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Ok. Hello. Hello everyone. Um Thank you for coming. Could I get some indication that these people hear me see the slide something in the trap? Anyone do you guys have access to the chat? You should have access? Ok. Thank you very much. Thanks for confirming guys. So yeah, so today's session is on chest X ray interpretation and it's gonna be delivered by Laurence or 100 team. Thank you. So, hi, my name is Lauren. I'm one of the final year medical students at uh Manchester. Um Yeah, I'm at so if anyone is interested, but today we're gonna cover chest ray interpretation with a heavy focus on kind of the route of looking at it. Obviously, it will help you in placement and on the ward when people show you x-rays as well. So not only is it important for your exams, it's important for um basically being a doctor in general, you will see 100s of these. Ok. So let's start at the beginning. Oh, by partners, there's a code that if anyone is interested and obviously this is done by students, this is not formal teaching. So absolutely, you will. Ok. So first of all, why do we even order chest x rays? Um So chest x rays can be ordered in uh in the primary care setting, my GPS and also in acute setting. And by that, I mean, things like A&E um inpatients can get them as well. Radiologist can always come around and do like uh be x-rays where they um put the slide underneath the patient in bed. Um Also do them in theater beyond chest x rays. Thinking about like leg x-rays, especially orthopedics, but specific for chest X rays. Anyone who presents to A&E with chest pain or a primary care setting will be referred for a chest X ray. It is a definite but kind of expanding on that. Thinking about fever, infection or sep sores. I've been thinking about pneumonia, a persistent cough, again, pneumonia, lung cancer, abdominal pain, looking for that free air under the diaphragm, any breathlessness that you have fluid overload in heart failure, pneumonia again, co PD or any traumatic injury. So we're thinking about broken bones cause not only P et the lungs, you can see like the top of the the chest as well, thinking about the shoulder and also pneumothorax. So why would we do an X ray of other imaging by that? I mean, like things like MRI CT scan. So firstly, it's super quick to perform, you know, if you've seen X ray, a chest X ray when you had a chest X ray, it takes mi minutes compared to like the hour that you're sitting in the MRI machine. CT is quick but more expensive, more radiation. Um Chest X ray is great because we can use it on basically everybody. Um It's a cheap alternative. I think MRI S can cost 100s of pounds compared to like chest x rays. I saw things from like 25 lbs to 75 lbs. So I just kind of estimated it's under 100 lbs per chest X ray. Um and also it's a really low dose of radiation exposure. So like not point not to receive, it is tiny, so small and we know that they're really great because we order 7 million a year, that's a huge amount of x-rays. So x-rays super important, super cheap, super efficient. We love chest x rays and that's why this is super important to know how to read a chest X ray efficiently. So not to panda um about X rays, it's just really good to kind of grasp everything around at chest x rays. So when we look at it, we know what we're looking at. So obviously, x rays are a type of radiation, they pass through our our chest cavity and they create this shadow on the film. And I've just put a little diagram here to show kind of how the shadow changes with density, so less dense, it's dark, the more dense it's white. So bone and metal will be the most densest objects that we see and obviously I will be back. So how do I interpret a chest X ray? Um So there's three prongs to this. The first one being confirmed details of patients very ay heavy two is assess image quality which comes with the acronym of ripe and then three an ABCD approach and we will cover this in great detail. Um I just wanna say a lot of this has been pulled from the GKI medics on their website, great resource for all osculated and medical students. However, my one great with it is that um it doesn't really come with enough images. I think some of it can be very anatomy heavy. And if you never looked or done chest x rays in the past, it can be very difficult to kind of get it into your head. So I've tried to translate a little bit into kind of layman's terms. So it's easier for you to kind of take back and remember and I've added lots of pictures for us to go through at the end. So there will be like a mini quiz, but I would obviously it's not my answer. So it's fine. OK. So confirming patient details, Brennan Butter of Bos for any sort of data interpretation of ECGS prory bloods, chest x rays. So you wanna look at name date of birth hospital number or NHS number if provided, compare that to your notes, you wanna look at the date and time the chest X ray was taken. Obviously, you wanna be as up to date as possible. Um Obviously, unless you're uh do a comparison, they could be a year apart, month apart. Always good to know and yeah, mistakes happen. I've seen lots of doctors looking at chest X ray going why is this person having breath with like extreme breathlessness and their chest X ray is fine because they're looking at the wrong patient. So it's actually really important. I know it sounds silly, but it is important. OK. So assessing image quality is the right acronym. So this is just making sure that the images is perfect for us to interpret because if the image quality is bad, it's not really gonna do us any favors and it's gonna not really show the things that we wanna see or it will make it more difficult to interpret. So the first thing we wanna do is look at the rotation and that just means basically they're kind of upright and they're sitting in the right position when the X ray is taken. So the two things we're looking for in rotation is that the spinus processes in our spine are vertical. So I don't know if you can, I don't really have like a pen or anything. Um But on the X ray, there's like a straight line of all the spinal processes going down like that and they should be in a vertical line. It shouldn't be slanted, it shouldn't be curved unless obviously they might have scoliosis. But for a basic x-ray, it should be nice and straight. And also looking for these medial ends of the clavicles, which are these bits here, you can feel them on your chest as well and they should be the same distance away from the middle spinal process if that makes sense. Um Yeah, so those are the two things to check. So vesical spinal processes and making sure the ends of the clavicles in the medial part or in the middle are