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We up and running. Um The live is still loading. So it might take a second. All right now we're live. All right. So we are live and in action and you guys will all have a special guest. My daughter will be joining us. So, uh thank you guys so much for being here today. If this is your first time, strongly encourage Deanie, how can you see the prior uh teachings? Yeah. If you go to our home page now on me, all which is a thing, um You'll be able to see it pinned so we have all those resources pinned. So you should be able to see a document uh with introductory information. Got it. And um so you guys have, I'm saying this cause we're gonna dive into today's teaching just, you know, I'll go over kind of how to read an x-ray briefly. But if you want more information on how to do that, as Deanie said, watch the prior um lessons, uh especially the earlier ones and they're labeled like how to read the x-ray and so forth, please, please do so. Um So with that in mind, let's see, um Dean, we usually will call some people. Um Do you think there's anyone that would be willing to come on stage with us? If any of you guys wanna come on stage with us and read the x-rays together, you can put it in the chat and I will invite you to the stage. All right. So if you'd like to join us on stage, just put it in the chat box. Um Otherwise we will go ahead and go over what I think is a cool case. I know it's an intimate crowd today. It's all very good and a lot of familiar faces. Yes. All right. Let's do this cause it's an intimate crowd. We got Bianca, we got Ivan here, Verina. Um uh you know, let's just go ahead and we'll just start with this intimate crowd. Is that OK? Sounds good? All right. So regardless of coming one stage or not guys, if you have thoughts con uh considerations, just drop them into the chat box. But I have a great case that we'll dive into at the moment. So let me go ahead and put this on presenter mode. I go ahead and share my screen. All right, Danny, let me know if you can see it. Yep, we can see it. Perfect. All right. So Deanie, I'm gonna need your help. So when I have this one for remote, I can't see people are putting things in the chat box. So do you mind just letting me know if people are throwing this in the chat box, you got it. All right. So if you've been with us before, you know, the way we read a chest X ray is we look first to see if the patient's rotated or not. After that, we dive into the spaces around the lungs. So the media is sign in the pleural space. Then we evaluate, um Hilum, then we evaluate the heart and then we finally dive into the lungs themselves and see if there's any abnormalities there. So we do that in a thorough way to make sure we never miss anything. So right off the bat, if you've been with us before, right off the bat, are you getting your spider senses tingling that, hey, there's something going on with this x-ray. So who thinks de let me know if you're putting comments in there, who thinks that this is a normal x-ray or an abnormal x-ray? Any comments jo diving in there? Anyone? So Verina says abnormal because the head is turned. All right, perfect. Fair enough. There's other abnormalities. So we we'll go into that. No worries. But the fact that you are recognizing, hey, something's abnormal here, even if you're right, the patient's positioning strikes me as not one I've seen before. Also important. So that's great. Anything else? No other comments? Anyone else have any ideas on what could be abnormal here? You guys can put it in the chart or since we're small. You might also be able to unmute. Oh, very good. No worries. All right, let's dive into this. So I'm gonna do the reading, but I want to hear what people have to say in regards to potentially the case. So here we have a 62 year old woman who comes to the emergency room. So just come to the Ed with chest pain, chest pain right off the bat. Let me ask you guys this. If someone's coming into the emergency room with chest pain, why would it, why would it, what would you think an x-ray? How would a chest x-ray help co uh solve the solution? Any any thoughts on why you would wanna get a chest X ray for someone with chest pain? What would you be looking for? And you let me know if there's any comments being given, no comments yet. No worries. So whenever we think of chest pain, we tend to think all right, the pain receptor, something's going off. The heart is one huge example, the heart can feel pain. Lungs don't right. There's no pain receptors in airways. So even at the world's bad, worse pneumonia, unless it's causing necrosis where the tissue is dying, tend not to get too much pain from lung pathologies. So when I get a a chest x-ray for patients coming in for chest pain, what I'm looking for is am I gonna find something in the heart that tells me something's going on there or something else happening in the chest that could be pain. Did the lung collapse, a lung collapse can cause chest pain. Sure, it's different. So what I that's what I'm looking for. So let's dive into this patient. So right off the bat as we heard, the head is turned, but even with her head turned, is she still