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All right, Deanie. Can you see me? I can see and hear you. All right, fantastic. All right, is uh everyone here still streaming in? All right, sounds good. We'll give it another second or so. Um As people come in. So awesome, good to see everyone. Very excited about today, Deborah. Good to see you again. My friend. We should have a good case today um that we will go over so very excited. We'll start in about one more minute or two minutes. We give people time to come in. All right, I see that it is 503. What do you think Deanie should we uh begin to rock and roll? All right. So good to see you guys. Um I'm very excited to have another um event with you all. Um Last one was fantastic. Uh The one thing I'm gonna say after this event today, our next one will be let me grab my calendar date, August 30th. So I apologies for the four week. Wait. Uh I'll just be traveling. So it'll be um I know I've conducted these before for you guys who have been with me for a while in airports. Uh and in other cities, um, it's just, uh, I can't promise I'll be anywhere that will have reception though. So, um, with that said, August 30th will be back um, in August 30th though, we will also have Doctor Tony Chang. Uh come back with us. He's our radiologist and we're gonna probably try to tackle a little bit more difficult cases together. I wanna say difficult, difficult in the sense of like the lung doctor doesn't pick up on some subtle clu uh clues. Um So it should be good to have him. And then next is um when we're back in September, we're gonna have one of our radio uh not radiologist, but an interventional radiologist. Doctor Clifford wise go over some of the vascular malformations. We see him and I work together in our vascular malformation clinic. So we'll go over some of those cool findings on chest x-rays as well. So with today, just like we usually do, we're gonna go over a normal x-ray, normal uh uh quote unquote. And one of the things about normal with the first one is kind of a way of sometimes as we use it in um medical lingo because normal could imply the general generality of a patient. Yes, they fit a lot of normal findings. But also when we say normal to patients that still also have abnormal findings, but it's normal for them, right? They have their own version of a normal because of certain diseases. They've shifted kind of the findings on an x-ray to kind of abnormalities. But if they're stable, then those abnormalities are just part of their own normal baseline. So we'll go over some uh subtle findings in patients with an obstructive lung disease and then we'll move into the case and I'll call a few of you guys on stage to come and go over the case with me. This should be cool, you know, fun. So we'll go over some questions to ask in the beginning and then I'll show you guys the x-ray and we'll take it from there. So for the 1st 5 to 10 minutes, I'm gonna go over a chest x-ray and then I'll bring some people on stage just like we usually do. Um If you wanna be on stage and Doctor Addie, good to see you again. Um You know, my friend, if you have questions by all means, but again, the intention of th this hour together is really to kind of enhance our own skills of uh reading and interpreting a chest x-ray. I standardize it in a manner that makes sense for me and my work. Um If you guys have been with prior lectures with me, with doctor Chang, radiologists have their own way of standardizing uh as well. And I say this because it's all part of the art of medicine as long as you can get to the significant findings that are gonna impact your patient's clinical outcomes that will be key. Um And Doctor Addie didn't forget um a case that you wanted me to discuss. So, um I'll, I'll put it on a reserve for next month. Uh So hopefully please join us August 30th. All right, let me go ahead and Deanie, my friend. As always, please just confirm you can see the slides once I move this um forward. Um and give me a second, this is always the most exciting time, right? Cause it's like, are you gonna be able to do it correctly? Doctor G? All right. So let me go here and let me go here, Deanie. Just unmute. Let me know if you can see it. My friend see it. Ah, ah, it's a joyous day when I get it correct right off the bat. So with this chest x-ray, remember what I said earlier for many patients because of certain diseases, they have having expectation of them having normal physiology or normal anatomical findings is not gonna ever occur. And so picking up their abnor abnormal findings while it's important, it also has to be differentiated from what's an acute abnormality that could explain potentially some dire clinical situations or what's a chronic issue that, you know, it's part of their baseline. We don't need to overreact to it. This is their new normal, one of my favorite lines because I'm also a critical care doctor is that the acute recognition of a chronic problem doesn't make it acute. So with that in mind, this is a patient of mine, this x-ray she obtained for preop uh a preoperative evaluation. She came to the hospital. Uh Well, actually she came to the emergency room, she had a fall, they found her to have a hip fracture. So the orthopedic colleagues are like, all right, let's, you know, snap a chest x-ray so we can prepare for the case. Now, you may be thinking to yourself. Wow. Do we need chest x-rays before undergoing surgery? There was a massive school of thought for the fir for the last 20 years that the answer was yes. And lung doctors have advocated, you don't need them. There's, there's nothing on there that is gonna tell me how to manage my patient or you know, during the surgery. So we've done away with them. However, you still may find an orthopedic colleague requesting it. So this x-ray was snapped in the emergency room and orthopedic said, well, we're gonna delay the surgery until pulmonary medicine can weigh in. They wanted us to weigh in because of some abnormal findings. But with that in mind, let me tell you how I interpret this x-ray. So as I go through this, this is my stop first things first, I always gravitate to the spinal process. I try to make sure that it is in this kind of oval shape, almost like a teardrop. If I find that to me, I know the patient has not been rotated. The technician has done a good job to make sure that they are upright um without their left or right shoulders leading in more than the others. Again, that's something it's an appropriate check to do for