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Hold on. All right, I think we are alive now. So what I'll do is let me, it's uh let me give you guys a bit of an overview of who I am and thank you so much for coming. As you can tell I am uh in a hotel at the moment. I am Boston to deliver a speech tonight. I was in DC yesterday. I'm in New York tomorrow. So a little bit traveling Mayan, but uh I will always make time to make sure I can teach you all. Um One of the, I think one of the most important skills you can develop as a clinician, whether you're one now or one in the immediate future. So my name is Panicky Scalia's that too is I'm an associate professor of medicine at the Johns Hopkins University. I am a Pulmonary and Critical care doctor. The intentions of these chest X ray rounds are for you all to get comfortable and reading a chest X ray, picking up some subtle clues from them, but more importantly for you all to try to understand what is a normal chest X ray and what makes it abnormal if you can try to understand something is off with an X ray. That is the most important aspect of being a doctor is by just recognizing something is not normal, even if you can't best to find it. What makes our profession amazing is that we are able to pick out abnormalities and then link them potentially to diseases or maybe they're just abnormalities and we'll leave it at that. So every time we do a chest X, right, I'm going to try to start off with a normal one and I promise you it will be normal and then we'll dive into the case. And then I'm gonna ask to of you to read the case with me. And as we go through these lectures in the future, these cases are meant for you to also begin to sharpen your clinical reasoning. Why did we get this? I don't want you to just view this one objective test and say, let's find the abnormality. As many of you have been on prior recordings with me, you know, our radiology colleagues, that's not how they read an X ray. They kind of want to be directed to what's your clinical question? So they can give you a data point to either confirm that or to make you suspect a differential diagnosis potentially. So we'll have a lot of fun reading a chest X ray and begin to use it to sharpen our clinical reasoning. Finally, the other part that I want to mention is to read a chest X ray really is going to be uh an art of medicine, right. There's gonna be hundreds of ways to potentially read it even though we're all going to get to the same outcome. When my radiology colleagues come here, they have a very different way of approaching this and say a lung doctor does or say geriatrician does or even a pediatrician, all of it is fine. There is a one way that's better than the other. As long as we get to the same conclusions, that's key. So the way I teach, the way I teach you may like it. You may not if you develop your own way of reading an X ray. Perfect. Fantastic. As long as we can all decide for them together, identify what's abnormal and dive in. So with that said, let's go over the first case for today. I promise you it'll be a normal X ray. I'm going to read it and then you guys can throw in the chat box, drop in some questions. I'm not, questions drop in some things that you want to discuss. And I discussed drop in the chat box. People who want to do the discussions with me and Dr Addy, I did see the question above the Julia deities um sign, you know, it's actually colon as opposed to free air under the diaphragm, I would say, you know, you're welcome to drop in any questions we're gonna try to stick to the relevance of the cases but to differentiate those, um that finding, is it free air or is it just colon two things? One I would say, always understand where the patient is, right? Is it someone with some bowel history? Because that's usually going to set you up for actually uh a false positive finding a free air under the diaphragm. In addition to um some extent of about pathology, the other part, you usually can still see some of the colonic lining. So I would say that's part of the ability to differentiate the two, but I'll seek some kill ERT um imaging findings and we can do it in the future as well. So let's dive into today's cases and then if anyone wants to uh read the chest X rays with me drop in as a volunteer and I'll call you guys out. All right, let me go ahead and share my screen. Alright, window. Let's go entire screen. We'll do that and then I will go ahead and throw this up. Alright, Dean, remind unmoving and just confirming you can see this chest. Uh I can see your screen. All right now, actually, one of the things that to mark on here, that's the one part. Oh, maybe there's some marking that can be done. All right. This looks like I can do it. Lays pen fantastic. All right, let's see. This was working. All right. The first thing that I do is find the spinal processes. Remember the way I read an X ray, I want to make sure that how I read it is always gonna be