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Are we live yet? We are lo uh well, it's loading. We'll be, yeah, now we're live. Hello, everyone. Good to see you guys Abdul Rahman, Mua Omar. Others. Good to see you guys. Um Brandan, good to see you, man. Um So it's doctor G uh a quick update before we'll start in another minute. Um This will be our last session for October and November. I'm gonna take off just because of a lot of travels and a variety of other things. Plus, deny who is our right hand person? Um She too was traveling. So I don't know, like one time I tried to do this in an airport, it worked out somewhat but I was like, I don't know if I can if I get so lucky. So we are going to reconvene the next lesson after this will be December 1st December 1st. Um We'll do two lessons again in December. Please watch if you miss us in November, you can watch the old recordings. Um So, and in December though, we will have a special guest that will go over some complex chest x-ray readings with you all. Um But today we have some great cases as well. So that let me ask, uh Dena, are you gonna do the survey questions you usually do first or should I start with diving in? Um You can dive in, they can answer it as I go, I'll tell. All right. So first things first, let me go over. Um today we're gonna go over uh uh what I think is a great case overall and uh one that I think uh uh fascination behind it, uh what ended up happening to the patient. But first I will set the stage, I will set the tone. We're gonna review a normal chest x-ray for you all. Uh Remember here in our lessons, we're always gonna try to find, I'm always gonna try to show you all a normal chest x-ray, normal. There are normal chest x-rays can come in a thousands of uh different ways. But the more that you create this kind of succinct review of how you go through an x-ray, even if they all look different, you'll realize at the end of the day, they are normal chest x-rays, the other conversation piece. So last week, so last week, I think it was last week, could have been the week before. Um, maybe it was the week before I taught our residents here at Johns Hopkins about how to read a chest x-ray. And actually let me set the stage with you guys as well, getting a chest x-ray as a lung doctor. And as an internal medicine doctor, I can tell you it's, it's often too look at potentially an acute issue happening in a patient, meaning an immediate health issue, I rarely use chest x-rays to evaluate chronic issues. Um It was chronic issues are gonna be really subtle like if a patients like, oh, I've been short of breath for three months. I wanna get a chest ct right AC A T scan, which is a three dimensional x-ray and would give me a lot more of those subtle issues for acute issues. I think a chest x-ray is reasonable. It's a quick data point and it tells you a variety of things that can be helpful. But so I say this in order to set this stage with you guys, right? When we discuss, I need a chest x-ray. I'm hoping for the most part you are thinking more of an acute issue, right? These are rule of thumbs. These are general guidelines. These aren't hard fast rules. Yes, I may break them here and there depending on the circumstance, but I do request this data point for more immediate issues happening to the patient. So I'm saying this because even when we break off in 2024 when you guys come back um in the new Year, we are gonna go and dive into cat scans and how to compare them with a chest x-ray and you guys will pick up how chest CT S find more subtle findings versus a chest x-ray and specifically helps you for our understanding the chronicity, the chronic um manifestations of the disease and how subtle they are on the lungs. So it should be a lot of fun with that in mind because I'm mentioning we get these chest x-rays, these two dimensional representations of our lungs. We get them solely for the purpose, not for the purpose solely, but oftentimes we get them for immediate health concerns, we should be mindful that the way we read them is to find some immediate health concern. So let me go ahead and share my screen for this first reading. And then we will, if you anyone wants to join the stage with me, ideally, someone who hasn't done it before and especially if it's your first time, come on down, it'll be a lot of fun. I promise you. So let me go ahead and share my screen and well, it's always my favorite part. It's getting it going and getting it correctly. Uh Danny, if you don't mind un muting, just telling me you can see, see the cat, uh see the x-ray. Yes, I can see it looks a tiny bit small but Oh really? OK. OK. Um Let me take it off if I take it off presenter mode. Is it, is it capturing the presenter mode or just the regular powerpoint mode? I know that some comments in the past were saying that sometimes when you point at artifacts just because it's small, it's a little hard to see. So maybe just emphasizing as you go um would be a good idea. OK. All right. Noted. Sorry about that. Uh There's always something I apologize. I'm always trying to make sure I can pick things up. So I have a patient. This is a patient. She reported to the emergency room with chest pain and in the evaluation for chest pain, I always think it it is reasonable to get a chest x-ray because it could be a data point that you can use in order to help supplement what's happening to the patient. So with that in mind, this is doctor G, I'm about to read you all a chest x-ray. First thing I do is evaluate the spinal processes. I can pick them out right here. Remember these are extensions of your, of your spine, of your vertebrae. You can feel them if you feel the back of your neck. The reason why I use these anatomical le marks is to make sure that the patient is not rotated. Remember if they're not rotated, the spinal processes should almost look like a tear shape. If they are rotated, they would look more like a two cans beak because that's how they look coming off your vertebrae. So the patient is not rotated