the purpose of assuring that a rotation won't have you misinterpreting something that is because of it, uh positioning uh and, and interpreting it as some dire anatomical situation. So spinal process is not rotated next, I go to the trachea and I follow it all the way down until I get to the carina. The Carona for me is an anatomical landmark to help me interpret the mediastinum. The mediastinum again is that space between your lungs, left and right in the mediastinum, you have lymph nodes, you have the trachea, the carina, you have the aorta branching um with its big blood vessels and then descending all the way down into the abdomen. You have the heart mediastinum has important stuff. Now, the mediastinum, you can tell to some extent using the cara as an anatomical Lear if there's something happening to or in the mediastinum. So one thing that I do is use the vertebras kind of as a poor man's landmark. And if the cry of falls in between the vertebrae boundaries, I interpret it as the mediastinum is not shifted, so reasonable um evaluation of the mediastinum. Um If something's pushing or pulling against it, the next thing I look at is remember I introduced you guys, the angle of the cry and I'm drawing a lot on here, I'll erase some of it. So it's a little bit easier to interpret. Look at the angle of the cry here and then I'm going to redraw it. What the angle of the Cronus should be is an acute angle. You will see in one of the cases that if you have a, a more of an obtuse angle, we call that a splay Carona, meaning something under the caron is pushing up against it. It could be the heart, it could be a blood vessel, it could be a lymph node, it could be a tumor. So this is a normal angled Carona. So the way you can just say that out loud when reading an x-ray is the Carona is not splayed. That's it. Next I go to the pleural space. The anatomical landmarks I use for this pleural space is the costophrenic angle here here and the apices ideally above the clavicle. And what I'm looking to see is if there's any air or fluid in the pleural space, fluid goes to the base, right? It we it's much more it's dense. So because of the high density gravity will pull it down. Now, I can see two costophrenic angles here left and right. However, if you've done these lectures with me and I encourage you to see the prior ones, you may say, Doctor G, I see those angles, they're they're, they're vampire fang. I, but they're not as sharp I've seen before. Good. Hold that thought we'll come back to it and then I go to the apex right left and right. What I'm looking for here is, is there any pitch black a sliver of it? Right. And when I say pitch black, I want it to look like this, right? That black because everything here is more grayish, right? So that, that just implies there's gas exchange happening because there's blood flow going there nicely up. That's not the thing I wanted to use. Let's go to the eraser. So in the ac above the clavicle, I do appreciate some level of grayness coming all the way to the top, which is implying there's going to be blood ves blood vessels, which is a reasonable surrogate to say you got lung tissue going all the way to the top. There's no air surrounding it cause air goes around, you know, travels to the top because of its less dense properties. So the pleural spaces here look normal, no air, no fluid. Remember you need about 300 mL of fluid in the pleural space to blunt the costophrenic s but I already told you something doesn't seem right about these. Not that something in the pleural space, but something to the lungs, we'll get back to it. Next, I go to the hy lung and the hilum, what I'm usually looking for on the right side is somewhat of a beam shaped kidney shape. And on the left side, I'm looking for kind of a nubbin to pop up over the heart. They fulfill that. But at the same time, your spider sense might be just tingling and saying, well, that looks bigger than what I'm expe, I've, I'm used to sitting on these lectures, lectures with Dr G. So you would be correct in thinking that. So again, normal, but something's off. Next. We look at the second most important organ in the body, in the chest, the heart, right cause the lungs are number one. First, let's go to the right side in no particular order. So the right side, you usually want this nice con vax shape with a nice little angle right here. Now, I would say I would interpret the right side as somewhat normal. You know, I you can be picky if you want, if you said uh maybe it's a little bit more plump at this, I would give you some credit, but it falls to the eyes. As in my mind, my opinion, it looks OK. The left side, right, the left ventricle, the apex of the heart doesn't extend all the way to the ribs. And there's a two slope approach, telling me that the left atriums pressures aren't elevated enough to make uh to have it uh where the left atrium would be enlarged, where you lose that two slope approach and you get one solid slope down. So the heart, I would read it as normal size as well. Next. And finally we get into the lungs. I, when I get into the lungs, you guys know this. What I do is I zig zag through and zigzag through and sorry for the five year old in the background and then I do a zigzag across. Right. That's how I read, um, the lungs. And what I'm looking for is somewhat of a uniform pattern from top to bottom. Knowing, knowing that I'm expecting the blood vessels at the bottom to be a lot more prominent than the blood vessels at the top. And a lot of that just has to do with gravity. Again, fluid goes to the base. So your bottom parts of your lungs have a lot more blood vessels. So I do expect more prominent blood vessels at the bases than it would at the top. And that's what I'm finding throughout. So overall, I would interpret this x-ray as normal. But if I, if this was the first time I've ever saw this x-ray, the comment that I would make is something's off because the lungs are actually rather large, the lungs, you know, presumably she took a big breath and held it. But one of the things that may not be very obvious to you guys is the, the space in between these ribs. It's actually rather large, it's big, right? These are big, large spaces in between and if you count ribs and we could do the uh posterior ones. You got 12345678. So it's borderline as you know, hyperinflated lungs. You have large intercostal spaces, you have lots of ribs uh from the posterior side. And at the same time, this angle isn't as sharp as I've seen in the past. What