systematic is always gonna be like reading a book for me. I want to, it's 1000 data points and I want to read it consistently. I want to read it in a way that I won't miss anything. Even if I have a clinical question in my mind saying to this patient have pneumonia, I'll look to answer that, but I don't want to miss anything else. So first things first, as you guys know, I look at the spinal process, I make sure that it looks tear shaped, cylindrical, right? And if it is, then I can rest assure that the patient is not rotated, not rotated. Assures me that the patient won't, you know, the way I read this X ray won't be any misinterpretation, right? If the patient's right shoulder sticking out further than their left rotated, then those sizes of the heart, the sizes of the lungs are to come across as unequal. So I always look at the spinal process first. Others may look at clavicles, etcetera, whatever works for you. But my system is spinal process. Next, I look to evaluate the mediastinum. How do I do that? And you may say, what is the mediastinum? It is the anatomical space in between the heart and lung uh in between the lungs where the heart, the esophagus, the aorta all comes together, but it is the anatomical space between the two lungs and to evaluate the mediastinum to kind of get an impression of is the mediastinum normal. What you look to find is the carina, the carina and apologies. My boundaries aren't the greatest at the moment, but here's the cry. No. Right. It's rare. The tricky a will end right before the bifurcation. A couple of things I want you to point out with the carina is if it's falling somewhat in between the vertebrae boundaries, then you can say, all right, the media centers not shifted. There's one other thing I'm gonna teach you guys today. And if you've done these before with me, this is the first time you were gonna hear it. So the other one that I think many of you may be advanced enough to take on. Now, let me just get the erasure out is is if the carina is splayed and you're like, well, what does that mean? Doctor G? So this angle that the crime is making is gonna be less than 90 degrees. A splayed. Carina implies that the angle is gonna be wider than 90 degrees. So what I'm looking for when I'm evaluating for an anatomical situation happening within the mediastinum is if the Carina is out of those boundaries, which would imply the mediastinum is shifted. So if it's over here over here, that it can be applied, the immediate Steinem's shifted or if something is pushing up against the cry know, causing that angle to widen a split carina, then again, something else is also happen in the Mediastinum. So before I even get into the lungs, I'm looking at the spaces around the lungs first is the mediastinum. And what I'm going to convey is is if it's shifted, that's it. You don't have to discuss the angle of the carina. I usually do that if and only if there's something off with it. But but I'm not mentioning usually implies it is normal. So the mediastinum does not look shifted on this X ray. Next, I'm gonna look for the pleural space and right off the bat. One of the things that's happening in this pleural space is as you can tell the costophrenic angles are cut off, it's frustrating. I usually would make my technicians retake, retake it to make sure they are present. But the cost a phrenic angles remember are developed on a two dimensional representation of our three dimensional body. It is the angle of the ribs coming together with the diaphragm and coming together where they make an angle that looks somewhat like a fang, right, a little uh you know canine if your teeth to some extent. And if you see that if you see that thing, you can imply that there is no potentially significant amount of fluid in the pleural space. Now, on a chest X ray, you need a little over 300 mL of fluid to take away those angles. So to evaluate if there's fluid in the pleural space, you evaluate the costophrenic angles, both of them another cut off. But my suspicion is at least what I can see, I don't see any fluid. The next I look to evaluate if there's a rare in the, in the pleural space and air we know rises. So I tend to look up here at the apex of the lungs. And what I'm looking for really want our lung markings that are coming up. Remember the lung markings at the top are going to be much fainter than the lung markings at the basis because of gravity, right gravity will pull things closer to the ground, which will make things at least the blood vessels look much more prominent than the top. And the fact that you can see the lung markings at the top of the AP sees you can imply that there's no air in the apex. The other part too is remember, air that would escape the lungs and get into the apex is going to be somewhat dark and black and you usually can see some dark blackness up here, none of that exists. So, lung markings are coming up to the apex and no dark blackness um that is present. So no