure you guys already know um it's normal chest X ray. I'm sure if you're familiar with the anatomy. So, um obviously got the heart right in the middle. Um on chest X ray obviously is flipped around. So the left side is actually the right side, the right is the left. Um So you've got the down the middle, um splitting into two, down the carina um into your left, main bronchus, your right, um main bronchus, your heart, most you can make up is just the left atrium, the left ventricle, right atrium and right ventricle approximately. And obviously, the S VC and the IVC that comes with it, um the diaphragm um and obviously the lung fields, um I'll go a bit into more of the actual lung fields in a second. Um So as I talked to you about earlier, the structure that I use most of the time is doctors ABCD E um especially for A I find it quite helpful. So um will be details. Um right, which says the image quality um ironically, actually soft tissues and bone should go with extras in the bottom, but it just helps to remember. Um But, you know, airway breathing circulation and the for diaphragm instead of what is it usually, I can't remember actually, disability. So, um that's what we've got usually. Um So you're starting off with kind of details, basic stuff, make sure we've got the patient's name right, age and date of birth, the sex, what type of film is this, what's the date of time of the image taken and any fevers to compare to? So um an oy you want to start off with looking at the chest X ray and say this is a portal chest X ray from apa view of a 56 year old man named Mr Smith taking an ed recess at a time of 1550 there are no previous images available for comparison. So it makes you sound smart, it makes you sound, you know what you're doing from this get go and that you are very trained in doing this. Um So always good to start with an O you with all these details. So just quickly talking about your type of film. So you've got your um obviously your pa a film which is posterior anterior um which is usually a gold standard. So you can determine your heart size of it. And you've got anterior posterior which is from the back towards the front in sick patients that can't stand or too sick to travel for um x-ray portal chest x rays usually do um common anterior posterior. Um You're not actually expected to determine whether a film is AP or PA it will usually have a label. If it's not labeled, then you can assume that it's actually APA image most of the time. Um We will always keep it simple for you in these OSK scenarios. Um Yep. Um One very important thing to know about, you know, as a junior doctor or resident doctors. Now, um is that uh a portable chest X ray is a very useful resource for you to have when dealing with a sick patient. So if you have a patient that is um you know, scoring high on a new score peri arrest, it would be really helpful to get a portable chest X ray um and they can come to the ward to do them. So the advantage of them is that you get an immediate assessment of the patient's status. Um And the patient doesn't have to travel down. Um But then actually, they don't have image quality that's as good as a normal chest X ray. And you'll only be able to do anterior posterior. So you can't really do things like assess the heart size on them, but they're actually really helpful when it comes to managing a sick patient. Um And all hospitals should have an on call, radiographers who can actually do these. Um they will usually be labeled as a mobile picture or mobile film. Um So you will have an idea that this is actually taken on a mobile. Um What about chest x-ray? I'll pause for chest X ray. So for example, in oy, what you can say is this is an erect chest x-ray in an anterior poster review of Mr so and so performed at this time and it's compared to previous chest X ray performed on this date. Um And you can say similar but say no previous images were available for comparison or you can say, oh the projection is not labeled on the film. So it's really flexible what you say. But make sure it comes across that you are looking through um these details and that you are being safe by confirming the patient identity. Um Another thing is that is also really important to compare against previous images and make sure you mention that you will because um it can make a difference. For example, you find a new lump or a new mass on the chest X ray, but it was already there and the chest x-ray 10 years ago and it's something you won't worry about. So it's always useful to compare and image and, and mention that you have. Um So next moving on to kind of talking about image quality, um it's really important in a scenario that you actually comment on the image quality and whether it limits interpretation of the image. So um I usually use ripe um which indicates rotation, inspiration, picture and exposure. Um Sometimes people use just er rip uh R IP one P means penetration and skip the picture bit, but it doesn't matter as long as you find a system that works for you. Um And the slides not changing. Um We're on the right side at the moment that's that is changing. Yeah. Um So, um yeah, so um in an O scenario, uh you can say a, a quick line saying that this chest X ray is of good quality with minimal rotation, good inspiratory effort and it captured entire lung fields and has good penetration. Um So I'll just quickly go through what all these bits mean. Um So rotation, you always assume that when you take a picture, the camera is facing right, directly straight at you. So that's the same for a chest X ray. So when the image is rotated or when it's not actually pointing straight into your chest, your image will become rotated. So um