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My fault. All right. Are we good now? I we, we are good now. Sorry, I should have caught that one. What a rookie mistake, everyone. Good evening. I'm so sorry. I am the one who has failed to hit. Go live. So welcome. I'm Doctor Pat Scalia. I'm a pulmonary critical care doctor here at Johns Hopkins. Today we're gonna go over a case of a chest x-ray. But first things first, Deanie, let me try this again. Who wants to come on stage and answer some clinical questions with me? Not recently, just throw it in the chart and I'll invite you to the stage. You don't have to feel super comfortable. Oh, awesome. I'll invite you right. All right. Who else would like to come on Abdurrahman or Fatima. Anyone want to join us, Gabriel. Good to see you, my friend to hear up. Anyone else wanna join Rahi on stage to Heroes coming on stage and so is Abdulrahman and Acom. All right, let's start off with those four. We got Rai sporting the UCL A good sir. Nicely done Rahi. Also on a side note, you and I and Dean are gonna get together this month. I apologize, my friend. Perfect. All right. Invite Arkham, invite Tahira and invite Abdulrahman. Perfect. All right, good Dean. This is why we were getting cricket guys. I'm so embarrassed. I had forgot to hit. No, I should have noticed that. You're fine. All right. So you four real quick. Put your thinking caps on. I'm gonna ask you the same question. I asked my residents today and I gave them the same lecture. When do we get a chest x-ray? When do we get a chest x-ray? Abdul Rahman. Let me ask you that first. You have a patient in front of you. What are they saying to you that says to you, I need a chest x-ray. Most likely if I want to get a chest x-ray, I probably want to check if there's any further complications. So perhaps if they've been telling me for like chronic short of breath and like, maybe perhaps a lot of chest, my chest pain. And after I ask them a couple of questions, I find out that maybe they've been smoking or they've been doing something. I want to get like a chest x-ray just to get a quick scan of what's happening in the lungs. See if like, maybe any like sort of, is it like just some fluid in their lungs? Maybe could be some pneumonia if they have coughing and no, no, that's great. Fantastic Abdul Raman. I'm gonna try to grab like very key things out of that what I love. Yes, Edwin. Keep in mind, yes. When I tell uh when I'm saying, getting a chest x-ray, I mean, you have listened to the patient write their, heard their story and yes, a physical exam is always gonna be implied. But what I'm asking is like, when are you suspecting? I need this extra data point to guide me Abdulrahman. One thing that I took away that I appreciated out of this is sounds like, hey, I'm pulling in risk factors overall from a pulmonary or just the chest etiology and also the timing of their symptoms, right? They're having a cough. Well, how long? All right, we we very well done. Rocky. When would you wanna get a chest x-ray? You have a patient in front of you, you've examined them, you and you can point point anything you want. But what would motivate you to get a chest x-ray? Um I would obviously look at like what the patient is giving me. For example, if the patient has sob, for example, that's definitely something that I would be like, ok, let's get a chest x-ray right there. But if I also see something from like the past medical history that also ties and correlated with what the patient is giving me at that moment, that's definitely something that makes me wanna get a chest x-ray at that moment. So definitely dose the two things noted. And so you guys both you and and Abdul Rahman are giving me certain symptoms, shortness of breath. For instance, there's one other thing that I want to take away. Right. Because what I'm trying to pinpoint here is you have chest x-rays and then you also have ac A T scan, you know, we'll go over CT Scan teachings in the future. And so the reason as a lung doctor or even a critical care doctor, I would want one or the other has a lot more to do with the acuity of the symptoms that they're experiencing and what they're experiencing, right? So, you know, uh daa, you're throwing in here like crepitation, physical exam. Signs of a yes, but which one would motivate you? Let's go, let's go send you for ac A T scan a three dimensional imaging of the lungs or do I send you for an x-ray two dimensional imaging? But it's a lot more, it's a lot faster and you can get that data point here. And so what I'm trying to convey the reason why we oftentimes pull in a chest x-ray and to hear an a um hang tight. My friends, I know I haven't called on you guys but we will. Um but the what I try to teach uh uh students, right? When and residents when you want a chest x-ray, you got to understand what you're gonna get from it cause it's a very limited imaging modality. By all means, it does not provide you the best insight into lung tissue by no means even the heart can be obscured or looks bigger than it should be depending on how the radiation is going in and so forth. So what you want a chest x-ray to do is to help confirm a suspicion or to take it off the table, but you got to know its limitations. And I as a uh critical care doctor and a lung doctor, I tend to really only punt to chest x-rays in an immediate sense for acute issues that the patient necessitates an im uh an immediate evaluation of like, so Rocky, you said shortness of breath, I told you the patients had shortness of breath for six months hasn't changed. All right. And just because it's the acute presentation of a chronic problem doesn't make it acute. I'm gonna write you for a chest ct get it done when you can this week and the patient came in and like I started feeling shortness of breath earlier today. Now I'm having some chest discom, chest pain. You're like, yeah, go to the emergency room. Let's get a quick chest x-ray, right? What I'm alluding to is you guys want to snap a chest x-ray depending on the data the patient's giving to you. And a big conversation