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Interpretation of Chest X-ray

Jan 31 | 3:30 PM

Join Dr. Salil Bendre as he walks us through the basics of interpretation of chest X-ray. We will discuss some commonly asked X-rays in viva, some practically important aspects of x-ray interpretation and some nuances of it.

[Music] hello everyone good evening i dr rucha welcome you all on behalf of team netflix uh we have one interesting session today interpretation of test x-rays the forms basic of everything wherever we go in every speciality so this is something we always come across uh so we have dr sallee benjamin with us uh he's a pulmonologist and transplant physician uh so he's associated with nanakti max hospital global and musina hospital we did one interesting session with third uh recently on lung transplant or do check out if you are interested yeah good evening good evening everyone good evening uh dr rucha and team netflix thank you for inviting me today for this uh discussion and this session on x-ray reading i'm sure there would be lot of people who have seen x-rays it would not be a new new thing at all because x-ray chest is almost like ubiquitous every one of our patients have cough and fever and breathlessness and x-rays something which i think every patient now carries it into the clinic there used to be a time where a doctor used to advise but now many patients actually come to the x-ray to the clinic with the x-rays so uh good evening friends and uh thank you for joining today for this session on x-ray chests uh chest x-ray reading and interpretation it's going to be a very slow process that i am going to go through the x-rays which i show you and naturally x-ray reading doesn't happen in one evening so obviously in one hour we are not going to understand and start interpreting the best way we can but at least learning would be a good way to start it so we'll go to the next slide so uh see we have got an audience which is a huge audience a lot of people lot of practicing doctors some are students some are interns some are practicing for many years uh some are consultants so i am going to go from a little basic of x-ray reading and gradually uh we'll be trying to see how much we can you know be experts in interpreting x-rays so as you can see first of all i have just put up a x-ray in front of you i would suggest each one of you start seeing these x-rays thinking what they feel is there in this x-ray so that each one of you can assess what you people can you know understand from this x-ray what is your inference and then as we go ahead with the point systematic approach to x-ray then we become a little more wiser to know this so those who have logged in first just take few seconds to go through this x-ray okay now this x-ray whoever has seen and who have thought of it is i will tell you the diagnosis because finally what what happens and what interests all of us is to know the diagnosis so this x-ray as someone said could be a consolidation could be a collapse it could be a hydrated cyst so there are many possibilities which come in okay x-ray is rotated or not so many things are there we can see that there is an opacity so someone would say it's a pneumonia it's a mass so i'll tell you straight away what the diagnosis is so that we know where we stand at this moment of time yes so dr paras has picked it up perfectly it's actually a aortic aneurysm so it's an aneurysm of the aorta okay so this is the way finally we need to land up considering the differential diagnosis okay differential diagnosis so this is actually a case of aortic aneurysm this is the x-ray which i just saw some time back in the clinic now we will go back and we will slowly go through the nuances of what is x-ray reading okay uh there is white black okay there are different different uh white black shadows on an x-ray uh we can see a white shadow we can see a black shadow we can see something like a gray so whenever i used to see x-rays in my college days in my first mbbs days i used to feel they are more like clouds you know they are like black white and i don't know what it is and our sir used to come and he used to see the x-ray and he used to just say oh this is tuberculosis or this is a malignancy and he used to walk away and it was so surprising for me even at that point of time how did he even understand because it looks all the same it was just black and white and black and white so uh different dish tissues they have a different way of absorption of the particular light so let's be very specific if it is more white the highest absorption is by the bone so it is more white the lowest absorption is by the air so it is more black and the lungs are not only air they are not only solid they are containing lymphatics they are containing air they are containing capillaries they are containing lymphatic they are containing the alveoli the walls of the alveoli so there are tissues and there is air that's why it will be a black and white mixture it's a great issue so the lung windows or the lung shadows are gray bone is white and black is the air okay so i am going to one of the x-rays which is present here so we can see this x-ray now try to see that in the center in the center we can see a heart that is the opacity which is white white because it is liquid so liquid is white solid is also white okay so liquid is white and solid is white and black will be the air now if you can try to understand from this particular x-ray you see outside the thoracic