I'm showing you guys here is a patient with COPD chronic Obstructive Pulmonary Disease. If this was a patient with asthma, this patient, I will tell you is having an active asthma attack. That's what I would be reading because asthma implies you have normal lungs. They just overreact to the right trigger. This is an asthma attack. But in a COPD patient, chronic, that's the first letter, they're constantly walking around with lungs that look like this. They're never going to improve. You can give them inhalers, you'll get some improvement. But the o in COPD for obstruction, just like an asthma, the obstruction is air leaving the lungs. So there's a lot of air trapping and there's a lot of hyperinflation in the lungs. And that is what you're seeing here. Why I'm saying this is a normal for the patient is because this patient's x-ray when the radiologists compared it to the prior ones, the radiologists like, oh yeah, her lungs have always looked like this. They've always looked like this. You're fine. One last comment I'll make because this gets Tony happy. My radiologist. I do also look under the diaphragm because this was brought up at our last session and you know, looking under the diaphragm, I'm just trying to make sure there's no blackness under the diaphragm to apply free air. Well, you may say, well, Doctor G, what about this grayish thing over here? Yes, that is gas. It is. But in your stomach, that's a gas bubble. So make and your stomach is on the left side and your liver over here is on your right side. So make that note to your mind. That is part of the normal process. I don't even interpret gas bubbles as abnormal. They're allowed to be there because usually we always are burping in some capacity. So let me stop sharing there. And before we go to the case, let me see if there's any questions. I'm gonna look in the chat box now. All right. So are you guys are just riding back and forth? How you uh you notice the pneumothorax? Yes, pneumothorax. You were diagnosed it by having some blackness, pitch black um up the apices um in the normal anatomical lungs, right? Cause air travels to the top. So I'm looking above the clavicle to find it. Yeah, there's no pneumothorax and there's no pleural effusions, right? Cause that's the water around the lungs. All right, Doctor Addy will finish with your question and then we'll jump into the case for today. Does COVID infection leave any long-lasting radiological signs on x-rays and how could you differentiate them from ground glass pass? Have you seen the COVID? Oh my friend, you're asking great questions. So let me guys for many of you on here have fun with the way we answer this. Um But you know, don't feel like you have to kind of immerse yourself in understanding everything in regards to the language that I would be using with Doctor Addy. So a couple of things post COVID, just like any other virus. You can get lung scarring, fibrosis that we have seen linger way beyond the prior infection for the majority of patients, the fibrosis. Doctor addy tends to heal and resolve usually in about 6 to 12 months. Maybe there's a little little lingering. There's a subgroup of patients we suspect somewhere between 1 to 2% of those who developed the fibrosis, a lung scar from the infection that actually that fibrosis never shuts off and the fibroblasts keep getting activated. I know this cause we see them in our clinic and we've had three lung transplantations already for such patients. So sometimes you get an aberrant healing, right? Cause fibrosis. I don't view it as a bad thing. Sometimes your lungs just need to scar a little bit and then heal it. But fibrosis has been the dominant one that we saw in the beginning, right? So in the beginning, your alpha three delta variances were causing more lung scarring because there were more parenchymal invading viruses of the SARS COVID, two newer variants, especially in the Omicron family with uh its uh ongoing sub variances out of the X PB category. Those are much more airway involving. So I'm not seeing as much lung scarring if anything, I kinda see some residual bronchitis like inflamed airways months, months later. And, but those usually, those patients also having a bad cough now with ground glass opacities, it's what we look for is just kind of the pattern. And even that is tough cause ground glass opacities could be infection could be fluid, could be just immune cells like in an autoimmune process or it could be blood. So it just uh there isn't a way for me to differentiate a ground glass opacity from everything else. Doctor addy, we can bring that up to our radiologist cause they will go over helms field units. But I'm like, look to a typical lung doctor. I don't have access to such technology as a radiologist does. But I would just say if you find GG os glass opacities, look at the uh clinical picture, look at the data points and see what you can do. So thank you. All right. And you, you know, you wrote, if it is hyperinflated ribs, then it takes a lot of time to recover hyperinflated ribs to get back in their normal position. So COPD patients walk with hyperinflation all the time. There's no recovery. Um we can somewhat improve their hyperinflation with good inhalers. But the, but it is an irreversible lung disease, unfortunately. So. All right. Thank you guys. Now, let's dive into the case dne. All right, let me ask you. Let's uh let's do, let's do four students. Any four students wanna come on stage with me and we'll walk through the case today. Sounds good. Yeah, if you wanna uh get invited to the stage, just say so in the chat and I can um give you access if you wanna go ahead and come on stage by all means uh put it in there that you wanna come on. Alright, Rahi, we got you. You'll get a go ahead and drop your question as we wait for some students, right, Rahi? You can't get enough of me today, man. Um uh uh Do you wanna come on stage or you wanna ask a question? All right, we got Ron. You changed places, man. Crazy. Yeah, I'm actually at the imaging center right now cause I work as a MRI Tech assistant with radiologist. So, all right, sounds good. Sounds good. All right. What other students wanted? Come on. Let me if, if you guys aren't dropping it in there, I might just start call. Come on, man. Let's continue some continuity. Can we ask you to come in? OK. Yoda you wrote which breathing exercise is more accurate for COPD patients, personal slip, breathing or diaphragmatic breathing. So, Yogi, you ask a great question and a lot of it just