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I wonder if we're good to go. Oh, there we are. All right. Hey, everyone. Um It's uh panicky scaly. It's Actos doctor G. Um If you guys are here, could you guys start throwing in the chat box? Uh saying, hey, I'm here. You can hear me loud and clear. All right, we got some chat activity, high Debra. How are you? All right. Thank you guys. Fantastic. Okay, good, good. All right. You guys, you guys always make me so happy. Um Good. So with that said it's 5 O2. Um We are going to today, we're gonna go over a normal X ray again. Uh So let me, let me backtrack. So how you guys, I'm panicky Scalia Satos. I'm an associate professor at the Johns Hopkins School of Medicine and I wear many hats. Um But I'm a lung doctor in critical care doctor and an internal medicine physician as well. And a lot of my interests around pulmonary medicine just really have to do with diagnostic work up and of course and treatments. And then so with this X ray rounds, um it's meant to be uh kind of a virtual shadowing with us and we're going to present cases. But specifically, I want you all to get comfortable on how to read a chest X ray. That's the big takeaway. If you can read a chest X ray, that's step one and then step two is, is that chest X ray normal or not? And that will come with time, that will come with time because you just have to see a lot of variations of normal to be confident that something is normal. That way when something is abnormal, it'll pop out, even if you can't be really certain of why it's uh abnormal with that in mind. Today. I'm gonna again read a normal chest X ray for you guys. I'm gonna read a normal chest X ray. Then I'll show you kind of uh the method that I've been doing, I'll stop and then I'm going to go over a case that's relatively new. Then we'll show the X ray and I'm gonna invite a few people on stage to read it with me. So it should be a lot of fun. You guys ready? Perfect. All right. Excellent. By the way, hopefully with this new platform and quick applause. Uh Two d any maiden who I know many of you have communicated to because this platform is um I think it's great because it allows you guys also to watch the past videos in order to kind of stay up to date. So hopefully you guys are enjoying that So with that said, let's go ahead and go over the first um X ray and again, it's a normal X ray. I'm going to read it for you all this one and the next one in two weeks, I will read the X ray, the normal one after that, I'm gonna start passing it off to you guys for you guys to start reading the chest X ray and so forth. So just an fy I All right. So let's go ahead and read today's first chest X ray. Share my screen window X ray. Perfect. All right. So we have an X ray and uh d any remember move this out of the way. So say you are on rounds with me in the intensive care unit and you're my intern as all of our new interns are starting this week, I pull up this chest X ray and essay. All right, good, sir. Good madam read me this chest X ray. So again, taking a deep breath and the way you dive into this is like diving into any book, start with page one and get to the end. Meaning you have a system to approach this. My system here is. So the patient does not appear to be rotated as a spinal processes. You can see them and they're evident and they're parallel to the floor there staring right at you. I can find the carina, it does not look splayed and it looks to be um in between the vertebrae, vertebrae boundaries, implying that the mediastinum is not shifted. Looking at the pleural space, I'll interpret the costophrenic angles. Both of them bilaterally appear to be apparent and implying that there's no clinically significant pleural effusions. Next, I'll evaluate for air in the pleural space. I've located the apices bilaterally. There seems to be lung markings going all the way to the top of the apices. I don't, I can rule out there's no clinically significant pneumothorax, pneumothorax, pneumothoraces. Next, I'll interpret the hilum and in the hilum, both in the left and the right, both of them appear to be somewhat translucent. Both of them appear to be of normal size and the hilum looks normal on my interpretation. Next, I'll evaluate the heart and its size. I can see the left ventricle the apex as well. It does not go all the way to the uh it doesn't go all the way to the chest wall. So the left ventricle does not appear to be uh large size. And the left atrium also appears to be of normal size given its slope and intersection with the left ventricle. Next, we're going to evaluate the lung parenchyma and the right lung does look rather uniform from top to bottom with the allowance of recognizing that the bottom vasculature, the interstitial markings are gonna be a little bit more prominent than the top. Given gravity pulls things down the left, same thing looks pretty uniform from top to bottom. And comparing both lungs at the same time, both appeared to be normal, uh uniform and I will finish off that. The interstitial lung markings also don't extend all the way to the chest while implying that there's no excess fluid, etcetera. So there's no consolidations, there's no opacities, there's no elevated interstitial markings in the lungs. So the lungs look normal overall so that the patient being rotated, the media signers not shifted. The pleural space doesn't seem to have any um uh abnormalities in it. The hilum looks normal, the heart looks normal, the lungs look unremarkable. This is a normal chest X ray. So with that said that's oh man, if an intern did that to me, first day, I would tell him or her drop that Mike walk off on stage, you're good to go. So what I'll do