properly positioned? And in this case, the answer is still yes. So even with her head turned, and I love that you're pointing that out, right? Because that's not something you've seen before. She still is able to maintain a proper positioning as evident by her spinal processes. There's still that tears shaped appearance, her head turning is likely could be anatomical. She could have something called kyphosis. And so that's the best that she can do to get her head out of the positioning, but she still is able to position herself properly enough so we can read the chest X ray. So don't have to worry about any abnormalities there. Doctor Addy said I asked if it's respiratory etiology. Um Yes. Yes. So you're right. So if someone's coming in with chest pain, getting a chest X ray could help us to make sure there's nothing happening in the lungs of any respiratory abnormality. Again, usually from my standpoint, lung pathologies tend not to give pain so much. I mean, again, the way people describe pain is very variable. So sometimes what they will say is chest heaviness is chest pain. But yes, but remember, chest x rays don't just capture lungs, they can help assist with heart. So we went into saying the patient's already rotated appropriately. So now let's read it. First thing you do is you're gonna look at the mediastinum. Mediastinum is a space between the right and left lung. So you may say, all right, Doctor Jean, how do I look at the mediastinum? And you do that by finding what's called the, the Corina, the Corinna is right where the trachea ends, the trachea ends and splits. So this section right here, that's your cry. Now, this is gonna be important, the significance of finding the carina. You're gonna evaluate if something's happening to the te how if you're gonna use the carna kind of as a landmark, if the carina is shifted to the left or the right? And the way I usually assess that is, is it deviating from the boundaries set forth by the spine, by the vertebrae? The crna looks like it's in between it. So it's not shifted, a shifted cry that usually means one of the lungs is either pushing or pulling it in the direction of the pathology. It doesn't seem to be the case here. There's one other thing I want you guys to pay attention to a normal Corina. The angle it'll have should be less than 90 degrees. The carinus angle should always be less than 90 degrees. The cr is angle here. So you guys all agree. This is not 90 degrees, this is larger than 90 degrees. Does everyone agree to that? If there's anyone that thinks otherwise let us know? But this Crna, so to read the Mediastinum, the way I would interpret it is finding the cri the media sign, it does not appear to be shifted. However, the CRNA appears to be splayed. A splayed. Rina means something underneath it is pushing it up, causing the branches to widen their angle. So this is normal, 90 degrees. This is abnormal. The carina is spla what causes a display of cry? One of three things, either a large tumor, a mass underneath it. Second, a large lymph node, the carinal lymph nodes, it's big and it's, and it's causing a coral uh branches to spread or the heart, the heart being really big, starts pushing up against the crying up. So right now, all you can say something's going on in the mediastinum because the carina displayed great. Now, let's go into the pleural space. We have a question from doctor a asking um about what is the Socrates history of pain? What is the, say that one more time? Uh S 0.0 dot C dot R dot At es for pain assessment. Let me see exactly what uh is being said. Sorry about that. All right. What is the Socrates history of pain now, Doctor Addy. Good sir. So that is an acronym II personally don't use. Um You're welcome to explain it a little bit more. And this is what happens in regards to medicine. Everything's a everyone's got their own kind of algorithmic approach. I imagine there's aspects to it of. When did it come on? How long has it been happening? What makes it better? What makes it worse? I can tell you what it stands for. It stands for site onset character, radiates associated symptoms, time slash duration, exacerbating slash relieving factors and severity. Perfect. So great acronym helps organize. It's essentially what I was just saying in the, in the sense, we're all communicating the same thing. This is the art of medicine. So sight her chest pains right over her chest, literally over her kind of sternum to left, um uh uh left aspect of her ch uh thoracic cavity onset. Last 24 hours. She left dialysis, um, yesterday morning and has been experiencing this pain, not sure what's causing it and it's not really radiating, it's staying local. What makes it worse is when she leans forward? What makes it, uh, I'm sorry, what, what makes it worse is when she lays pat. What makes it wor uh alleviates it is if she leans forward and that's about it. That's n nothing else. Last 24 hours. She feels like she's got a cold since Sunday. So this is Thursday. Four days of having a cold. That's, it feels worse when she lays down better. More relieved when she leans forward. Chest pain happening right over um her sternum and left breast. Great questions. Let's go back to