pneumothorax. So right off the bat, the pleural space, I can't find any clinically significant fluid nor any clinically significant air in the ape in the pleural space by looking at the costophrenic angles and looking at the eight disease respectively. So next, I look at the highland hilum. I've begun to get you guys more involved in the hilum. Really should look like this on the right side and like this on the left side, on the right side. Remember this is the right side over here, it looks somewhat kidney shaped like a bean and a it's a poor man's bean. And on the left side, it's gonna look kind of like the top of an ear, right? Cause the rest of the hilum is really covered by the heart. The hilum is where the lymphatic system, the airways, the blood vessels are all coming out. And if there's ever an issue of the hilum, the majority of the times it is the lymph nodes, it is the lymphatic system. So we'll discuss that in the next case you'll see. But I look to see if the hilum is normal and then here so far it is, it covers the bound, it covers the shapes that I would expect and keep in mind a normal hilum. It's gonna take countless readings over and over and over again to identify it after the highland. I go to the heart and in regards to the heart, I look at the right side and I look at the left side and I know the right side has not been one that we've been emphasizing before and now it is when I do want to begin to introduce a little bit more and more, but the right side really is gonna take this kind of convex shape that plumps out and comes down nicely. If the pressure is on the right side or too much, it's usually blunted, it's usually or bigger. But this sharpness down here that you see won't be as present for the left side. We look at two things, we look at the left ventricle. If there's a space between the left ventricle and the chest wall, we usually can feel pretty confident is call this of normal heart size, left ventricle to be enlarged. Usually it's more of a sign of clinicity, right. Years of struggling against a high BP or other reasons, it's enlarged. Um maybe heart attack resulting in really poor ejection fraction or um oh, sorry, let me pop that up over there. Hi, thank you. Sorry about that, Dini. Um or uh if it's enlarged, it could be from more acute processes, but usually it implies chronic reasons. Now, the other part that I was just circling here is the left atrium. It should come nice and down. Allowing a second slope of the left ventricle to come off, the left atrium is not creating that slope and it just kind of goes into the left ventricle pretty quickly. You mean some elevated pressures in the left atrium again, usually more of a sign of an acute process. I know I'm seeing a lot to you guys. We'll see how I bring it all together for this reading. But for the heart, all I'm trying to review is if the heart is of normal size, if there's anything that you remember, just remember this, if there's a space, you know, 99% of the time you can call the heart normal size, you will likely be correct. The right side. A little bit more delicate conversation has this conduct shape with a definitive angle down here where the heart meets the diaphragm. And the left atrium up here has a slope coming down that is gonna be different from the slope of the left ventricle up. So the heart I would say is of normal size here. And now finally, we go into the actual lung itself. Remember the way I look at the lung, the way I review the lung is kind of a zigzag. I go back and forth with the lungs overall knowing that the bases are gonna show lung markings much more prominently than the top parts of the lungs specifically because of gravity, more blood flow is at the base of the lungs. So those lung markings are gonna be a lot more prominent and I'm gonna zig zag from the left as well. I'm looking for is uniformity throughout. So pulling this all together how I read a chest X ray if you pull this up the way my eyes indeed ago about is I can tell you the patient is not rotated because I can identify the spinal processes that do not look rotated themselves. The mediastinum does not appear to be shifted with no mass effect. The costophrenic angles our our cut off in this image but no definitive plural effusions are evident. The apices of the lungs seem to still have interstitial markings that extend upwards with no obvious findings of a pneumothorax. In regard to the highland, the look of normal shape, bilaterally, the heart does not appear in large with the left atrium and right atrium appear to be of normal size. In regards to the lung markings. There's a uniformity distribution throughout from top to bottom with some allowance of more interstitial markings of the basis. So this is overall a normal lung. So let me stop sharing and go back to you guys before we dive into today's case, any questions on how to read a chest X ray at the moment. So I see some people put six is in the chat um or those people that