cage outside the thoracic cage there is air outside the lung outs outside the entire x-ray plate that is completely black that is completely black whereas if you see the lung fields just next to the heart shadow they are comparatively gray gray okay that is gray in color that is grayish there is some tissue there are alveoli lymphatics so it is grayish in color so why i am explaining this again and again because sometimes we start seeing such x-rays and start considering there is emphysema okay so this is not black this is only and only gray in the appearance so there are two gray areas on either side of the heart and there is a diaphragm which is the curvature okay curvature which is seen that is the diaphragm on either side okay there is a diaphragm on the right and on the left also so let's go through this anatomy very slowly because each aspect of anatomy will help you understand what is the disease in the x-ray which is seen so we have got a lung field which is gray there is a hard shadow which is completely white which is opaque opaque because it is filled with liquid just above the heart shadow just above the heart shadow you can see a faint gray line in the center of the clavicles there are two clavicles on the adjoining side and exactly in the center of the clavicle there is a grayish line that line is actually the trachea those who are able to assess this it's fine but there are many x-rays which could which you are going to see so gradually you will understand what i am talking about as the trachea but for the moment just train your eyes to understand what a x-ray looks like it's a gray area of the lung there is a heart which is bordered there are domes of diaphragm which are convex upwards and there is a black black you just for comparison outside the x-ray plate you can see a black area which is the air around the person okay so that is the black area so that's black but we are here talking of the lung so there are a few principles which we need to you know go through most important principle and the way you will find out what is an abnormality is it abnormal is there something wrong is by comparing both the sides of the hemi thoracis okay it is to compare both the sides of hemi thoracis so dr vinod is asking to explain in hindi i will try to mix hindi english as much as possible so the most important thing is we need to see both the side and compare right to right middle part to middle part lower part to lower part so it has to be all comparative don't focus your eyes anytime by just seeing one part of the lung and thinking oh this is the disease try to see is it there on the opposite side in the same area so always compare that is the first principle of course the next principle will remain to see the date on the x-ray there are many patients who may come to you with an x-ray with a complaint but if you don't see the date then you will later on see that the date could be sometime about a month ago and if you don't see the date then you will not get a proper idea you may assume that he has come today with symptoms so today his x-ray has got but this x-ray is actually one month old so always and always see the date on the x-ray and always and always also ask the patient do you have any previous x-ray even if it is maybe a weeks backs 15 days back one month back still you should try to ask him of a previous x-ray so try to understand these principles unfortunately in the rush of seeing patients and getting a patient's x-ray to be seen we try to forget these things don't do that you always need to compare the sides of the x-rays you need to have a previous x-ray also please understand one thing we are not here to see an x-ray and give a diagnosis of etiology etiology diagnosis happens on either sputum or a biopsy or analysis of the fluid okay that comes only after investigating the tissue so if you ever see a doctor saying i can see this patient's x-ray and it is suggest you of mdrtb or it is suggest you have active tb or it is suggestive of a particular type of cancer it is not the correct way to think about you need to just know the change in the structure of the lung x-ray is a structure so it is going to only change the solid liquid is it more liquid is it less liquid is it more air is it less air it's only and only that so try to understand the principles of this comparison and the date and always think about the earlier x-ray now again go through this very slowly when you see an x-ray however senior you are and however junior you are first and foremost find out the position of the trachea it's an automated thought that you will be seeing the position of the trachea it will be seen right in the center as a black line gradually as we follow the trachea down the trachea then ends into the media standard okay that is the heart the cardiac sealout and on either side the junction where you see the trachea and the heart just on the either side is the hilum so three things should be the first thing which you should see the trachea the position of the heart and the high level again unfortunately when anyone of us sees an x-ray the first thing which our eyes goes to is a cavity or a consolidation or a tumor or a mass and we forget to look at the trachea the hilum and the heart shadow okay the next part comes the diaphragm because you are going to follow it in a very very synchronized manner you see the trachea you see the heart you see the hilum and you see the position of the diaphragm so it finishes the mediastinum and the diaphragm