now is let me go over a little bit more thoroughly how I read this chest X ray to give you guys an understanding of what I'm looking for and then I'm going to go over a little bit of how to read the lungs. Okay. So back to share in the screen and okay that could you make a screen of full screen? Some people are asking if you can make the X ray bigger. Is it not full screen right now? No. Uh I think you just have to press present maybe. Uh Hold on, let me okay. No, cause okay. So right now you guys cannot see it full screen. No, it looks like it's not in presenters mode. Okay. Let me try. Hold on, let me try because my computer it does look like full screen. But let me see if I can figure out why it's not. Let me just go to the entire screen. I'll share that. All right now. Now, is it? Yes, that's perfect. Fantastic. All right. Now, I just got to figure out how to market again and then we'll dive into uh All right. Do you need your bottom left cover? Yeah. Fantastic. Okay. I'm learning my friend. I'm learning. Okay. So to you, all right, these are the spinal processes that we were commenting on and I'm so sorry you guys were having to read this. I had it on full blast, but I apologize. Okay. So that's the spinal process. You know, you can make the comment, it's parallel to the floor to the ground or if anything, it's a staring right at you, the trachea coming down and then getting into the carina. As we learn last week about the carina, the angle should be more of an acute angle like this. If it's greater than 90 degrees we call that splayed. And there's implying there's something in the mediastinum pushing up against the um Karina. Next, we look at the costophrenic angles. Uh These are perfect costophrenic angles that you can see here analogous to kind of a vampire fangs and you can see them nice and sharp. Next you look at the apices. So this is the right apex right above the clavicle. This is the left apex, right above the clavicle and there's grey coming all the way to the top as well as some lung markings. You can kind of faintly make out implying no pneumothorax. Again, if there's a rare there, it's gonna be pitch black as it is here. So next, I go into the hilum just like last week when we're interpreting the hilum, you wanted to be somewhat translucent or transparent and to some extent you wanted um to fulfill certain shapes, right kidney shaped and this one kind of the top of an ear logo, most so normal shapes there. Next, we're looking at the heart, the left atrium is right here. The left ventricle is right here and the two slope system and the fact that they're sparing to the chest wall all implies a normal sized heart. And then next, the lung markings. One thing I want to point out is you want all these lung markings to really end before they get to the chest wall, that implies no excess fluid and kind of a normal lung marking pattern. So with that said, what I wanted to show you guys as well was let me get rid of this, the whole notion of how to read the actual lungs once you get to them has to do with more of this. This is what I'm implying. You guys, when I go ahead and zigzag and Doctor Lin um was one of our radiology colleagues. But literally, this is what your eyes are doing regardless of where you're starting. Our radiologists always like to start at the bottom and work theirselves, work themselves up. I usually start at the top and go that way. But this is what my eyes are doing. Their zigzagging bagging forth as I take in the inventory. And what I'm just trying to make sure is that something stick out in one of these territories that makes that area different from its predecessor and make that area different than what is about to come. So you want to find something that may distinguish it and see how that is very different. You'll see a case of that in a little bit and then this is the other way at the end, right? So you're going, how's the right lung look? How's the left lung look and then uniformity between the two. But when I keep mentioning zigzagging, this is what I'm doing. This is how my brain is working to interpret and review the lung parenchyma in of itself looking for three things. Consolidations which implies complete white out opacities, which to some extent has a definitive border, but it's rather cloudy, right? You can kind of see through it and then interstitial markings which implies these lines that are rather large. Uh And thickened and a little bit more prominent than what you're seeing here. There's other abnormalities, but those are the three key ones at least be familiar with right off the bat. So let me go ahead and stop sharing. Let me see if there's any questions before we go into today's case. Any questions? Let me check the chat box, Deborah. Yes, I'm so sorry. All right. Did you already invite people to the stage? Know? So I changed it so that if you guys would like to share, um share your face is um and speak, you can. So metal is awesome in that if you have under 50 participants, um it allows it to be closer to a zoom interface. So I believe the people who are on the stage um just joined, press the join button. All right, sounds good. All right, fantastic. All right. Any questions on going through a normal chest X ray at the moment? Drop in the chat box. Do you need your way to raise their hands or not? Really? Um I'm not sure about raising their hands, but all very good. No worries. All right. So with that said, let's go over the first case. And in regards to the first case today before I show off this X ray, we're gonna go over it and keep in mind and X rays in tension is to be a data point to help confirm a diagnosis, help lead you to a suspicion of what something could be means