has to do with what they're experiencing for those experiencing a little bit of a breathlessness. That's more equivalent to say an exacerbation. I would be more in favor for personally breathing cause once they do that, it can allow their exhalation to ca to have more time to get the air out. So I teach a lot of my patients personally breathing for that purpose like during a, during a flare or during just like even anxiety where they're like, oh, I need to calm down, diaphragmatic breathing. I tend to teach them for everyday situations and I usually try to reinforce it during pulmonary rehabilitation. So both are important one though, uh especially for slow breathing. Much more of val of value to them during a flare. So thank you Yodo and thank you Abhi Shaq for advocating. All right, Boston, we got you good. We're gonna do one more. Let me get one more student to join Grace. Grace. Co come on my friend. No worries. And you guys, you guys can keep asking grace. Are you there? Do you want? Is that ok if we add you? All right. Great. No worries. Let me see if we can get one more person. Does anyone else wanna jump on stage with us? Come on. It's, it's very friendly. I promise you. What about Felicia? Hetrick? Felicia? All right. I can call in anyone if we don't get one more person. Oh, we Got Grace. Never mind Felicia. You're good grace. Welcome. Oh Grace, you're, I can't hear you. So if you're talking, I can't hear you. Grace. I can't hear you. Are you on mute? Are you, are you yelling Yogi? I love that. You're a physiotherapist. That's awesome. My friend, Grace. If we can't hear you, you can just type your questions. All right. No worries. You'll get up. No worries. You stay put. Uh We got Felicia here too but Grace, go ahead and drop your questions or I've never read a chest x-ray before. Well, guess what? That's why we have you here. You ready my friend and see. Good. You guys are amongst friends. All right. One thing I wanna make very clear, this is a safe space. This is a space that I want from physicians to students to ask questions. I don't care if you guys get things wrong. You don't have. This isn't for you to be like let me uh fancy up to doctor G and uh really let him know how much I learned. No, I want you to make mistakes. I don't from my standpoint. This is a safe space, learn and then go and impress others, go help your patients. Does that make sense? Grace Felicia and Bassim. Is that ok? So take a breath, you'll be fine. I promise you. All right. Good grace. Even better. All right again, cause I think he is also in high school too. So No worries. OK. You're amongst friends. Is that all right? Grace? Do you feel? OK. All right. So let me give you guys a case. We're gonna go over today and the x-ray really nails down this patient's diagnosis. So the way we're gonna do this is I'm gonna present you guys a little bit of background and then I want you guys to ask me questions so you can try to think of four differentials for this patient. Could he be having an infection? Could this be? I'd like to teach like, oh, that's very, thank you. You'll get up, we're very passionate here. Um All right, and you'll get up. You said it's nighttime. Where are you coming from? My friend, drop it in the chat box. Let us know where you're at. All right. So in regards to um this case, we have an 80 year old gentleman, 80 years, years young, 80 years young. He calls me on the um clinic line and goes, I'm very short of breath. What should I do? So I'm like, look, if you're that short of breath, you go straight to the emergency room, let's get you there. So patient goes to the emergency room and this was what gets revealed. 80 year old individual past two weeks began to feel more short of breath. Kind of dismissed. It thought he caught a bug but it kept getting worse and worse and worse. He had a hard time sleeping at night laying down flat, he would wake up. Also on a side note, Yogita, 2 58 in the morning. You are awesome, my friend. So thank you so much for joining us. That is awesome. All right, back to this 80 year old patient, 80 years of age short of breath going on for two weeks. The way the reason he came in is, you know, it started off with just like some minimal activity and you go, I got to catch my breath. Maybe I'm catching something a week later. He's having a hard time sleeping. He's like I lay flat and I can't, I gotta sit up like I can't even lay in bed to sleep. I'm, I'm sleeping in a recliner now and then what tipped him over is getting short of breath. Even at rest. His wife's like you gotta come call doctor. They called me. I was like, you, you don't sound well over the phone. He was gasping, go straight to the emergency room in the emergency room. They see him, they snap an x-ray past medical history of this 80 year old gentleman right now. Takes only a baby aspirin. That's it. Nothing more, nothing less. However, one year ago, he finished R chop. R chop is a regimen for treatment of certain kinds of lymphomas. When he was 76 years of age, he had fevers, night sweats, not doing well, went big lymph nodes biopsied. He had diffuse B cell lymphoma. And then so over the last few years he got treated. But one year ago, his like oncology team is high fighting and saying, hey, guess what? Good, sir. You're good. You're in remission. We'll follow up but you're doing great, go and live your life. So with, with that said a year later, he calls the lung doctor cause I've been part of the team. So Rahi Felicia Grace Basim from high school to college. I'm not expecting any of you guys to ask me medical things. What I wanna know? Oh Yogi is asking already about the JVP. We'll go over that Yogi. What I wanna know from each of you guys is ask me a question and tell me when you ask that question. Are you trying to see? Um Thank you, Deborah. Uh The five year old, are you trying to, when you ask it? What are you trying to gain out of it? Are you trying to think of it as an infection? It's cancer or something else? So, Rocky, you've done this before with me. You get the first question to ask. Um I guess my first question would be um I guess are there any activities that make it worse? So for example, I know you were talking about sleeping, but are there other activities? So this is a great question, right? Whenever you guys hear of pain or breathlessness, you can think of them in the same context. What makes it worse. What makes it better? Right. This is great. So, in it, in regards to what makes it worse? Well, it's changed over the last two