want to be invited to stage to ask questions or are you all just putting it there? So that whenever doctor G asks if anyone wants to participate, you guys want to participate. Okay. I think those are just people that want to participate when they're given the chance. Okay, just want to make sure they weren't trying to want All right, you got it. Perfect. All right. So let's do this. Let's use Hussein, Jasmine and Rocky. We'll do three of you guys. All right. You guys ready to dive into today's case, three people, Rocky Yasmin and Hussein, you guys ready, Dean? Is there a way to invite him to the stage? Yes, I'm inviting them to the stage right now. All right, once we get you guys to the stage, we'll go ahead and dive into today's case and Gabrielle, you are correct. The zigzagging back and forth. It's just meant to make sure everything looks relatively uniform. Hussein. Good to see you. Hi, Doctor G, who's in? Where are you right now? I'm in Pakistan right now. All right, I'm sorry. It's so late there, Rahi. Where are you? Good, sir. Looking for that mute button. Can I um, meet you? Yeah. And then Yasmin Azra, he tells us where he's at. Yasmin, where you come in? Hello? Hello, everyone. I am. I'm a Mexican medical graduate, but I am living in San Antonio, Texas. Excellent. Excellent. Jasmine and hopefully, Ra he's coming back. Yeah. IV also wants to participate. Should I invite her maybe? Um Sure. Let's add IV. And then Rahi, I promise you my friend, we work out technical differences. We'll get you back. We're gonna be doing this a lot. No worries. Yes, I'm here, I'm here. Sorry, I don't know. It kicked me out for some reason, but now everything's working All right. And Rahi, where are you at? I'm at Anaheim, California right now. All right, good, sir. Excellent. All right guys, we're gonna discuss the case. I'm gonna call you guys out individually as we go through this. Keeping my IV. Welcome as well. IV, where are you coming from? Your lab? Apparently. IV. Where are you at the moment? Oh, you were um, you did, did you want, are you able to talk? IV? I cannot hear you. You want to try again? Uh We can't hear you. It's okay. Ivey. When I call on you just drop in the chat box, the answer. Okay. All right. So let me go ahead and share this case and d any. No. Actually, I'll ask Hussein, tell me when you can see the slide. Go ahead and share my story. All right. Who's saying? Can you see the slides? Uh can All right. So let's start with you Hussein since you're on with me. You have this patient. She is a 52 year old who has been complaining of some chronic shortness of breath over the last about year and a half, nothing that sent her to the emergency room. But you know, she wants to bring it up to the doctor today. So let's go over her film first Hussain. You sent her to get an X ray. She comes back my first question to you. The detection set her up properly. Was she flat up against the wall not rotated. Um Yeah, she was because we can view her pure drop shape. Spinal processes very clearly. Excellent. Excellent, good, sir. All right. Next, let's go to Jasmine, Jasmine, you're there, of course. All right, my friend, what is he having chemical landmark? We're gonna look to evaluate the mediastinum first, the trachea, the airway. Um We're going to see if it is uh if there's any deviation. And do you remember what that anatomical mark? Uh anatomical finding is called at the end of the trachea that bifurcates into the left and right. Bronc. I the never seen kind of sounds like a popular beer in Mexico. The carina. Yeah. All right. So your spot going, you're going to look for the carina, right? And the carina is right here and you're, you made the case. I think you just said that the carina looks like it is in the boundaries of the spinal vertebrae. So you are saying the mediastinum does not appear to be shifted. Correct. Exactly. Hold okay, you're right. But hold that thought real quick. All right, hold that thought. Let's go back to this. Look at the carina here. Look how sharp that angle comes down right now. Taking that mental picture and tell me, does this angle, well, let's not go there yet. Does this look as sharp as what you just saw, man? It doesn't, I'm not sure if it doesn't, I'm looking at my image, but you see that sharp, jasmine. One thing I want you and every other student to be able to be confident with your right. This isn't as sharp, you're right. This is likely more than a 90 degree angle. Exactly. This is called a splayed Karina. And it is implying that there is something in the mediastinum, something is in here that is pushing up against the Carina, there's a mass effect there. The one that I've taught you guys that I teach every intern is if the media crying has shifted. The other thing I teach to pulmonary trainees, lung doctors is the shape of the angle of the carina. If it looks more than an acute angle that's called a splayed carina and something's happening underneath it. So you've