that's how you will have to train your eyes to read x-rays gradually when you see thousands and thousands of x-rays it all will happen like an automated reflex once you go through all this then we are going to see the lung fields okay we are going to see the lung fields that is the area of the lung which was the gray tissue which we talked about so we are going to see the trachea we are going to see the hilum we are going to see the cardiac siloed we are going to see the diaphragm then we are going to talk about the lung fields if that is clear then we will go to a little bit of technical issues which i think we can spend about five minutes on that before we start seeing x-rays okay it's not the excitement of seeing x-rays it is the excitement should be of understanding what is happening in this person's thoracic cage so if any of you have undergone an x-ray yourself then i'll tell you the procedure you are told to stand with the x-ray plate kept in front of you okay the x-ray plate is kept in front of you the x-ray rays come from behind okay the x-ray rays come from behind you are not facing the x-rays the face is towards the wall and there's x-ray plate in front of you that's why it is called as a pa view the posterior anterior view means the x-rays are shot or sent from posteriorly and it's a pa view it's a posterior anterior view one two three things happen when your x-ray is done and if you have noticed it and if you're not noticed dude please remember the person who tells you to do or take an x-ray the technician tells you to keep his keep your hands on your hips okay on the sides it's a very important uh position you need to keep the hip hands on the hips he tells you to take a deep breath okay and then he does an x-ray now all these things change the x-ray plate so imagine or understand that if at all a person is standing with his hands on the hip but his right shoulder is abducted means his right shoulder is not in line with the left shoulder it is abducted or slightly moved then the distance on this side on the right side between the clavicle and the sternum will appear more because it's abducted now if this is the position where the distance on the right side is more the abduction is there and he's not keeping his hand straight the heart will appear to be shifted to the right side the trachea will appear to be shifted to the right side okay so that is what is called as a right lateral rotation it's called right lateral rotation so go back to the basics again that we need the patient stance he's told keep your hands up take a deep breath and the x-ray is taken now if at that point let's assume that who's the patient who's x-ray is being taken he tilts his neck a little this way okay on the left side a entire change of the rotation will cause a false impression that the trachea has shifted it may give a false impression that the heart size is increased so it is all important to understand that it should be not a rotated plate rotated plate can give rise to huge errors and the commonest error which happens because of a rotated plate is an x-ray report saying cardiomegaly okay because the heart appears to be big in size because it is a rotated plate either there is a left lateral rotation or a right lateral rotation and that causes the heart to look very big and globular and the impression which is written on the x-rays cardiomegaly kindly get a 2d echo done okay so we need to really remember that first of all to understand an x-ray you need to know whether it is rotated or not so this is a quick uh expression of the dist of the rotation what was talking about you should always see if the medial ends of the clavicle medial ends of the clavicle are the equidistant from the sternum okay for sternum you may take spine as a marker so spine and are the clavicles equidistant so if the spine is suppose there is more distance on the right side between the sternum and the sternum between the clavicle and the spine then that distance then it will be a right lateral rotation if there is more distance between the medial end of the clavicle on the left and the spine then it's a left lateral rotation and right lateral rotation will make the heart look more to the right left lateral rotation will make the heart look more to the left not only the heart it will also make the trachea look as if it shifted either to the right or the left so it's purely a technical thing many times this creates a problem in people who have undergone a supine x-ray means a portable x-ray because when they are lying down they are not going to keep their shoulders at an equal level there is a high chance that either one shoulder is deviated or one shoulder is up or the hand is in a different position and in a portable x-ray there is a very very high chance of a false cardio megaly to be seen so before we start jumping on is this a mass is this a collapse is this a tumor is it to be i think first you need to know we should try to reduce the errors which are technically related okay that is just about rotation there is one more slide which i had put up about penetration or exposure so when we say an x-ray is taken it is actually called as exposure we are exposing the lungs to a particular amount of radiation more the exposure the lungs look more black lesser the exposure the lungs look more white so please remember sometimes you may see black lungs and they are actually over exposed now what is over exposed it is a little bit uh you know sort of i would say too much technical