on this image, you can see that this is actually a, a good image that's not got any rotation. So your end of your clavicles in the media side is actually um equal distance from a uh spinus process. And you can actually see the spine that's going down straight. So that means you've got good rotation. Um But actually, in look, in the, in this case, there is actually um different in distance between the clavicle and the spine. Um And the spine doesn't actually travel straight down as well. And it's more towards the left side of the image, which is the right side of the patient. Um So rotator films actually mislead you quite a bit because it causes tracheal deviation. It makes your heart look bigger than it should and it can make you or make it appear that you've got a bit of a pleur fusion there because of the soft tissue. But actually, this is a perfectly normal chest X ray taking account into the rotated film. So it's important to make sure that the film is straight and not rotated. Um And uh you're also important to make sure that there is good inspiration, effort. So good inspiration effort means good interpretation. So here it's a chest X ray with very poor inspiration effort. So they actually take this, this x-ray is actually taken when the patient is um in the expiratory phase. So when the patient's breathing out, so you can actually only see three ribs properly. Um And um you can't actually really make out the costophrenic angles um or, or the lung fields and it looks like there might be some consolidation there. Um So uh good chest x-ray with good inspiratory effort, your um sixth rib should cross the diaphragm in the mid line at least. Um So this is actually the same patient um as the previous slide. Um But you can see that actually when the lung feels are opened up a lot, um there are no consolidation and actually is essentially a normal chest X ray. So it just shows how important actually having a normal uh ex er inspiration effort is um in, in a chest X ray. Um So the opposite of poor inspiration effort could, well, we could say is hyper expansion. Um but hyperexpansion doesn't normally mean bad quality um it can be because of some patients having um an obstructive Pulmonary disease such as CO PD because their lungs are accustomed to being obstructed. Uh the lung feels go bigger. Um So that's what reflected in this chest X ray. You can see that um Y there are at least nine or 10 ribs that are visible on this chest X ray and there are kind of um flattened diaphragm as well, which is actually a sign of hyperexpansion. It doesn't mean it's bad quality, but it just tells you that this patient possibly has a diagnosis of obstructive pulmonary disease. Next is pictures, picture. So, um you need to make sure that a good picture is taken. Um So it's just like you, well, you're taking a picture of your friend, you know, your family on holiday, you don't wanna chop the head off. So, um exactly the same is that you don't wanna chop the apexes of the lungs um of the lungs off cos you actually need to evaluate the top of the lungs as well. So you can need to make sure that all the lung fields are fully visible um that the scapular is not within the picture and it, you know, affects interpretation and make sure the bottom of the lungs, the costophrenic angles um are visible. So in this case, the ac are cut off um because this is a portable chest X ray, which as I say quality might not always be the best. Um But it's rot taken. So you see the ac and the lung feels, it's still not the best. You've got quite a bit tilt some rotation, but you may do with what you've got. So, um uh yeah, so it's important to make sure that all you need is in the film. Um And also it's always helpful to come in on any artifacts um as far. So this is um actually uh a chest X ray taken in the ICU. So it's for the sickest of the sickest patients. So you actually see there is um you know, ECG leads, there are two chest strains that's gone in the side. Um There's a breathing tubes, so it's just very, very complicated. Um but it's always helpful to comment on them things like, you know, central line ECGS oxygen tubes, um energy tubes as well. Um and also pacemakers where possible as well. Um And uh when coming in on NG tubes, uh make sure that they cross the carina, middle of the trachea and goes under the diaphragm. And that's when you tell whether an energy tube is in the right place or say for feed. Er, but most places now require um a radiology registrar to report them before you can feed them anyway. Um So it's less relevant nowadays for you guys. Um Finally, it's also important to look at whether the film is well exposure um or there's good exposure or penetration of the x-ray. So you can see the critical structures. It's same as taking a camera if anyone's actually into um manual uh cameras. He said the exposure too high, it goes too bright, it goes too low, uh it goes dark. So the same in chest X rays. So this on the left is actually a underexposed image. So you can't actually really tell part the heart and the spine um right there cos it's a bit way too bright and you can't actually see the diaphragm joining the spine. Um This can all, well, most of the time it can be adjusted using the uh computer software on packs. So that software where you view all the X rays and after adjusting, you can see the spine a lot clearer, you can see the heart borders, you can see what's behind the heart. Um and you can see, you know, clearly the rib on the side that's separating the arm or the air um with the lung fields. So it's important to get a good exposure when you look at um these chest X rays. Well, overall, there's actually not much you can do about image