equidistant. The same distance between the middle spinal processes that sits in between. I hope that makes sense. Um We're also looking for inspiration. So obviously, you've had chest xx ray before you have to kind of breathe in and hold. So the lung is completely filled with air and it inflates it to the max. So we can kind of see all the pathology and the way that we check it is three things. So number one, we wanna look at the five anterior ribs, these are not the ribs that are most visible that are kind of flat in the front, they're the curved ones on the side. And it took me a while to get this when I was first looking at them, I haven't really drawn anything on which has been annoying, but it's um I don't have a pointer. Um very sorry. So if we're looking at the posterior ribs, which is like the ones that look like they're in front. Um It's kind of the curve on to the side and it comes around like this and this bit at the bottom is the anterior rib and that's what we need to be looking for. And we're looking for a minimum of five, some sort of say six, but I think minimum five six second is we wanna be looking at both lung apices. So this is the space above our clavicle. We just wanna make sure is it there? Because if they haven't inspired enough, that's not gonna fill up with air and it will just be really, really tiny or just not bad. And third of all, we wanna make sure that both costophrenic angles are present. These are the two bottom two corners at the bottom of the lungs. I'm sorry, I haven't annotated the slide and I'm sorry, I can't point to anything but it's basically like these two little angles at the corner of the lungs. We may wanna make sure they're nice and sharp and we can both see them and that's what's really important. So inspiration, five anterior ribs, we wanna see both lung apss, the top parts of the lung and the bottom parts of the lung, which is the two bottom corners. Any questions so far? No. OK. OK. So the P is projection. So when we're looking at an X ray, there's two types of chest X ray. It's called the AP or the PA. So it's basically just how the x-ray is shown through basically the chest cavity and where the, but the film is. So typically we do the posterior anterior one, which basically means the radiation is shown through the posterior part. So through our back and it's upper front and then the film will be at the front like at the front part, as you can see in my handy diagram on the side. Um This is a standard X ray. This is what most X rays will be done with um ap so anterior, posterior, so imagine it's going through the front out to the back or the film will be on your back. This is more reserved for people who are bed bound or they have mobility issues. You often see this in like ICU or critically unwell patients that may have like a altered gcs or consciousness level or they're just too unwell to get out of bed so that we still have an option for everybody to have one. Um Yeah. So with the pa film, people normally stood up while they're sitting in a chair. So it's, it's the best. The best x-ray is the pa one ap, less good but still adequate enough. And as I've noted, if there's no label on the chest X ray, which there should be, I assume it's a pa if it's an AP, it will often be marked AP and also just for reference I also get confused with this looking at x rays is what direction you're looking at them. So this kind of like diagram at the bottom, right shows you're looking at them from the front, but the images from the back, it's a really odd perspective. It's like when you look at act and it's actually foot up instead of like head down. Um don't worry about it too much, but if you like to be orientated when you're OK, which is like I do, that's a good diagram to look at, but it is a bit confusing, but just remember the letter stand for the direction of the beam going through the chest. So pa a back to front ap, front to back. Um again, looking at projection, we're looking at the differences between a PA and AP chest X ray. So this image kind of shows what they would look like. So the main way to tell is actually just identifying if it's an AP exam or an AP chest X ray. Sorry. So heart size will be exaggerated on the AP film. So we often don't draw conclusions like uh a cardiomegaly which is a big heart on an AP exam because it will just be larger. Anyway, some consultants and some doctors do still just say cut it regularly on an AP film. If the heart is like really, really large, I'm talking about bigger than that even like when taking up the whole chest X ray and you go, I go fair enough. But in your do not do this, make a comment about that if it is an AP exam that I cannot comment on the heart side because this is an AP film. Um and the visual, the visible scapula in the AP film are on the edges. If you look on the AP film, on the right hand side, you can kind of see on bilaterally, there's this like white blocks over the scapula, they are present on almost all AP films. Very very because obviously in like when you do like a uh a respiratory exam, you ask them to cross the arm, same as a PA X ray. So you wanna get the scapula that way. But obviously, if they're lying in bed, the scapula are there and they're gonna be in the wrong position. Therefore, you can see them on the chest X ray. OK. OK. So just to kinda at home AP exam will have a heart side effect is exaggerated. So we cannot make conclusions and we can see the scapula on the AP film. OK. And then last for image quality is exposure. So this is just basically how well does the radiation go through the chest cavity? Either the x-ray will be well exposed or it can be over exposed or underexposed. Excuse me? OK. So we want this good exposure because we wanna visualize the pulmonary vessels and the lung fields and the bones accurately over exposure will make the dark will make the lung fields much darker. And the pulmonary vessels, pulmonary vessels more difficult to see and obviously under exposed nicer lung fields. And the bony anatomy almost becomes invisible because it is so bright as you can see at the top um fine. So to check for exposure, we wanna be able to visualize the left hemidiaphragm. And by that, I just mean the left hand side of that diaphragm. So you wanna make sure it touches the spine to the corner of the lateral lung. So it's that thing, you wanna make sure you can see it from this side all the way to the bottom of the lung or to the lateral wall. And if it isn't, it might be over or underexposed based on how it looks. Um and also the vertebral bodies. So the big chunky bits of the vertebra should be visible behind the heart at the the bottom x-ray is what is a, is a well exposed x-ray. And you can clearly see that the, you