told me there's some abnormality in the Mediastinum that excellent, nicely done. Jasmine. Also to everyone else. I want you to do what I just asked Yasmin to do. You guys just tell me what you see. Don't try to, you know, guess what I'm thinking. I'm going to try to lead you into it, but medicine is built on observation. So just tell me what you see. Is it black? Is it white? Is it sharp? Is it not just tell me what you see? That's it. Don't feel like you need a fancy immunity differently? All right. IV I know I can't hear you. So Yasmin, you're gonna have to read iv's answers in the chat box. I'm gonna go now to the pleural space. So, IV, tell me, can you see the costophrenic angles? And Yasmine, please read to me her answer. Excellent. These, you, she's spot allowing these are costophrenic angles. You can see it here and you can see it here. Yes. Does the right look sharper than the left? Sure. But it's still present, it's still there. So that's all you make a mention of it. If it was too deep, that's a different conversation for a different day. But that's not the case here. Next, let's go. Still sticking with IV and Jasmine. You will be her reader. Tell me, can she appreciate at the apex? Good lung markings that are going up here. Granted, there are fainter than they are at the bases, but good lung markings going up at the apices. Can she appreciate that? All right. So I be nicely done. You have already made the point that in the pleural space, no significant fluid or air is present. Excellent. So far the only abnormality we have found is a splayed. Karina, a new introduction to you all. Very, very interesting. Rahi. Are you ready? My friend? Yeah, I'm ready. We're gonna go over the hilum. Now, I want you to look at this hilum and a couple of things as I'm outlining it. Remember I said, nice kidney shaped. The other thing with the hilum to some extent and when the left side, it's more of like the top of an ear lobe while it is cloudier than say the lung still pretty translucent, right, transparent, you can still see ribs going through it and everything. So yeah, there's a shape to it but you can still see through it. So, you know, when you read a hilum, you're looking for those kind of subtle, like how does it look and can associate through it? Tell me here, does this look as transparent rahi as the prior imaging? Not really. Yeah, it looks much more fluffy, looks fluffy. Er, right. It looks more, uh, looks like, uh, more opacifications. The other part, this the right side loses, it actually looks more like a potato now, as opposed. I know I'm giving you guys fruits and vegetables as opposed to a kidney shape. So the right side hilum usually is a lot more easily to pick up the pathology left side is harder. Usually on the left side, what I'm looking for is just that denser finding the opacities as you already made a case. Um, but not to put words in your mouth. Do you appreciate the shapes that I'm pointing out? Especially on the right side, Rahi? Yeah, for sure. So the fact that the shape on the right side is different and the fact that there's much more opacifications, um, that to me is reading as a abnormal hilum. So right now, the way I would read the hilum here is bilaterally there are, there's an abnormality, the hilum, I would call it enlarged, the right side looks bigger. So I would read this as bilaterally enlarged hilum. So right off the bat, something must be happening around the Mediastinum as well as extending into the hilar regions, space, displaying of the carina and bilateral hilar enlargement, something's going on. So the plot continues to thicken. Next, let's go to the heart in the heart. On the right side, we still see kind of a good right side at heart comes down to a nice angle. Have no concern of the right side. But Hussain, do you also appreciate that? The left atrium and the left ventricle still? Okay. Still, reasonably not enlarged. You still got the two sloped situation here and I mean, the left ventricle was probably bigger than I like it to be. But yeah, and you know, from my standpoint, if I'm ever concerned, if this patient took a deep enough breath, I will count the ribs where we got one, then I've counted the posterior ribs, 234567. So maybe the patient just didn't take enough of a deep breath and the heart looks a little bit bigger, but there's still a space in between that. I would not read this as cardiomegaly left. H one looks of normalize and the right eye look. Do you agree to that Hussein? Yeah, you're saying stick with me. You'll, you'll drive the points home. Let's look at the lungs themselves. And as we zigzag other than the hilum. But do you still appreciate some uniformity throughout um, the lungs brain? It may be some dense uh interstitial markings. But if you want to make sure the interstitial markings, these lines here aren't pathological, they should all kind of go away by the time they get to the chest wall. You appreciate that. All right. So let's stop