using a variety of ways. But one of it is usually a diagnostic tool, right? So if my patient's coming breathless or with chest pain, when you get a chest X ray to see, could something internal be explaining it? So you guys ready? Put your thinking caps on, let's do this. So the question that I will pose, I'll put in the chat box. I have a 32 year old male patient chief complaint coming to me in clinic showing up in clinic fevers and Malaise. Malaise just implying kind of like you'll run down fuel rather fatigue. So you have that question. I can tell you I can oversimplify all of modern medicine. Your differential is usually cancer infection, autoimmune or maybe something else and we'll keep this something else uh to the side. So that's it cancer autoimmune infection. So you have, I know you guys aren't physicians, but you're gonna start thinking like one right now. I have a 32 year old patient fevers and Malaise don't try to be too much doctors right now. What do you want to know? What do you want to know to try to help you with? Potentially coming up with an idea of what this could be? What's your next question? You guys can just drop it in the chat box past history. So does this patient have a medical history? Ra he he does not. So this patient has not seen a doctor since his pediatrician at the age of 18 has seen one now because his fiance has asked him to see Alfonso you wrote. When did the symptoms start? Fantastic. So, Rahi again, past medical is great. It's important plays a role. Alfonso when your symptoms symptoms start because this is key, right? If I told you he started three days ago, you're thinking a little more infection. If I told you three months ago, you're like, uh I mean, infection, sure, but not a lot of infections do that. So in Fonzo, this patient's fevers and Malaise started about three months ago, Brendan, you're asked, is it sudden one said her hasn't been going on? I'll pick you back with that with alfonso. This patient's symptoms have been going on for three months, three months. Austin you wrote, does he have a smoking history? I'm gonna expand that. Does he have any exposure to things that really would offset the lungs? So does not smoke, does not Vape and as work, it's all clerical. He sits behind an office all day. So no occupational exposures and no prior lung injury from birth to the age of 32 Deborah. You're asking when do the fevers occur? Are they at night as best as you can tell he can't really put a rhyme or reason. He does get night sweats, right? He does feel fevers and night sweats. He wakes up in a pool of sweat at night and then during the day, he has the same thing he tells me he's like, look doc, I'll check my temperature. I don't have a fever, but I'm getting chills during the day. So does have night sweats, does have fevers and nights. And throughout the day, by the way, the reason why I'm seeing chills fevers. And when you guys come in, doctors make this point, fevers are both objective and subjective. Objective is a slap the thermometer. There's a fever, right? 38 degrees Celsius or higher. But if a patient feels chills, those are subjective fevers, right? The chills that get you rattling because you are burning up inside, that may not register in a thermometer but do not dismiss it because that is just as clinically important as an actual temperature recorded in a thermometer. So, Deborah, he does have both subjective and objective fevers. Um Ahmed. You wrote any weight loss? Great question and I'll follow it up if you guys ever ask weight loss, do David, for instance, David Amica Ebay, you were with me yesterday in clinic and you saw a patient that I saw together and I asked him about his weight loss because it's like you look thinner. But I followed up with a very important thing. Is it intentional? So I've made great question about weight loss. But end supplemented with, is it intentional weight loss or unintentional? Because intentional weight loss, good, unintentional concerning uh so this patient has no weight change though. He does feel like his clothes fit a little looser because he just, just doesn't have an appetite. But overall his white from the scale doesn't seem to be that alarming to him. Erin you wrote. Does he have a family history? Uh Great question. No. So the challenge with this patient, this is, you know, you guys would love this when you guys all become doctors, you really don't need to watch television shows because you're like, you know, you hear these amazing, fascinating stories all the time from just amazing people. But nonetheless, this individual was adopted. His uh he came from a war torn part of the world orphaned, brought over to the US and adopted. So he does not have insight into his own family history. Great question Erin Journal. So why he came now Journal? He came out three months later because his fiancee's asked him to one of my favorite things about and you know, maybe this is a gender thing, we'll see it. But uh males tend to come to doctors' when they've never seen them either because they're dying and they're showing up in my emergency room or they're being dragged by some family member. So he is coming now because his fiance as she put, it is tired of him complaining of having fevers and feeling tired. So rahi severity of symptoms. Well, I'll put it to the malaise. You know, we really don't score it. So much. He's not having pain but he isn't, you know, emphasizing that it's keeping him from really performing his daily work functions at his clerkship office, Deborah Hemoptysis. No, no bleeding, none. No coughing up blood, vomiting of blood, know urinating a blood, no dark stools. No passing a bright red blood journal. You asked like any