again. Why that's significant is to make sure that the way you're going to evaluate the anatomy of this is proportional to what's happening in the patient and it's not skewed by them being rotated. All right. So the patient is not rotated. Great. Next, I'm gonna dive in and evaluate non lung landmarks and non lung anatomical spaces. The first one being the mediastinum. So for the mediastinum, I tracked down the, the trachea, I look to see when it bifurcates into the left and right bronchi and using that in order to evaluate the medias uh the mediastinum in comparison to um uh evaluating it for any pathologies that are happening to it or against it. So the cry again is where it bifurcates. First thing I uh well, one of the things I taught you all is having an acute angle uh of a cry means there's no spleen, right? If uh there's more of an ob two angle, more than uh 90 degrees or something under the cry of pushing up against it, oftentimes it is the heart. Now this, you know, if you were going rounds with me and you made the comment, Doctor G, I feel like the mediastinum is somewhat shifted, right? And you're making that case because doctor G is always emphasized, look at the boundaries of the vertebrae and use those boundaries to evaluate the carina. If the carina falls in between the vertebrae boundaries, you can make the case, the mediastinum is not shifted, but here it's looking rather shifted. So you wouldn't be wrong to say the Ronin looks shifted and I'm and I'm concerned about the Mediastinum. I'm gonna get back to why that is in a second. But I promise you, I still would call this overall normal with some abnormalities. So hold the case for the Mediastinum. Now let's go to the costophrenic angles. Remember these are angles made at the border between the ribs and the diaphragm. And you can only see this on a two dimensional depiction because you get, it's sandwiched with x-rays, right? You won't see this on cat scans and then they should look like some look like vampire fangs and you can see them. Now, let me pause here. What I get a lot of interns residents struggling with. You want to tell me I can see the costophrenic angle but it looks hazy. Doctor G Yeah, you can still see that if it's hazy. If the costophrenic angles look hazy like you see here something outside of the space and it's causing the haziness. If there's something in the pleural space, it's not hazy, it's, it's liquid, it's or blood or fluid of some kind or an infection, it's gonna be wi it out. It'll wipe out the pleural effusion. Uh the pleural space, I promise you the haziness in this case is a female's breast tissue creating that haziness. So the costophrenic angles are evident. However, you will probably notice if hopefully you're having some bells ringing that the right side is much higher than you would expect, right? The right side tends to be a little bit elevated in a chest x-ray, but not by this much. So, if this patient does have a hemidiaphragm elevation, I promise you it's the majority of patients. This is an asymptomatic situation. If they have any symptoms, it's usually when they bend over. And so the clinical report you get from patients is oh, I get really short of breath when I bend over the time I shoot. Right. So your diaphragm, if there's an elevated one, such as this, usually there's something happening where the nerve isn't conducting appropriately or some injuries happen to the uh diaphragm and of itself. So it compensates when you're sitting upright or standing up because of gravity, but gravity gets lost the second you lean over. But the reason why I'm pointing this out, this elevated right sided hemidiaphragm is what is causing the pushing up against the mediastinum. To some extent, the squishing of the lung is bringing for that. Uh the trachea crying out. So you wouldn't be wrong if you thought like, could the mediastinum be shifted? It not, it's shifted. Yes, because of the pull from the right hemidiaphragm. But if you comment and you're like, I don't think it is because I can make a case for the right hemidiaphragm uh influence. I'd be fine with that because this is not a true pathology happening in the mediastinum. All right, I'm babbling too much here. So let me move on next, you go up to the plural space. Uh uh Do you go up to the pleural space? Up to the Apy? And what I'm looking for here is to make sure I can see some grayness and hopefully even a little bit of lung markings making their ways. Uh This is me just mapping out some lung markings going all the way to the top. So no air in the pleural space. So the pleural space seems normal. I can see the costophrenic angles, I can see uh the A PC without any obvious signs of air there. So next, let's go and evaluate the hilum. The hilum. If you guys remember it is where you have the airways, the b uh the airways, the lymph nodes, the lymphatic system and the blood vessels all coming out together. And so on the right side, it should look like somewhat like a kidney shape and it should be somewhat transparent, translucent. The challenge here that I mentioned earlier is you're already having a mediastinum that somewhat shifted. So this hilum is barely visible, but that level visibility looks somewhat, no looks normal. And then on the left side, you have a little nub in right here. So from that standpoint, this looks normal to me, I wouldn't make any other issues happening with the high lung. Next, the heart, there seems to be a space here. There seems to be a two slope approach between the left atrium and the left ventricle and the costophrenic angle. Uh I'm sorry, and the angle on the right side does look somewhat present. So the heart to me, I would interpret it as a normal size. Next zig zagging. Oh, sorry. I know. Sorry. I don't know what I did there. So, Dean is my uh screen back. I'm gonna take that as a yes. Right. No, you're fine. You're fine. You're like, where's the mute one? Next? we go through the lungs. So one of the things I introduce to you all about the lungs is the way we read these