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All right, Dean. Are we live team everyone. Can you guys see us? We are live. Excellent. Excellent, Doctor Addy. As always, thank you for joining us over there in England. Were you watching any of the FA cup games just now? Uh Doctor Addy and if you like soccer. Uh um but I know the fa games were on today, so um not that you have to watch soccer but always uh it's always fun to connect with. Um Thank you all so much for being here today. Um uh Hopefully you enjoyed last week's video or last week's last time's video. Again, the challenge I had with that is I couldn't find a room um to actually get you guys um engaged. So II II opted to not bring you on stage just because uh it was I was trying to conduct it in a public space, so sorry about that. But today I'm in my office. Life is good and we have a great case today um that it's going to just have a good conversation with you all, especially those who are clinicians about when to pursue an invasive procedure. Um Sometimes it's, it's there, it's obvious it's black and white. Other times it will be great territory and that's what we're gonna discuss today. Deborah. Hello, my friend. Are you in Charlotte? Still? Sorry for recording you on the spot. Let's see if you're in Charlotte cause I will be there in a week. Um All right. Oh, you wrote, uh you wrote, I'm in Charlotte. Excellent. Well, if our stars align, well, we can meet up, let's do it. Um All right. So for today's case, let me see if I have the names here. All right. Who would like to come on stage to read an x-ray? Let's take, let's say, what do you think, Danny? One or two people? I think two is great. The Z two. All right. Who would like to come on stage? Um And Deborah, you're always welcome to throw your hat in the ring. I know you've done this before. So you're welcome to come on stage if you like, but whatever makes you feel comfortable. If you put in the chat, I'll invite you guys to the sta Yup. Th as Deanie said, throw in there and then we'll go through a case together, Ralph. I'm just gonna be by myself on stage. I know we have some newcomers so maybe they may not uh be eager but Raja, let me know Gabriel. I think you guys have done this before. If anyone would like to come on stage. This is a friendly environment. So don't feel like you'll be pressured in any way, shape or form any takers. It's a good case. It's a lot of fun. I promise you. I recommend Deborah. Thank you for the plug, Deb just because of a, a very uh modest crowd. Oh, Gabriel Raja. Did you guys volunteer or is Deborah volunteering you to join? What's uh what's the outcome there? Gabriel Raja. Would you guys like to join? No pressure, Deborah? I might just ask you to join me on stage that Gabriel, is that a, is that an, is that a? All right, Gabriel is coming on stage? Excellent. Raha, would you like to join as well? Hi, Gabriel. Raha or Deborah, whoever puts in, I'll go next Deborah. Do you want him to join? And then if Raha sends in the chat box that he'll join, I'll invite him as well. Deborah. Is that OK? All right, perfect. Yeah, Gabriel, that's fine. So we got Gabriel and Deborah. Can you invite them to the stage? Yep. I just invited both of you guys to the stage. Excellent. Excellent. So for the, for those who this may be their first time, a couple of things, we have older recordings that go over the basics of how to read an x-ray like beginner level, by the way, this is all beginner level to some extent, right? Cause you're like, I'm not a clinician. So no worries Deanie. Is there a way to find those early? I am in the. So me all did something new where there's now threads and resources on our home page. So in a few minutes, this will be like spotlighted to our home page, the introductory um documents you guys can find that first document that explains how doctor G would um take you through reading an X ray and you can see our first video. So if you've never participated before, that might help. Perfect. Perfect. Um All right. So we got Deborah and did you get uh Gabriel? Are you able to join in? Are we able to get Gabriel coming in? I have invited you to this stage. Um You can put in the chat if you're having any issues and I can try to help. So as Deanie mentioned, um um take a look at the um earlier lectures, but what we do with these um oh Gabriel, it's OK. You can uh Deborah. Do you wanna guide on how to get into the stage? Let him know. I think he can hear you if you're unmute. I don't think if he can because he, he says that he has no mic normally show up on invitation for a day stage. Uh There's no mic OK. Got it. OK. Understood Gabriel then yes, by all means you can just drop it in the chat box. No worries. Thank you, Deborah. It's you and me. Is that OK? Yeah. All right. I just want to tell everyone that this is a safe space. So don't feel shy to participate. It totally. OK. I have done a few times. Sometimes I get the their answers right. Sometimes wrong. And there's no problem. I love what you just said. So to everyone here, I know we've taken like seven minutes to go over this. But the what the Deborah mentioned is spot on this is not a test. This is not me testing you all. This is me having a fun moment with you guys teaching you a skill and a safe space or you know what I want you to get things wrong. I want you to. Why? Because as you learn, you can take