can basically see the big blocks of the vertebra, that's what it should look like. And you can also see the um diaphragm basically connecting on either side and you can see on the underexposed one that you cannot see the best of our bodies overexposed, I can visible again, underexposed as well. The less hemi diph just kind of disappears at the heart because it's, but it just is too bright to even connect it. OK? Any questions so far you can drop them in the chat. I'll answer them, but that's it for imaging assessment. OK. So now the real me of a chest X ray, we are looking at the ABCD E approach. This is looking for major pathology problems. This is what is important even though it's all important. But this is the wrong me to let us go. What's the diagnosis? This is what you're thinking about. So, oh, sorry, ABCD E airway, breathing cardiac diaphragm and everything else. Much like an ac assessment, you know, airway breathing cardiac. Ok. First of all, airway, let's divide it into four parts because these are the four key parts, trachea, Corinna, which is where the, the broncho deviates. You can see it just about on the X ray about halfway down to the black tube in the middle of the spine. Suddenly it will just deviate. That's the Corina. And then the, obviously you've got the bronchi and then the hila where the bronchi enter the lung and the hill are kind of like these hazy white patches. On the other side, you have the tea, the Corinna and the hill. So t you out, the main thing you wanna be looking at is, is there any deviation? So when we look at a chest X ray, we wanna see that nice and central. Um and when it's deviated, it can either be true or apparent when we say true is either being pushed or pulled. We'll go into a little bit about that later on when we do lung fields about what, how it is being pushed and pulled. I've just listed some pauses here about pushing would be large pleural effusion. So that's fluid in the pleural space. Touching pneumothorax, which is pneumothorax to the point where it's like impacting the heart and pushing the trick here. Um Thinking about diaphragmatic hernia. So like hernia that comes through the diaphragm and it's pushing up, sorry, and the thoracic mass. Um and then pulling a tia thinking about lung removal and lung collapse. Um An apparent deviation is just when the patient's not rotated equally incorrectly. Sorry. So that's why it's really, really important to assess image quality because it, it might not actually be deviated. It just might, they're just leaning a bit and I have seen that and sometimes you'll go. Oh, is that trachea deviated? No, they're just at a bit of an angle. So always, always, always double check it and they just say as well. Um So obviously, if it is true deviation because you would have recognized if the image quality was rubbish earlier. So if it's true deviation, you wanna comment if it's left or right, that's really important. And you can comment on whether the key is being pushed or pulled later on, you'll be really good just to get much better if you're not feeling too comfortable with a chest X ray. Be like that is being pushed, that is being pulled. You can just look at it instantly, you know, but be like, ok, the tricky is deviated to the left. I will come back to it if it's being pushed or pulled later in my assessment. Oh, sorry. Just to address the two x-rays on the side. So the top x-ray it's got um right side of deviation. It looks like the trachea is being pulled because it's being pulled into the pathology because you've got that white humongous white mass. And then on the bottom one, I actually got it. Oh, so it's a bit grainy that one actually. Ok. I think the key is being deviated towards the right side and I think there's some sort of mass we'll come back to that. Sorry. That's a terrible, but the top one is really good. Obviously, the key is being pulled back into the pathology. OK. So more the airway, this is a better diagram to see where the corona is and the bronchi, it's a bit difficult again, you have to practice looking at it and you'll be able to spot it really easily. So the main thing is, are they visible um on a normal chest X ray, they should be visible. Um We normally see the right bronchus is more vertical and wider and shorter. So it will kind of just go down like this and it's much thicker that often comes up in pass me about um, foreign body inhalation. So if someone's choking and then they've got pneumonia afterwards, like aspiration, pneumonia, where would you expect the consolidation to be? It's always like middle or lower zone because that's where like the thick, long and straight bronchitis. So things just fall down it really easily. Um So, so just to recap, deviation, Corina and bronchi, are they visible? And that one is the heller. So the heller, we're just looking for enlargement, abnormal position and is it visible? Um So on a normal chest X ray, we it should be visible. Um It should be the same size on either side, but the left hilar can sit slightly higher. That's just um normal variation. So if it's not, if it's sitting at the same level, no problem. If it sits slightly higher, higher, no problem. Again, kind of thinking about the diaphragm, how the right diaphragm is higher than the left. Kind of no like what we expect to see. So when we're thinking about the hila becoming enlarged, so by and large, what we're kind of looking at is you see, so this chest chest X ray on the screen is a normal hila and it's kind of like patchy, it's not really that big in large would be more dense, huge. That's what that means. But if it's on one side, malignancy would be a huge cause. But if it's bilateral, obviously big cause is sarcoidosis or TB um an abnormal position is, you know, if it's really high out, really low down from comparing to each other, is it being pushed? Um It could be like soft tissue mass like cancer or is it being pulled like one collapse an absent hilar position? Um an absent hilar point, sorry would be, there'll be a lesion at the point obscuring. Um The hilum. So thinking about lung tumor, lymph node enlargement. OK. So these images highlights what a bilateral enlargement of the hila looks like if you've seen this, think about sarcoidosis TB should be top differentials. So you can see they are humongous and if we go back, you can see that they're really small, kind of almost invisible, but they're kind of just normal lung markings that we wanna see. Not too big, not too obvious. These super big, super obvious we don't wanna see them. Ok. And this would be unilateral enlargement of the hilar. So again, that would be things like malignancy with the ne Yeah. So if it's big on one side, cancer or uh some sort of uh tumor, you can