is we zigzag back and forth, we zigzag back and forth, back and forth, back and forth, back and forth. Then I zigzag across them. Right? And then more than anything, let me get rid of everything that I just drew. Last thing that I do is let me get that pen back is all of the markings somewhat should be present up until about midway of the lungs. Ok. So, meaning remember all the markings leave the hilum, every single one of these blood vessels, airways, et cetera, leave the hilum and somewhere around the middle, they thin out where the diame gets smaller and smarter blur. So you really shouldn't see these, these interstitial markings extending all the way to the edge of the chest. And also you really shouldn't see them that present up here because of gravity. So three abnormalities that I'm looking for in the lungs one is if I can see the interstitial markings extend beyond this boundary that I wrote. If I see that, then I make the case that prominent interstitial markings are present. That's not the case here. Next, I'll look to see if there's any thing that is uh uh I look to see for an opacity. So meaning something in the lungs that, you know, doesn't really have too much of a border or maybe it does, but it looks more like a cloud present in the lungs and an opacity that cloudlike structure should also be rather transparent. You could, you should be able to see through it. There should be some parts that are really gray, some parts that are lighter gray, you could see through it. So no prominent interstitial markings, no opacities. And then the last thing is no consolidation. Consolidation is exactly what it sounds like. It is a complete wi out of the lung and oftentimes the consolidation uh interprets blood or inflammation like a pneumonia. So when I review the lungs, what I'm looking for to point out to my team is the way I, what I'm looking for. I can't really say the lungs are normal. I would say they're unremarkable, but I'm looking for prominent intersect markings, capacities, consolidations. So putting this all together again. All right, we have, this woman comes in complaining of chest pain. We snapped a chest x-ray on her. I've noticed her spinal process. I can tell she is not rotated. I find I'm finding her Carona, it does not look splayed, but you can make the case. It's somewhat shifted. So I'm wondering if there's something happening with the mediastinum. Now, let me go to the pleural space. I can see two costophrenic ankles. However, the right side of the lung looks rather elevated and that elevation probably is what ha is causing the dia uh the media somewhat to shift. So good to, uh, now I can kind of understand what's happening there. Next. Let's go to the ac they look great, no air present. So the pleural space overall looks normal. The hilum somewhat skewed on the right side because of am uh ma mild shift of the mediastinum. But what is present seems to be a normal size shape and transparency as well as the left side. In regards to the heart, it looks abnormal shape on the left side and on the right. And then when I'm evaluating the lungs, I see no prominent interstitial markings. I see no opacities. I see no consolidations. This patient has no present findings of any acute immediate issues. So let me stop sharing. Go you guys, right? Any questions on reading a normal chest x-ray before we go to the case, Tahira, you have a question, go ahead and ask was the large zigzag four. So remember I did a minor zigzag within the lungs back and forth, back and forth, back and forth and then a large one going from right to left, right to left, right to left. Because what you ideally the lungs should look rather uniform, right side and left side, right side and left side, right side and left side. So the larger zigzag is met. So I don't miss anything as I compare because I can go through the right. I'm like the right looks relatively normal, then go through the left. It looks relatively normal when I would compare both of them. I'm like, wait, something's off and that's something off tells you something's not there. All right, any other questions you need? Did I miss anything? Um Oh, we have one question asking why the right lung is higher. So this, this patient has an elevated right hemidiaphragm. So, meaning her diaphragm is higher than it should be. Why I'm not sure it could be. Did she have a prior surgery that nicked the phrenic nerve? There are certain viruses that can invade the phrenic nerve? They can shut it off briefly. COVID is one of them. Um or it could be a congenital presence, right? If I had a chest x-ray at first 20 years ago, it'd be good to see what's happening there. Um Larger livers, can someone do that as well? There's countless reasons, but I promise you an elevated hemidiaphragm is not, will never cause chest pain. So it's not an explanation of what the symptoms she's having, but the cause of it. You just got to sit down with a patient and talk to them what's, you know, try to figure out the chronicity of it. Opacities. Karen opacities can represent four things. Fluid, blood inflammation, right? So, fluid blood inflammation, fluid, blood inflammation or infection. I'm like, what am I missing? All right. Infection. So all of those four can create opacities. All right. I'm not sure what you mean by physiological or question mark. Did I say something that that said physiological or? But yes, to hear a opacity to represent a a pneumonia, if it's, you know, uh it's brought on by an infection, could also represent an autoimmune process. Um You know, rheumatoid arthritis can cause opacities. Um It could also represent a spot of blood, it could represent fluid. Those are the four things they can represent. All right. Now who wants to come on stage? Let's dive into this next case. So we only, I think have one person who's new who wants to be invited on stage? Ok. Um And then we had Abdul Raman and Gabrielle who both said they'd also be willing to go on stage again if no one knew wants to go. So bring them on all. Very