this back to impress people. So you can be like, look how good, I know how to look how great I know how to read an X ray. Don't worry about impressing me. You impress me the second you joined us tonight. That's awesome. I love the courage. The goal is taking these skills in helping a patient to impressing someone. So as Debra mentioned, this is a safe space. So Deborah and Gabriel will tackle this together. Let's dive in. OK. So the case I'm gonna represent is a 56 year old gentleman with a past medical history significant for a neuroendocrine tumor that's metastasized from his pancreas to the liver. He's been on extensive chemotherapies that have resulted in somewhat of an immunodeficiency. All right. So let me just put in chat neuroendocrine tumor with metastatic me metastatic disease to the pan, from the pancreas to the liver. This patient reports to the emergency room at our hospital with three days of shortness of breath. Let's review the x-ray. I'm not asking you guys yet to think of anything else, but let's dive into the x-ray. Are you ready? Deborah and Gabriel? Yes, perfect. All right. Now I have that up. Let me go ahead and share my screen two seconds to do. Share your screen. Here we go, Deborah. Since you can unmute, just tell me if you can see the screen, I can, you can fantastic. All right. So my way of interpreting an x-ray is no different than you all reading a book, right? You may be giving, you know, les Miserables to read 500 some pages and you're like, this is gonna be overwhelming. So what you do, what you open to page one, start reading the first word, second word, first sentence, first paragraph and so on. Until you get to the end, there's a lot of data that you'll collect, but you probably will retain the most important things out of that book. Introductions, the protagonist, antagonist, the climax, et cetera. That's it. That's how you all walk away. Reading a chest X ray is the same thing. Thousands of pieces of information are present. However, to not overwhelm, we make uh an approach that we can replicate over and over and over again in order to identify an abnormality, once we identify an abnormality, then we begin to think what could be that abnormality. And does it explain why we got a chest x-ray? For those of you? The other aspect to add, we get chest x rays for emergent reasons. 95% of the time I'm making up a statistic, but by all means chest x-rays are good, but they're not great. So if we're gonna get a good data point, that's not great. We're getting it because it's really efficient to get. It's really quick to get. And chest X rays are just that. So they help us get some good data. They're not as great as a uh chest CT which is a three dimensional representation uh using x-rays. However, chest uh computer tomographies are harder to obtain. So we rely on chest x-rays often. So here we go. What I will do and I will walk through uh Deborah and Deborah if you don't mind when I call on Gabriel, cause when I share my screen, I can't actually see the typing. Could you read his responses? Is that OK, Deborah? Yes, I can do that. Perfect. So what we do when I see a chest X ray is, you know, right alphabet. It's hard to not say OK, I'm being overwhelmed. I have some suspicion on what's going on, but then I pause, take a deep breath and dive in and first I assess for assurance that the patient has been properly positioned and use the spinal processes for that. Then I start exploring things in the chest by using anatomical landmarks. The first I find is the carina, carina is right where the split of the trachea occurs into the right and left airways. The bronchi, the Corin is a great anatomical landmark to tell me what's happening in the anatomical space known as the mediastinum. The mediastinum is a space, negative space created between where the right and left lungs end and in that space are your aorta, your trachea, your carina, your heart and other organs like your lymphatic system and your thymus. So, what I'm looking for there is to see if it shifted a shift of it can tell me potentially some pathologies happening that is either from the mediastinum or impacting the mediastinum. Next, I look at the pleural space. The pleural space is the space that surrounds the lungs and then that space could be fluid or air. And to gauge that, I look at the costophrenic angles where the diaphragm and the ribs meet with a two-dimensional smushing of these of a three-dimensional um uh body. And there I look for fluid cause fluid is heavy and it goes to the base. Then I go to the apex to look for air. All right, to see if any air is left, the lungs escaped and got into the pleural space. Once I evaluate the pleural space, then I'll go to the hilum. The hilum is the beginning portions of the lungs. It's where their airways start, the lymphatics start and the blood supply starts and returns. So what I'm looking there for the hilum is more shape and the translucency of it after that I go into the heart. And really the only thing you can assess about the heart is, is it big? That's it. There's no such thing as a small heart that can capture well on X ray. Um But you're looking to see if it's a, if it's disproportionately big. And finally you dive into the actual lungs zigzagging top to bottom and then across top to bottom, top to bottom, top to bottom. What you're trying to look for is uniformity from the