kinda see here that there's some sort of like fluid in the lung. Often we see people who have cancer of the lung or they've got cancer in the chest cavity. They can often have pleural effusion in that on that side. And sometimes it can be massive to the point where it's like filling up the whole lung anyway. So you can kind of compare it to the left side where it's kind of like this sort of less dense dot And then on the right side it's massive. Ok. Sorry, I'm just a bit wary of time. Make sure you guys have enough time to your revision this afternoon. Oh, tonight. Sorry. So the breathing by this, you mean the lung fields and the pleura, we don't assess the lung fields by lobes because the chest X ray kind of captures really tiny parts of the lower lobes, especially on the right side. So even though the left arm only has two lobes, still divide it both sides into three zones. So it'll be up middle, lower and it should be one third of the image each. If you're not sure you can always say, oh say for her instance, oh I think this lesion is in that middle to lower zone. That's totally acceptable. Nothing's gonna be absolutely perfect in the middle. Obviously, if it's at completely at the bottom or completely at the top, you can mention it's just in one zone. But obviously, you can mention more than one zone or just say it's all throughout the world. OK. So looking at the lungs, first, lung fields should never be completely white or completely black. They always have lung markings in them. That is no, that is what we want to see. Um So to systematically inspect each zone, we're looking for absence of lung markings, lung markings are these like hazy white lines that kind of go like this and they should be completely through the long fields. So in an absence, it will just be black. You can still see the bones, but the lung feel themselves will be completely black. And then for that, we're thinking about is this pneumothorax and then you're on start with pleura, which we'll talk about. Next. Is there white shadowing or increased shadowing? So that just means like a white, completely white, increased white haze, you can describe those sorts of lesions with increased shadowing or white shadowing interchangeably, it doesn't matter. And that's things like consolidation, pleural effusion, clap, pneumonectomy, tumors and pulmonary edema, pulmonary edema will often be symmetrical. So that's just something to keep in mind. Um And obviously, if you find any abnormalities, comment on what zone it's found in if it's on both sides or one side. So for example, I wrote, um there appears to be some consolidation in the right, lower lung zone, not part on the left, such as an example of how to phrase that. Ok. So I'm gonna kind of go through the causes of shadowing the lungs because I don't think you are this very much. So this is consolidation. Um I've just kind of written a definition, consolidation of the fluid, the ave and bronchioles. This fluid can be pus fluid blood or other material. Chest X rays do not tell the difference between these. So that's why we kind of put it on this umbrella of it. Conjunct solid and most of the time it's pneumonia. So that's why you might often see it and people go, oh it's pneumonia. But in reality is just consolidation, it could be more than that. So it will appear white and patchy or just white and there will be no volume uh lost. L that means the air or the size of the bones don't change with it there. So this X ray is showing a consolidation on the right middle to lower zone. So you can kind of see it's not in the middle, it's not in the lower. So we say the middle to lower, right, this one shows consolidation on the right, middle to lower zone. Left lung is clear and has normal lung markings. I would actually say this is a lower zone, consolidation, middle, no one's gonna take marks away from you if you don't say one or the other, if it's kind of like in between like this. Um But this kind of shows like, can I hope all of you can appreciate the lung markings, which is what we want to see on the lungs. I have mistaken it a few times for things like consolidation and really, it's just nicely exposed to the lung markings. I'm like, oh, it must be consolidation. It's not, it's just normal lung markings. Um You get better with it over time. My advice would just be look at a million chest X rays. Always ask to see a chest X ray. Oh, this person had a chest X ray. Let me see it. I'll look at it, ask questions. That's the best way to do this. OK. That's the pleural effusion. It's just fluid accumulating in the pleural cavity, like consolidation. It cannot distinguish between the substance of it, but usually it will just be fluid um because it's the most common. So the main thing we're looking for in a pleural effusion is that if they're standing on mobile, we'll see that nice kind of it will go from top up because the gravity, think about fluid will set on the bottom because it's heavy gravity pull it downwards. And the main thing is is the meniscus. So hopefully, all of you can appreciate kind of like that new shape on the top of the pleural effusion. Um So obviously, this is a pleural effusion of the left lung ups the upper zone and a little bit of tracheal deviation can be seen. Maybe this is tension, pneumothorax. Um because you've got a bit of heart movement and the trick is deviated it, but there's definitely pleural effusion. Oh, no, sorry. Tension, pneumo, sorry. Take that back. It's just, it's so big. The pleural effusion is pushing on the trachea and causing deviation, not tension, pneumo. I'm so sorry. Ok. So this one pleural effusion a little bit smaller, just so we can appreciate kind of very small pleural effusion, very large pleural effusion. I haven't even seen chest x rays where you cannot see the lung anymore because it's so much fluid on the lung. So pleural effusion and hopefully all of you can appreciate like the costophrenic angles. So normally you want that really nice crisp corner that blunting of it is most likely pleural effusion and you can be specific. It's like it's in the cost of running angle, lung collapse. Um Obviously, the main things with the new about is lung cancer as of foreign bo looking for a white shadow over the lung field. Um looking at tracheal deviation, media, spinal shift, that just means like middle contents going this way or that way. Um And it normally goes towards the side that collapsed because it's like being pulled inwards. Like I like to think of it as like um say you're on like a spaceship and the wall and the spaceship gets breached and everything inside will be sucked down into the vacuum of the space. That's what's happening here. When your lung collapse, it's like a vacuum and