piece that's happening in my mind is the timing is the timing, right? How immediate has this uh begun? And how am I gonna use a chest x-ray to what I'm thinking and how I wanna perceive this because the patient I'm gonna present to you all is a 46 year old female who for four days has been having fevers, night sweats and chills and she shows up to an outpatient physician and she goes, look doc, I'm not feeling well. This is uncomfortable. And so let's pause here. Tahira, by the way. II, I know where you're coming from in your journey, in your professional journey. Uh Abdul Rahman. Where are you in your career? If you don't mind me asking? Oh, I'm like at the ends of my college, um senior year getting the cats. All right, good, sir. Oh, all right. Excellent. Uh I will buy you a, a coffee once you're done. Thank you. I'll, I'll be sure to remember doctor. Please do, please do uh to hear where are you in your career? Hello? Um I'm medical graduate from Afghanistan and, and I recently came to the US. I'm uh in the process of passing the uh step one, step two. Awesome to hear out. All right. So let me ask you a question to hear up. You have this 46 year old patient, four days fevers and night sweats and chills. She lives in uh an urban area here in the United States. What questions are you asking? And the reason why I'm asking for you to ask certain questions is because I need you to tell me if you want a chest x-ray on this patient or not. Does that make sense to Hiro? Yes. All right. Fevers and night sweats. What's the question you want to ask her? Uh um uh I asked her, uh, so you said four days, I asked her if there is anyone else in the, in the home who has the same things, the same, uh, signs and symptoms? Perfect. Perfect. I love that. Right. Cause you're like, hey, this could be infectious. It sounds infectious fevers and night sweats sound like that could be from an infection. And the way infections get around is by close exposure and proximity to other people that are infected. She lives alone, works by travel, but she hasn't traveled in over three weeks. So this came out of nowhere. She hasn't seen anyone hasn't traveled anywhere, lives alone. So love the love the question, love the question. That's not a knock on your question. That's an, that's the same question I would ask like, hey, have you been around sick people if he says no and this is pre COVID by the way. So it's not like we're in a pandemic. Thank you. So to hear. Hang tight. We'll come back to you. I promise. Good question. Great question. All right, Arkham Victor. Hello. Good sir. Where are you in your uh career? Uh OK. I am uh I have been uh uh here again in the last uh session. Uh I am. Yeah, I am from Jordan. Uh, remember me? Got it. I do. Good, sir. You're probably like, this guy calls me all the time. I'm sorry. Well, hang tight on stage. Um, and daa, you're asking some good questions to. We'll get to that. But Arkham, this patient's in front of you. Four days, fevers, night sweats and chills to hear. Already. Ask the patient, hey, any other sick contacts? She's like, no, I live alone. I, for work, I travel and I haven't traveled in weeks. This came out of nowhere. What's another question you'd like to ask? A ok. I will ask uh some questions about the presenting symptoms. She said that she has a fever and night sweat. Any other associated symptoms like chest pain or any sputum uh production? Anything like uh is there a specific time for the fever and the sweat? Yes. So all, all incredibly great questions. Let's go over those. And daa, this is kind of going to a little bit of your own questions in regards to um associated symptoms. So the fevers and night sweats are what got her to the emer uh to see you outpatient clinic. She's just really uncomfortable. She's like I wake up in a puddle of sweat. Night sweats have been happening rather consistently. The fevers happen throughout the day. They're easy to break, but they're just very frustrating to her. She measures them objectively and they're there no chills though. There are no chills. It is just a sense of a fever. She checks her thermometer. It is about 38 to 39. Now, in addition to that, she has a cough, she's like, it's, it's kind of come on. It doesn't really bother me. It is new. I'm not someone who coughs but I've had it. It's dry, nothing comes up doc, it's a dry cough. 46 year old, healthy, like no medication. She's not on anything past medical history. She actually doesn't know she's one of my favorite patients cause she's adopted. She's like, I don't know anything about my genetics, but I can tell you about the family that adopted me. Don't need, that's very, doesn't help us out from your genetic standpoint. So she walks in, your clinic does not take any meds up to date with um her preventative health stuff doesn't smoke, doesn't drink and again, no travels in the last several weeks. And when she does travel, it's kind of local here in, in the United States debt. No smoking. All right. So Aum Ray Abdul Rahman and to hear you both all have asked great questions. I'm going to pause. Some of the audiences ask Sylvia. You said cough. It's no sputum, nothing, it's dry. Nothing comes up, Rama, Rama. You ask other questions. So no shortness of breath. No G I symptoms, none. Like the only symptom that she can. The only other symptom that she can associate this with is like a dry cough. Like yeah, it's here and there and I feel it. All right, Tohira, she is from here in Baltimore, right, urban city in America. Born and raised, she's just adopted so she doesn't know too much else. Um, and she doesn't live with anyone else. The cough is dry. Nothing comes up with this cough. Uh It's good. I love it. You guys are like lung docs, um, and then no other symptoms below the diaphragm. So I say all this you examine her right? Rai you put a stethoscope on her. And what actually you find a little odd is that on the left side, upper lobe, you got some, you got some decreased breath sounds, you're like, all right, wait, let me, let me just make sure it's not my ears. You listen to the left, you listen