top to the bottom of the right lung, top to the bottom of the left lung and at the right lung of the left lung look relatively the same with expected differences in the bases since they have extra vascular um presence there. So with that in mind, Deborah, I'm gonna tag you to assure the patient is not rotated. You're gonna read the media stum for me. And then I'm gonna have you read the pleural space. Then Gabriel, you'll go into tell me how the hilum looks and how the heart looks. And then Deborah and Gabriel, you guys will both tell me about the lungs. Is that ok? Yeah. Yes. Oh, is that Gabriel? Did you just unmute? Yeah. He's just Gabriel. Oh, excellent, my friend. Excellent. Love it. Alright, let's do it. So, Deborah, we'll go to you first. Let me just find how there we go. You ready to read the pleural space? My friend. Yeah, I'm sorry. What, what, what are you saying? Spinal process, sorry. Multitasking. All right. My friend finding the spinal processes here. What do you think? They look like a nice tear shape? Yes. The patient is not, not rotated. Correct, correct, correct. Don't be thrown off. Sometimes patient, you know, I will get intern saying he may be rotated, right? He, yeah, he may be looking somewhere um but he is not right. He is up against a flat surface even though he, his head is technically rotated a little bit. All right. Next, let's go to the Carina. Yeah, right there. So yeah, perfect my friend. So what do you think is the cry of, you know, it's what we usually say is like, hey, as long as it falls in between the vertebrae's boundaries, it's reasonable. What do you think? Does it seem pretty? Ok. Yeah. And then this angle of the carina, would you agree? It's less than 90 degrees. I do. Perfect. So to the audience, the carina angle again, the carina is where it bifurcates um into the right and left airway. By the way, this l over here signifies left. So this is the right side over here. It should be less than 90 degrees if something's under pushing it like a lymph node or a big heart or a tumor, then the thigh, the carinal angle will be greater than 9090 degrees. Uh So more of an obtuse angle we call that splaying. So there's an, an implication that something's happening in the mediastinum. Nicely done. My friend. You're gonna go over the pleural space and then we'll turn to Gabriel. You're ready. Yes. All right. So, Deborah, don't overthink this. Let's go to the left. Do you see costophrenic angle on the left side? I can see. All right, perfect. Perfect. What about the right side? I can't see, you can't see it uh To everyone, this is so vital. A costophrenic angle is not something you need to squint to find. If you're squinting, it's not there. It should be very obvious. It should be very present where Deborah is looking where it would be. Is everyone make a note of it? It is white it out. You cannot see this. So let me pause here, Deborah, you're good. You're great. Well, actually Deborah, let's finish with you real quick. Let's go to the top and then I'll go back to the bottom. Um What about the a pies? The apex? Are they look? OK. Nice and grayish or any concerns for blackness? That would be implied as air? No look. Ok, good. So what Deborah's mentioned is that the both apices are present without a hint of air in the pleural space. I agree with her. She makes a case that the left side, you can see the costophrenic angle, but the right side, you can't, the right side right here is white it out, right? This is a white out, otherwise known in medical terms as a Oh my gosh, this is gonna take me forever to write. But let me see if they can write it out. A consolidation. Consolidation implies a white it out um part of the lung. And so li all right, we're getting there. So, with regard to consolidation, there are four reasons you would have a whited out area of the lung. There's four differentials. So if you get whited out sections, ak a also known as a consolidation, four reasons. One pneumonia, an infection waiting it out, two atelectasis, atelectasis is when the lungs self collapse. When the lung self collapse, it can create this level of a white out three water but not water in the lungs, water around the lungs, what's called a pleural effusion, right? That will wipe out the lungs, actually wipe out the chest, the chest and then four is actually a lung resection. So if I took a piece of this patient's lungs and that rest of the lung was unable to grow, right? Uh uh not uh not that it grows in your lung, parts of the lungs just expand. So if I cut out a piece of your lung and it's unable to expand over time that empty space that's filled with a negative pressure will be filled with fluid and that will white out. So when you have a consolidation, it's either infection, it's either effusion, it's either atelectasis or there was a lung resection. So you gotta know the patient. So in this case, knowing where it is occurring, right, the location can also give you some indication of what it could be. So, Deborah, you said you can't see a costophrenic angle on the right side. That differential opens the door to that could either be because of its location. It's at the base, it's at the base of the lung. This could be a pneumonia, this could be atelectasis. The bases tend to self collapse regularly easily. This could be um a pleural fusion. I cannot differentiate those. Well, you may see what, what