worse things. So, does anything make it worse or better? Not really, he'll take some Tylenol and Ibuprofen somewhat alleviates but nothing really helps Merak Maria. You wrote any associated symptoms. These are the things I can really flush out. I've asked some other things in a reviewer system. Any headaches, not vision changes. None, any swallowing difficulties, sore throat, none, any bumps that you're feeling. He said, you know what he has, you know, he feels like his glands are a little swollen but only if he really pushes from them. No chest pain, no breathlessness, no chest discomfort, no changes in bowel movements or bowel habits. No abdominal pain, but he just doesn't have an appetite. He really feels like if that's why his clothes are a little baggy because he just doesn't like to eat as, as much. No rashes, no pain and his lower extremities are not swollen, travel history. Great question. Mustafa, mustafa, none. Alfonso. Are you having any pain? No pain? No, no pain, sky, no pain. I'm not. And has he taken any medicines? We'll take two more questions than I'll pause. See, take any medications no medications other than some ibuprofen and Tylenol to assist with the fevers. No travel history. Great questions. We talk about chest pain and cough. No shortness of breath. Good. None. His breathing is great. I promise you are symptoms concert. Do they come and go? Great question Emma. Is it fluctuating? So, it is fluctuating. The fevers come and go though. He feels like they go away because he takes something for it. But nighttimes are the most annoying. So he tries to take the Tylenol before going to bed his um malaise though. He just feels like it's just always there. It gets worse if he just tries to be active, like let me go cook some food gets worse so he can run himself down much faster and Rahid no cough, none, no pulmonary or cardiac symptoms. Now let me give you the physical exam and then you guys throw in thoughts. Now listen, I don't want a disease. I don't want you to be like, I think he's got tularemia. No, don't do that. Just give me infection autoimmune or cancer. And look, I fully acknowledge you guys, you know, are coming at like kind of have a distort of this. What I really want you to do is think about from your own experiences if you have some approximation towards people that have had cancers, infections, etcetera, yourselves, like, you know, in 2023 presumably you've had an infection. How did it come? On and how did it go away? Right? Cause that's usually incredibly common. So, physical exam, lungs sound clear. Uh heart sounds great, but he does have some swollen lymph nodes in his neck. He spotting no swollen lymph nodes above his clavicle, which is an important conversation. We'll discuss it later. Adamant, unremarkable eye exam mouth, everything else is fine, no rashes or anything. He did feel warm to the touch. He didn't have a natural fever in clinic, but he did feel warm to the touch. So Deborah, you're going right into cancer. Okay. We've got one for cancer. Anything else? What do you guys thoughts? Because again, this could be autoimmune, this could be cancer. This could be infection alfonso, you're throwing off infection. Excellent Deborah man, Deborah, you got your thing. You got, I got, you got your lymphoma's covered and you got your tuberculosis covered. Excellent. You just covered your bases, my friend. I love it often is going with infection as well. Good. Lots of infections. So let me and David for the autoimmune Gerb. Thank you, David. Perfect estella. Perfect. All right. Now, what I'm about to reveal to you guys is not, it's, you know, guidance towards the thought process between these. The challenge is these are guidance is not. Oh, thank you, Danny guys. Throw in your poll questions so much easier. Um Thank you so much. So let me give you guys some background of how I think when I come across a patient like this, so little Topo Chico. So, in regards to this patient's case, the fact it's been going over three months, makes me think of what could be going on for three months. Infections. There are some that can do this. These are gonna be the infections that we'll send you to the hospital. These are not gonna be the infections that make you miserable and shut you down. Right. Think of COVID 19. If any, if you've had COVID at came on pretty strongly and you're done, you're like, I need some time out. I need some time to myself. He never had that. His symptoms are always just kind of like they're there, but he still went to work, just run down, right. So there are certain infections like that. Tuberculosis as um Deborah pointed out can be one non tuberculosis, non micro bacteria can also cause it as well. So I'm looking for some kind of insidious infections. Mentioned tularemia. You guys should look up tularemia. It's an interesting bacteria tends to come from rabbits or pet rabbits, but it too can cause um something very similar other infections. For instance of Bartonella that can come from, it's called cat scratch fever, but it should be called kitten scratch because it tends to come from kittens. But Bartonella is another one, but there are certain infections, little insidious ones that can cause these symptoms. So, not a typical infection that we tend to think of that sends you to the hospital with pneumonia. But there are some that can cause this cancer wise. Yes, cancer is definitely the back of my mind. Would I think of this as a solid organ cancer, probably not solid organs tend really, especially they're gonna call systemic infect symptoms like malaise and fevers. They really will cause also issues happening locally, whether it's going on the kidneys or lungs, et cetera of the solid