to the right patient takes in a nice deep breath, very nice and pronounced on the right, the left. It's, it's there. You hear it, it's there. Not as much Carman. Great question. No, recent travels. None. So you got a physical exam that shows some abnormality of the lungs. She has a cough, but the overarching symptoms are all fevers and night sweats for the last four days in a patient who doesn't really touch base with me medical health care, you know, aside from an annual physical exam. So with just that I know this is a leading question to here. Let me ask you this with just that information. Other than blood work again, there's other tests. But would a chest x-ray be something that you would want? Yes. Uh I wanted to ask if she has received all the vaccinations uh uh like BCG or? Yeah. So it's a great question. So, and here in America for uh vaccinations, um you know, childhood vaccinations include really against things like pertussis, tetanus diphtheria. Um Then as you get older, uh certain Hepati, you get it right for hepatitis B specifically. Um Then you do get annual flu vaccines. She does get it for her work. This is pre COVID. So there's no COVID vaccine. So there's no RSV or anything. And then the adult world here in the US, we really don't do BCG D uh vaccinations for tuberculosis. So that's not something she would have PURs uh pursued. So dry cough, somewhat of an abnormal physical exam on the acoustics of the lungs. Uh fevers and night sweats are happening. Do you want a chest x-ray? Yes or no. Yes. Yes. I, I'll take the vitals and uh I go for a chest x-ray. Excellent on, on this chest x-ray. Tell me what you're looking for. I know I'm putting you on the spot. I apologize. But then I'm going to turn to Abdo Raman to see if he agrees or disagrees in this chest x-ray. Right. You're going to send her for a die point. What are you looking for? Like, are you looking for pneumonia? Are you looking for heart failure. Just tell me where your thoughts are with this. Um, sorry, is this a question for me? Oh, for you. Yes. Yes. Ok. Last question to you, I promise you. Yeah. Yeah. Um I'm looking for, um, pneumonia. Yeah. Ok. Perfect Abdulrahman. What are you looking for or do you want a chest x-ray? You tell me, I mean, I wouldn't doing a chest x-ray because you said I heard something strange in the left upper lobe of the lung, not as much breathing. So I do want to get that checked out considering there could be other causes for illnesses like from spores from mo mold or fungus or something like that. Ok. Got it. Got it a ray. Last question to you too. You guys agree with Tahira and Abdulrahman. You guys are, they both say, hey, I want a chest x-ray. The abnormality on the physical exam seems to point me a little bit towards that direction. Keep in mind she does have a cough. So there is a subtle insidious symptom there. But he, so you guys are getting blood work. Let me tell you the white blood cell count, normal, normal, not even a shift in neutrophils. Her CRP though is massively elevated, it's t it's 20 times its normal value. So there is an inflammatory acute marker that is raised the complete metabolic panel unremarkable. So, electrolytes are fine. Liver looks good when renal function is good. CBC as I said the white counts are not elevated but there is an active inflammation that's being picked up by the CRP. With that in mind. Blood work, physical exam, Rahi and AOM. Both of you come out will mute. Tell me if you guys agree with Tahira and Abdulrahman in regards to desiring a chest x-ray. I agree. OK, I agree. Yes. Uh The first step it will be a chest x-ray but um I wouldn't think about cancer. Yeah. No. So this is where I want you guys to put on your hats, right? To hear a, you know, made the, you know, she put her stamp down first. She's like, look, I want a chest x-ray. Four days. Remember it's four days of this infection still kind of lingers in my mind. There's nothing, not a lot of things in modern medicine that present very quickly, very fast. Um, infections tend to do that to here. I see you wrote Fungal. Fungal for the most part tends to be actually a little bit more insidious in immuno competent people. Ex, unless you get the right exposure like histoplasmosis can create some fevers for a few days. So I do get that right. That's a good mold out there and, um, and so forth. So fungal is reasonable. You just need the right travel and the right finding for it. I think that's a reasonable one to put bring up and then cancer outcome you uh made a case and you're right. There are cancers that can do this. Not a lot, lymphomas are probably the mo the ones that get a lot more attention. So you guys are thinking all in the right direction. Here's one more thought. You all. What about autoimmune? Any autoimmune diseases? You guys could suspect that could be making this patient feel like this. Anyone, anyone wanna say this could not be autoimmune or should we just throw that in there to? We got malignancy, we got infections bacterial to mold. Natalie Whitfield. Put her foot down with saying yes, not only just an uh autoimmune, but I'm gonna go with sarcoidosis. All right, let's go ahead and talk about this case. All right, I'm gonna share my screen, Dany. As always, can you just confirm that you, we can see the swollen when it comes up? Uh Let me go. Let me click on. All right. Oh Entire screen. I'm gonna share my entire screen and then I'm going to put this in presenter mode. Is it? Can you see this? Yeah, we can see it. You can see it. Perfect. Danie. Thank you, my friend. All right. Ray. Let's start with you, my friend. We're gonna read this chest x-ray together is the, you've done this a few times before. So I hope you don't mind that I'm gonna dive in with you immediately. Um Is this patient? First of all, is the patient rotated or not rotated, not rotated, not rotated the weight. Oh I don't use a laser pointer the way. Oh Maybe. Uh No. Oh You said that the way he pointed that out is with these, the spinal processes, spinal processes for everyone here, especially for your first time. You can grab