but if you see the rib cage and if you are seeing the intervertebral discs the thoracic intervertebral this the first the second third fourth fifth inter vertebral disc so obviously on an x-ray you can see the vertebrae and in between the two vertebrae is what is called as a intervertebral discs so if you are able to see more than three intervertebral discs thoracic intervertebral discs it is a over exposed plates over exposed so if there is over exposure there is a high chance that the lung shadows will look more black we will go through these x-rays as i said we there are x-rays which which i'm going to show you but unless and until you really really you know keep this as in the background of an x-ray reading you will be mixing up and making unnecessary diagnosis so if it is more white then it is possibly an under exposed explain if it is more black then it is a over exposed x-ray now each of these facts which i am telling you makes a big difference if ever you see your patients x-ray your relatives x-ray your neighbors x-ray they are going to talk to you as because they expect you to understand x-rays and if there are two x-rays of the same patient ten days apart okay you are treated a patient say you're treating a patient for pneumonia or a patch in the x-ray and after 10 days he comes to you with an x-ray which looks more white the patch looks more white or more opaque don't get alarmed because there could be a difference in the exposure of both the x-rays which is making you feel that this second x-ray it is more white or the patch has become more dense or it is become more opaque so it would give you a wrong impression that my treatment is not working why are my antibiotics not working why is the disease increased why the opacity is increasing but it may be neither of it it may be purely because of the technical change or over exposure or under exposure that you may get a false impression that either the disease is worsening or improving okay so first and foremost again i am going to go through each point mentally whatever you have heard first and foremost remember the date on the x-ray okay it's very important to see the date on the x-ray second always ask for the previous x-ray if they have that helps you a lot comparison on x-rays help you a lot third whenever you see an x-ray compare both the sides right left right left upper part upper part middle part middle part lower part lower part compare them other important thing will be the is it rotated or centralized when it is a well taken x-ray where the shoulders are at an equal level the x-ray is called as a well centralized x-ray then we should see whether it is over exposed or under exposed okay overexposed or under exposed because under exposure means it will become more white overexposed means it will look more black and obviously we are going to see look at the trachea first then we are going to look at the cardiac cell out in between the trachea and the cardiac silo on either side there is a hilum or the hyler structures coming down below the heart is the diaphragm the convex right diaphragm one space below the left one space higher left diaphragm is one space lower and of course we are going to talk about the lung fields that is the lung zones so this is just to know what we are talking of in terms of x-ray reading i hope there are no queries or no questions or no doubts till now we'll be moving on from here and if you have any doubts you can anytime put it in the message box and i will try to answer your queries as much as possible it's going to be not not so easy to finish off x-rays in an hour as i said but let's see how much we can learn from this particular session so this is again to emphasize that fact now in the circle in the center if you see it you can see a a particular black line or a gray line right in the center of that circle more towards the 12 o'clock position more towards the 12 o'clock position that is actually the track here so that is the truck it's like a faint area because it turkey contains air that's why it's gray in color all right so that is how the x-ray the trachea would look like in the center usually in the center there would be the sternum and if the patient has undergone a surgery especially we see patients with a cardiac surgery either there is a bypass which has been done so they will see sternal wires which are seen around the particular area of the sternum but i i think right now you just remember that first of all you need to understand how the x-rays to look like now also one more thing one more thing rather i missed i should say is that when i said the person is told to take a deep breath why is it taken because when the person inhales or inspires and holds the breath the diaphragms are pushed down so the moment the diaphragms are pushed down the lungs opens up and since the lungs opens up we can see the lung diseases or lung abnormalities much better in a inspiratory plate now let's assume that the patient has been told to take a deep breath lumbee salsa is told to take a deep breath but he did not hold the breath and when he exhaled the x-ray was taken okay so there was an inspiration he could hold the breath but he couldn't and then x-ray was taken when he exhaled out what will happen when the x-ray is taken when he exhales out air the diaphragms will come up and as the diaphragms come up the heart is pushed up so what happens to the heart the heart which should have been normal in shape gets pushed up and it looks more flat so what