everything, it just gets sucked into the side. So obviously, lung collapse, there's nothing there. So the rest of your body cavity kind of goes oh there's more space available and it just moves. Ok. So what we're looking for is a white shadow. So increased density on the right upper zone expense extends into the middle zone. Um And this is an example of right upper lobe collapse. Um So here we're looking for white shadow deviation towards the side of the pathology. OK. OK. Long masses often white and gray and well defined. Um We don't know if this is an abscess or a cancerous mass or a benign mass. Um, effusion can also be present as I mentioned earlier, especially if it's cancerous. Um But we're looking for that increased density, nice and well defined and seems to be nowhere else plus or minus the pleural effusion. Ok. OK. Pulmon edema is the fluid leaking from the pulmonary capillary network into the lung in and out. So the lymph system is unable to take all the excess fluid away, that's kind of coming out into the lungs. Um So either it's cardiogenic or noncardiogenic pulmonary edema has lots of key findings. One of them interstitial edema. So that's kind of why that white haze everywhere. That's interstitial edema, curly bee lines. It I find it really, really difficult to see curly bee lines. They are very, very fine white lines on the edge of the lung fields. I'm not looking at the screen like I'm pointing. Um But the best way is to do some Googling on Google images because it's difficult for me to point them out and there'll be like nice and lots of zoomed in images that pleural effusion. So that kind of bottom up um meniscus cardiomegaly. So the heart becomes much, much bigger. We'll go into the definition in a minute and upper lobe diversion. That means kind of like the air and the blood goes like upwards into like the main upper arteries and veins. So more focuses on the kind of like the upper lobes. It's not really present on this one, but it's called the scag Antler sign where it literally does look like an antler of like kind of the, I don't know how you call it. Like it's more obvious that the, the veins and vessels are there. Ok. Sorry, I'm, I'm rushing just because I'm mindful of time. Um But often with pulmonary edema or pleural effusion, if the patient is sitting up and immobilizing, um the fluid will fall to the bottom and that will cause that pleural like most meniscus. But if they lay down a lot because they're short of breath and they can't go anywhere, um gravity and they're lying down a lot and then they're taking the X ray when they're lying down. All that edema kind of goes from being right at the bottom to all the way up the lung because gravity is now spread out through the whole lung instead of just the bottom part if that makes sense. OK. Oh Yes. So these arrows are actually pointing to the code. They, like I told you what to, I forgot about this photo, but they are very, very difficult to see in my opinion. Um I wouldn't say it's the main part. If you go, you kind of Poe is quite obvious when you see it, you know, you see it. But if you wanna get the, if you wanna let the examiner know what you're talking about, if you see these white lines in the lateral margins below like these blue arrows, that is the curly bee line, they just kind of come out of this very, very fine, that's the curly bee line. And obviously this X ray on the right is just showing massive pulmonary edema cardiomegaly is definitely there. You can't even see the costophrenic angle on the left side, humongous interstitial edema all the way up bilaterally. OK. So I just took this table from passed because I thought this is a really great way to differentiate if the tricky is being pulled or pushed. Um So cause a tracheal deviation when there is increased density over the long fields so that it's being pulled or pushed. So pulling, as I said, the breaching spaceship is being pushed into like the vacuum of the cavity, like the chest cavity, pushing the content of one side is so large that it has to like basically go outwards. And the only way, the only thing that's pushing out is the rest of the chest cavity and that includes the media spinum and therefore the trea. So it's like such a big mass, it's going oh I don't know where else to go. I wanna push on the now. So that's pushing. So that's when we think about things like massive pleural effusion because that's fluid, accumulating, accumulating, accumulating big masses, bigger and bigger and bigger and bigger. And obviously when it's been pulled, lung collapse and lung removal, there's nothing there, things fall into it. So that's from me. If you wanna do some further issue on that, that's got some really great resources as well. OK. B breathing. Oh my God, I've got so much to get through. OK. Um So breathing um pleura looking at abnormalities, the pleura should never be visible on a normal person. It is very thin, we don't wanna see it. So when you inspect it, you wanna make sure you're going in all the zone going on the edges being like, right? I definitely cannot see it in any of the lobes. Make sure you're checking the apss as well. If the pleura is visible, it means it's thickened, which is mesothelioma, which is from asbestos exposure, which is a type of cancer. And if there is an absence of long markings and then there's a very thin white line below it that can indicate pneumothorax. So the pleura has come away because of that is, is pushing it down and we'll look at some images. So it makes more sense. So this is a simple pneumothorax. Hopefully, everyone can appreciate that the absence of lung markings on the right side like it's completely black. When you look at the left, it's much more for the lung markings. And you can see the pleura has much has come away from the wall and it's created this very thin white line around the pneumothorax or where, where the air is pressed on for lung. Um Yeah. So in this because it's not, there's no tracheal deviation or mediastinal shift. This is not tension, pneumothorax. It is just simple pneumothorax, but that's quite a large pneumothorax cell. Um ok. If you wanna go over things, we will have a quiz later. Hopefully if we have time. Um So tension pneumothorax, this is, this is very obviously tension, pneumothorax, like no lung markings on the left side, everything has just shifted away because there is so much air, it's just expanded and it's just pushing on everything. The reason we worry about tension pneumothorax is because it can cause cardiogenic shock because the heart can't pump outwards properly. So it can't pump blood. And the people who go into cardiac arrest very fast and they will die. It's rare to see tension pneumothorax on chest X ray because it