the slides. This is great. So actually where I'm at here, you can see the, you can see the full screen, right. Danny, the x-ray. Yes. Ok. I just realized I don't have to be on presenter mode and stare at. I can. All right, where I'm at right now, I can see the questions. So as they're dropping in, I can see it. This is great, good. All right. Now, let's read the pleural space. So in the pleural space, if you look at the right side, you all have, if you've come to X ray rounds before you know the way I talk about what's called the costophrenic angle is what I look for is a nice, oh, we'll go back to pen. What I look for is a nice kind of deep angle. This is not it, this is not a deep angle. So right off the bat, I would say the right phrenic angle seems blunted the left side. I don't know where it is. I can't find that costophrenic angle here. So I would say the right side, costophrenic angle blunted the left side. II can't, I can't see it. I can't make it up. And then last thing and I'll look at the question I was just dropped. We look at the apex of the lungs. Now, this patient likely probably has kyphosis. So there's not too much space above the clavicles. But what you're looking for there is just to make sure there's no signs of air. The way you pick that up is really black spots that have no obvious lung markings in there. However, you can see some lung markings in here and you can make out some in here. It's not the best quality, but I would say this patient's apices are uh are present and there isn't a sign of a pneumothorax. So let me go to the questions. I put something in the chat box, two messages, how uh slides and the recording be made available with feedback form posted here. Yes. All of it will be available to you Bianca everything doctor Ay, you're asking for the EKG E CG. Good questions. Good, sir. But hold tight because we are just reading an x-ray right now, right? That's it. I promise you all this other collateral information is important but all you need everything you need is in this x-ray. I promise you, I promise you, I'm not gonna let you down. All right, we talked about mediastinum. Thea is explained, costophrenic angles. The right side is blunted, the left side is absent even if you haven't seen the x-ray, even if I don't show you this and I'm telling you this out loud, the heart should be a big culprit concern here. Blunting a costophrenic angle means there's excess fluid splay the carina with blunted costophrenic angles usually means the heart is the culprit that level you're getting at is your pericarditis. That's a concern here. No. Next we go to the hilum. The hilum actually looks rather ok. On the right side, the left side, you can't see anything because of such a large heart. So nothing to see on the left side. On the right side, you can make the argument that maybe the, uh, high number here is a little bit more dense, but it still looks relatively actually. OK. On the right side, now, I already let the cat out of the bag and said the heart looks big and sure enough. Yes, it does. If you remember what I say about the rules of the heart. If there's no space between the heart and the chest wall, that's a large heart, it's a large heart, many reasons for it. Maybe uh they have left ventricular hypertrophy or maybe they have a big Pericardial fusion. Let's talk about that in a second. Next, we look to see if there is a two slope approach. Actually, what's interesting is I would say there almost is. So whatever's going on. Oh, let me erase. This looks like the left atrium is still relatively doing OK, not a lot of pressure against it as it comes down for too slow. So looking at this heart, it is big. But internally, I'm not sure if the pressures are excessive. So the other thing too is you'll notice right here, the right ventricle is bulging out as well. So if I had a look at this, the left atrium looks preserved, left ventricle can't make it out. It looks big or something surrounding it is big. The right side also looks bulging, but it looks bulging without the left atrium being bulging. So let, let me explain how I'm thinking right before I've even gotten into the lungs. Oh, the highlighter and the eraser. All right. So a couple of things just from this x-ray, right? I know EKG S are important doctor and don't worry, I'm not dismissive of that. No, I don't apologize. But everything you need is right here. So think this through with me, right? You have a heart, it looks big. You could say, all right, maybe they had a heart attack, maybe they, maybe they're in heart failure. But this is interesting. The right side looks big. It's bulging, but there's a two slope issue happening here. So the left atrium doesn't look like it's overwhelmed internally with excess pressure. So why I'm saying that is even though the left side of the heart is big, I can't tell you that that means the left ventricle is big or something surrounding it is big. But because some my suspicion is that the internal pressure of the left side of the heart is OK because of the size of the left atrium, the two slope approach, my money is that something surrounding the heart is enlarged. AK a also known as the pericardium. So, Doctor Abby, you