your hand, put them about behind your neck. That what you're feeling your spine. Those are called the spinal processes. They stick out out of your vertebras. If they look like a nice tear shape, like I'm drawing here, it just gives you the confidence that the patient is flat up against a wall or against something and snapping an x-ray. The reason why that's so important is because if goodness forbid the patient has any rotation to them, any rotation, then how to best interpret, especially the size of these things is gonna be thrown off. So, yes, patient is not rotated. Next. I would like you. Good, sir. I have you right here. The Kina, we're still sticking with you here and then we'll move on right here. Is the corona. Tell me if the Carona remember for everyone listening, the corona is the anatomical landmark where the trachea, the windpipe comes down into your chest behind the manubrium, the right, the top part of your um of the bone on top of the sternum behind there, the m uh trachea branches at the left and right bronchi. That's the carina, the branching point, the Caro on a chest x-ray we use as a anatomical landmark to tell us about the Mediastinum. The Mediastinum is the space between the left and right lung. So, what does it tell us? Well, you're gonna hear Rahi answer these questions, Rahi. Do you think the Mediastinum has shifted? Yes or no, no, no. The way Ray will explore that is to see if the carina falls in between the boundaries of the vertebrae, right? So these two lines I drew you, that's a poor vertebrae boundary. Sorry man. Uh But you still answered it appropriately. What he's looking at is the boundaries of the vertebrae. And if it falls in between, the other thing that you can get out of the carina is if it's splayed sp blade implies that the Cronus angle, this angle right here is more than 90 degrees. This looks like an acute angle, less than 90 degrees. Rahi. Would you agree to that? Yeah, I agree. Perfect. A splayed corona is one where the angle is. I'll draw it under here. It's bigger. The way you get a bigger Carona angle is if something underneath it is pushing up. So obviously, in the Mediastinum, it usually will imply something interior. Um and that could be the thinus or the heart oftentimes it is the heart um or lymph nodes underneath it. So the c the mediastinum looks good. Excellent, Tohira. Do you mind if I call on you next? Yes. Yeah. All right, my friend. Listen, I'm going to walk you through this, I promise you. Ok. Ok. So before I even go into the lungs, I'm making sure the patient is not rotated. That assures me the way I'm gonna interpret, everything is gonna be accurate. There's no muddying the waters because the patient could be rotated. Next, we look into the mediastinum, right? Because again, I'm looking to see if there's any pathologies potentially in it or pathologies in the lungs that are impacting it already made. A mentioned the Mediastinum using just the cry as a landmark, it looks normal. The next space I'm curious about is the plural space. The pleural space, the two abnormalities that can happen, there can be fluid or air in them. So to hear up, you're gonna answer the questions. Is there fluid in the pleural space? The way we evaluate that is by looking at the costophrenic angles, you have the right one here and you have the left one right here. So Tahira, my question to you are the costophrenic gangs present. Yeah, we can see that. Perfect to hear of my question to you. This comes up often with a lot of my interns, they get a a little nervous, they wanna say they're present, but then they'll say they're hazy. Do you have any uh Do you feel like you're confident to tell me why you think they're hazy or do you want me to answer that? Um I don't know why they're hazy. No worries. They're hazy for two reasons. So, costophrenic angles, if they're present, they are present. There's no fluid that is ever hazy. Fluid is fluid. Fluid will always be dark, uh not dark, bright and white, whether it's blood or fluid from heart failure, costophrenic angles are there, but they're hazy. Something above them outside of the pleural space is making it hazy in men tends to be gynecomastia or some excess adiposity on the chest in women, it's their breast tissue, right? So if you see the costophrenic angles, but they look hazy and there's a lot more haziness actually, even around the periphery. This is all from the breast tissue. That's why it looks hazy. Does that make sense? Yes, thanks. Perfect. I say this because like I'll have an intern who's like I, I wanna say they're there. Doctor G but they look hazy. I'm like they're there, they're 100% there. They just look hazy because there's breast tissue in the way. Still sticking with you to hero um with the pleural space. But let me ask you this. I know it's under the pleural space, right? This is the diaphragm up here. What's this underneath the diaphragm right here on the left side? Oh, that's the stomach. It's the stomach. That's a, that's gas in the stomach, right? Perfect. What if you saw this gas though over here? Would you be concerned? Yes. Uh That's perforation that you're small. My friend under the right side is your liver So there shouldn't be any gas. If there's gas there, then yes. Call your surgeons. They need to go and open the abdominal cavity. That's the urgency. Yes. Last comment you told me there's no fluid in the pleural space. But tell me if there's air for air, what we do is we locate the clavicle like this and we look above the clavicle. What I'm looking for is if there's any dark blackness, right? When I, when I see dark blackness, look wherever I'm drawing right now, I want it to be as black as that. OK. Is there blackness that, that dark where I circled up there? Uh No, I think this one is just the upper lobe. Yep, because that's where air goes. Remember air goes to the upper lobes. Yeah. So no, the pleural space is free of fluid and free of a pneumothorax. Excellent, nicely done to hear. All right, Arkham, you're next. You ready? Yes, I do. All right, my friend. I know you're a, what time is it there? My