can be diagnosed clinically on the spot because obviously you see on a person you see tracheal is deviated. They're so short of breath, they're decompensating and now they're hemodynamically unstable. That person has new tension with thorax. You have to act now with an aspiration. So almost never will see chest X ray unless yeah, pa standing attention active. You will never see that. So, but it's still good to know what the signs are just in case it came up. And a, I'll be very surprised if it did, especially with Manchester students, but still good to know what we're looking for. So, me, um, humongous airspace like markings. Ok. All right. I appreciate the thickening of the pleura. Ok. Right. Cardiac, we only assess heart size in a pa X ray as I said before. A ps, make the heart a lot bigger. Sorry, I'm rushing the time. A normal is the heart should be taking up no more than 50% of the width of the chest cavity. So, cardiomegaly as you can appreciate on this X ray, it's massive, it's taking up way more than 50%. Thinking about heart disease, cardiomyopathy, pericardial effusion, heart failure, heart failure, often seen with pulmonary edema as well. There's a little bit of pleural effusion in the um right lower lung as well if you've got a keen eye. Ok. Again, we're assessing the heart borders in a normal individual right atrium makes the right heart border, left ventricle, makes it the left heart border, abnormal findings. Sorry. Um So pathology can increase your like basically the whiteness, overlying the tissues. So borders are hard to see a reduced definition of the right heart border. Thinking about uh a right middle lobe consolidation, reduced definite definition of the left heart border, likely lingua consolidation and put a picture here because I didn't actually know what the lingua border was. It's basically this tiny bit of lobe. That's what the lingua is. So left heart side, maybe there's some consolidation in that part of the lung. Next diaphragm. Um Nor would be the right is higher than the left because we're looking for the liver to push up. There often is a gastric bubble under the left. That does not mean this is free air, it's just the stomach. Um And the diaphragm should never be discernible. So you cannot see whether diaphragm starts and the liver starts or. Sorry, the diaphragm stops, the mother starts on the right side and we wanna make sure we're seeing these nice crisp Cren angles and they're very clearly visible. So we're looking for like nice acute angles. OK. Ophthalmology is being safe free gas. It will be oh OK. Sorry, I've, I've done some transitions, but I've had to put this in a PDF. So it's come up a bit oddly. So I apologize. Um So due to we after this of the pictures of the free gas under the liver or underneath the right side of the hemidiaphragm and it will basically just separate it. So it will be like a line, some free air and then the liver will appear, we're also looking for a flattening of the diaphragm and costophrenic bunting. That means it just goes like this and there's no acute angle of the costophrenic angle, we often see this in hyperinflation. So you think about COPD and loss of the costophrenic angle. Is it food to fluid or consolidation? So that means the hemodia phrag is not flat, you just can't see the angles. OK. So you can kind of see on this x-ray on the top that you cannot see the costophrenic angle because of some sort of fluid or consolidation. OK? And everything else. So we're looking at mediastinum, bone, soft tissues and medical equipment. I will race through this mediastinum. The middle part, the two things we're looking for is the aortic knuckle and the aorta aortic Pulmonary window. So that's the wedge. There's a little bit of an image here, you can kind of see at the top. So the aortic knuckle is the one bit on top. The aorta pulmonary window is like this kind of wedge shape in between the aortic knuckle and the pulmonary artery. So aortic knuckle, we're looking if it's there, if it's got reduced definition or or enlargement, thinking about aneurysm for the aorta pulmonary window, there was an X ray underneath this showing some good x-rays. I do apologize. The aorta pulmonary window um is the space between the aorta and the pulmonary arteries if that space is lost or there's something not that wedge anymore. Basically, wh him out is a mediastinal lymphopathy because there's lots of lymph nodes in the mediastinum. So if they will get enlarged because of cancer or some sort of other disease, then they will basically obscure that wedge. Ok. Every oh God, sorry, everything else bones. We need to inspect all the bones in the chest X ray that includes that body, uh ribs and also just a quick appreciate of the collar bones in the shoulder joint as well. Um Is there any fractures or lesions and also soft tissues? Are we looking for any abnormalities? Like a large hematoma? I think this image was oh oh, here we go. So on this X ray, you can actually see some rib fractures on the left side, very, very faintly. So that would just kind of give you a picture of they kind of got spot, but once you know what they look like you'll spot them. So they're just showing there's nothing wrong with the lungs, just the rib fractures on the left and the middle side on the posterior ribs actually. So these are like the big ones coming out from the spine. Ok. Medical devices that often on it, especially in A&E you'll see lots of ecg uh stickers on people on the X ray NG tube, it should dissect the corona. So it basically it comes like this through the esophagus and then it goes all the way down because a never event is when the tube instead of going down the esophagus, it goes down the trachea and into the right bronchus. And that's why we get aspiration pneumonia from tubes. That is a never event, we never ever want to see that. So that's why we always check ng tube placement lines, thinking about a central line or an ECG cable, as I was just saying, artificial heart valves will have this ring shape. So on this X ray, this actually shows a few things like the pacemaker as well. So the ring over the heart that's not over the spine is an artificial valve. That's what these rings are. The little clips all the way through the middle is when people have open heart surgery and they staple them back up. Basically, that's what that is, it's there for life. And also you can see the pacemaker go all the way out and then putting the wires into the heart. Ok. So things I just wanted to add for the s this is more relevant for Manchester students and I do apologize to anyone who's not at Manchester. Um I only see the chest X ray coming up in two situations that being a data interpretation station, which is just data, there's