here and let me stop sharing. Uh huh. There we are. Stop sharing. Perfect. All right. So in this situation, we have a patient in her fifties comes into us a year and a half of shortness of breath. We um get a quick chest X ray to evaluate her. And the only abnormalities that we are seeing have to do with. Actually, it's not even in the lungs yet the hilum and potentially inside the mediastinum as well. Now, why this is important is because the hilum gets enlarged for various reasons, right? Specifically the lymph nodes there, either draining and active infections or they're draining things from the heart or they're draining autoimmune diseases, cancers, etcetera, right? Can't really tell what it could be draining, could be a variety of things. But the differential when I see bilaterally enlarged hilum and nothing in the lungs becomes really small. Actually, it's like, oh, I can answer this without diving further in. So let me go over a few points that I wanted to share in regards to just that. So let's go over some teaching points. So when I see the hilum enlarged, right? And let me try to, you know, really emphasize this. So from a size to import, um, you know, we made the case normal size, you know, we don't really know what's normal and that, that's why I try to make you guys not say normal size heart. What I just try to have you guys should say is the heart's not enlarged, same thing with the hilum doesn't look big. That's it. You can't really count for size too much on an X ray because you can only really do that in a three dimensional viewing of the hilum that comes from a CT Scan. So really, all you got to say is it doesn't look enlarged, that's it. And so in this case, the normal kidney shaped hilum was lost, it was a lot more plump, right? Kind of more of a potatoes. What we usually say that tells me that it is enlarged. The other thing that we're looking for is if the trachea is splayed, a pushed hilum just means kind of like the mediastinum is shifted. That's it. A splayed. Trachea is what I showed you guys earlier. And this is key because I can see sometimes enlarged hilum without any effect to the trachea telling you all the pathology is there the hilum. But if I see a split trachea, not only is the hilum involved, but something in the mediastinum is also involved and again, it tells me a little bit of a more unique differential. So what I'm trying to view is, is everything just in the Mediastinum, is everything just in the hilum or is it a combination of the two? And I would say this patient's chest X ray tells me there's pathology in the hilum and in the Mediastinum. Next, the question is, is it unilateral or bilateral? And usually you can get that sense by looking at the highlands themselves, we already know the right side lost at kidney shape, shape. But both of them, as you rightly mentioned, they looked more oh, pacified. Finally, this wasn't the case for this patient, but you look to see if there's any like very bright spots, calcifications where the spots look just as bright as the bones. And then you just try to describe them as much as you can. That wasn't the case here. But with all that, this is what you're trying to figure out is a nice differential. So the hilum is down here, this is what you guys were reading, right? If it looks too big, if it looks more pacified, you can actually get media stein a little abnormalities that extend out right as well. And that's what this top arrow is showing you. And here you see another example of a splayed Karina. This is and most importantly, the rest of the lungs all look normal guys. This is a nice clean lung. So the reason why we go over this as a lung doctor is because it will help me understand what this potential differential will be. If only the hilum was involved, you know, limited quickly down to sarcoid, potentially an infection, certain cancers or certain occupational exposures like silicon silicone or um coul if the mediastinum is involved, which will likely also involve the hilum just because of the way that the lymphatics drain. Suddenly your differential begins to blossom a little bit more as well. There's infection in cancers that doesn't change and sarcoid. But at the same time, other things begin to pop up in my mind. IPF this is a really rare presentation of a idiopathic pulmonary fibrosis. So it's there but you don't have to, doesn't come up often hypersensitivity. Uh pneumonitis does as well, but usually I'm gonna find some lung involvement, meaning if there's a ton of media steinem involvement, I'm usually going to find something happening in the lungs as well. So it's a little abnormal to get hypersensitivity, pneumonitis without lung markings. But anyway, I'm circling a lot of things here. But what I will let me find the erasure. I'm gonna take this off the second. But the reason why I wanted to show you guys today's x rays, it's because oftentimes there's not um there's not a lot that an X ray will help me get