friend. Thank you so much for joining us. I and uh this is uh at midnight actually, it's uh 12:33 a.m. All right. Well, listen, I appreciate you and others who join at different time zones. Um and I'm hopefully not ruining your d your night. So, but I, I really appreciate it next. We're gonna go into the hilum. Thank you the hilum. I will tell you, uh you know, it's always hilum is probably one of the parts of the lung anatomy that just takes a while to be comfortable with a, a normal hilum. And so I say this because I'm drawing out for you, two of them right here. So I'm actually gonna tell you, this is what I'm gonna tell you. I want you to tell me, but the hilum should do two things. What? On the left side, you should see some of it begin to come out outside of where the left atrium and the left ventricle meet and that's it. This is all you're getting on the right side. It's gonna look like a kidney shape like the way I just drew it out. Both of them though should be somewhat transparent. They shouldn't be completely right. You should be able to somewhat see through them. Would you agree on these, this imaging that it is? Yes. Yes, I agree. Yeah. Perfect. All right. My friend and out of the hilum for people that are new. The hilum is where blood vessels, airways and lymph nodes all cluster together and come out before they branch out like tree branches. All right. Last thing a um, you're gonna go over the second most important part of the second most important organ of the chest, the heart. Yes. All right, good, sir. You're gonna tell me is the heart big or not big? I'm gonna ask you to tell me if it's, is it big or not big. And then we'll go over to better explain that. What do you think big or not? Uh huh. No, it's not big. Good. And um that's all you guys can say on a chest x-ray. All the only comment you can make is is it big or not? So one, two and then three is here. So these are the three parts that I'm looking at. So if there's a space here between the left ventricle and the ribs by no means is at least when an x-ray is it big? This two slope approach, meaning this up here is your left atrium. You want this to be smaller than the left ventricle right in the slope because it implies there's not excess press pressures in the left atrium. I'm saying a lot, you guys don't need to commit all of this to memory. If you commit only one thing, it's this space. This if you just tell me that I'm perfectly fine, the left atrium size is a little bit more of a nuance. I tell it to you all to teach because over time it will probably stick, but you don't have to try to commit it. Um And then this is the right side. What I'm usually looking for on the right side is this space right here, this nice little angle to be present. Now, with that said, I will tell you and this is just more of my eyes, this component how much this pops out. I find it a little concerning. So the right ventricle here or uh, or uh and, or right atrium pops out the right side pushes out a lot more than I would suspect the issue with uh, by me saying that it usually in this context probably applies to just something happening in the lungs. All right, nicely done. A thank you, sir. And now our senior in college, are you ready to um, uh, read the chest x-ray with me? Sure. All right, good, sir. So when I read a chest x-ray the lungs, the lungs, now we're in the lungs. Um You know, or maybe you don't or maybe you remember what, what I do. Uh Not the eraser pen. What I do is I zig zag that was zigzag. Well, zigzag and then I'll zig zag back in here. Ok. What I'm looking for is, is the lung uniform from top to bottom and left to right. A couple of other things, when you're going to mention something in the lungs, you're mentioning one of three things, one of three things you're gonna mention that uh prominent, you're gonna mention if there's markings, markings means exactly what it sounds like it means there's marks. Now, when you wanna mention prominent markings, there's a rule to apply here. The rule is that the markings are here, here's the clavicle, we'll go to the middle, markings are fine to fine closer you are to the heart, right? Because the blood vessels are the biggest in diameter, the closer they are to the heart. But the further you get away from the heart, you really shouldn't be seeing any markings closer to the chest. Same thing applies here. So if you wanna tell me the interstitial markings are prominent, you better be sure that you are seeing a all these extend all the way out to the rib space. So three things you can mention in the lungs. One is interstitial markings are prominent. Two, you're gonna mention if there's an opacity, opacity means some things in the lung. It's cloudy. I can somewhat see through it. That's it. That's an opacity, different shades of gray and white coming together. And then the last thing you can mention is there's a consolidation. Consolidations are usually as white as what I'm circling there can't see through it. It's white it out. So my friend, as we go through the lungs top to bottom, left to right first. Is your abnormalities in the lungs? I mean, there are some that I want to point out in the left. All right. So you're going your first one you're pointing out. Is this left upper one, correct? Yeah. All right. You tell me what are you going to call this an opacity, a consolidation or prominent interstitial markings. I call it opacity because I I can kind of see through it and it doesn't look like artificial markings going across the lungs. Perfect. Yes. No, you may go. Oh sorry you guys are to see my electronic medical records. My patient. I love what you just said. Look guys look at closely to this, right? What you can see ah marking there. Look at this. Can you guys all appreciate a long marking going through here? Right? Let me let me stop sharing for a second so I can see your face is or all right. Could you guys see that lung marking going through the upper left that um Abdo Rama mentioned? Yes. OK. So why that's important? Why that's important is because it signals that this opacity seems to be