about a lung resection? Yeah, look that's fine. But lung resections also have other clues like surgical scars with um metal sutures that are left behind. It's hard to get a lung resection without that indication, Deborah. Does that make sense? Why a lung resection is not on the top of my list? Because I can't find any other reasons the patient or I can't find any other indication the patient may have had a surgical resection. Does that make sense? Yeah. All right. So right off the bat seeing this, you should say, can't see the costophrenic angle, there's either a pleural fusion there or a pneumonia or a, uh, um, pneumonia in you or atelectasis or it could be all three. It could really be just all three happening at once. Does that make sense so far? Depo, are you ok with that? Yes, I am. Perfect. No, Gabriel. Are you ready? Yes, let's go ahead. All right. No. First of all, as Deborah said, this is a safe space, I'm gonna guide you into this. Is that ok? Yeah. So what you're gonna tell me next is the highest, the high line should look like on the right side, a nice kidney shaped or being and it should look rather transparent. You should be able to see through it. You should be able to see through it as well as you see through this area of the lungs. You should be able to see through it. Ok. On the left side, it should be a little bit of a nub and popping out just like that cause the rest of it is hidden behind the heart. That's it. But still should be very transparent. What I'm looking for in the hilum is, is it normal or not abnormal hilum would be like the current one on the right side where it is larger than expected and it's not easy to see through. Right. It's actually pretty white it out. Would you not agree for the right side? Yeah. Gabriel. Yeah. So Gabriel, you agree on the right side, it is an enlarged hilum. That, that, you know, for someone at your level, you may not pick up on size as easily, which I understand. But at the same time, you are making the case that, you know what, it's hard to see through doctor G it's rather wiped out. Is that fair to say? Actually so far? I remember. Uh, well, um, before, before anything, um II am Gabriel? I, I'm Gabriel as, as you can see on my, on my screen. Um And I, and I'm from Mexico. So so far I reme I remember from my, from my medicine classes there is a, a sign uh which is named uh butterfly sign so far. II remember which, which uh refers to um how, how do you say this is not the best? Um The ileum is bigger, way bigger when you see the the butterfly side? Excellent, excellent, so perfect. So the hilum you would agree both on right and left. It is abnormal bilaterally. Is that fair to say? Uh Yeah, so far I can see it do it does look like the same left. You and me are gonna evaluate the heart. Are you ready? Yeah. So with regards to the heart where you're looking to evaluate is cardiomegaly. Now, the challenge that I would pose is and this, there's, there's a lot we look for one of two things we look for the space uh AAA reasonable space between the apex of the heart and the chest wall and there is a space here. And the other part that you look to see is if there is a two slope, I call it two slope where the left atrium comes down and then the left ventricle takes off. But this looks like it's a one entire slope. So you may wanna say, hey, maybe the left atrial pressures are elevated. Um But let me, let me pause here. The heart, the heart to you. Does it look? OK, what's going through your mind? Mm OK. Uh We have to remember 2222 points which uh the first one is the cardiothoracic index so far. II remember it has to be um below 0.5. So if the Ky is above uh yeah, that, that, that number. So, so, so you can refer any um a, a cardio megalia. And also um you have to imagine like a line which uh pass uh in the middle of, of the, the clavicle, the clavicular, this bone from the shoulder. So the apex from the heart has to be uh behind that line. So if, if, if the a if the heart apex is uh above that line, you should uh think about a cardio megalia. So for me, the based on, on what I can see, I can see a, a card. So great points, fantastic points, Gabriel. The challenge that I would pose, right is that those are great in two instances a on the type of x-ray that gets done usually a pa so posterior anterior where the patient is being shot at at a unique angle versus an AP which usually is done in a more critical care situation cause the patient is gonna stay in the bed and you're snapping it there. So great points, great points. But you we have to be at the mercy of the data that we got. Cause the other aspect is what is one thing you usually ask a patient to do when you're getting a chest X ray in order to get those measurements, Gabriel, what does, what does the technician tell the patient right before snapping the x-ray. Do you have to ask the patient to, to take a deep breath before? Perfect. Yes. Take a deep breath. Now, question to you, Gabriel. Is that an easy thing to do when a patient's breathing 30 times a minute and deat? And so we're gonna have to put some oxygen. Is it easy to hold your breath when you are work or breathing is intensified? Uh It's, it's not easy. It is uh iv's homework. So, yes, II would not consider any. Yes. So you're spot on. So one of the things that II tend to not do unless I'm kind of forced to is kind of assess. Is this an adequate