quality um in your chest x rays. Um As I said, you can take account into the overall under exposure um on packs, er but ultimately, there's not much you can do. Um So in a oy situation, you can always say, well, if it's good quality, you can say it's good quality minimal rotation, et cetera. Um You can say there is some rotation but there is adequate inspiration, penetration exposure ation with lung fields. Um to sound smart, you can say that this film is under exposed. I'll consider using functions in a pack system to adjust for the under exposure if possible. And however, the lung feels are fully visible. If you come across a really, really, really bad chest X ray, you can, you can say in your osc or examiner or on the ward, on ward round, you can say it's significantly rotated with poor inspiratory effort is over exposed, the lung ac are cut off. Um I would consider to ask for a repeat chest X ray and that's absolutely acceptable as well and that's what we do in clinical practice. Um So, so far um we've gone down, we talked about the details and the image quality of the chest X ray. Um So to summarize a little bit what we can start off in our ay or when we repeat, sorry, when we report our chest X ray, we can say this is an erect chest x-ray for Mr. So and so um date of birth, not short of breath, I'm sorry. Um date of birth of so and so, and this is APA film performed at this time. This chest X ray is of a good quality with minimal rotation, adequate inspiration exposure and the four lung fields are visualized and that's what we've got so far in terms of structuring your presentation for presenting your chest X ray and acies. So this is a massive elephant in the room. And it's the same thing when it comes to chest X ray. Um because there are always, well, when it comes to abnormal chest X ray, there's always a striking abnormality. Um So if in the scenario, your patient is hemody dynamically unstable or very, very sick, what you can do is instead of going through your doctor's ABCD. E first, you can go through your detailed image quality. No problem that men, they mention your immediate finding um that striking abnormality that needs managing quite immediately. So for example, if there is a tension pneumothorax on the chest X ray that needs to be managed immediately. Um You can men, you can mention something along those lines. If there is a major emergency finding on the chest X ray, which is a right sided tension pneumothorax, I will immediately call for help and perform a needle decompression with a large needle in the second intercostal space in the midclavicular line. So that makes you sound smart, makes you sound, you know what you're doing, makes you sound competent and make sure that you're safe. Um And then after you've done all those well, you said you would do all those and then you can go back to systematically reviewing the image. Um So doctors ABCD E soft tissues and bones as I said we'll leave it to the end. So, looking at the airway, um you want to look at things like um tracheal deviation or tension pneumothorax. WW which I'll go through in a second. Um A tension pneumothorax um or, or a theory effusion or a mass can cause um tracheal deviation. Look at things like a widened mediastinum which is a sign of an aortic aneurysm dissection or a mass, um which I also discuss a bit more. Um and um pneumomediastinum which is air within your mediastinum, which is normal postoperatively, but any damage to your esophagus or your airway, things like behe syndrome will cause that. Um And in the case of obstruction um or foreign body like here, there is a, this is a X ray of a, maybe a, a child. Um There is a coin or what we call radio opaque um object within the mediastinum or within the airway. And um yeah, so it depends on, you know, how you want to manage it and you can always want to get a lot from you when it comes to uh foreign body in the media sty um or anywhere really just to see um you know, maybe get a better idea whether this is in the trachea or the esophagus, which is actually still hard to tell with it, but it gives you a bit more information that is more uh anterior than posterior. So again, when it comes to reporting your findings, um, have a structure that helps you. So, what I tend to say is, oh, the airways and media stannum appears normal with no obstruction, um, or deviation of the trachea, er, or any wider Medianum or New Media Styn. So that's what you can say during oy, sorry. Um, this is uh case um when it comes to evaluating the airway, um, that this is a 23 year old male who's a marijuana smoker, he's got a torn, a slander statue. Um He's got a sudden onset severe chest pain. Um On examination, you've done an A two examination on him. Um Airway is patent, he's got increased respiratory rate and oxygen requirement. He's got completely no chest sounds on the left side and trach deviation to the right side. Um and he's got, he's got increased work of breathing. He is in shock. He's got a horror from an anxiety and then low BP. He's got quiet heart sounds. Um DNE is essentially unremarkable. Um What do you think's going on and what the first line investigation would be? Um Welcome to put in the chat or shout out if you want to chest X rays. Yes. Yes. Pneumothorax. What kind of pneumothorax? Yes. So the tracheal deviation to the right side and the shock comes, comes across as a bit of a tension pneumo thorax. But should we do a chest X ray on this patient? Um If you suspect attention, pneumothorax clinically, you should just treat it. That's what we always say. Um because this patient's hemodialys stable, um We should just go ahead and treat it instead of requesting a chest X ray. But no one