somewhat airway sparing and it's just in the lung tissue opacities by default, mean they're in the lung tissue. All right, Sara, yes, it is an opacity. So Abdul Rahman, I agree with you. It is a op opacity. Do you agree with the right side is where as well? Hold on, share my screen back to this, share my entire screen. All right. Do you also agree on the right side? Would you also call this? Yeah, an opacity. Yeah, I was to point that out as well. Like there's like something weird like around that. So now this part, I do not expect you guys to know at all. So just sit back and relax and we're gonna go over this for a second. Let me erase this. OK. And I tell this to every single resident. Look, the only people that I would suspect to ever see something like this or to train your eyes to see this are gonna be lung doctors and your thoracic radiologist. So the left lung is just two lobes, upper and lower. That's it. That's all you got. There's no middle in the left lung because the heart takes up where the middle would be. You can't really tell. Like if you told me, hey, Doctor G, I think this is in the upper lobe. I wouldn't say you're wrong. Not at all. It could be the uh lower lobe. And I see this because the way the lower lobe is here, I'm gonna draw the lung, the, the way the lungs are, here's upper and here's lower. I'm drawing this as if like hold on, let me draw a head. Oh Guys, I'm sorry. This and this is his chest. This is his belly. OK. This is the world's worst. Here's his eyes, I'm sorry. OK. All right. So anyway, and this is his back back here. Sorry. This is a horrible, horrible drawing of a human being but the lungs on the left side, upper and lower. And then the reason why I'm pointing this out is because the left lo lo we call it the lower lobe just because it's like behind the upper lobe. So what I'm alluding to is I don't know where this is in the lungs. I think uh saying upper is fine, but you know, you could still surprise you be in the lower lobe. But on the right side, let me erase this horrible horribly drawn human being on the right side, you can make the case if you think it's in the middle f uh lobe. And the reason why that is, so, look at your eyes, I'm gonna draw this very faintly right here right here. Now, I'm gonna make this go away. So when I read a chest x-ray, I always try to find that subtle, subtle little line that peaks out of the ribs right here. That line separates the middle lobe from the lower and upper. The reason why I'm saying this is that this line looks like it's going through as this is here. That opacity, then I can tell you this is not in the right middle lobe. If this is in the right middle lobe, it should abide by that boundary. So right off the bat, what I'm telling you this fissure right here separates upper versus middle. But the fact that this opacity does not seem to abide by it. This opacity is in the lower lobe. Now, I said a lot, you may delete that from your mind. This is like advanced level interpretation. But confidently using this middle fissure line, I can usually tell where that thing is found. The left lung, all bets are really off because the fissure is hard to find. Um It's usually a straight line somewhere up here. But even with that, I can't make many guarantees. But the right one I can fancy usually a lot of my med students cause then we get ac A T scan and sure enough it's there. All right now, team, this is the same patient. Now, I want you guys to answer a question for me. What's different? You guys can unmute those on stage, unmute. What's different between this and this? What's different? There's a lot more opacity on where on like the bottom half of the lungs for both and the left lung is a lot more opaque than previously. Are you seeing, do you mean this side right here where I'm circling? Yeah, that side is a lot more opaque than for the right lung. And as for the left, the entire thing has a lot more opaqueness where in the bottom, in the bottom. Yeah. OK. But definitely a lot more on the right side, right. Yeah. OK. So we went on the right side, the left side, we ended up biopsying a little bit the right side, we ended up doing what's called a bl. So I si the reason why this is a lot more. So the left side, I not appreciating as much. I mean, you can make the case maybe some blood got in here but the left side, look at the left side real quick. I'm sorry, the right side, the right side. OK. Sorry. Look at the right side. OK. All right. Look at this. Right. You like there's an active line here. So for this, we went into the right middle lobe and we squirted a ton of water in there to, and we lavage it back. We just wanted some cells. That's it. We didn't go in the same lobe where the nodule was because we tried to get to it to biopsy and we just, we really couldn't reach it. Um And in all fairness, we got a good lavage from the upper lobe in the left. And so we did another one in the right. All right. Let me stop sharing here and tell you guys what happened. All right. So we biopsied. All right, let's recap this patient. Four days, fevers, night sweats, chills two big masses that you guys saw. Let me see if I can give you guys another piece of data to kind of go off with this. So when we got this, the cells back when the lavage, the most prominent cells were lymphocytes, a lot of lymphocytes and in regards to the lymphocytes, none of them were cancer cells. The the cyto came back negative for cancer cells, right? The biopsy came back negative for cancer cells. So cancer is not an issue there. How many people right now are thinking um could this be still a autoimmune process or could this be still an infection? It's not cancer. The biopsies came back negative for that Natalie Whitfield with a granuloma. I'm gonna pause there before we even get there. What came back a lot in regards to this case from a lymphocyte or CD four and CD eight cells. Specifically, this ratio was a little bit lower. So low CD four CD eight cells tends to gu guide us towards a granulomatous disease known as sarcoid. So this patient, Natalie Natalie unmute yourself. Why