organ cancers that will cause Malaysian fevers, usually renal cancers. But again, you're going to have some very direct symptoms prior to that, right? Because usually this is implying it's kind of metastasized, but so nothing is solid. But I am thinking of hematological blood ones, leukemias and lymphomas definitely or in my mind right now and then autoimmune, of course, any autoimmune lupus rheumatoid arthritis, all of them will cause these lingering fevers and malaise. From an autoimmune perspective. I do think of more things like lupus and certain vasculitic, these, these anca associated. Sorry, I know I'm rambling with a lot of medical diagnoses, but literally as his patient's giving me his symptoms, the way I think as a physician is, I begin to prioritize. All right, what do I think it is who I just laid out my differential of all those things I've laid out now. This is how doctors think. What is the one I need to rule out immediately because a it could kill him if I miss it and be it warrants immediate attention and then they really look, they're all important. I'm not trying to prioritize one over the other. The cancer really is at the forefront. Cancer really needs to be taken off the plate in regard to this patient. The one quick thing I could get done that very moment was blood work and sending him for a chest X ray. Ideally, I'd want a chest CT, but we just happen to be over filled at the hospital where there's no available elective chest ct. So I was like, look get blood, go snap an X ray. We'll start right there and then we'll do more work up in the next 24 hours. His blood work came back positive for a white count of about 22,000. That's a lot, it's elevated. The thing is so doesn't tell me infection, autoimmune or cancer, all of them are there. So then I looked at the differential and actually what was rather interesting was of the differential, meaning what kinds of what blood cells are elevated are their neutrophils? Which would tell me you maybe it is a insidious type of bacteria or lymphocytes. His lymphocytes were rather elevated. So these B cells and T cells, the rest of his blood work was actually unremarkable. His kidneys were good, liver was good. So everything was fine. So with that in mind, let's look at the X ray. Danny is, does that mean lessee Sophara David and Ahmed are gonna be reading these with me. Um Let's see. Yes. All right. So can you guys just turn off your micro or a Knute? Just say a quick hello? Tell me where you're coming from and we'll dive into this. Let's see. What about you? Where are you coming from? And tell me if I'm seeing your name correctly. It's Lacey. Lacey. All right. Where are you coming from? Lacey, Georgia, the whole state or the country uh state? All right, we're in Georgia, my friend and I'm picking, I want to know I'm from Buford, Georgia. All right, welcome. Today. Is this your first time reading and chess sector with me, Lacy? No, I've been here, I've just been absent. Oh, you're, you're fine. You got life. Just watch the videos later if you want. If you want guys, this is for you. So you do a bit with you want, don't, don't worry about being absent, my friend. You're never absent for me. Silence does not imply absence. Well, welcome, Lacey, Lacey. You're gonna be reading an X ray with me. I'll tell you one. I'll call on you to read the certain parts. So get your thinking cap one next. Let's go to Ahmed Ahmed. Oh, De Toro. Toro. Are you there? Ahmed. If you can um mute, go for it. If not, we'll move on. But just a mute. If you can. Are they throwing the chat box by any chance All right, let's go to Sophie era. Sure feels so fear. A are you there? Yes, I'm there. And am I saying your name correctly? Yes. And Sophia, where are you coming from? I'm coming from Brooklyn, New York. Brooklyn, New York. Are you a Brooklyn? Er, yes, Morgan raised. Nice. Good. Alright, Sophia, welcome. And David, I know you're in Baltimore, man. I know you just shadowed me yesterday but David tell the class where you're, you know where you're from in and, and all that jazz. David Amica. Okay. There you are David, right, buddy. Uh Yeah, David, I guess right now, I mean Hopkins, it's doing internship with Doctor GVA here and uh school in Kentucky. So even are you outside? I love it. Good for you, man. Um All right, you guys are gonna be reading X ray, I've met you haven't a muted which is okay. Um So what we'll do is we'll just work with the four, right? With the three Lacey Sophia and David. You guys ready? Yes. All right. Well, you don't have to twist your like now it's awkward if you say no. So let me go ahead and share my screen. All right. And so Fera I'm gonna call on you first. Can you just confirm for me that you can read E this X ray? I can see it. All right. Are you ready to rock and roll with me? Yes. All right. Let me hide here. Let me go ahead and grab the pointer. All right, Sophie era. I wanna know real quick before I dive into reading this amazing X ray. I just want to make sure that I'm not gonna misinterpret anything. So you tell me my friend, what do you think of the spinal processes? Are they uh are they because uh um they're staring right at you. You got it. All right. Still sticking with your severa. Next. Tell me about the carina. What do you think is going on with the carina? Do you think it is falling within the vertebrae or does it look shifted by any imagination? And I'm just gonna trace it out for you a little bit. What do you think? Uh it looks a little shifted to, I'll give you that, I'll give you that. It's right here, right? It's kind of going out the boundaries of the vertebrae. If you trace these down, it doesn't look splayed right. This angle looks to be less than 90 degrees, but I'll give you that nicely done. Safe era. All right, Lacey. You ready? My friend from Georgia, ready, by the way. What's the weather like right there? Is it hot and humid yet? In Georgia? It's hot? Okay. Uh I've been, I've been in Atlanta in July. Uh my gosh. Uh Anyway, Baltimore's not any better, so. Alright, Lacey, next, let's go to the costophrenic angles. So what do you think of them? Are they there? They're present they are present. All right, but I'm gonna pick on you. So for a, for a second, do you appreciate that? There's a haziness right here coming over top of them. Do you appreciate that? Like, you know, giving you the boundaries and there's the haziness right there? Do you see that? Do you, do you know what this is? What that haziness is? Lacey? Are you there? 