would be brave, brave enough to stick a needle in someone's chest without a chest X ray. So um went for it anyway. So this is uh tension pneumothorax. Absolutely correct. Um But going through it systemically. So what we can say is this is a chest X ray image. There's no patient detail projection on the film. Um There's some degree of rotation of the image but it's got good infl effort. Whole lung fields are visualized, there's good exposure of the film. So the striking abnormality in this film is a left sided tension pneumothorax with left side, right sided tracheal deviation. Um So this is your strike and, and this is your elephant in the room. So I will immediately call for help and perform a needle decompression with a large needle in a second intercostal space in a Mivi line. And then you go on to systematically review the film. So there is no wider mediastinum nor pneumo mediastinum, other than the right sided tracheal deviation, there are no other abnormalities in the airway or the mediastinum and then you can move on to breathing blah blah blah, which we'll go on and talk about. But essentially, it's normal lung fields, no other, no other abnormality in the chest X ray, other than this obvious pneumothorax. So here you see, um this white arrow is pushing the trachea towards the right side and there is an absent absence of the lung markings. Um And what you see here is actually the collapsed lung that has actually been completely compressed because of the pneumothorax. Um And your whole mediastinum shifted, including care in the heart and shifted towards the right side. Um And there is a change in the contour of the diaphragm as well. Um But as a med student, as an F one or an F two, you should be able to spot this immediately. It's a spot diagnosis and you should be able to manage it, manage the, you know, emergency. Um The second case is that um we've got a 19 year old with no eating disorder. Um, she's presented with sudden onset chest pain, radiating to the back after repeated purging and vomiting episodes of blood. Um She is hemodynamically stable. Um She's got a raise respiratory rate, a raise BP and tachycardic. It's a little bit of a raised temperature and she's got a bit of a mildly tender abdomen. What do we think is going on? What are your top differentials might be a bit of a tricky one? Um So you think about someone vomiting, repeat of vomiting with blood, think of um ma tear. Um Oh, no aspiration pneumonia, definitely a good point. Um Something we should definitely consider as well. Um But she's not got an option requirement. Um, she's got a temperature which actually could be consistent with aspiration pneumonia. So that, that's actually a good point. Um, so these are some of the differentials that I actually thought about in addition to aspiration, aspiration pneumonia as well. Um, with someone with repeated vomiting and blood and central severe chest pain. Um, you would think about Bo syndrome. Um, when you talk about a patient with central reading to the pa back, chest pain, things like aortic dissection, aneurysm comes to mind as well and a pneumothorax. Um but in her age, an aortic dissection, aneurysm is unlikely and a pneumothorax um possibly. But um the vomiting uh puts our wise tear and A B syndrome a bit further up the line. Um aspiration pneumonia is a good point, but uh it wouldn't usually associate it with severe central chest pain, reading to the back. Um So this is actually an image showing um pneumomediastinum. So there is actually gas between the pleura and the hot border and the media DM. So within, within the media and there's air right there. Um So this is actually consistent with possible damage to the esophagus or the trachea or any structures in the media sty. Um So, you know, this is a critical finding. Um What I would do is I will obviously comment on the detail and uh quality of image. Um Then I would say only the left side of the thorax, visualized the striking abnormality in this film appears to be some pneumo media styn and adjacent to the left heart, left heart border. And given the history of repeated vomiting of blood and sudden onset chest pain. This may represent Bo syndrome or other damage to the mediastinal structure. I will perform um A well, I will request a dedicated CT Rx and abdomen to evaluate further and seek surgical opinion. So that's what you can say in your, ask you to make you sound a bit smarter that you know what's going on and then you can go back to finish off your um systems review. Um going through all your breathing circulation, et cetera, et cetera. So, um the final case on kind of airway uh again, but we've got a much older gentleman this time who's got severe tearing, central chest pain, radiating to the back, um feel free to uh suggest any differentials while I just go through this um on the chat. Um But um he's got a patent airway, he's got a bit of an increased respiratory rate. He, he's tachycardic. He's got um different BP in the left arm and the right arm. Um He's got a loud systolic ejection murmur. Uh He's got a collapsing radio pulse and a radiofemoral delay. And as the chat suggested, um this is what we suspect aortic dissection. Um I mean, despite us being very certain that this could be aortic dissection, your consultant wants to do a chest X ray fast. Um So going through the um chest X ray, um again, going through your details and your uh quality. So there is no rotation. Um It's a good quality, it's good in effort, effort. The whole lung is visualized. Well, it's good exposure, blah, blah, blah. Um So actually here there is a widened media Styn on the chest X ray. Um So if you imagine that's your heart, that's your left side of the