impression you will get cardiomegaly again see please remember that you may get a false impression of a cardiomegaly in a expiratory plate in a expiratory plate you may get a false impression of cardio megali so you need to see whether it's an inspiratory plate and how do we make out inspiratory plate inspiratory would be obviously when we say normally what is the position of the diaphragm it's the sixth seventh intercostal space so if the patient takes a breath the diaphragm goes down so you should be at least be able to see six to seven intercostal spaces you need to able to count the intercostal spaces obviously i can't teach you online how to count the intercostal spaces but you should be able to count the intercostal spaces and if there are more than seven intercostal space spaces seen properly then it means it's a inspiratory plate but if you see on the right side only five intercostal spaces that means the diaphragm has gone up and because the diaphragm has gone up the heart appears big in size so it may be cardiomegaly falsely thought off so again i am trying to explain that if ever ever you feel that there is a cardiomegaly first check whether it's a rotated plate first check whether it's an inspiratory or a expiratory plate okay so inspiratory or expiratory plate is very important to know about cardiomegaly same holds to again i apply this to all of you dr sangeetha dr whoever all of you are you know who are joined with me today dr narayanan and so many of them you can think about a patient whom you have seen you have treated for a lung disease say a consolidation and after a week of your treatment the patient comes back and you find that the consolidation has increased in size you feel now the opacity though but it's increased in size now this could happen provided the first plate was inspiratory and second plate is expiratory okay so if the first plate was inspiratory the consolidation was well seen now the second time when the x-ray was done though the patient should have been clinically good and x-ray should have shown better but because of the expiratory plate the diaphragm went up because the diaphragm went up then the haziness or the consolidation came together and it looked more dense okay so it came more dense on that so you may get a false impression and you may say now we should change the antibiotics patient is not improving the density has increased it was lesser earlier it has more now but don't be under that dilemma because inspiratory plate and expiratory plate can cause a lot of errors all right so inspiratory at least on the right side you should be seeing the seventh intercostal space and downwards okay that will be the way it is now for those who are unable to understand about the counting of the rib cage in the x-ray which is in front of you i am sure you can see the ribs and if i tell you trace the ribs then your finger should go actually to the spine and you should start tracing the ribs from the spine downwards okay so it will it will come to the spine in the center then the rib then the next below the that rib the next rib so that's how you will count from above downwards so start from the first thoracics vertebrae then you come down second the second rib third rib fourth rib five fifth three bender of course the spaces between those ribs will be the intercostal spaces so those who are unable to see the ppt i think the technical team will take care of it and slowly you will be able i mean there must be some error in the mobiles but don't worry you will be able to see them as soon as possible yeah so we are taking care of it and those who are not able to see uh quickly you can click on the support button and rejoin that might solve your issue uh so please do that yeah so please continue thank you thank you now i'm not going into this slide because it's now let's go through this this is one more confusion about you know the cardio megaly so first of all when you talk of cardio i'm purposely not showing you too many slides of effusions and mass and consolidation because the confusion of every of those pathologies will persistently be there if you don't understand what are the one two three you can't jump on a 99 without knowing one two three four five six so cardiomegaly is something which you should know and if it is not a expiratory plate if it is not a rotated plate then please see how to know whether there is a cardiomegaly or not so the cardiac sit out the small red arrow is up to 50 percent of the maximum internal thoracic diameter okay so that is the dimension so if it is more than that means the heart shadow is much more than half of the particular internal thoracic diameter means the heart shadow has increased in size okay it should be up to 50 percent of the internal thoracic diameter that the simplest way to talk about it now there is someone who is asking about bronchoalveolar markings or bronchovascular markings so please remember bronchovascular markings as the word suggests they are markings or their findings on an x-ray caused by the bronchial tree and the vasculature of the lung they normally are present in the lung they have to be present the bronchial markings and the vascular markings so every x-ray will have bronchovascular markings so it is nothing like a disease they don't become prominent they don't talk of any abnormality so saying that i can see bronchovascular markings on this x-ray that is expected that is supposed to be normal so there is nothing like we should be really really pushing