no simulated patient present. So it'll be inside um some patient histories, maybe ecg blood work, et cetera and you'll be given a certain amount of time, maybe like four minutes, you have to look at all of it and then you'll present your findings to the examiner. Come up with a diagnosis of like diabetes and a management plan. The other way I see this coming up very more unlikely is with a simulated patient. You asked to take history, the examiner will then cut you off after a time, you'll be given some sort of investigation. I've had bloods before it could be a chest X ray, especially if it's a respiratory history and you'll be asked to give you a differential based on the history and the findings of the chest X ray. Um For level of knowledge don't go too in depth with, if there is, you could just go forever with chest X rays. Stick to geeky medics, pass me and your TCD online or in person as a minimum. Um in the exam, they can show you a normal chest X ray. I had a normal chest X ray and ECG for my data interpretation. Se it's very off-putting but in the moment you could go, I think it's normal. Say you think it's normal still do, right? ABCD? E go through everything. Um Not knowing the diagnosis is not an automatic fail basically, like treat you like your mass exam at school. Show you working, show that you know what you're looking at as long as you don't find pathology and then say, oh like there's a big mass and then you say it's normal, don't do that. But if you're like, I fully cannot find findings, just say you think it's normal, it's fine and make sure to summarize at the end, right? Any questions, there's no in the chat. So I will carry on. So let's practice some analysis. I'm gonna put an xray on the screen. You can think to yourself or type it in the chat. I'm gonna give like 10 seconds because we really press the time. Um, just say what you think the diagnosis is. Ok? So here's the first one. So you can either think it's yourself or put it in the chat, ok? So this is pneumonia of the right lower zone consolidation. So you can kind of see this patchiness over the right, lower and middle zone maybe. And the lung field on the left was completely normal and above the consolidation looks normal. Please put any questions in the chart. If you're confused about why the diagnosis of that and not something else as well. I'm not expecting anyone to do the right ABCD E or you can't see the X ray. Oh, can anyone else not see the X ray? Ok. Mm Odd. Ok. Has anyone been able to see any of the x rays in the whole of the P VF thing? Ok. Right. Ok. How odd. Can you see this x-ray at all or is it like this is a different x-ray? Yeah. Please let me know if you've seen any of the x-rays. Ok. So you've everyone seen the x-rays in the previous side? Amazing. But all right. How odd. OK. I don't understand why this one's not working. Ok. This one's a paired Great. Thank you. The my is there. OK. Amazing guys. Let me know if you wanna have a second to think about what the diagnosis is here and then we'll keep going. So for this x-ray, it's actually CO PD hyperinflation. So we're looking at the signs of CO PD. So that's more than six anterior ribs visible. So that's that hyperinflation, a flattened diaphragm and the hyperlucent lungs. So I think excessive air making the lung feels look darker. That was very, very mean. I do apologize, but this is very, very important to know what AC O PD x-ray looks like. Ok. Next xray, please also let me know if you can see these still or if you can't see them. Thank you. OK, I'm gonna keep whizzing through. So this is again CO PD, it's the same thing. So six anterior ribs, hyperinflation, very flat hemidiaphragm at the bottom as well. So that can be appreciated. Um Just to know this tricky is not deviated, they're just rotated really ugly like this if, if you could also hopefully appreciate that as well. And this X ray just have a quick think. Ok. So this is actually just cardiomegaly. Just huge heart. Um I hope you can appreciate that the heart is taking out a much more significant portion. Amazing. Thank you, Kevin. Yes. Cardiomegaly. Great. Um So just a huge heart. Yeah, it's just taking up more than 50%. Um It can just be the only findings. Obviously, you can see a bit of a valve replacement as well in the clips in the middle as well. Ok. Next slide have a little think about that. I do apologize. I'm actually just gonna w through this. Ok. So this is a left pneumonectomy. Um So you've got complete right out of the left lung and you've also got that tracheal deviation, which makes you think is this just a lung removal? Um Sometimes you'll also see that media spin and shift because the heart's moved into that empty space as well. Um You can, normally, if you're, it is sometimes easier to tell the difference between um like a lung removal and a pleural effusion because pleural effusion will be acute, maybe background of heart failure or cancer. Pneumonectomy, they'll know that they've had a lung removal. It will be obvious they might have had a history of lung cancer and then they've had their lung removed. So don't worry about that, but it's still good to know what they look like. Again, next slide have a little think I'll give you 10 seconds. So this is actually a normal chest X ray. Again, these can come up on the exam. It's good to know what they look like because when you see in a, a regular one, you'll know and the more you train your eyes and you train your brain, you'll be really, really good at these. Ok. Amazing. Thank you. Yes. Normal. OK. Next x-ray have a little think so. This is just, unfortunately, it's not tension but yes, pneumothorax. Great. So it's pneumothorax. The reason it's not tension is because there's no media, spinal or tracheal shift. It's definitely right sided pneumothorax. It's quite big. Um Any questions, like any questions about pneumothorax, the difference between them just drop them in the chat as well. I'm happy to answer any questions. Ok. Next X ray having a quick think. This one's quite obvious. It's a lung mass well defined border. How do you know it's not a collapsed lung? Ok. Great question. Thank you. So, a collapsed lung. Let me just ii think I might have a picture of a collapse lung at some point anyway. So a collapsed lung is more white out. It will be more defined. It will kind of be like a straight line. It will be that nice white out of the lung. Pneumothorax is uh getting into the, the pleura. So it's decreasing. The density lung collapse is increasing the density. So a simple pneumothorax with pneumothorax will have that black area that does come away. It's almost made it really like a really tiny lung. Lung collapse has increased the density because lungs has gone. Oh I don't