00 Did I say Sophia? Oh Sticking with you. I'm so sorry, Lacey. Sticking with you. So question to you is this haziness in the chest wall or outside of the chest wall outside, outside 100% what I'm trying to. So this is breast tissue. This is a male already told you. So this is some extent of gynecomastia. I don't know if it's gonna be relevant to the case, but it was interesting when I saw the x rays like that looks like breast tissue, breast tissue, excess, breast tissue will create a haziness. That's what I'm trying to point out because you know I'll get plenty of interns or like is the costophrenic angle there? I don't know. It's he's e guys if you can see the costophrenic angle, it's there. If it's hazy, it just means there's something above it. If there's something in the pleural space, the costophrenic angle will go away there isn't hazy fluid. That's what I'm trying to get at. There's no hese fluid, it's there or not, right? All fluid or somewhat seem very bright. So the fact that this is hazy right here that Lacey was reading this is just usually out outside of the chest wall and B usually implies breast tissue, but again, read it appropriately. Uh in regards to could it be breast tissue? It could be something else. Alright, Lacey, you're gonna stick your my pleural space person. Not. Yeah, Lacey, my Georgia friend. You are doing the pleural space with me. Next let's go two the apex. So what do you think? Do you think there's obvious dark blackness up here or no? Doctor G? That's still kind of grayish and I can see less of them lung markings going up there. What do you think? Um It's for for comparison, dark black look where I'm drawing right now. That's what I mean. This is something this shade of black in here. If not, you think so? Just yeah, this is great and look, this is a training, right? Lacey. That's what I'm gonna try to imply. This is all training. I want your eyes to get comfortable. You will see some pneumothorax, I promise you it will be well there. That's black, there's nothing up there. There's not even a hint of gray. This is the level black, right? Cause the pneumothorax just implies that there's a rare, right where I'm drawing right now. That's just a rare, right? A pneumothorax means there's just a rare outside of the lungs. So get comfortable with just a gray. Does that make sense? Lacey? Uh Not like just like uh Yeah, Lacey. Yes. Sorry. Yes. Uh When I have this one, I can't see the names. So lazy. You. Rock. Thank you, my friend, Lacey. Severe. Hang tight. David. Over to you. Good, sir. Are you ready, David? All right, ready, buddy. Okay. All right. Let's talk about the heart and I kind of left this part out last time when I read it. So this is the right side of the heart, right? And what I always make a mention of with the right atrium to look normal, you want it to be kind of a nice concave like this with a nice angle right here. So David, do you agree with me that that is a normal size right side heart, is that okay? All right. Next, let's look at the left ventricle, which is also in this part right here is known as the apex of the heart as well. And do you agree that it does not extend all the way to the chest wall? Yes, excellent. So normal size left ventricle. Now, this gets tricky and if I just lean back a little bit, I will tell you, I'm thinking the heart kind of comes up like this. Now, you were saying you may say, hey, doctor, you, but doesn't it come up like this? The challenges? I think there's something going on here, which I'm giving it away a little bit. So I will tell you this. If you were my intern, David, I would say it's hard to interpret the left atrium. I think there's something going on there. So I'm giving you a cop out right now. This is hard to interpret the left atrium because I think something's going on there. So the left atrium, as we said should come down because where's my pen? You guys can all make out this something and this slope coming down. But I'm confident that there's something happening here as well. All part of potentially something there any way David, I'm giving you a cop out for the left atrium. So no worries of interpreting that. But you have read that the left ventricle and the right atrium are of normal size. So with that said, David doesn't mean you're out of this. Let's go over reading the hilum together. Okay. You ready? Yes. All right. So this is the right hilum and my question to you, does it look see through ish when I say see through ish, I mean, is it white it out or is it c through ish? This is what see through looks like. Would you agree that you can? Yeah, you can kind of see through it. Yeah, the left side, I got a little bit right here. That's all I got. I, and I would, if I was reading this, I'd say the right looks normal. The left eye can't, I can see a little bit of it, but I can't make out too much more. Leave it at that. Is that ok, David? Yes. All