good. Amazing. And if anyone else, if 1/4 person wants to join, let me know in the chat. No, I'm excited about this next case, Deanie. Let me know when everyone is present, everyone's present. All right. So I have a 64 year old patient who re is reporting coughing up blood. What do you guys wanna know? He calls me? He's like doctor G I'm coughing up blood. What should I do? Is this an emergency? Should I be going to the Ed? What should I do? Doctor Jee? All right. What do you guys wanna know to hero? You go first to hear if you are talking, we cannot hear you. Can you hear her dean him or I cannot sorry, can you hear me now? Yes to hear, we can hear you now. Uh OK. Um So I wanna ask uh the patient um how much uh blood and uh if the blood is uh brown or uh it's right. Uh right, like bright red and, and I check the vitals as well. Uh So uh according to the vitals, I sent her to emergency department. Perfect. All right. So great. You, you said you wanted three things. So the amount of blood it's like it's probably the size of my nail. It's mixed in with some of the sputum that I'm coughing up two. It looks bright right to him. Three. He's got a pulse oximeter that's only he has at home. So he puts that on and he goes doctor. My heart rate is sixties. My oxygenation is 99%. Great questions. Tohira. Hold your thoughts, Ab Rahman, my friend where Abdul Rahman, where are you? I'm on campus. So I like took a room for one of the conferences. And here I am. Where, where's your campus again? It's, uh, and Hall University over in South Orange. Got it. Is that like New Jersey? Yeah, New Jersey. All right. So, there, there's a, wait, how many oranges are there? There's East Orange. West Orange too, right? And then there's South Orange. I think there's 1/4 1 but I think it's just either orange. I don't remember its name but it's not North Orange. I know that it's all right. Sorry, everyone, we're going over some New Jersey. Um, geography. All right, my friend Abdur Rahman. Um, you heard from Tahira? You guys are a team. What else would you like to know about this patient? I definitely wanna know if it's how recent it was, uh, how he's been coughing blood if it's been going on for a long time or just like, just like last weekend and he just started coughing blood. Any other associated symptoms he's been having either lately or overall, uh, just to quickly, uh, as a, a ascertain whether or not I have to like, give a chest x-ray or quickly send him to the, er, if like, he's can wait a slight moment. It's already been for a long time. You can wait for, uh, perhaps I, I wanna get some family history, some, uh, see if there's any like, uh, diseases that are prominent in his blood history or not. Got it. Love how you're laying this down. So this is a patient. Did I give you guys his age? 62 64 64. Ok. Um, he woke up, didn't feel quite himself. Yeah, he, he couldn't put a finger on it, checked his temperature, it was normal, just felt off, but he still went to the gym worked out for two hours and then he, as he got home he's like the chest wasn't feeling well. He's like I gave a cough. There's blood called you doctor G first time. How was it? Um So not a chronic issue. Immediate. He is endorsing feeling off. Bye. He put his finger to it, coughed up blood. All right. Next Gabrielle, by the way, Tahira, when I get back to you, remind me where you're at too. I apologize. Gabrielle. Where are you at? I'm in the State Georgia. I'm like an hour or so north of Atlanta. It's pretty nice here. Good weather outside. That's why I'm by my window. Is it anywhere near? Do you know where Northside hospitals are out there? Yes. Actually, my mom works at Northside Forsyth. I do a shadowing program there. Excellent. Last March I went and toured all four hospitals giving talks there. So, very nice. Good, good too. Um All right, my friend over to you. What other questions do you wanna ask? All right, so I think Tahira and Abdul Rathman got a lot of what I would ask. I would be thinking like family history. I would be thinking like, how often does this occur? And then since you said you felt off, I'm gonna be like, well, how do you feel off? Are you feeling chest pain? Are you feeling fatigue? Can you describe how you're feeling off to me? Yeah. So and recall like he went to the gym for two hours, right? So off but not often enough to deviate. He's a one thing I need to mention you guys. He's retired but he's picked up professional body building. Uh, he does. Yeah. So off the best he can. He's like, I feel like I haven't slept, but I did sleep. That's what he feels like. Um, but no other symptoms, no chest pain, just one cough. So, did you, what else did you wanna know? Gabrielle? Um, I think that's pretty much all I wanna know out of it for now. All right. One thing that I'll add to this a week prior, he had chills didn't feel well, tested positive for COVID. We treated him with Paxlovid. So that was a week ago. Uh, day seven. He's like, I feel great. Day eight back to normal. Day nine called me something's off. I coughed up blood. So that's the only other thing I was gonna, I, I held out on you guys, uh, retired from what great question doctor had he asking about occupational. Um, he was a former security guard, so 40 plus years, um, working at various buildings but you know, nothing diabolical. Um COVID was his only thing he had, he had 48 hours of feeling 100% back, went back a lot to the gym and now this Alexander has any signs of infection. None inhalers, one inhaler for asthma. That's it. And an inhaled corticosteroid. So Tahira Abdul Rahman Gabriel, do you guys mind if I dive in and just tell you some thoughts of what I'd like to do, then you guys are gonna read the x-ray with me. So I will say in my years of doing pulmonary medicine, um he's not on, on any other in um medication with not an, not even an aspirin. Um Whenever a patient tells me they have hemoptysis, coughing up blood, even if they like can quantify it for me. I'm trying to think of reasons not to send it into the ed now coughing