immediately to a diagnosis, okay. Some diseases it can. And this is one of them, this is a 52 year old patient, year and a half a shortness of breath. We ended up diagnosing her with sarcoid. Now, the X ray was what pushed us over wasn't the only data point I will tell you right when she came in, we did a full examination. We always do that as lung doctors like being a lung doctor technically is being a cancer doctor, a rheumatologist, an infectious disease doctor all at once because all of those processes impact my lungs. Actually, it's kind of being a cardiologist to write cause everything impacts my lungs. I gotta go, I gotta be familiar with everything. So when I was doing a full body exam on her, some of her skin findings on her shins developed, I had this kind of redness to them called everything, you know, dose um thick redness that kind of stood out so that she was also of a certain race. She was black. All right. There's a certain pathology there that, you know, I know it's a social construct, but there's a genetic tie to that social concert to some extent where sarcoidosis tend to be a lot more prevalent in black patient's especially females. Sarcoidosis can show up in males as well and in non uh and whites and others. Yes. But we oftentimes see it in certain clusterings in certain demographics. So I have these findings, sociological ones, physical exam findings and then that X ray bilateral Hiler enlargement, I got my answer. And so with that said, with that said doctor, your doctor, you got to think it's or did, did I call her sarcoid? The second she stepped out? I didn't because as bold as I can be with regards to my diagnosis, I still have to get tests, further tests done. So let me pause here. There's certain diagnoses that in modern medicine are really gonna come by me excluding a lot of other things like for example, if I wanted to prove that she had an ammonia, well, I need a radiographic findings, I need the right symptoms and maybe I pick up some other surrogate markers of an infection, elevated white blood cell count, etcetera. She's got fevers say I wanted to pick up a cancer. Well, there's certain biomarkers that can send off, but I need a biopsy sarcoid. I need a biopsy of those lymph nodes in the highland. So we put her through a bronchoscopy where I went down, they got biopsies still not done there. But those biopsies came back as a very specific immunological finding that hundreds of other diseases can call. So I had to rule out tuberculosis on her certain autoimmune process is all of them came back. Negative sarcoidosis is not something I make a diagnosis in the clinic. I make more of a strong hypothesis towards that diagnosis. Her physical exam finding and that X ray like today, you guys learned hilar abnormalities, right? Something I haven't really taught you guys in the past, but now you have and you learn what they look enlarged, you know, and understand if they look denser, right, not as transparent. And you learned about a splayed carina, that can also imply there's mediastinal involvement because usually just means those lymph nodes of the hilum are growing and some under the carina are also growing, splaying it out a little bit sarcoidosis thought to be kind of an autoimmune disease to something we don't know what's reacting the right biopsy, the right radiographic findings, the right clinical presentation and then me ruling everything else out, gives me the confidence to diagnose her with that. Her treatment was steroids, something we've known since the 19 seventies and right now she's in remission. It looks like she's doing well. But my teaching today is that hilar lymphadenopathy. Now, the other differentials that you guys saw there are really meant for hilar abnormalities when there's no lung findings, right? So those can be cancers often is the lung foma silicosis comes up often and coal miners, lungs come up often as well. But those are, I will tell you more exclusive to Pulmonary medicine because I've and you have to see a case of silicosis. I imagine they exist. But so I have not seen them if this patient has some level of calcifications, could that still be sarcoid? Sure. But then I'm also thinking of potentially fungal infections probably more from the past and active ones. So gave you guys a lot of information. I'm sorry. This case got me excited. I thought you guys would like it. But let's dive into some of her questions. So Dr Addy, you're asking, what does that find moma look like? Well, in an adult, we shouldn't be there at all if it is enlarged and we should be rather concerned of what could be happening, that's getting it there. Um But for cases of a thymoma tumor of the thymus, I can look to see if we can find any. But the way that should present on an X ray really should be more mediastinal involvement without hopefully without hilar involvement. What I'm looking there is more of a potentially splayed carina and a PSA levels. So I I will tell you this