heart and that's your right side of the heart. No, you can't there. So there is the left side of the heart and that's the right side of the heart. Um And your aorta would usually go around and come around down there. So you've lost your aortic arch there. Um And your, there is a widening of the mediastinum measured kind of from here to here. So it's usually more than eight centimeters when you're classified as a widened mediastinum. So imagine your aorta going down this way and because the dissection is filling it up with blood, your um uh well, and obviously with the extra flap, your, your, your aorta is expanding and expanding. So, um in this case, this chest X ray is actually suggestive of any aortic disease and in this case, aortic dissection, um I mean, usually in a patient that's hemodynamic and stable, we won't go for a chest X ray, we'll go straight for act aortogram. Um But just for the sake of this um tutorial, I just mentioned this chest X ray. Um But what you can say in your of these is the striking abnormality in this film is a widened mediastinum provided history of central chest pain reading to the back aortic dissection or aneurysm should be considered. And I will request a CT aortogram to assess for the aorta and meanwhile escalate this to the vascular surgeon on call. Um Yep. So that's airway. Um I hope that's clear. Has anyone got any questions at all about airway before we move on to breathing? Ok. Let's go ahead. So, um next, after airway, we go into breathing, um essentially breathing. You want to outline the lung fields and the pleura and look for things like a pneumothorax, especially on AP CS, any opacity, atelectasis collapse and cons and consolidation and only pulmonary infiltrates things like edema or any lesions at all. So, um one helpful way that I found to describe all these findings within the lung fields is actually to divide uh your lungs into different areas. Um I know that anatomically there is no middle lobe on the left side. Um But for the sake of kind of radio radiological imaging wise, it's helpful to split um the two lungs into apical, upper middle and lower region on the left side and the right side. Um just so that you can describe the lesions a bit better and then moving on. You want to go through all the lung fields in a Z shaped fashioned fashion. Um So, for example, in this um X ray, here, there is an obvious consolidation on the right lower lobe. Um There on this one, there is a consolidation of bilateral lobe and even behind the heart. Um And here, this is a case of a lung nodule which might represent lung cancer or primary lung cancer. Um They're on in the right middle lobe. Um And this is consistent with what we call Kennon ball metastases. So, these resemble Kennon ball cannon balls characteristics all over the chest. And these are characteristic of um metastases from mostly from kidney testes. Um and uh maybe endometrial cancer as well. So they can present in metastatic state with a chest X ray like this and it's not pleasant at all. Um Yep. And then next, you want to outline the pleura, um the pleura is not usually visible. So, what you want to do is actually you can want to go down the edge of the lung, make sure that there isn't actually any abnormal findings there. Um So in this case, there is a large pleuro fusion um on the left side. And that's why you can't actually trace it all the way down. I will talk more about the infusion in a second. Um These are pleural plaques um that are mostly associated with asbestos exposure. Um And they can increase the chance of someone getting or risk of someone getting mesothelioma. Um And, uh, in this case, in this case, there is a pneumothorax. Um, and you can see the pleural lining actually coming down towards the collapsed lung instead. Um, but in this case, there is no associated for cure deviation. Yeah. And then, um, this is the, oh, I'm just going through a quick case of, um, in breathing. Um, so there is, this is a, a 63 year old gentleman who's produced, sorry, presented with a three day history of productive cough and fever and pruritic chest pain. Um He's got a bit of a high respiratory rate. Um and uh he's actually not requiring any oxygen, but he's got some right basal crackles. Um heart rate and BP is stable. He's got a bit of a temperature. Um and on his blood, he's got a bit of a race white cell count, a race C RP and the urea of six. So, um it seems like this patient has got probably got rid of a chest infection request of a chest X ray, which um actually shows a bit of a right um based consolidation. So again, you want to go through the details and confirm the patient details, assess for the quality. Um And the striking abnormality of this film is the right lower zone pneumonia back in this patient. It's not hemodynamic and stable. So you don't actually have to do anything. So you will continue through your systems review looking at the airway. Um There is no foreign objects in the airway. Um There's no wider mediastinum, there's no tracheal deviation, nor there's any pneumomediastinum. You're moving on to b um there is a obvious right sided right, lower base uh consolidation which may be consistent with uh pneumonia and then you will obviously see you've not got any consolidation. Um Sorry, we wanna see there's no any cardiomegaly. Um We got the, the diaphragm is visible dose slightly looks good um by the consolidation and then everything else looks fine. So you wanna finish off and say in summary, um the right base pneumo uh right based consolidation is suggestive of a community acquired pneumonia. Her cos curb 65 score is one which indicates she's of low risk and is suited for outpatient management and I would