inspiratory film? This is not, this patient does not have an adequate inspiratory film because you can do count the ribs or you can recognize one unique thing that I'm seeing in this uh uh heart, right? And this kind of impression that I'm getting with the two slope approach, having it so linear in a patient where much of the congestion is happening in a central part. So to the new piece coming here, this is really kind of just years of just taking this data in this patient is giving me a poor inspiratory pressure. The other way you can assess that is this. Look here, let me get the pen out, you can count ribs. People always advocate for counting ribs less than eight. Usually it's a poor inspiratory film, but there's this creation, right? As opposed to having a nice flat diaphragm, you have it kind of squished, you kind of have this angle coming up. So that means it's coming up but up against the heart. So you don't get a nice flattening of it. So Gabriel great points to make about taking into account, you know, a ratio of heart and chest and then taking into account positioning. The challenge that I would pose is when you're dealing with patients that can't abo abide by taking it standing, taking an extra standing or holding that inspiratory breath. You're gonna have to rely on kind of more surrogate markers. So the surrogate markers I tend to teach are do you have a space here and you have a two slope approach? These tend to help me out in more critical care level settings. So great points, my friend. This is the beauty of medicine, how to adapt to the situations that you are in. So nicely done. Concern. Now with you and Deborah, let's dive into the lungs and let's review them. Are you guys ready? Ready? Excellent, Deborah. Are you ready? My friend? Yeah, I'm ready. All right, we're gonna start with the left lung first. So with regards to the left lung left being over here, the goal is zigzagging back and forth. And so what you're looking for is a couple of things in a normal lung. You should have vasculature that comes out somewhat straight lish but more or less a line, right? That is more prominent up until about you get to the mid clavicle and then really you start losing it as you get to the end. Ok. That's it. There should be nothing that's fluffy. Nothing that looks like a cloud. Nothing like that should be present. So, question to you first. The first question I'm gonna pose is the lung the left lung normal? Does it abide by what I just mentioned, lack of fluffiness, lack of consolidations, sh they shouldn't be present, it's normal and you should have really just kind of linear vasculature extending from the hilum lost by the time you get to the edge of the lungs. So, is this normal or not normal Gabriel we in normal or not normal left lung, not normal? Because you you can see, like, uh, diff, diffuse, uh, diffusing filtration. Is that correct? Excellent, Gabriel. Excellent, Deborah. Do you agree or disagree? Yeah, I agree. Not normal. Yeah. So, here's the two aspects of the left lung that are not normal to me and to the viewers out here it's this, these are all, these are opacities, right? Opacities tend to look like clouds in the lungs. Right. That's, or as my five year old daughter says they look like cotton candy, right? Meaning it's fluffy. There's not a definitive border and it you can somewhat see through them. And then I believe this is what Gabriel was highlighting as well. You see all these interstitial markings extending the challenge though I will pose to you all. I think this patient is being captured on an expiration, right? A lot of it is because of this angle that I pick up here. So being on an expiration, all the blood vasculature will look more prominent, but this is the part that is a this is huge. Next Gabriel and Deborah, the right lung normal or not normal. Deborah, you go first, normal or not normal and tell me why you think it's one or the other not normal. Can you tell me why my friend because I can see like some opacities too like to the middle, to the lower. Yes, that is correct. And we brought this up when you read the costophrenic angle right? Here's AAA remarkable thing. To some extent, you may even say it kind of aligns like it seems like it's following and behaving some border. Excellent Gabriel. Do you agree with or do you disagree and say no, that's a normal looking right lung. Uh Yes. As, as the bo said, I can see a cardiac infiltration in the lung base of, of obviously the right one. So no. Perfect. Yes. And then you could also make the case. There's still opacities up here and prominent interstitial markings. The challenges with this patient is, you know, he m my bet is uh not bet I can tell you he is captured on an expiration. Let me show you one quick thing about the chest ct and then we're gonna go over this case. This is a chest ct and to people that are new. Let me tell you what we're seeing. So this right here is the heart, this is everything that's bright and shiny is bone. This what I'm highlighting over here. This is all lung on his left side. OK? This is his left airway. This is his right airway. We have crossed the path of the high uh crime. So we're no longer there. The right lung. This where I put check marks, this is healthy, normal, this is normal like all of those streaks you've seen here. That's just blood vessels coming in and look, look what's cool about