right. Now, I've already hinted at David. David. Go ahead and go on mute and I'm gonna call you Lacy and Saphir a in a second. I've already told David that something's going on in the Mediastinum. Look what we went and, uh severe pointed out very nicely. Is that yes, the Mediastinum does look shifted. You guys look at this and what I forgot to point out was, can we look at the carina? So fear a since you brought that up, does the crying a look splayed. Meaning is this bigger than an acute angle? Um Yes, it's kind of large. Yes, because remember look at, look at the angles here, right? The angle is coming nicely down. The angle here is spread out a little bit more so that displayed Carina. So something is in the Mediastinum and that's something his rival you can kind of make it out. Is right here. This, by the way, this what's coming up is the aorta coming up and then about to go down, right? That's the just the aorta but this, there's something here. So with that said that we're not done yet. David and Sophie era and Lacey come off mute. Let's dive into this. I'm gonna read the, you guys are gonna read the right lung with me. We're gonna do the zig zagging. You guys tell me on the right side to stop. If you feel like there's something there. If there's not, then just stay silent. You ready? Sophia A David and Lacey. You guys ready? Yeah. All right. Let's go through the right side. Just tell me to stop if you feel like do something looks different. Yeah. Mhm. Stop. All right. Where do you want me to stop? Sorry. Back up here like, yeah, I think that's too far where the carina wouldn't like reach their normally. So you mean the okay. So are you commenting on that? There's something in the lung or you commenting that the carina has just been pushed over a little bit? That's what Lacey was implying. Okay. But in the lungs itself does something pop up that looked unusual or do you think it's all normal? And I'm not trying to be misleading? I promise you it looks normal to me done. You are correct. That was severe. Lacey David. You guys agree. That is normal. Yes. Yes, normal. Let's go into the left long. You guys ready? Tell me when to stop. Do do do do true. So you can stop here. Stop here. Well, you can you mentioned it earlier like like there's another like kind of lump that's not the order. So I mentioned that correct. You're right. And is it the aorta supposed to like go down has a slope? Is that the slope down there or no uh the slope of the order is right here, okay. All right, David. Uh So fear a or Lacy anything else that stood out now watch this? Anything that stood out, which is fine guys ready everyone. Look at this. Yeah, you see it. Yeah. Subtle. Write some uh incredibly subtle. That is what I want your eyes to be trained towards. That is what I'm looking for you guys to be able to acknowledge, right? That subtle nous Look at it like let your eyes keep your eyes on it for a second. This is an opacity, right? This is what I mean by opacity. You can kind of see the boundaries and it's not completely whited out. If it was this shade of white, that'd be a consolidation, but you can kind of see through it. That is no opacity. Look at this like let your eyes really take this in because next time you guys won't miss something and again, Lacey. So fear a David, you guys are all sorts. You guys rock this case. If I give it to 100 interns, 100 interns are missing it. I promise you maybe a few of them will talk about something in the mediastinum, but they're all missing that one spot. Subtle subtle Lacey. I'm gonna put you on a spot. Describe it to me in your own words, just describe it, shape color, describe this. Don't use any medical terms. Just use Lacey from Georgia terms. It's a great dot Great dot Perfect Severe. A how would you want doing a add to that or take anything away? How would you describe it? Now? We'll go with that just like a cloudy dot Yeah. Cloudy know you're at it. I love it. Cloudy dot Let me ask you guys a question. When, when you say dot Though, what shape are you inclined to me? Like a circle of square circle? Excellent David. You got cloudy, you got great. You got circular. Anything else you want to add to it? No, it's just right in the middle, right in the middle of the red, right? All right, good. All right. What I want you guys to do when we find abnormalities, I'm going to ask you guys to describe it without any medical jargon. Use your vocabulary to become a physician when frustrating thing is we teach you all these scientific words. But what should never get lost? And it's a skill you can begin to work on now how to describe something that's key. Yeah, you may find the language later, doesn't matter what all your doctors did 100 years ago. You know, before we came up with the medical jargon was we just described, we described, if you guys ever go to a pathology room and read the autopsies, people just described really well. So when we go through x rays and we're gonna find abnormalities, I will ask you describe what you're seeing. I don't care if you say doc, I might just pull some out of you a little bit. Like, tell me what adopt means. Is it right? Like you guys did tell me the color, does it look black? Doesn't look gray? Tell me, you know, all of it. I want you guys to be comfortable with how to describe it because when you guys are gonna be interns one day starting your rotation as a physician, that's what you're going to lean on when you just can't recall the, you know, $200,000 tuition that you just paid, which is gonna happen intern year. I promise you every intern in July feels the same way. They're like, did I really learn anything? What you can always fall back on is your skills of understanding