said this earlier with this patient have a history of pericarditis. Uh I told you she had a cold for a couple of days. Chest chest pain, listen to this worse. When she lays back. When you lay back, the heart slides deeper into the chest cavity and is more surrounded by the lungs. When it leans forward, it gets relieved. Nothing's rubbing it up against it. That's a telltale sign of pericarditis. And sure enough, when we listen to her with a, with a stethoscope, you can hear the rock. Now, there's another abnormality in this patient. Her lungs actually look relatively ok. I mean that, you know, going through them, her right side seems to be doing ok. I mean, you can maybe appreciate a bit of a fissure here and her left side looks ok too. Yeah, she's got some interstitial markings, but I would still probably read that her lungs look normal here. Now, what's fascinating is you may say I will, she even comment on her catheter and she's got this, this catheter is big and thick and it's clearly going into her subclavian as you can see the ending right here, big and thick. This is a dialysis catheter, right? So she has a dialysis catheter and she went to dialysis yesterday. So, whatever you're seeing here is not an issue of volume, she's not having excess volume. She didn't skip the dialysis session. This patient has pericarditis. So take a look at this. Let's go to the next slide. So lungs look normal. I mean it, yeah, you can make a case for some fissures here and there maybe a little bit of fluid. But why does she have a pleural fusion without the heart actually being the culprit of it? So here it is. This patient has pericarditis. This is a CT Scan. So in this CT Scan, oh, let me go back to the pen. Here's where the heart is, this is the heart. And then here is the pericardial effusion. And I will tell you the pleural effusions that she has that we are seeing isn't because the heart is struggling and going into heart failure. It's not. We said look, the left atrium looks ok. It doesn't look overwhelmed. And at the same time, there's no prominent interstitial markings in the lungs. What's fascinating about this case is she has a peri she has pericarditis. She has a lot of fluid, right? Pericarditis means inflammation of the peri pericardium. Whenever you have inflammation, you get fluid accumulating there, right? If you guys ever cut yourselves, what happens to that cut gets a lump, fluid goes there. But her pericardium as you can see, communicates with a pleural space. That's why she has a little bit of a pl pleural fusion. It's just excess f uh inflammation flowing from the heart flowing from the pericardium into that space. That's crazy. That's um wow. All right. Now, if you see a pericardium, a pericarditis with this much fluid, the next thing you should say is do I need to drain it? And so let's go to the next slide. Bye. So in this slide, I'll finish with this and then we'll go over what happens. Hold on. Yes, perfect. Uh Yes, perfect. So, in this slide, you can see the heart still in here, there's the heart and look at all this fluid around it and it's communicating with a pleural space. That is why she has a pleural space. The reason why I'm saying this, the reason why I'm paying so much attention to teach this to you guys is well, you have to decide. Yes. Is there fluid in the pleural space because she's in heart failure or is there fluid in the pleural space? Because it's an extension of the inflammation from the pericardium because that's gonna dictate the management. But because I can make the case, it's not, I don't have to act on it immediately. Now, if she's got pericarditis resulting in heart failure just from the x-ray alone, you don't even need an EKG after adding you call the interventional cardiologist, I need you ASAP, but I'm gonna tell you we'll still call them but not based on that. The reason why I'm gonna call them is I ended up getting an echocardiogram in this patient and if we go back to this slide here in this slide, the right ventricle is right here. And when an echocardiogram, you can make it out that the pleural fusion around it is beginning to push into it. She's not in Timna but she is close to it. So what did we end up doing this slide? The answer is there right here. It looks like a little bit better, right? But right here is her catheter, we called interventional cardiology. And they went in and placed a catheter, a pericardial uh uh drain to remove that fluid right off the bat. Immediately we trained half a liter of fluid, half a liter is around his heart. So let's go over some teachings about this. All right. Anyone here ever experience um a pericarditis diagnosis? Anyone here. So, Doctor Abby, yes, you're asking more EKG findings. She, she had the only EKG findings she had was the Terance, right? The pericarditis that you can see with it, right? No tymp but not physiology. The echocardiogram didn't signify it. So the reason why I'm gonna ask this, does anyone know what plays a bigger role in causing a tamponade? Tamponade means the fluid around the heart is crushing the right side of the heart and then ultimately the left side and it's unable to send fluid forward, right? The patient will go to a