up blood while it's a concern. You gotta know the patient 100% got know the patient know who they are because it shouldn't just be a reflex sending them the most biggest concerning reason for hemoptysis. That is life threatening is if there's a bronchial artery that some way shape or form got eroded and it just splashing blood into the lungs and you're, you know, the patients about to drown in their own blood. Literally, that is rare. It is rare. It, you will see it in really extensive bronchiectases. Like patients with cystic fibrosis or you'll see it in the right patients with advanced cancer, often squamous cell cancers that are eroding the bronchi. But again, those are patients with chronic issues that have now revealed themselves. They aren't subtle. Suddenly you have that the majority of the times with hemoptysis that are not lifethreatening is an infection that pneumonia can cause it. Right. Especially if they do cough, even a good violent cough. The sheer stress can bring out some tears in the um, airways that can bring out blood. So his was unusual, the fact that he didn't have any coughing until that day. One cough blood out with it. So the way I'm thinking about this patient is, I do think I'm gonna have to send you to the ed even if it's the world's shortest trip. And what I'll ask of them is just evaluate for any other concerns of hemoptysis in a patient who just had COVID um, a week ago. Omar. No fever, not subjective, not objective. Remember, fevers, there's two versions of that. There's the objective ones that we ask patients to slap a thermometer. Somewhere, subjective ones don't dismiss they're important. Those are chills. If a patient has chills or riders, that's a subjective fever. That's just as important. Alexander. No nasal bleeds. You guys thinking of HHT All right, hereditary hemorrhagic te or maybe you're just saying you have nose bleeds trickling down. He's coughing up. I like the way you're thinking. Let's go ahead and share my screen. Tohira, you're up first. And what I'm gonna ask you is also let us know where you're at to here. I forget, I apologize. Ready. Uh, no smoking history. Let me put this back on the center note. All right. Can you see the presentation Tohira? Yes, I can see. All right. Oh, by the way, I'm sure. Where are you at? Yeah. Where are you in the world? I'm in Alexandria, Virginia. Excellent. East coast. Not too far from me. Fantastic. All right. This is probably one of the most beautiful spinal processes you'll ever see. Would you not agree? Uh Yeah, I can see four and to drop. Um All right. So is the patient rotated or not rotated? Uh No, not rotated? Excellent. All right. Tell me about the patient's groin and I'll, I'll help you out here. So we're going down the trachea right and lean back a little bit. Anything. Do you think it, let me ask you, is it blade? And if you want me to explain that what that means, you let me know uh splay. Yeah. So slide is when the carina, the angle here is more than 90 degrees, more like it's an ob two angle. Is this angle spy or not sped? No, it's normal. Perfect. That's normal. Uh Not. So you would say the, the Carona does not look sp sp blade stretch. The carina move it further apart out the two branches means something is below it and pushing up good. And how does it look in regards to the Mediastinum? Does it look like it falls the using the Rya as an anatomical landmark? Are you comfortable saying, hey, it's falling in between the borders of the vertebrae? Um Yeah, but uh no, I think this is normal. The the aorta also. Yeah. Yeah. The aorta is right here. Yeah. Yeah. But I drew you the borders so perfect. So cry does not split. Mediastinum is not shifted, the patient is not rotated. So there's no confounding of the interpretation here nicely done to here. Abu Are you ready, my friend? Yep. All right. That's you're gonna interpret this, the pleural space for me. So tell me what you think, what is the right costophrenic angle look like? Is it present or not? Well, it's present, it looks like a nice little thing so good. Not uh at least minimal fluid to none, right? So, uh so what you're seeing is I can see the cost of ale uh what you, you're right in some to some capacity, it doesn't truly remove no fluid in the lungs. Conversation. You need about 300 mL of fluid in the pleural space to have uh blunted out costophrenic angles. You're right, you know, while you can see them and you cautiously safe, but it doesn't truly remove the um uh notion that there could be even maybe some minor fluid in there. How's the left. Look to you the last one, it's slightly blunter but not enough that I can't see the costophrenic angle. Yeah. So this one, I love the way what you're doing and talk this out loud, talk this out loud and see where you land because you're like, look, I can see like a fang. It's not blunted but it's nowhere. It's not as, even as this. So when you know, someone asks, why do I do the big vertical zigzag? It's for this reason, right? Because if you didn't have the right to compare to the left, always compare right and left, the left, you would like I see it. Yeah, it's there. Doctor G but the fact that you've also seen the right and you're like, wait a second, that doesn't look the same right now. Your spider senses are tickling, right? You're like, I can see it. It's there something's off about it. Hold that thought. Good, sir. All right. Take me to the apacies. Can you see them or do you think there's air um somewhere around them? They, they don't look black like the outside, they look a nice shade of gray. Good. So the pleural space as far as you can tell, you cautiously say, I don't think there's flu. I, I uh I can't uh imply that there's fluid, I can see both costophrenic angles. So there's a concern I have about the left and I'll tell you how to better characterize that the reason I'm not giving you the language right now is just because I haven't taught you the language. So hang tight and then, uh, you can see, appreciate the ABC. So there's no obvious