discharge her with a five day course of amoxicillin and arrange a repeat chest X ray in six weeks time to successful for rever resolution. So, um it's important when you present the chest X ray to combine your clinical findings or come up with a differential and suggest your management for this patient. Um Because again, you want to focus on looking or uh the whole patient in general instead of just looking at the X ray in front of you. And also remember when you've got a patient who's got a well, who you're treating as a pneumonia, make sure to request a chest X ray in six weeks time to make sure that is uh resolved because this pneumonia could mask any underlying malignancy, um, or nodules. So you want to make sure that, um, a chest X ray is repeated in six weeks just to make sure that, um, if there's any nodules that's picked up at all. Um, so the next case is, um, there's a 86 year old man who's got a 40 pack year smoking history presented with worsening shortness of breath and wheezing, he's also in reduced consciousness as well. Um He's got a significant oxygen requirement with an increased respiratory rate. Um She sounds, he sounds very, very wheezy and is needing some accessory muscles. Um He hemodynamically stable at the moment other than the oxygen requirement, but he's quite confused and he looked quite malnourished. Um An ABG showed a type two respiratory failure with a ph of 7.1 and a ratio two of 13.5. Um So what, what are your thoughts for this patient? Um What, what underlying condition do you think this patient might have? Yes. So yes. So um he does have COPD. So um we managed to get a chest X ray for him and um it actually looks quite hyperinflated. Um So, as I mentioned previously, when you have hyper expanded lungs, that's a sign of any obstructive disease. So, just to go through this chest X ray. So again, there's no patient details or the projection of the film. Um There is no rotation of the lungs or of the image. Um uh Inspiration efforts appear to be hyper expanded. The whole lung foods are visualized and there's good exposure of the film. OK. The airway airways in the mediastinum appears normal. There's no obstruction, no deviation of this fear, no widened mediastinum or no me uh pneumomediastinum as well. The lung feels a bit clear with no mass consolidation or pneumothorax, um et cetera, et cetera. And you go through your circulation and um your diaphragm, ex et et cetera. And um in summary, this is normal chest X ray other than your hyperinflated lungs, which is suggestive of CO PD and given the clinical context of a type two failure with acidemia. This patient should be started on N IV immediately to manage the decompensate CO PD. In addition, he should also be treated with steroids and this patient will need to be admitted under the medics. So that's what you want to say during a ski when it comes to um a case like this. Um Any questions in terms of breathing before we move on to circulation? Um ok. So we'll go on to circulation. So, um most important thing of circulation is that you actually want to look at the heart size of um the patient. So, on the right side, this is a normal chest X ray. Do you wanna look at the cardiothoracic ratio? So, um this normal chest X ray, um the ratio of the whole thoracic cavity um compared to the heart, um it's less than 50%. So the heart is not taking out more than 50% of the thoracic cage. And that's a normal heart size. And compared to this one, the heart is definitely enlarged and you've got uh the heart taking up more than 50% of the whole thoracic cage. So that suggests that it's cardiomegaly, megaly. Um And again, to note that heart size is only accurate on a pa a film. Um And you should not really be assessing um heart size on an AP film. Um also important to look at the hot border as well as the hilum vessels and the surrounding lymph nodes as well, which I'll go through. Um So looking at heart borders, in this case, there is an obscured left heart border um associated with this large consolidation on the left side. So sometimes there will be quite subtle pneumonia and consolidations that behind the heart and it will distort the heart borders a little bit. And that's how you pick up subtle pneumonia or subtle masses um or nodules behind the heart as well. Um But in any doubt, you know that we will usually perform a cat thorax in these cases, also hyaline lymphadenopathy, lymphadenopathy. So, you know, there is obviously enlarged lymph nodes here um on this chest X ray and this is um bilateral sarcoidosis is mostly characteristics of sarcoidosis on an exam. So when someone's got bilateral hilar lymphadenopathy on an exam, that buzzword is sarcoidosis. Um Other causes could be TB or mycoplasma pneumonia. They can also cause higher lymphadenopathy, not a malignancy such as lympho lymphoma and carcinoma or cancer. So, they can cause uh lymphadenopathy as well. Um We'll move on to diaphragm first and then we'll go back to the case for um circulation cos this all comes together um, so quickly go through diaphragm first. Um So when it comes to diaphragm, what you want to look at is um the hemidiaphragm level. Um So, normally it's more raised on the right side um because of the liver precision and there are many reasons why that uh a diaphragm would be raised and um usually we can split it into three reasons. Um So intra intrathoracically. So, um for example, um in this case, um there is actually a mass on the right lo right upper lobe causing a collapse and this actually pulled er, the diaphragm up uh on the right side. And this patient or this X ray is a actually after this patient's had a lobectomy, um which is the removal of the right upper lobe. And