the blood vessels. They're nice and big and they get really thin as it gets to the uh periphery, get closer to the chest wall. And even right here, this is not normal though. Now, let's go to the right lung. I'm sorry, this was all left over here. This is the left lung. Let me put it out here. This I could make a case. This is healthy, left lung. Ladies and gentlemen, this is not healthy lung, Deborah. What stands out to you about this consolidation? What stands out is it? So let me guide you. Is it completely white or not completely white? And if it's not completely white, tell me what you are seeing, it's not completely white. And I think I can see like some vessels you see vessels. Perfect, stop right there. Love it. Deborah. The fact that you can see the vessels and the fact that the vessels are black. Do you think these are blood vessels or do you think they're airways? Um Air air looks black. Yes, yes. These are airways, ladies and gentlemen, these are airways going through the consolidation. We call these air Bronchogram. We can see them right? Cause air is black, right? This is air up here, this is all air and it's black, right? Let me look at me writing and we'll put in r this is air. These are Air Bronchogram. Air Bronchogram going through a white it out section reaffirms this is a consolidation, this is a consolidation, right? So the answer is is this pneum, you know, there's this pneumonia I told you that's one of the four possibilities, pneumonia, atelectasis, lung removal. This isn't the case here. Um Or an effusion. This is not an effusion. Could there be some effusion down here? Maybe, maybe. But for the most part, this is a consolidation. So let me stop sharing earlier. You began rightly. So as you should saying, this is what I recall about reading something. I'm looking for A B and C. I'm looking for these points. Never forget it, love it. The the challenge with medicine is the art of it, right? The art of it. And that means, hey, what I've been taught, this is a different situation. How do I adapt to that? Does that make sense? What I did? I took your recommendation? They're perfect. I promise you there's nothing wrong with you said to the listeners. He is correct. The challenge is that's gonna work 100% of the times for a person who can stand up against the wall, getting a pa A that's a posterior, it just posterior interior just depends when the angles of the X ray is going and he can hold a nice deep breath. This is not that patient. Unfortunately. So what you mentioned, right? We have to be mindful. I even just made a point of saying he's got prominent blood vessels, but he's expiring, right? So those could be prominent cause his lungs are getting squished on expiration So the only thing that really stands out is what you and Deborah highlighted the consolidation and the opacities. Uh the consolidation and the opacities has in the enlarged high lungs. It, it's just important to recognize medicine is not perfect. So you're gonna have to interpret things with the data that you get. So I wanna make sure you, you understand you are not wrong. It's just the way you're taught for that. It's hard to apply to that situation. So we have to adapt. Does that make sense? Good, sir. Yeah, a lot of sex. Yeah. Yeah. And that's it. That's medicine. This medicine is such a great field because we and our patients never read our textbooks. So here's what I wanna ask you all. What would you do next? What would you do next? And Deborah and Gabriel, you can be my leaders here. This is an important question. I told you, this is a 56 year old patient with a neuroendocrine tumor metastatic from pancreas to liver and immunocompromised because he just got chemotherapy. What do we do next? So let me ask you, Deborah and Gabriel, there's no wrong answers. What do you do next? You guys are my, on my team. We just got consulted about this patient. What do we wanna do? Any immediate falls? Go ahead. Uh LA is first. Why, why were we are doing the chest X ray with this patient? What is the chief complaint? Sorry if I miss 56. He came in short of breath. He's short of breath. Ok. I didn't see him. You're in the room? He's doing this right. White count's horrible. Right? He's neutropenic fever. So you're like, I, he seems infected maybe. So, what do you wanna do next? What are you gonna recommend the oncologist or reading Deborah? What are you gonna tell him? What would you recommend? Uh I think we should probably he has an infection and as he's immunocompromised, maybe start like with the treatment but like get do some tests before. Of course, to see what, what, what kind of infection could be a blood culture, a virus. Everything perfect. So, so the audience Deborah made a great point. Let's start the intervention because we know delaying antibiotics is gonna result in death. So let's start them. And at the same time, yes, let's get test as well. Maybe we'll find the infection, right? So blood cultures, if he's making any sputum, maybe give you that he's not. And by the way, those crystal clear air bronchogram also imply this patient is probably not making sputum. So whatever is invaded in there in there is something that tends to spare the in the epithelial cells of the airways. So we got, oh let me, I'm gonna overwhelm. I apologize, just hear me out. So I can tell you right off the bat. II will, if this was Vegas, I would put