you've been thinking sarcoid since the beginning? My friend, why? What made you think of sarcoid? Can you unmute nathalie? Oh Amy. Do you have to invite her to the stage? I think I would. Um Sure. So as, as you're inviting nathalie. So a couple of things, this patient when we got, so I will tell you we were all fearful of cancer, specifically lymphoma. I can tell you lung cancers, squamous adenocarcinomas. They do not cause it tend, they tend to cause no symptoms. You have fevers or night sweats. What they will cause you at some point in time is a bad bloody cough, especially if it's a squamous cell cancer, right? So, cancers in themselves, lung cancers don't cause any symptoms, breast can anything that metastasizes to the lungs as well? None. But when we saw this, our bigger concern, right? So if I just saw this chest x-ray, I will tell you, yes, I'm thinking lung cancer. But when this patient tells me night sweats and chills, I'm like, oh, you, this isn't gonna be lung cancer. I think this is gonna be, we have Natalie on the stage. Yes, I'm gonna talk to her in a second. Yes. Thank you, Danny. If it is gonna be cancer, I'm thinking more of lymphomas. Well, it's kind of atypical to see lymphomas cause opacities unless there's some level of associated lymph nodes. But who was it? It was a told me it was like, hey, the hilum looks normal. Yeah. So lymphomas would tell me a bad um uh the lymphoma should present itself with bad hilar disease disease in the hilum. So, meaning this patient, what I love about this case is when I saw, you know, you know, she's sitting here four days. I'm like, look my money is on what Tahira said. I think she's got a pneumonia, then we snap her x-ray. I'm like holy crackers. She's got two big things happening there, right? Two big opacities that Abdul Rahman mentioned right in the left upper lobe and in the likely in the uh in the lower lobe of the right lung. And I can tell you when I my Ed friends because send to the emergency room, like it's the only way I can get things done fast. They look at me like, oh man, you're gonna have to break the news that this is cancer. I'm like, what make sure you think this is cancer. You know, if, if it is and I love my Ed friends. I wasn't picking one I was like what cancer uh like lymphoma would be the one to cause these symptoms. But there's no lymphadenopathy. That's a really important point to make the case of. There's no lymphadenopathy. So I wasn't even thinking of that. I'm thinking she either had a very unique atypical type of infection, right? Because, you know, there's not a lot that we should cause these two unique distinct or autoimmune. Once I saw that chest x-ray, I was almost convinced that this was gonna be an autoimmune process. Yes, Juliet, sorry. The CD four CD eight ratio is uh did I see lower so higher? Yes. So that is the first clue. But the diagnosis comes from the biopsy you have. Well, I actually time out it's not the the biopsy told me there's granulomas there, Natalie. What made you think of sarcoid to begin with? Uh Well, I'm a second year medical student and it seems like that's like the answer option for a lot of these really like these cases where you have no information on that. I think the uh CBC being negative kind of ruled out infection and cancer. And um also with the CD four CD eight ratio, Natalie, what medical school do you go to? Like, you just get Rocky via um College of osteopathic Medicine in Inglewood, Colorado. Excellent, my friend. Excellent. No, congratulations. Um So from my standpoint, a couple of things, so Sarcoid tends to be kind of like we teach every medical student you should think of that. So um uh like the CD four CD eight ratio really comes up a lot for us around sarcoid. But I will tell you it's this isn't a diagnosis, a CD four CD eight ratio or the biopsy of a granulomatous disease still doesn't diagnose you with sarcoid. So now let me just talk about sarcoid briefly with you all. Sarcoid is what's frustrating. Sarcoid is one of these diseases that you diagnose it by excluding everything else. So what does that mean? So when I got this patient's biopsy back and granulomatous disease, now, uh I can tell you it's one of the most intellectually fun things to have a conversation of. But then it's also like I gotta wait, right? Because the patient's miserable. She wants a treatment. The issue though with once I get granulomatous disease, then I gotta wait for my sts to come back to make sure it's not tuberculosis, right? So I'm waiting for my A FB stings. They come back pretty quickly. At the same time, I got to rule out other things you guys mentioned. This could be fungal. So I have to make sure my histoplasmosis and other molds and fungal uh infections are ruled out because sarcoid treatment is steroids. But if she has an active infection and I hit her with steroids, she's gonna hate me. She's gonna get worse. So as soon as we got this back, I'm telling her look, look, we can admit you to the hospital, you can go home whatever you like. I just need about 48 hours to make sure it's not an active infection. She said I'll wait it out in the hospital. That's what she did. 48 hours went by. Not an active infection. The challenge. That's good. But then I'm thinking, and by the way you say active infection, these are insidious things. These are things not only that are not gonna pop up in your CBC, they're not gonna give you a white shift like a bacterial infection. Would, these things would be a lot more insidious? They're not gonna give you that typical presentation. Now, could this be sarcoid? Could still be? There's a lot of other autoimmune diseases that give you granulomatous disease. Anca is another one. A NC A. We'll do a case of one of those in the future too. Ank does have biomarkers so I can rule that out. I can test for those and we did, we drew a ton of blood in her. We checked for HIV, we did a variety of things and I'm saying all this because that workup then takes about a week. But what's beautiful about autoimmune diseases in the lungs? I can treat them all the same way I can