this um because of the area in the right side of the lungs, it's pull, it's continued to pull the whole lungs up. So, uh as a result, the diaphragm is still uh that sorry diaphragm is still pulled up. Um So causing a raised right hemidiaphragm. Um and some infradiaphragmatic causes, um actually made this word up. So, I don't know actually if it exists, but um in, you know, causes from the diaphragm is um phrenic nerve palsy can cause uh a diaphragm to be chronically raised cervical myopathy, um and neuromuscular disease. So, when you think about your nerves, applying your diaphragm, if there's any issues with the conduction of the nerve, it can cause a permanent palsy or raise of the diaphragm. Um most likely cause of a race diaphragm. You see most of the time is intraabdominal causes. So, if you have a race in your abdominal pressure, like an abdominal tumor, uh you get uh organomegaly orif like such such as um uh hepatomegaly or splenomegaly, um or subphrenic abscess, they can push your diaphragm up at the same time. So that's your most common cause of a race in the diaphragm. Um When you look at the diaphragm, it's important to look at your costophrenic angle. Um It should be clear and sharp. Um if it's blunted like this one here, um it's likely to be pleural effusion. So that's your costophrenic angle. Um and this area between the costophrenic angles, what we call the costophrenic recess. And if you have pleural eus, there are many causes of it such as heart failure, which I'll touch on in a second malignancy. Um Nely Me syndrome sometimes can cause pleur eus um and an infection can also cause a pleur effusion. And that's when you apply your light criteria to determine whether this effusion is exudate or uh trans date. And that can help you determine to manage the patient, but we're not gonna go into that today. Um And then moving on to something that um frustrates me a lot. Um is that when we look at free air under the diaphragm. So in this case, there is a um free air under the diaphragm um bilaterally and this is traditionally associated what we call uh pneumoperitoneum. So there is air within your abdominal cavity when there shouldn't be any and it's actually indicated for possibly perforation um of the gastrointestinal system. Whereas here, that's a gastric bubble um which is air in your stomach, which is completely normal. Um Traditionally, people will get a right chest X ray when they suspect patient who's got a, a gastro intestinal perforation. But nowadays, there is no value in that. So I'll go through that in a bit more. And uh in patient who you suspect a gi perforation should get a ct pelvis instead of wasting time getting a right chest X ray. Um OK. So um just moving on to a bit of a combined uh circulation and diaphragm uh case. So we've got an 83 year old male who's presented with worsening shortness of breath on exertion. Um He's needing quite significant oxygen and he's got some bibasal crackles with a raised respiratory rate um, I've got a bit of a raise BP and a heart rate of 100 and two has got a severe systolic uh, ejection systolic murmur. Um, it's got a significant pitting edema to size and a raised JVP. Um, anyone, you know, da guess what might be going on. Um, so, um, in a patient with, yes, both. Correct. So, um, there was um, the aortic stenosis from the ejection systolic murmur and it is decompensated heart failure leading to pulmonary edema is my guess. Um So yes, his pulmonary edema. So, looking at his chest X ray, um looking at uh well, we'll go through it systemically. So um go through your details and your right. So your quality, um the striking abnormality in this picture is the bad wings appearance and the left side of the fusion and cardiomegaly. So um bad wings appearance. So that's the higher, you can't see the higher anymore. You can't see the heart border, it's all obscured by the ba wings opacity, which is characteristics of pulmonary edema. So, when your heart feels fluid back into your lungs, create this um characteristic batwing appearance. So you've got um batwing appearance, you've got uh pleural eus in there. Um looking at the blunting of the costophrenic angles um and also some er curly bee lines, but I don't think we can appreciate it on the screen actually. Um But so to go through it, you want to say in terms of an osk. Um This is a chest X ray of so and so taken at this time. Uh It's APA film. Um it's of good quality of minimal rotation, this good inspiration effort um et cetera, et cetera. Um but the striking abnormality in this picture is the bad rings appearance, the left side of eus and cardiomegaly and this is indicative of pulmonary edema and decompensated heart failure. And I'll start the patient on a stat flusemide at 50 MGI V to manage their symptoms. And I'll discuss it with a senior and I'll continue to review the chest X systematically. Um So you go through as we say, so the airways and mediastinum appears completely normal. There's no obstruction, no deviation of the trachea. There's no widened mediastinum or pneumomediastinum. There's bilateral infiltrates resembling the bat swing appearance and indicative of pulmonary edema. Kelly B lines were also noted otherwise, there are no other masses of consolidation noted. The cardiothoracic ratio is larger than 50%. So you see the heart is quite big compared to the cardiothoracic ratio there, sorry, compared to the thoracic cage there. Um And this in distinct right and left heart border which are indicative of pulmonary edema and heart failure. Um The left diaphragm is obscured by um opacity and the blunting of the costophrenic angle on the left side indicates pulmonary sorry, er er P er pleural effusion and there