money down this patient does not have a staph infection nor is it strep streptococcal pneumonia and staphylococcus aureus. That is not what is happening to this patient. Deborah and Gabriel are probably looking at me like how are you? So confident those two infections tend to impact more of the epithelial cells of the airways. So the way to get pneumonias is by blocking the airways causing excessive sputum formation and that invades the parenchyma. Whatever is happening to this patient is a parenchymal seeking out infection. So lesion Ella proteus being one of them. Um steno stenotrophomonas another one or it could be fungal. Those tend to be more parenchymal invading. They'll get through the epithelial staph and strep tend to love it. So those patients will cough. Uh lots of lots of gum comes out of them. Tons of phlegm. Great Bronchogram. The guy's not coughing up anything. Ladies and gentlemen, what Deborah mentioned is spot on. I would high five her to sign off on her note. Start the IV antibiotics. Move on. Perfect. Now, here's the challenge we get. And this is what I wanna tell you guys. The challenge when you deal with a patient who doesn't have a proper immune system is that the typical bugs that I would see in an immunocompetent patient, a staph infection, strep infection, for instance, that's what we're gonna start antibiotics for, but there might be stranger infections happening that we're not covering. He came in with three days of shortness of breath to the ed. He is then transferred to the medical floor of oncology. Five days goes by and he's getting worse. He actually ended up intubating him. So, through these antibiotics, he has not gotten better. And so the question comes to us, can we do a bronchoscopy? Can we do a bronchoscopy? Which means taking a camera into the lungs, squirting it with some salt water, sucking it back out as we suck it back out, things will come. Well, that's, and that gets us culture data. We can figure out if there's a bug there. But with that as well, here's the kicker and the oncologist called, they knock on our door and they're like, look, this could also be cancer, right? And they make a great case. Look how beautifully consolidated it is. You know, they, they really tested us and the infectious disease doctors, they're like what bug would cause that. And look, even if I can mention the ones that I rattled off, they don't cause that well of a consolidation that looks that great, especially the right side of the lung is right above the liver. It's a great place for it to easily metastasize. So their concern is was that the cancer that went into it. So what the access is to get biopsies challenge with that. And we told them, and we told the family if this is cancer, those biopsies he's gonna bleed and that's hard to control. So along with it, the whole intention of today's lesson, four things to take away three things. Sorry. One is consolidations. If you guys see consolidations white out, those are four differentials. By the way, when I say pneum pneumonia, you can even scale it back just to say it's the immune system in some capacity. Either immune system reacting to infections, immune system reacting to cancers. But it's one of those the immune cells kind of targeting that two atelectasis, the cell collapse of the lung will white out three water behind, right? That will create a nice white out. And then the last one is a lung resection. But as I said, you look for surgical cues, clues to clue you in, by the way, this white out was in the upper lung. If the upper lung was white it out, you can make the case of like I don't think that's an effusion. It would be really odd to get fluid up there cause fluid gets pulled down fluid wes a lot gravity. Um So those are good differentials to take away from when you see a consolidation two. As Gabriel and I just discussed earlier, you may have in your mind a way to interpret and read an x-ray. Actually let me s scale it back. You may have a way to interpret data in medicine or in clinical scenarios, just be prepared to know when to deviate on those circumstances. Like for instance, Gabriel and Deborah a patient that's immunocompromised, immunocompromised, right? Immunocompromised. I see you over and over again. What's one of the first symptoms that tends to not be as robustly present as their white cells go away? Like w for you, Deborah, don't over think this Deborah and Gabriel. How does your body tell you? You're not feeling well? Like what's the first thing it's gonna do to you see there that you may check to see how you're doing. What's, what am I thinking of begins with an F gi said gap fever, fevers. Oh, fevers. Yeah. So as your immune system plummets and leaves, bugs, infections don't cause fever as your immune system does. So that's another aspect where you start deviating from kind of normal things depending on the circumstances. And here's the final thing, one of the reasons that I applauded Deborah for her answer and I'm confident Gabriel said the same thing in modern medicine, you try to approach noninvasive strategies first because the noninvasiveness really implies pay the risk benefit. It's gonna be a allowed on the patient side. The benefit, invasive things tend to be a lot, carry a lot more risk to them. So there's definitely nothing wrong with the approach of just start these antibiotics not knowing what it is