air in the pleural space. Nicely done. Do you feel comfortable hanging out with me and doing the high long? I don't mind. Unless, no, no, no, we're going to turn it over to Gabriel. No, she'll have her turn in a second. I promise you. All right. Let's dive into the hilum together. Now, anything that you wanna point out about the hilum and I'm not trying to lead you. I want you to tell me what your thoughts are on the right hilum. Does it look normal shape? Does it look somewhat transparent? You can see through it. I want your interpretations my friend because the more you interpret it, the more you get comfortable of how this looks and if I correct you, I correct you and you can shift your thinking. Yep. Um, it doesn't look transparent. It looks slightly larger than it should be because it's usually like the small kidney beam as opposed to the normal one. I can't see if that's anything yet or that's just how big his lungs are because his lungs are big. Got it. I like the way you're pointing it out. Yeah. And that would make the argument. The size didn't stick out to me, but it is much more dense than I would appreciate. So I, I would buy that. I would make a case. There's some unremarkable findings around the right eye lump. The left one I can tell you I'm having a hard time really finding. Um, but there's a, there's an intentional purpose behind that, so maybe it's somewhere here, but I can't really make it out anymore. So I'm not going to comment on the left if that's all right with you. Yeah. All right. Now let me, I will do the heart and then Gabriel Gabriel, we are going to do the lungs together. Is that all right, my friend. Ok. Gabrielle. Are you there? Yes, that sounds good to me. Sorry when you guys, when uh, when I have this one, I can't see you guys or if I do, then I anyway, so no worries my friend. All right, let me give you guys a heart interpretation. I can appreciate that there's a border, uh, between the left ventricle and the chest wall and to some extent, I do think there is a too slow approach as subtle as it is. Um, but now let me pause here. No, you know what, I'll wait till the end. All right, Gabrielle, let's let me ask you something. Let's go. Let zigzag with me back and forth, back and forth, back and forth. Ok. On the right side, you tell me, are there prominent interstitial markings? So the, the meaning that these markings extend all the way to the chest wall. Are there any opacities? And are there any consolidations on the right lung? Go, you tell me as you zig zag from top to bottom, I would say looking at the markings, I'm not really seeing those that many opacities, maybe near the middle of the lung. It's a little bit hazier. I feel like the blood vessels are more prominent than I'm used to seeing. Ok. All right. Go to the left. Tell me what you think about the left. OK? The left lung looks a lot grayer to me than the right lung. The right lung looks more clear. Ok. More gray in the middle, kinda closer to the brachial region also goes to the heart. Got it. So I would, so, one of the challenges with this gentleman is um because of uh being such an athlete bodybuilder, he does have um prominent chest muscles that are gonna lead to some level of haziness. Like you're gonna appreciate more haziness whenever you see more haziness near the chest wall. I promise you that's just more, it's either muscle or breast tissue or gynecomastia. But I think what you were implying is there's more grayness here. All right. Now, I'm gonna put you guys in a spot. I know I know the left lung is smaller than the right lung. But let's go back to the slide before this woman. Uh This is a little skewed just because of um the right hemidiaphragm. But nonetheless, humor me a little bit here. Do you feel like aside from the heart, say the heart wasn't present? Do you feel that the right lung and the left lung? Do you feel this line here that I draw is as long as line two, I know you can obviously measure this and be really scientific. But humor me with a quick STT what do you guys think is line one the same as line two, I would say no. OK. Good line one is bigger. Would you guys agree? Ab the Rockman and uh Tahira. Yeah. Line two looks shorter. Yeah. Right. Even if we get lower down here. Line one, where is the vertebrae right here? Because there's lung behind the heart. You guys are, right? This is incredibly subtle, but the right lung seems bigger than the left lung. Like line one and line two should be same. So when we say the lung is bigger, it's just the right lung normally is bigger than the left lung, but it's bigger because there's a part of the lungs that is missing because the heart's present there. That's, it's called the lingula. But the size, you know, these diameters that I'm drawing out shouldn't be the same. This is a very subtle pick up that again when you do the big zig zagging of the, of the lungs, that's when this should pop out. Like I'm hoping your spider senses are picking up like time out something is not right with this patient, the right lung versus the left. All right, there's something else I want you guys to appreciate. So, when I told you guys, I want you to pick up prominent interstitial markings, opacities and consolidations 100%. That's what I expect every med student in their third or fourth year. That's what I expect every resident. And I would say even it's what I expect most fellows until their last year. So you guys are fine with that piece of knowledge, but I'm gonna introduce you one other thing. It's not fair to you, but it's incredibly subtle. So Abdul Rahman, I'm gonna go, I'm gonna pick on you first because you're, you made the case. I don't know how to explain this to you. Doctor G, right? You're like, I can see a thing. It is nowhere near shape or form as more as prominent as the right one, right? That's what you were telling me. Correct? All right, let's explain why. Good, sir. Do you appreciate that? You, there's some tube ask thing that is happening here. Look at the boundaries, I'm drawing to you