ourselves to think about oh now this bronchovascular markings are there now i should think of a disease please don't do that even in this x-ray in front of you right now what you can see there are some white gray opacities in the lung fields okay i i will say just right para cardiac border beyond the right paracardiac border there are certain white white lines which are seen those are bronchovascular markings they're supposed to be normally present so you don't interpret an x-ray saying oh this is a bronchovascular marking present now this is bronchitis it doesn't happen so they are normal that's all now this is the area of the highland this is exactly the area of the island okay so this is right in the center we can see trachea you guys if if those who have heard me a few few minutes back uh we'll be able to see the trachea which is a grayish line right in the center between the two clavicles going upwards and below that it moves down into the cardiac sealout and just laterally is the area which comprise the hilum okay it's a hilum i'm i'm slowing down because you should actually really really really you know go back and see this x-rays again and again and again so x-ray reading what i'm trying to explain to you have been like we have been seeing x-rays x-rays x-rays i being a pulmonologist i naturally see x-rays x-rays and x-rays but there would be multi-speciality doctors here who would be interpreting different investigative modalities so x-ray reading is like you constantly see them again and again and again and again so that is the area of the hilum now there would be certain x-rays which would be mentioning hilum is prominent now that is very very deceptive what does the hilum contain let's ask ourselves go back to your anatomy books of grey's anatomy or character or whichever book you thought of what does the hilam contain so hilam contains three structures one is the lymph nodes second is the pulmonary vessels and third is the bronchus now bronchus is not seen on an x-ray because it's filled with air so nothing so the only two structures are left either if the hilum is prominent it would mean either the lymph nodes are enlarged or it would mean that the pulmonary vessels are enlarged so highly prominence means either lymph nodes or pulmonary vessels just keep this in your mind at this moment of time there are ways to differentiate between that as well but first of all we should be able to understand what is the hilam all about it okay so i hope you people have understood till now we've already been at almost 9 40 now and we have not even talked about many x-rays but this needs really a slow pace and slow understanding so let's harp on it a little bit date comparison previous x-rays rotation whether it is centralized or not exposure over exposed under exposed check the trachea check the heart cardiac seal out check the hilar area check the domes of the diaphragms check whether it's an inspiratory plate check whether there is a cardiothoracic ratio maintained or not then and only then go to the lung windows or the lung zones okay this is the basic of x-ray reading one more question which i saw come up was the aortic arch yes aortic arch is visible and as the name suggests it's an arch so it's like a curvature you will be able to see with x-rays how the aortic arch looks like maybe another x-ray you will see it much clearly cardio costo cardiac angle or cardiophrenic angle i think the person is trying to ask about the cardiophrenic angle is not really a very very important site of a disease so we need not think in terms of a cardio phenic angle okay as you see more x-rays your doubts will get cleared we will go through them one by one so once you finish that and you come to the lungs finally we come to the lungs please divide the lungs into the upper three intercostal space next three intercostal space and the area below near the diaphragm so its upper zone mid zone and lower zone whenever you are talking in terms of x-rays do not ever say there is a mass in the upper lobe do not say there is a collapse in the lower lobe do not say there is an infiltrate in the middle lobe lobes are something which are to be discussed when a three-dimensional picture is given to you here we are talking of x-ray as one dimension dimensional we are seeing only from front we don't know how deep it is where it is aligned whether it is lateral whether it is posterior whether its anterior we never know so you need to talk in terms of a zone if you have a lateral x-ray if you have a lateral x-ray you may get a fair idea whether it's in the upper lobe or a middle lobe or a lower lobe but for that you need a lateral x-ray lateral view but as of now right now you should just remember that it's the upper zone upper zone always and always always compare upper zone upper zone middle zone middle zone lower zone lower zone don't do right lung upper zone mid zone lower so never do that you should be compare compare compare now let's go through the basic x-ray after whatever we have heard of right now till now think and go through all the points you can see on the right hand corner a letter r written that is very very very important because it indicates the right side of the patient and there could be some patients who may have a situation or a dextrocardia so you should always insist or at least look upon where the right r is written okay it's written although it's every time in an x-ray plate it is mentioned now each of you go through this x-ray think of all the points