and see if that helps, that tends to help 90% of the cases. This didn't help him. He got worse. He was intubated. It was not the wrong decision. That's the part of medicine you gotta live with. It's frustrating. You make the decision based on the data you get when you get it. If the patient doesn't have that outcome that you want, it doesn't make it wrong, it never makes it wrong. As long as you can say, this decision is what all my colleagues would have done, right? Don't do retrospective stuff. It doesn't help because again, it's, it's a data point that skews. So Deborah, we ended up getting a bronchoscopy and a transbronchial biopsy, biopsies, two specimens. So, transbronchial biopsy. What it is? Let me just paint this to you guys. This is important. The patient is on a breathing tube that goes to the cry. I'm introducing wires that are about 30 inches long. That end with alligator clips, little clips. When I go into the patient, the alligator clips of the wires get lost at some point, right? As we're going down into the cylinder, right? As we're going, here's the wire as it's going down at some point, I can no longer visualize it. I can't. Transbronchial biopsies are done blind. You can get an X ray if you want in there, you're still blind. It's all about a field. Do you feel a little bit of pressure? Once you do that? You open close, pull out and yank a little bit of tissue out on her second bite. The patient bled. You saw, you started seeing all this blood rush out on the camera destroying my bronchoscope. At that moment, we pulled the bronchoscope out, we clean it, we put another one in. We grab the coldest water you can and you shoot cold water into the lungs to freeze, to escalate the coagulation cascade. So it starts clotting that section off. At that moment, we called in our surgeons as well and we called in anesthesia backup cause we needed to discuss to be one lung, ventilating one lung, ventilating to the students means I am ready to block off the right lung and just slowly ventilate the left until the. So the blood of the right lung doesn't get into the left lung. So that's the one lung ventilation strategy. What I'm trying to get at with this and not the scary one. But whenever you do an invasive procedure, you need to be prepared if there's a consequence. So if we had students in the room with us at that moment, they would have seen us who collected, probably not even think of anything that's happening, that's wrong. You gotta be prepared for the side effects. But we don't take doing an invasive procedure when a patient's immunocompromised lightly. But we did it cause oncology made a very strong point. We need those biopsies because if that's cancer really is gonna change management, we just wanted a lavage of just looking at the cells. Do you ever the patient survived and has been extubated. The challenge is that with cancer? So you guys are. So it's all cancer. So, you know, they'll discuss next steps, but it's not a good sign that it's gone from the liver now. Tolan. So with this case, the third thing that I'm hoping you all take on, listen, for those of you who wanna be clinicians, you'll be amazing clinicians, but please recognize making the decisions to do something invasive. You better be prepared to talk about the risks and benefits and if the harms happen, be prepared to pull back. That's what makes us physicians so great. The do no harm policy, right? They do no harm is cause we can know how to provide an antidote if we cause the harm. Gabriel and uh Deborah, do you guys have any questions? G where are you at? Um Sorry, what again, please? Where are you? You look, it looks beautiful wherever you're at. Oh, and this is my, well, this is actually not my university. Uh in, in Mexico. I came to, to, to hear a speech about nasa's topic. Uh So far I remember and actually it's about to begin and yeah, so check, check this out. It's, it's nice. Yeah. Yeah. It's, we have to come to you next time. OK. Yeah. Yeah. And you have to uh well, uh actually I do not have a question. Uh I just wanted to, to say that this, this session was uh I II really liked it like it. II gotta say um the way um the, the heart warming way you, you, you spoke to us. II really appreciate it. So and so far I can say II did and learn a, a lot of things about I II myology because I remember ba ba back to in, in six semester. My, my, my teacher was old, so I didn't understand a lot of um radiology as a, as, as I wanted to. So this, this session helped me out to, to, to, to clarify my, my questions. So and finally, ii really sorry for my, for my English. It's not the best, but you're fine trying can ask my friend Gabriel. You are fantastic. And that's look for all the learners. I know you're, everyone's coming to different parts of this come and you know, as you learn from different physicians, understand, you know, we're all saying the same thing. The big part of medicine is no one to deviate. There's no one to be prepared to interpret things that are different than you're used to. So, Gabriel, you are sounds like you're an amazing physician, my friend. Congratulations. Good sir, Deborah. Thank you as well. And uh everyone enjoy your Wednesday night. Um Dean and I will be back in two weeks. Gabriel, hopefully you'll join us again in two weeks. Um See you, then I will thank you guys. Thank you. Perfect. Thank you guys. Take care.