hit them all with steroids. I just gotta make sure she doesn't have an active infection. That's the big learning point. That's the point I make the case to everyone. If you get a biopsy back, that's a granulomatous disease in the lungs. You better do your due diligence to make sure there's not an active infection there. Wait for the TB results. Wait for that because these patients aren't dying. Right. They're not, they're miserable. I get that. But she's not hypoxemic. She's not, um, decompensating. She's ok. We got time on our side until we pull the trigger for steroids. If I may ask, at what point do you um perform a biopsy after ordering a chest x-ray? Oh, immediately because again, I can't tell you like sarcoid needs a biopsy. But at the same time, not only the reason why we did these biopsies was look as mu as, as bold as I say like, hey, it's not cancer. Cancer should lung cancer shouldn't cause you these symptoms. I'm bold but a lot of cancers also don't read the textbooks. They're like, you know, you'd be damned, you know, 99% of the time. So I would uh do a biopsy once I saw these, this patient's getting a bronchoscopy. So, yeah, the only issue that I have is sarcoid is a disease of exclusions. So you gotta make sure you rule everything out. Then Kathleen, I just saw your question. Uh So if I'm working in urgent care and don't have labs back yet, I just see this x-ray, what should I do? So I'll tell you what every urgent care should do. They should 100% write antibiotics. I'm not dismissive of that. Right. Because could this still be, you know, you're waiting for the labs to come back? Sure. I don't, I'm not dismissive of that, but she 100% especially the pattern. Right. One is in the left upper lobe, the other one's somewhere in the right, middle or lower lobe. There's not a lot of infections that do that. Bacterial infections don't they like to stick to one side? They'll disseminate if you're kind of immunocompromised or you're developing a rds. So who's that patient right now is because remember she walked into my outpatient clinic, I have nothing against urgent care saying here's some, here's on the antibiotic, maybe some steroids. But what I would urge you is please see a doctor within the next 24 48 hours, especially knowing that you're gonna prescribe steroids because if this is sarcoid, it's gonna really take away the ability for us to have that diagnosis as well. So making sure they have appropriate follow up, the steroids won't do that immediately, but they will do that if they're going on for some time. But I recognize the reason I'm telling you this is because I recognize the urgency of an urgent care and wanting to act on this pretty quickly. Um If you think it's sarcoid though, from a pulmonary perspective, you got to make sure you rule out sarcoid involvement in other organs as Well, that's the other key part because you're gonna say like how much steroids do I give this patient? If it's just pulmonary sarcoid 20 mg is fine for predniSONE. All right, this is a fun case. Why I think I say this is fun is because you really have to know this patient. Like if I just gave you guys to here, I'm gonna pick on you my friend. If I just gave you this chest x-ray and I said, read it, you're probably thinking cancer immediately. Am I right? By saying that? Is that reasonable Tahira or Natalie? Anyone? Would you guys think it's cancer? Uh If, if you just saw this Lupus? Yeah. And what I really ask of my students is like this is why I started off the lecture. Why do you get a chest x-ray? Why do you get a chest x-ray? You have to know why you're getting it so your mind can be prepared to not have a surprise, right? That's the like I really encourage you all when you the the best thing you can do for a patient is listen to them, listen to their story, listen to them, listen to their story, examine them. So when you request a data point, you're not gonna be surprised this x-ray didn't surprise me. It just suddenly made me go. All right. There's less things now that I'm thinking right. I'm gonna do, still do a bronchoscopy. I'm still gonna get a biopsy. I'm going to cause you got two whopping things there that necessitate a further workup. But you got to be prepared for what the data is gonna show you and best how to guide. Because I finally I'll finish with this. My, my biggest frustration is there's plenty of patients that have like this who come and see me at some point who come and they're like, doc, I've been told my daughter, I have cancer who told you have cancer? I went to this urgent place or em emergency room. They saw that and they're like, it's cancer. I'm like, what are your symptoms? What's going on? Let's talk about this. And so that's it. You know what I would say? Tell you all is when you request a data point, know what you're expecting from it. And before just leaping on to a data, one data points conclusion, make sure it ties into the rest of the patient cause I cancer would not have been a suspicion of mine. Even with this kind of imaging, listen to our history. Four days of symptoms, cancers don't do that, not lung cancers. So anyway, so the noncaseating granuloma came from the biopsy. The biopsy showed us that. But noncaseating granuloma, you can find them in a multitude of diseases. If you guys look just a quick Google search, there's a kind of a funny paper that tells you a through Z, each letter gives you a different differential for a noncaseating granulomatous disease. So it's a lot just got to know the patient. All right, good people. We're ending, we're gonna be back in two weeks, same time. But starting in November, we're gonna probably shift the time because people like Arkham are like doctor G man. Come on, you're killing me. I'm not going to bed till one in the morning. But you guys have been awesome. Natalie. Tell your friends to join as well from med school center to hear a good luck on your journey. My friend email me if I can help Ray and Abdul Raman. Thank you both for joining us. You guys are awesome, Danny as always, thank you for all. You do take care everyone. Bye.