weeks. What makes it worse in the beginning was just doing activities, like, at rest, I'd be fine. Then you realize, hey, sleeping, I can't do it laying flat. I got to sit up. Right. And then more recently there's just nothing, he's like, I can't get comfortable sitting, laying, doing activities or not. So it has progressed over the last two weeks. So nothing makes it better anymore. But before he just all the activity he could, he said Grace over to you. Grace don't ever think this. What's one of the first, what's one of the first things your mom tells you if you, if she thinks you're sick or he, you know, what do they do? What do they check? What does your mom or dad check if they wanna know if you're sick? All right. So you question Grace. All right. You're not even taking the clues. I'm giving you. All right. Oh, fever. Yes. Iron. That's where I was going to. So, Grace you're asking? This is a great question. Have you ever experienced this before? Well, Grace is asking, I want you all to make note of just like he right. What makes it better? Same or worse. These are good clinical insights. Look, your patients will have the answer. You know, they'll give you the data or they actually will give you the answer grace. The way you ask this question is the first thing I teach every intern, I'm like, make sure you ask them if they've experienced this before because you'd be surprised patients will give you the symptoms and you're like, oh my gosh, this could be 1000 things. And they're like, then I'm like, all right. Have you ever experienced it before? And then you'll be like, oh yeah, I had this the last time I had a blood clot in my lungs. Like, oh, we're gonna rule out a blood clot in your lung. All right. So Grace, he's never actually experienced this type of breathlessness before. He, you know, he was like, I had asthma as a kid, but I don't, it never got ever this bad. This young man has never experienced any breathlessness like this ever before. And if you guys are asking about fevers, no fevers, none. That's what I was trying to clue gray in. So what is your question that you wanna ask? Um the question I wanna ask maybe is, has this occurred in his family before? All right. So family history. Hey, anyone in your family that has any disease that will cause breathlessness? Great question. Now, one thing I wanna point out, I have nothing against asking family history. I think it's always important. I will tell you there's a little bit of ageism into it. The younger the patients are ask them, the older they are, I still ask them. But I can tell you once you reach 80 you probably beat many of the genetic malformations in the past. So, it's a good question. I'm not dismissive of it, but I'm trying to clue you into is that piece of data? How vital is it? You know, because, you know, if you're asking a 20 year old and he's like, yeah, my dad had this, my grandfather had this like uh something's going on 80 year old. You know, he's gonna be like, I don't know, everyone's dead. And uh let me try to think. Good question. I'm just trying to put it into context. So from his standpoint though, he does have a mom that had COPD. That's it. But she's like she was a heavy smoker. So nonetheless, good question. But you nicely done, Felicia, you get the last one before we dive into the x-ray. Any question you would like to ask Felicia. I'm not sure if you're typing or not. No worries. So, and I saw you throw back on mute. So no worries. All right, let's go over this. Does he smoke? He does not smoke? Oh It's sorry, Felicia. Throw in your question, my friend into the chat box. As you're throwing in your question, I will give you the vital signs. Vital signs are signs, right? These are objective markers that we take that if they are thrown off, we presume this is life threatening. All right. No worries, Yogi. So you guys are fine. Smoking was my question. Yes, nonsmoker. This man. So his past occupation, by the way too, if you're like, oh, I wonder what he did for a living lung. Doctors think of that all the time, right? Because if you're out there being a fireman or woman, I'm like, oh, all that inhalation is gonna cause things. If you're a construction worker working in the naval shipyards, you probably got some asbestosis exposure. So io occupational history is always important. But let me give you his vital signs. So BP is 98/60. And if you're wondering, is that normal? It is not. Well, if you're wondering like, what do you talk me about like normals for patients? This is not normal for him. His BP usually sits top number in the one twenties, lower number somewhere in his seventies and eighties. This is very low for him. His heart rate is 130 BPM. Also not normal for someone. Well, keep in mind heart rate being elevated. It could just be a reaction could be a good reflex to compensate for some stuff. His oxygenation saturations, right? 84%. He is what we call hypoxemic. So we threw in some oxygen on him to help that out. But that's supportive care. We got to figure it out what's going on. And next respiratory rate was elevated probably in the twenties or thirties. Um but no fevers, 36.4 was his temperature. So, Mauri, I love that you're asking physical exam questions. You all should put your hands on the patient. I though we're, I'm gonna dive into the chest x-ray, let's dive into that and then you guys can weigh in on what's going on. So listen, Grace and Felicia, you two, your microphones are not working. I'm gonna do my best to see actually Deanie Maiden. Can you read Grace and Felicia? You got it. You got it, my friend. All right, this is what I'm gonna ask you, Rahi, you're gonna look at the spinal process. You're gonna tell me if he's rotated or not and then I'm gonna find you the trachea and you're gonna tell me, is it blade or is it wide or is it blade right wide? And if the media sign have shifted, so you're going, you're, you're sticking with the spine stuff scene. You're gonna look at the costophrenic angles and the Aps with me. And then Grace and Felicia are gonna look at heart hilum and lungs. OK? All right, good people. Let's go ahead and bring up this case and I love that you guys are throwing this in there. Keep adding. Keep adding. No. And ri all of the uh all your physical exam questions, I promise I will answer. I just want people to go into this with the chest x-ray in mind in modern American medicine, by the way, when patients come into the d especially if they're really bad. Right. By the time I've even walked over to look at