right now. Do you appreciate that? Oh, and now I do, I didn't notice it in the first place. Uh No good, sir. No worries because look the way I'm asking you guys to read x-rays and this, I promise you the ways you guys are reading x-rays leans you in a good clinical setting. The nuances. I'm asking you guys to interpret here are very subtle who's going to pick it up are lung doctors and radiologists. That's the beauty of chest xrays. If I gave this to an ed physician, nothing against them. It's just how they have to interpret. They would read this as no acute process. They wouldn't be wrong because what I point it out to you isn't acute. It's not an immediate issue. This has been going on in the patient. What some time? All right. But do you appreciate what I drew out for you? Yeah, I see it a little too like slightly, all right to here up. Do you appreciate these circles? I'm drawing out right here. There's one right here uh or is there another uh there's a subtle one right here too. It's very subtle, it's very subtle. There's one also right here. Do you appreciate these Tohira? Yeah, they are black. Yeah, little holes, but there's something interesting about these holes. There's holes but around it, it's somewhat cloudy. I, so Gabrielle, I'm gonna erase these. But do you appreciate the holes as well? I do appreciate the hos. All right, being 100% honest, when you first pulled up the x-ray, like my vision kind of went to the how outlined the blood vessels were and I was like, what is that? And why is that there? Yeah. Well, this is what I want you guys to do like as you guys read more and more chest xrays with me. And I'm just saying we're all this, the more you read these, the more you're gonna pick up the subtle nuance differences more immediately. But before you dive into just looking at that, you got to make sure you didn't miss anything. That's why I ask you guys all to be systematic, right? It's like picking up a book that you love that you've read 1000 times. Yeah, you, you wanna get to the climax but you're still gonna read leading up to it so you can stay thorough. Same thing here. All right. What I'm picking up here when you see kind of this kind of either a circle like this or the tube that I pointed out to Abdul Rahman, right? This circle here, right? It's a circle. It's a grayish hole and around it is whiteness and this tube is the same thing. It's grayish in the tube and then white around it. What this patient has is bronchiectasis. OK? I put, I, I cut those parts, blew them up a little bit more. And I have you guys see arrows that s bronchiectasis and what this patient is experiencing is a subtle superimposed infection post COVID that's resulting in hemoptysis. So, but this markings, this finding for bronchiectasis is called peribronchial coughing. Now, it is not exclusive to bronchiectasis. Yes, you can get this with asthma during asthma flares. You can also get this with pulmonary edema because all it implies is that the blood around the airway is enlarged. So, yes, you can get this with pulmonary edema, right. Your heart's not working well, the blood vessels around the airways are prominent if you can get that. But how I pick it out that it's bronchiectasis, it's because if it's peribronchial coughing brought on by the heart disease, you won't really still see the airway coming that far down. You won't get this kind of tube-like phenomenon that you see here. And at the same time, you won't get what's happening here, Abdur. And what's happening here is this patient. We've already said that the right lung I'm gonna draw on the board. We said the right lung is bigger than the left lung. And I bet you if I got ac A T scan on this patient, their bronchiectasis is prominently more predominant down here where it's resulting in a loss of functional lung space. That's why this lung looks smaller is because where there's bronchiectasis, it's gonna get shriveled because there's gonna be gunk and infection there. So what I wait, what I love what you said about this and please make a note of it. All of you in your heads. When you interpret a costophrenic angle, if you can see the angle, it is present. If it's not as prominent as you're used to. Something in the lung is pulling up against it. Does that make sense? Something's pulling it? And what's pulling it is a lung that's kind of self collapsing because of bronchiectasis. This patient has bronchiectasis, not a cystic fibrosis level. So it turns out this patient when he was a kid, had a horrible infection that resulted in a lifetime of a lung scar. And bronchiectasis suddenly in parotid parts of his lungs, he got COVID cleared it fine was on Paxlovid. And then though COVID does what COVID does left a little bit of changes in his microbiome and those changes, some of it took advantage and it was like I'm gonna cause an infection. So yeah, his hemo was because of active infection. Now you may be saying, well, doctor you time now time out good, sir. He felt off. He still went to the gym for two hours. What's going on here? This isn't fitting the usual picture of being ill. And that's an important takeaway for all of you. The clinical spectrum that you need of the average human being to say I'm ill. We want fevers, we want chills. Yeah, I get that. That's your average human being. What if they're immunosuppressed? And what if they're on constant tacrolimus, CEUs, mycophenolate, predniSONE, et cetera. They're not gonna get fevers. You're suppressing your immune system, you're not gonna get if they do it's really bad. But they're gonna probably tell you, I feel awful little today. And then what about the other end of the spectrum? You're superhuman individuals. You're Olympic athletes take care of, a lot of athletes, not a single one of them unless you got a really bad pneumonia. It just don't, they usually just tell me something's off. I don't, I don't feel well and especially if you got an infection, something they've been vaccinated to. Right. Your immune system's firing away. It's doing its job. That's