cardiac arrest. Does anyone know what dictates it? Is it the amount of fluid we told you this patient had half a liter of fluid around the heart, no tamponade or is it the rate of fluid? And the answer is the right. If that fluid came in fast, she probably would timp a not, but this fluid sounds like it's been accumulating slowly over time over the last four days. So that kind of accumulation allows the heart to make some adjustments. But what's great about per, so this is pericarditis. She had um early signs of tympanal. So that's why they place a pericardial drain. But when you see these cases, when you think when you hear a patient, the big lessons to learn from this, if someone has chest pain, someone has chest. Oh Verena, you wrote uh how can you tell there's fluid around the heart in a CT scan? So VNA, did you see how I highlighted those sections fluid around the heart? When a CT Scan on those windows, you can make out where the borders end around the heart and where the heart is. Let me know if that makes sense to you. If you need me to explain it again, I'm happy to go into it. Um So the big thing here is if you hear chest pain and you're grabbing an EKG, what you, I'm sorry, I didn't get you a chest X ray. Oh Doctor A You got me thinking about uh EKG S man. No worries right now. Good. When you get a chest X ray for someone with chest pain in the back of my mind. What I'm looking for is OK. What's the heart look like? Every time I get an X ray for chest pain? I always look at the heart. What does it look like? Does it look abnormal? In this case? It did, it looked big but its bigness was interesting. The right side was bulging out and the left side looked big, but the left atrium looked normal. So that meant to me, let me spin it differently. If the left atrium looked big, then what I would make the case is the left side of the heart probably isn't pumping fluid enough. So it's backing up the left atrium, making the pressure big and it's probably gonna go into the lungs. So I would have expected big, prominent interstitial markings and then that's all backing up into the right side. But we didn't see that the left atrium looked normal lungs looked normal. So that bulging of the right side to me, I was like, all right, you know what it is? I guarantee you it's pericarditis, it's pericardial fluid. And sure enough, we saw that in the CT Scan and then the pleural effusion is just an extension of extension of the inflammation. Why? That's important. It's not a guarantee. It just tells me she's not in an active tampon, no, which could be approaching it. That's why we do echocardiograms. If we don't have echoes, then we'd be sitting there checking her doing uh physical exam findings to make sure she's not going into it. That wasn't the case here. But the echocardiogram caught it early enough that we ended up still taking her to interventional cardiology and placing a catheter to drain it. It's a great case, right? This is all abnormal uh mediastinum where the heart lines explain the trachea, all abnormal pleural space with fluid due to an extension of the inflammation from the pericardium. So we'll stop there. Questions, any questions comments, Doctor Ay was asking about EKG findings. So let me tell you what I was saying. Um What I was discussing is the altering these um uh uh um findings where there's um here and I'll put it in there. There's, there's a website I like going to about pericarditis findings. So pericarditis it is here. I'll put it into the chat box. Pericarditis has, aside from the EKG findings has actually some really nice physical exam and historical intake. Remember what I told you when she laid down? Oh, my heart hurts. Yeah. Cause when her heart, when she lays down the heart slides and if there's inflammation, it's gonna be coming across the lungs when she leans forward. Oh, she have to relieve the heart drops right into the chest wall and it's not hurting her as much because it's not rubbing against the spaces. That's a great sign. The fact that she's got a cold also when we tested her. She was positive for RSV. She had RSV pericarditis. So those are things to look out for. All right, any other questions? Any questions I missed? No, no questions that you missed. Excellent. All right. Well, we will end there. Stop there. Strong work everyone. We'll be back in about two weeks. Thank you guys so much. Thank you, Dean. I appreciate you. Thanks everyone. Oh, ok, Verina, you just ask and there'll be other causes for your grow other than infections. Yes, autoimmune diseases, cancers. I would say those are probably the top two after that and sometimes just idiopathic. We don't know there are certain autoimmune disorders uh where we highlighted can cause it but a autoimmune uh three the autoimmune drug reactions to your lyme. This is a big one that does that and uh cancer. So that's it. Nicely done, Verina. Thank you all. Do you need anything else I missed? No, that's it. Awesome. Thank you guys so much. Yes, Jason Jason Congrats on starting pa school uh or yeah, hopefully start a school. You will. Good sir. So happy to help watch this later on. You'll like it. It was a fun lesson today. All right, everyone. Take care. Bye.