wanna be here anymore and it's, it's pulling away. Does that make sense? So, pneumothorax, black purus pulled away plus or minus mediastinal lung collapse, increased density white area. Ok. Maybe that's the answer to your question. If not, we can go review some slides, just let me know. So this is a long, last nice, well-defined border. Ok. Next x-ray. And this is actually a total right sided lung collapse. Um It is difficult to tell the difference between a pneumonectomy and a total lung collapse. PF What is PF, sorry, sorry. I don't mean to maybe my brain is running at a million miles an hour. Just can you just elaborate what PF is? But uh this would be a very tough question to get. I don't think you would get something like this, but this is a total right sided lung collapse. So you've got the tracheal shift, the total went out because of the increased density. Pleural effusion. That's absolutely fine. Don't apologize. So if it was a total pleural fusion, which can happen, it is quite rare. Um The trachea would actually be pushed the other way because it's like fluid is coming up, coming up, coming up, coming up, it's not filled all of the lung or the pleura. It's like I've got nowhere to go. So it's gonna start going outwards and that's gonna push on the collapse. It's that vacuum, it needs to kind of um fill in that empty space that is gonna fall inwards, but great um kind of comparison point between a complete pleur eus and something like a pneumonectomy or a lung collapse. So, pleural effusion, if it is a total pleur effusion, very rare it can happen, it be a total white out trachea is pushed away lung collapse in this case, which is a total lung collapse. If that total white out below tachy has gone inwards into the vacuum. OK. Let me know if that made sense or we need to go over it again. It's totally fine guys. This is a, a learning space. We're all here to learn next one. I'll give you a few seconds to think about that. And this is just the left lingual consolidation like I was talking about earlier. So you can kind of see that the left heart border is very uh blurry. So we are we thinking about left lingual consolidation again, this would be a hard question in the exam. I doubt they give you something like this. It's just fun to know and it just kind of makes you think about, I really should be looking at everything like the lung fields are obviously very obvious to analyze. But the cardiac boards are just as important because look how small that is, you would have missed that. So always, always, always make sure you go through all the steps and write ABCD E OK. Next one, I'll give you a few seconds to think about this and then we're gonna instantly move on. I do apologize. So this is tension pneumothorax. Um So it's on the left side and hopefully you can appreciate the pleura coming away from the chest wall from basically top down and in like that, um you can kind of see the thin white line of the pleura around inside the lung markings. And then there's the mediastinal shift towards the right side because all that air is pushing on the trachea and the mediastinum and now the heart so again, rare to see something like this. Um but it still happens. Um And I think that thing on the top is just a necklace. It's not um any medical devices. So you can see jewelry um and just a key point as well. Some people will get confused by this, but you often do see breasts on chest x rays. It's just the lines. That's it. It's not any gastric bubbles. I've heard people say gastric bubble, it's not, it's just breasts. Ok. Fine. So that's tension pneumothorax, hopefully that makes more sense in terms of distinguishing simple pneumothorax and tension pneumothorax. So tension pneumothorax, deviation is key, simple pneumothorax. There should be no deviation. Ok. Next one, a few seconds note this is an ap exam as well. X-ray, sorry. OK. This is pleural effusion. This is also bilateral. I would even he I would probably make a guess that this is actually someone who has heart failure, having bilateral pleural effusion. You can hopefully all of you can appreciate this. Uh bilateral meniscus. There's meniscus is on both sides. Um So there's obviously fluid in the lungs, maybe a little bit of interstitial edema uh definitely, definitely pleural effusion. OK. Next one, few seconds to think about this. Oh, I'm so sorry if I'm running behind on some guys. OK. This is an ap called pneumothorax. So this is something I think this is the last one actually. So we're at the end now guys. Um please put any questions in the chart if you have them, but I'm just gonna go over this really quickly because this is super important. The apices are so often missed because it's harder to say this is a difficult x-ray to analyze. I do apologize around the I think the third anterior rib, you can see the like the pleura coming away from the wall, right at the top of the lung. It's very, very small, but it's just at the top of the lung, there's a bit of air in the pleural space. Hopefully, you can see that if not, let me know and I will describe it in more aggresive detail, but basically from the, it kind of comes down to about the third or fourth anterior rib and it goes all the way up and across. So inspecting the aps of the lung, super, super duper important. You can see how easy that would have been missed if you just kind of like over it. So make sure you take the A pe the apex, a api of the lung, please do that. Ok? And lastly thank you for listening. I know it's been a really long hour. Thank you so much guys. Are there any questions before I leave? Um I haven't got the QR QR Code, but I will now send a feedback form for the, um, just the teaching portion. Obviously, you guys can wait until I see you ask your revision to send feedback. But we would all really, really appreciate feedback about how the rest sessions run, how I've delivered the presentation as well. And if there's any improvements we can make, I'm so sorry for running over, by the way. Yeah, like good. It's all right. Thank you, Lauren. Um So we're going to go into breakout rooms now. So I've got, oh, how many volunteers that we have? We've got four of you guys. So there's rooms with the facilitators names. Um So if everyone who's attending the session wants to join one breakout room, if there's too many of you doing another one, And we'll see how that goes. Does that sound? Ok guys? And if there's any um, questions put them in the chart, let me know if you guys are struggling to, into the breakout rooms also just to let you guys know. I don't think Bethan is here. So, um try and join one of the other four breakout rooms. So everyone's still in the meeting. Are you struggling to get into the rooms or popping in the jaw?