why this patient, this body builder of a human being is great physique guy's awesome. Him being off, tip me something's going on, right? So that's why I sent him the Ed. I'm like, look, your body is compensating, but I wanna see how compensating it's doing. So when we scanned him, sure enough, he had this gunk in his left lower lung. Um his bronchi were over thickened from the bronchiectasis and from an active infection, we started him on IV antibiotics for 24 hours and then we sent him home and he just did 20 another seven days of antibiotics. Tohira. When I asked you, when I started this conversation about sending the patients to the D or not, you guys all appropriately answered it. You like, you wanna have some information on vital signs, et cetera. But you also, you guys brought this up. I just kept the information from you guys. You wanna know who this patient is, what other diseases he have. I wanna say he has asthma. He does. He also has bronchiectasis on top of that and those are the patients. And even if you're well compensated because if you're own physiology when they tank, they tank. So that's why I pre cautiously sent him to the Ed. I was like, look, you already have hemoptysis. I can explain that your infections will cause blood because you have such fragile airways that anything poking there will cause blood. But I just wanted to make sure he wasn't on his way to like horribleness. So, but peribronchial cuffing is such an awesome pick up that the reason why I wanted to introduce this to you guys is to be to the next thing for you guys to understand that I'm gonna ask to look for if you guys can pick up airway abnormalities on chest x-ray readings at your level. Now you're at a tending level radiology or pulmonary doctors, right? Because what I've asked you guys is to pick up subtle things that can happen in the parenchyma. The lung tissue is called the parenchyma, prominent interstitial markings, opacities, consolidations. This Ed x-ray by the radiologist was read as normal. I don't blame them. They're right. There's no acute issues or it was read as un unremarkable for an acute process. That's the terms they use and they are correct. Peribronchial coughing is more of a chronic issue as I said, you can get it with heart disease, but the heart would look big. His heart was not big. All right, peribronchial cuffing is a new term that I'm introducing to you. All thoughts questions. Fun case, right? Like es especially Roman, what I appreciate about you, man, about this transparency and honesty you gave to us tonight when I pointed it out, suddenly your eyes went there and I promise you moving forward, your eyes will always try to find that right? It's like reading the second you learn how to read the letter is you'll never unable to do that ever again, right? You will always read, right? You're not gonna look at a few letters and like I don't know how that sounds, right. You will always know how to read. Same thing on x-rays. The more you pick up things that get introduced, the less you're gonna not, the less chances you're gonna miss it in the future. Is this a good case? You wrote? I love it. Tahira wrote. This is great but cool case, right? Gabriel Tahira Abdulrahman is absolutely. That was a really cool case. Yeah. Bronchiectasis. I'll finish with this cause I oftentimes bring it up often with CF cystic fibrosis, cystic fibrosis, bronchiectasis is more upper lobe. So if you ever see peribronchial cuffing and you're like, there's bronchiectasis and it's all upper lobe, they have cystic fibrosis, 100% guarantee 100%. So sometimes it's sad, right? Because if you pick that up and that's the first time being told if it's all lower lobe, it could still be cf it's less likely, but it could be 1000 other things his are remnants from a childhood disease. Um oh, and last thing I will say, last comment, the reason his lungs look different isn't because of just the active infection. This is one thing that I plea with patients. If you have pulmonary disease, go exercise, exercise, exercise, exercise. Because what his lungs have done beautifully beautifully is his lungs have grown and compensated the reason why his right lung is so much bigger than his left. it because his right lung is very healthy and it steals all the blood from his left lung where the disease is called shunting because it's like, look, if you're not gonna do appropriate gas exchange, I'll take over, give it more to me. For instance, we see this a lot of times in patients, five years after a single lung transplant, say they have a lung disease, you got a transplant, put just for one lung, the other lung remains with this disease. Five years later, this lung shrinks. This lung expands. Lungs are so awesome. That's why there's a unique difference. It's part part of this bronchi, this picture. It's not a bad thing. He, he just tells me this guy is working out. He's following through what we're asking him to do. All right, we'll stop there. Um Many of you guys like again, if you have friends invite away like, uh we love teaching. I'm hoping you guys enjoy it. We're gonna be back December 1st. I apologize for taking off in November. Um but you will hate me trying to do this in an airport. Um But you guys have been awesome if you need anything, never hesitate to reach out to Deanie or myself. Um You know, shoot me an email, Danny, can you put my email address in the chat box? Cause for reason I don't think I can. It says I have to verify my account and I don't know how to do that. Is that all right? Yes, you got it. All right, my friend. All right, good people. Uh, as Jenny throws in the in the chat box, um by all means, you know, if you guys have any questions, don't hesitate to reach out. All right, perfect. Thank you, Deanie. Everyone guys have a great November for those of you in the US who celebrate Thanksgiving. Enjoy it. And we'll see you, December 1st December 1st December 1st. All right luck. Thank you for coming. Well explained. Thank you. All right, good people take care.