them and x-ray is already up for me because they are just napping them. So sometimes this is usually the process that is happening. So let's go ahead and knock this x-ray out Deanie. I'm gonna ask you if you can just confirm that you can see the slide. Awesome. All right, let's start drawing. All right, let me get there. We are 10. All right. So in regards to the spinal processes, good, sir. So let me draw you out. We got trachea, we got corona, sorry. This is kind of moving a little bit and spinal process if I can make out just kind of one of the first ones, well, a little bit there, a lot of it is kind of lost. So with that in mind, if I can't find the spinal process, Rahi, I'm gonna throw you a curveball. I apologize. The other way of making sure that they're not rotated is actually looking at the clavicles. So we're gonna do the clavicle one at the moment because I'm having a hard time finding those spinal processes at the moment. You ready? Yeah, I'm ready. All right. So when you look at the clavicle eyeball, it, do they look like they're the same size left and right? Yeah, perfect guys. 99% of the time I usually can find the spinal process. I feel like I'm confident there's one right here. But what you're seeing in this case is a patient with a lot of artifact that's keeping us to find them. So with that said, I have another anatomical landmark. So clavicles look like they're the same size from my standpoint. That's been implied that the patients not rotated next. Let's go ahead and dive into the trachea. So Rahi, I can still find the vertebrae. First thing using the Krona as the landmark. Do you feel like? Oh, that's a bad drawing. Do you feel like? Hold on, let me give you the other patient has a little bit of scoliosis happening. Do you feel like the corona is staying within the boundaries of the vertebrae? Yeah. All right now, good sir. Everyone take a note of this. What I'm about to show rocky, right? So look at, I'm gonna have you guys compare look at this CNA. I remember we talked about the acute angles of the CNA. This is a normal, so normal acute angle of a Cryo Rahim compare that to this. Look at the carina. Here is this an acute angle? No. So this is a sorry, I'm throwing off my drums, but this is a splayed cry. A splayed cry is implying that there is something pushing up against the Cronus, widening, it, widening its angle and that implies something's going on in the mediastinum. This could be a really bad lymph node, maybe his lymphoma is back, right? And he's got massive lymphadenopathy in the mediastinum lymphadenopathy, implying lymph nodes are enlarged, pushing against the cry of widening it more and more. So the plot thickens or it could just be a big heart. We'll find out in a second. Basim Rahi as always my friend. Nicely done. Good, sir. Awesome. You ready? Yeah, I hope so. All right, man. Well, look, reading x-rays. I'm gonna take the pressure off. You guys. You just tell me what you see. That's it. It's not a trick question. So I'm asking you right here as I'm drawing it out. Can you see a costophrenic angle there? Um Do you, do you see an angle? Let me put it that way. Like I'm even drawing. Yes, perfect. Not a trick question. I promise you my friend. You know, if, if I, if I'm struggling like I did with Rocky just I'm like, oh man, I'm struggling finding the spinal processes. Um I will make it clear. Um Even with those, I think the scoliosis is throwing me off because the most I can make out is probably be but nonetheless, if I can't find them quickly in seconds, I default to my second way of assuring the patients not rotated. All right. So Rahi, you just told me there's a costophrenic angle here. You are correct now, not Rahi Bassim. Listen, listen for the left side. I want you to tell me if there's an angle there, you don't have to tell me anything more other than its sheer presence. Yes or no. If I can draw one, it's usually a good indication that it's there. Ok. You ready? Is there a costophrenic angle right here? Yeah, awesome. Now though, uh Bassim, tell me how was this costophrenic angle? Think of the color and you know, in x-ray, you only got black and white and grayish. How was this different from this costophrenic angle? Tell me that. Tell me by the color. Which one is darker? This one or this one A I feel like an Opto op optometrist. Now A or B who is darker and who is more hazy A or B A is darker A is darker 100%. Guys. What Boston just emphasized here A is a normal costophrenic angle. OK. Hazy costophrenic angles like in B are gonna happen for one of two reasons. Either the heart is so big, it's going over there or they got breast tissue in a woman, you know, excess mammillary glands in a male gynecomastia. But if you can see a costophrenic angle, that means there's no fluid in the space. A hazy costophrenic angle does not imply fluid in the space. If there's fluid in the space, it's gonna wipe it out, there's no in between phrenic angles are either there or they're not. There's no uh So that's why I set you up bussing for success, right? I didn't want you to fail. I drew it, you saw it. It's present. This is key here because there's no plural effusions here. None, none whatsoever. Keep that in mind. Next basing you're still, you're still my man. You're still rocking and rolling with me. Tell me how, tell me if there's any dark blackness above the clavicle, tell me if there is dark blackness on not too much space. But can you appreciate that? There is lung markings still going all the way to the top? Yeah, perfect. So ing what you have just shared is, hey, the pleural space looks OK. So whatever's going on something in the mediastinum because ra he pointed out a splayed cor up and you know, from your standpoint, you're like, you know, the costophrenic angles are present and the pleural space is present. Keep looking somewhere else. All right, nicely done. Good, sir. Nicely done. Felicia and Grace. You guys will be throwing the chat box, Deanie. Are you ready to read the responses for me? All right. High one. A hilum is an anatomical landmark. Not, well, it's short landmark, but it's an anatomical structure that has airways, blood vessels and lymph nodes all coming out and then you know, projecting into the lungs. Look at this patient's hilum. A couple of things. The right side, there is an obvious shape that's kind of the kidney shape or beam. The other part is that you can somewhat see through it right it's not pitch white like the ha like the heart somewhat is you can see through it. Now, let's