is the art of medicine. So what Doctor Addie's asking is if we check these angiotensin converting enzyme levels and it is it a biomarker of sarcoid? It can be used, it can be not used. I'm in the under the camp without really strong clinical evidence that I really don't explore ace levels about sarcoid experts that do have other sarcoid experts. That don't me, what I'll put stock in is the biopsy. If a PSA levels were to help me with her therapeutic interventions, I would potentially pull them, but they don't in that case either. So I think a PSA levels can help if I know I can get a biopsy done. Sure, I'll draw them right. If I know a biopsy won't be done for months. Let me draw them now through high. Even more of a stronger suspicion. It's sarcoid, but I was able to get a biopsy within that week. So I opted not to draw them a PSA levels. I tend to pursue if I'm feeling like it can help me with a diagnosis or, and I can't get a biopsy. Deborah, you asked if her calcium levels are okay. Hers were in Sarco. You are correct that there could be an over reactivation as some of the um proteins involved in the breakdown of calcium to some extent. And from that standpoint can raise those calcium levels. Hers were normal a good question. Any other questions that you guys have though? Um So Yasmin uh CD four CD eight has to come from a uh during the bronchoscopy. You get a lavish, right? You get a cell count from that. The challenge with the CD four CD eight count from a lavage. The would a lavage is for everyone else. I went in with my bronchoscopy. I went into the lung. Actually, you can get that far in you just kind of park it and you introduce some sailings, some saltwater, you suck it back out and you take those cells and you run them off to a lab. Not every lab can run a CD four CD account, right? It's very like if you're working in a row, oral hospital and you're like, hey, I need you to run a CD four CD account. They're like, all right, we'll send it to Hopkins or Mayo and your weight for another three months to get the results back. That result is not, that's one that will ask them to board test, giving us the impression that, hey, that's probably a finding. It's not, we'll run them, but it will take months to come back. Actually, my biopsy results come back much faster. Uh The reason not to get a biopsy sometimes can just be operator dependent, right? If you're not skilled to do an E bus, taking a needle through a very small ultrasound and stabbing a lymph node and taking that to a pathologist, find do a bronchoscopy alone and call it a day. Were skilled. I can do an E bus. I can get a biopsy sample. I'll send that. I do do a lavage to do a cell count more for a cell differential. I rarely do a CD four CD account because again, my biopsy result is gonna be all that I need. I won't diagnose at least with the resources I have to me, I won't diagnose sarcoid without the biopsy proving it often times just because I don't want to miss anything else because treating sarcoid is, is gonna mean me giving you steroids. So if I'm missing a certain cancer or if I'm missing a certain infection that can make things really worse. So, really, I'm gonna rely when the biopsy and excluding a lot of other things. CD four CD A can help. Sure. But the biopsy to me is the gold standard. All right. What other questions did you guys ask? Did you check pathology? Yeah. So when I send for biopsy, the pathologist checks the histology. That's what were implying. Um Not, can heart abnormalities call splaying of the crying. Who's saying yes, they can just depends on how big that heart is getting? So we'll try to show you guys some of those cool findings. All right. Right. If there's no to slope, so no to slope means the left atrium is pumping out. That's what it's implying for the left atrium to get really enlarged. Usually something's happening at that very moment, right? So a bad heart attack or you know, maybe some level myocarditis, something is happening to raise the left atrium pressure, pressure's pretty quickly. The left ventricle being big usually is more of an indication of clinicity. Again, these are rule of thumbs, not necessarily constants. All right. Any other questions? Was this a good case? Did you guys like this? All right. If there's no other questions, take a moment to fill out the feedback you guys being here means you can access these videos at all times. Oh Dr Addy, no worries. Good, sir. Join us as often as you guys like next, I'm gonna try to be one back by the way again. Next week, we'll try to do this every week during the summer. If I'm gonna be away, I'll let you guys know. But this shouldn't be my last travel until August, but we'll do new and fun cases. But I brought in five of you guys to do this. Now, we'll bring in another five into the readings next week. Uh That's it. All right guys. See you next week, Danny, can I just end this? Is that it or you can just do this? All right guys have fun. Take care.