are no other extra findings in the film. So, in summary, this chest X ray and the history suggestive of pulmonary edema secondary to decompensated congestive heart failure. I will manage this patient using diuretics and optimization of the medications and I'll discuss it with the medical registrar for admission. So that's how you phrase the whole presentation of your chest X ray, including your patient's um findings, et cetera. So, um almost there. Um we talk about uh oh another diaphragm case. Um I've got a 34 year old male who's presented with severe abdominal pain and shortness of breath. Um He's got a bit of a raise BP and tachycardia pressure of the pain and also um uh increased respiratory rate. He's got a bit of a temperature on abdominal examination. He's very peritinic er with er guarding and the agastric region. And you discuss this case with your consultant who is um quite old school. He's almost retiring. He's like get an erect chest X ray and he's a consultant. You're gonna have to do whatever the consultant says. So, um you requested a chest X ray. So I'm gonna break this down into two scenarios. So the scenario one, the outcome of the chest X ray, you go through your details, right? It's a good quality x-ray. You go through your airway, your breathing and circulation, your diaphragm. It's actually a completely normal chest X ray and you go back to consultant and say, oh a chest X ray is normal. Um but they still think that this could be a perforated duodenal ulcer. So you go on the request a CTA or Pelvis a scenario two again. Um so same patient but a different outcome on a chest X ray um go through your details, right of good quality. And then there is a striking abnormality in this film as air and of the diaphragm um indicating a pneumoperitoneum and this is strongly suspicious of a per duodenal ulcer with that history. So I'll request a surgical opinion and a uh abdominal CT to evaluate further and you continue with your systems review. So both scenarios resulted in a CT ABD pelvis anyway. So there's actually no place for erect chest X ray in a acute abdomen or to evaluate for a pneumoperitoneum. But you are expected to notice, recognize it for your UK MLA um and your finals and S and F one and F two. You are expected to know this and you are still expected for your exam purpose and your sys purpose to do this the old school way. So if someone comes in with um acute uh abdomen, like acute abdominal pain or acute abdomen, uh you would want to suggest that you would do a erect chest X ray alongside a CT abd pelvis um to evaluate for perforation on pneumoperitoneum. So that's what you have to do in terms of exams. So finally getting back to the soft tissues and bones and everything else. Um it does vary a lot. There are many things to look out for, but you're not expected to recognize the subtle findings. The most likely that you need to recognize are rib fractures. Um So, for example, in this case, there is a displaced rib fracture here, um and here as well um as a result of a trauma. Um and uh there is a pneumo thorax associated with it as well as you can see, it's an absence of a lung marking there and it goes uh and your pleura goes around around there. It's not the clearest of the images. Um But in terms of rib fractures, um when you, you, you're concerned about a patient when they can't take deep breaths in or they have a fail segment. So that's when your ribs actually broke into two bits. Um So you create a segment of the rib that's floating up and down. Um A as you breathe in um or when they have a pneumothorax, then um that's when you should consider a CT thorax because actually a chest x-ray is not very sensitive in detecting um uh rib fractures. So that's when you need a CT thorax to evaluate um for rib fractures. Um Most of the time, sometimes you pick up dislocation or fracture of the shoulder and scapular as well on a chest X ray. But I'm sure the M SK session will cover this a bit more. So, finally, just a bit of a summary on how to actually present the chest X ray. Well, um in terms for OS purposes or for your ward round purposes. So I think practice, practice, practice, develop a structure that works really well for you. So it could be doctors ABCD E for me, but it could be ABCD, just ABC for someone else or they have their own structure. Um address the elephant in the room show that you're a safe doctor. Um You can manage acutely unwell patients. Um and um focus on not just a chest X ray in front of you, but also the patient right in front of you that you need to manage. Um And um yeah, so show that show that you're safe um act on any critical findings right away. Um show that you're competent and sound smart. Um And finally, I just want to touch on um never forget about pulmonary embolism. Um They are very difficult to diagnose and they are um well, they are fatal. So, um if you have a patient who's got shortness of breath and chest pain, but they've got a normal chest X ray. Think about pulmonary embolism, think about your well score, your D dimer and uh CT pulmonary angiogram if um if needed. Um So I think that's all for me. Um Any questions I'm happy to take um I'm sure I appreciate that might be quite heavy. Um But if anyone wants to have a quick chat about anything? Just let me know as well. You're welcome. Mhm. Um Is there a feedback for integrated onto me or something? Um II can set that up in a moment and I can circulate. Oh, send a feedback form. Oh yeah, I can send a feedback form. Yeah. Um I think it should be able to be Yeah, so it's in the message. So I didn't know there was a po option, should we? Um Yeah, thank you for coming. Um Very much. Yeah. How do you stop recording?