go to the hilum in this patient, Felicia and Grace type your answers. A yes or no. Is there an obvious, is there at all an obvious high lung that looks like that kidney shape that you guys saw earlier? And I'm gonna try to, I think that's probably its extent. And at the same time, is it as transparent as the last one was? I'm kind of setting you guys up with my tone. Yes or no. Is it? So what I'm uh so is it too big? And well, let's start there. Is it too big? They Felicia says too big. Good and Grace. Is it um Whiter, is it cloudier hazier than patient Ed? Would you agree to that? Yes or no? That it is cloudier. Grace says yes, a lot hazier. Good. All right. That's awesome guys. Look, all I, all I'm asking you guys is just to tell me how you see something. It's not a trick question. Just tell me how you see. One of the first things I teach. Every physician, every resident, every student don't overthink this. Just tell us what you see. Just tell us what you see. You're right. Look at this patient. You can kind of see through it. You can't see through that high one. All right, the left side, I'm not even going over it because I can't find it. Why? Because let's go now to the heart. Remember in this patient, Felicia, there is a space, is there any space between the heart left ventricle and the chest wall? Yes or no says no, no, correct. So you would say, hey, the left ventricle is large. Now, let's look at the left atrium to some extent. Well, that's not the left entire left atrium. So there's some blood vessels there, no worries. So, my suspicion for the left atrium is probably lost a little bit in the aorta, but it's got to be somewhere over here. So I'm gonna bypass that because you already told me there's cardiomegaly here. So the left atrium size is not gonna really change much of my thinking at the moment. Um Plus I think it's being confounded by a little bit of the aortic arch. Nonetheless, we got one checkbox for cardiomegaly in the right side of the heart. You do see that loss of that convex shape like you would hear, like look at this nice shape that you got here. You've lost that here. So you can make a case that the right side of the heart also has some level of enlargement. This one's a lot more subtle. Honestly, if you guys were my first year interns looking at the heart, what I'm hoping that you would agree with is that there's obvious cardiomegaly, megaly. And now finally, the last thing I'm gonna bring up Felicia and Grace is going through the lungs. I want you to, to simply tell me this, this is the normal lungs. Look at these normal lungs, they're somewhat blackish. You can see lung markings through them. Are these lungs normal or not? That's it. That's your only question. Both of you answer Grace and Felicia. Are these normal or not lu uh normal lungs or not normal? Say not normal. You got it. So let me tell you how I would read this. So the way I would read this is look at the patterns I'm gonna pick out and especially for like doctor Addie and other physicians, a couple of things that come to mind when I'm reading this. So there is significant interstitial markings that's a little bit more subtle. But look, you can see airways, right? You can see airways. So to me, nothing's happening actually in the airways themselves, the fact that I can see airways popping out implies whatever's going on has got to be around it, right? So airway disease is not what I'm suspecting here. However, these interstitial markings and opacities, opacities is the key term here. The haziness of them is really all extending all the way out to the ribs. This is key like look at the pattern more dense, the closer they are to the heart, but they still extend all the way out. Ok. Much more dense, closer to the heart. Like think of the heart like gravity, the closer you are to the heart, the denser it is, but the further away, a little bit less dense, but it's still present. Ok. So you have interstitial markings with diffuse opacifications throughout the lungs much more prominent at the base than you are at the top. And the fact that I can see airways to me is gonna imply to some extent, potentially non airway disease. So with that in mind, let's go over this case a little bit more and now I'm gonna go over the physical exam. So when I examined the patient, all right. So now going over this case on the physical exam, someone asked about his JVP jugular venous pressure. So let me tell you guys what that is, you guys, everyone right here. Great. I can see you right? Lean in a little bit more. I wanna see your neck ready. Uh Good. Now do this for me ready. Bear down, bear it down, bear it down as much as you can. Don't, don't extend too much, just bear down like, you know, you're like flexing your abs, right? Bear down. If you guys bear down enough, you can start seeing a vein popping out. That's your internal jugular vein. If you guys do it on a patient, you take your right hand, you place it over their liver and you push down and you hold it for about 10 seconds. Left side is a little bit harder grease and bossing the right side is where we want to look because the right side drops right into the heart. It's a straight shot. Love it. So, what you do is you just kind of tilt your heads a little bit. You lean them back at a 40 45 degree angle. And I really ask them to bear down because most patients are just not. Well, so I take my right hand, put it over their right space, push it down and I hold it and watch it pump up. I look at where it is. So I'm looking for a hepatojugular reflex. That's another way of measuring the jugular venous pressure in a normal patient like grapes or basting. If you start doing this at night, you're like, all right, let me bear down. Let me pop it up once it's popped up after a while, it just goes away again. Cause all the blood nothing circulating. That's a normal hepatojugular reflex for patients with elevated cardiac pressures. That thing stays high in this patient. Their internal jugular was riding up almost through their jawline, almost through their jaw line. Yes, good. Are bat winging, shadowing. Nice guy. That's the thing I was implying. But we'll go over what that means in a second. This patient ss internal jugular vein when he, when I did a HEPA of the reflex was all the way to the jaw line that implies blood trying to get into the heart is struggling. It can't, it's congested. It's backing up. Couple of things also, legs though, not swollen, skinny legs, very skinny legs. So here's the thing, one other thing