of reading and interpreting David. You were with me yesterday when we had a diagnostic mystery. All the questions I asked that patient are things that like that, you know, their doctor league I was trying to go down. But you heard me really go through a comprehensive describe something to remember that. Yes, that's what we fall back on when every physician doesn't know how to, you know, like, I don't know what that I'm seeing right there. But what you do know how to do is interpret it, you know how to read it. What's the shape, what's the color, where is it, how big, how small separate always do that and everything that you guys just did in this when I asked you hate, this person came into my clinic with symptoms. I loved it. You guys were like, does he have a past history? Because I have a family history. When did this start? Why is he coming in now? I love the, why is he coming? And I always ask that question. I always love asking. So this patient was sadly, um well, they're all, I mean, there isn't a win, win here, but he was diagnosed with a pay para-aortic tumor. The para-aortic tumor on biopsy was found to be a diffuse B cell lymphoma. So Deborah, I know you wrote lymphoma earlier. Kudos to you, my friend um uh with uh Deborah. You are, you are in medical school, correct? Deborah? Oh Deborah. Are you still there? Oh, Deborah. Well, I'm not sure if you're looking for the mute button or not or? Yes, perfect. Excellent lymphomas uh constantly part of the differential that in tuberculosis. Um So with that said this case, what I wanted to convey to you guys wasn't so much the mediastinal mass. You guys saw that you saw the splaying of the carina, you saw the kind of interfering with the left hilum, took those things away that you guys were comfortable with. You saw that push the mediastinum that severe a pointed out. But what I wanted you, David Les Les seats, Saphir A and others to take appreciation of really was more of that zigzagging because when you guys do that zigzagging a consolidation, I promise you will be very obvious. There's a nice white it out interstitial markings probably harder but opacities, those can be tough because that one was right on the rib. It's not on the rib itself. It's when the X ray it falls on the rib, right cause it's two dimensional representation. So that's it. So, questions comments, thoughts concerns. I think I have a question since I had David. It was uh the blob on the left side that you said you were confident all of us there. Are you confident? Did you take into effect already that the carina was, the Mediastinum was shifted to, I think there's something in the Mediastinum. I think what clues me in more to the Mediastinum being something being there was more of a splayed carina which I forgot to point out when I think Severa was reading it. Um But that's plate displayed Carina when it, when as opposed to being an acute angle is much wider, that that's a big tip that something's going on in the Mediastinum. Um it could be from an enlarged heart, give you from enlarged lymph nodes, it could be from a mass. So that was one key thing. And then the other part was the fact that I lost that to slope situation with the heart because that left ventricle looked really good and the left atrium to be enlarged without any interstitial markings. I know I'm talking shop to you guys. I apologize. That would be unusual. So I wasn't suspecting that. So, from my standpoint, what I was suspecting was something a mass in the Mediastinum that took away the to slip interpretation of the heart and really was taken away the left sided hilum. I could barely see the little nubbin sticking out. That's what queued me in the carina being splayed and I would agree with severe. There were some shift nous there that to me, I was interpreting as something, something's going on in the mediastinum, a mass itself. Any other questions? Did you guys like this case? Do you guys like being able to add some clinical contacts? What? All right, Andrew you wrote was the opacity that you pointed out outside the splayed. Yeah, the capacity was in the lungs. So there was already a metastases of this lymphoma when there's a chance for a patient to have a cancer tumor CT scan. Yeah. So um Rocky, the reason why we just got an X rays, I just needed something done that day. I wanted a CT Scan. I wanted a CT Scan. There's no CT Scan available. We had an X ray to start off with the X ray is making me now go for a pet CT, right? That's what we did. And then he ended up getting biopsied. So that's, you know, I wanted to show you what I had in that very moment. So great question. Overall, Mri's so the challenge with MRI. MRI. S are good. It's no radiation. We love Mri's for that purpose. Mri's are just a very time consuming. I can get a CT Scan done in 10 minutes with a patient. Find add contrast, 20 minutes. Mri's. You're there for an hour to two hours and the challenge with MRI S, they're not abundant, right? So I've had patient's going for an elective. MRI pulled out of there to let a patient with a stroke come in. So we'd like to use summarize. We just got to figure out a way to get them done faster and see if there's any other questions and treatment for the patient. Probably R chop. So it's a variety of chemotherapy drugs in order to treat him. The acronym that we tend to use is R chop. I'm put in there. Uh huh. Great questions, guys. All right. We'll end here. Have fun. Proud of you guys. We'll be back in two weeks. Not on the fifth. We'll be back on July 12th. Okay. We'll have a fun time. We'll have another cool diagnostic mystery and maybe lazy. Maybe you'll see some air in the pleural space. All right, my friend. All right guys. Take care.