from his physic, from his history, you guys were throwing this in there orthopnea was what he was experiencing, orthopnea. What every cardiologist and lung doctor asks a patient if you're breathless at night or not at night when you're laying down, are you breathless when you're laying down? You've now removed gravity from helping any patient with blood flow. When you remove gravity, suddenly the heart's got to work a little bit harder to make sure blood can't get pumped adequately. But if you have bad heart disease, that's heart failure, right? The squeeze of the heart is struggling, they're gonna get short of breath. That's huge orthopnea. Your differential really falls a lot to the lungs. So that's why these patients have to sit upright just to breathe better. So, clinical uh history orthopnea was found. So the laying down question was huge. And then physical exam, they have elevated JB P. Now for the doctors here, you might be thinking, but why is there no fluid in the pleural space? And why is there no fluid in the legs? Right? Because the heart is struggling to send blood forward and it's backing all the way up into the lungs at some point that fluid is gonna enter the pleural space and the legs. I know I'm going way beyond for some of you don't worry but hear me out, this case is important to recognize. Has this been an acute issue or is this a chronic issue that just suddenly became worse? So everyone here, everyone, not just Rahi Bay and Felicia Grace. Throw your answer to us right now. Do you think this patient's heart condition that he called me complaining about her two weeks? Do you think this has been ongoing for the last year? Or did this just start happening in the last two weeks? Literally, when you felt symptoms is exactly when it started and there was no subacute pro pro uh problem. So a lot of you were writing chronic, chronic, chronic, ongoing. Ok. Let me tell you why I'm gonna tell you, I think actually it's rather quickly and it's rather quickly because of the lack of fluid in the pleural space and the lack of fluid in the legs, having pulmonary edema in the uh having lower extremity edema and fluid in the space usually means the body is trying to compensate for some time and it's getting the fluid out of the alveoli and just throwing them into the pleural space. Those are compensations. So the fact that those were missing pointed out the pleural space is just fine. This seems like something's been going on very quickly. Now, you may say with the left ventricle look really big. Doctor G, doesn't that take time to develop can unless you got something very correct to cause the myocardium to fail myocarditis can do this from SARS COV two or Cocci the Coxsackie virus or in this case, this patient during his, during his treatment for um his lymphoma was given DOXOrubicin. You guys googled Dox C Rubin. It's well known to cause heart failure. And a key thing about the timing here is it usually causes it about a year later and kind of just comes out of nowhere. So this patient's heart failure, this 80 year old who's just taking a baby aspirin a year after his lymphoma treatment developed a complication from his DOXOrubicin. The pattern that you saw all that alveolar feeling, the opacities, the opacities, the interstitial markings, the fact that I could see airways so they look like they're spared tells me everything is just flooding into the alveoli of this patient in the past before modern medicine, he will either pass away or the lungs will start pulling out the fluid and sending it into the pleural space. Get it in there, dump it out there as long as he can survive. Now, why this is important is because when we started treatment in this patient, the way I even got more, even confident is all fluid in his lungs. His lungs within 34 36 hours, much better, much more improved. The challenge is his heart still struggled. So he's doing better now. But his uh heart squeeze, it's about 20 to 25%. I just never know with patients post DOXOrubicin if they're gonna regain that back. So, the big takeaway from today's lesson guys. So Basing Felicia Grace Rahi, everyone round of applause for them. Grace. Hopefully you're gonna become a doctor because you did great, my friend Felicia. You rock too, Rahi. You always do. Good, sir. And basin good to have you back. You did. Great. All of you did fantastic. This case right here was a case of acute co uh con acute congestive heart failure brought on by DOXOrubicin. The key findings on the chest x-ray a couple of things. One is the trachea that always pay attention to the trachea, not just this position, but is it normal acute angle or splayed? Rai beautifully pointed out that it was a splayed trachea implying something is pushing up against it. In this case, the patient's heart, then the costophrenic angles, no fluid. But you know, obviously you guys are like his heart is huge to me. That's telling me something's been going on rather quickly, right? Because getting fluid into the pleural space and into the legs usually means the body has been learning how to compensate for some time and just dumping fluid in other uh crevices. So to me, this is a heart that's gone down rather quickly in the last two weeks. Sounds like that's it. Um left ventricle big heart failure and the pattern that doctor Addie mentioned is kind of that bat winging bat winging is exactly what it sounds like. The wings of a bat tends to spare a little bit of the, you know, the closer you get to the lungs. But in this case, the fact that they're all dense, closer to the heart, the pattern and less dense as the closer you get to the ribs, cue you cues you in that this is fluid because of a bad heart. That's it. That was City's lesson. Were you guys? Good everyone happy. All right. Yes, he has heart failure with a reduced ejection fraction. That is correct. Doctor Addy, his specifically was 20 to 25%. He's still in the hospital at the moment. But he'll be, I think he'll be ok but we'll see my oncology friends never know. They're like, I don't know his heart could get better or he may struggle. So we'll find out I'll report back. All right, next lesson. It's August 30th. Watch this one whenever you guys want. But this was great guys. You guys mean a lot to me. My email address in the meantime, is this if you guys have any questions, comments send, we'll be back in four weeks and if anyone is in Greece or the Mediterranean in August, let me know I'll give you some talks so you guys can swing by. All right guys. Take care. Bye.