which we just now discussed to yourself think for yourself take 10 seconds and try to remember each of the points which we just now talked about i'll wait for about two seconds then i will try to enumerate them so if each one of you have gone through then i want each of you to know that you could have seen the track here i hope each one of you could make out where is the position of the trachea in this x-ray i hope each one of you could make out the cardiac sillout i hope each of you can see the domes of the diaphragm and i hope each of you compared the upper zones mid zones lower zones of the lung fields yes as someone just noted the left medial end of the clavicle is a little away as compared to the right medial end means there's a left lateral rotation okay left natural rotation if it is not causing too much of a change in the cardiac silo that's fine that's perfect but at least it is found and it is noted is a very important part of x-ray reading so with that we will go on to the next x-ray again please don't start seeing x-rays just because you know there is some abnormality seen go through the points which we thought of which we discussed it may take some time for you to analyze but it's going to be sort of a self-teaching experience so that you get habituated to the way of x-ray reading it's not that we diagnose one case of pleural effusion and say this was my diagnosis it's like you should never miss any x-ray of pleural effusion that's more important yes now we can see here first of all those who have been able to see the trachea i will compliment them okay first and foremost because never ever miss on seeing the locating locating the trachea so those who have looked into the track i'm sure many of you haven't many of you have taken away by looking into something wrong at the hilum but please those who have first seen the trekkie i am very happy for them so always look at the trachea the next thing which i said when you talk look at the trachea you come downwards and then you can see the heart you can see the heart shadow very well now at the area of the hilum if you remember i will go back to this x-ray you can see the hilum over here and you see the hilum over here there is a opacity or there is a higher prominence i hope each of you have been able to identify that the hilum is more prominent in this x-ray and is it more prominent on one side or both sides answer it yourself so no no dr paras please don't say that dr paras is mentioning sarcoidosis i do not want i would request you to refrain from diagnosing the etiology please please avoid doing that however great i mean however good we are at reading x-rays we would refrain we should refrain ourselves from coming to a ideological diagnosis on an x-ray okay we'll come to that no doubt finally we are going to head towards that as well so the both the hilum are prominent both are definitely much more prominent than the normal x-ray and if you have found that that is also more than enough i am really not concerned about which size is more which size is less and how big it is and all those things you have been able to identify hilar enlargement perfect now what are the two structures in the hilum we said which can give an abnormal x-ray one is the lymph nodes and second is the pulmonary vessels that's all so stick to that we are not here to have a vision which goes through and we can see those lymph nodes no we are not going to do that so my differential would be bilateral high layer prominence possibly lymph nodes possibly pulmonary vessels now there is something in medicine which is always called as a differential diagnosis and we have to enlist the differential diagnosis based on what is the most probable cause so some person has not been able to locate the trachea so i think you should be trying to see right in the center of an x-ray center of the x-ray starting from the area of the neck and you will see a faint grayish line which is the trachea if you trace it down just the right paratracheal yet i don't know how to you know sort of move the finger or maybe point marker on this but on the right paratracheal right side paratracheal also there is an enlargement okay there is an enlargement or a prominence you see an x-ray before this this is the normal x-ray now you exactly put this x-ray in that place and you will find that the high alarm are enlarged that's all so we'll stick to this that there is a widening of the hilum now let's go to the next step when we say opacity when we say opacity it means that the air in that area is becoming less and the solid in that area is increasing okay solid is in that in solid or liquid both solid or liquid will give rise to opacity haziness means whiteness whiteness means opacity so if you see a opacity on an x-ray image then three things you need to locate or find out you should be like detectives whether it is localized or it is diffuse localized means only in one particular position or it can be throughout that particular area is it homogeneous it's completely opaque or there is patchy opacity opaque black white black white black white if it is black white and patchy it's called in homogeneous opacity is there a shift of the mediastinum or not means is it the trachea moving on either side or getting pushed on the opposite side so try to remember these three points is it localized or diffuse localized would mean there is a border to it or a margin to it homogeneous means it is completely opaque and with or without a shift of the mediastinum okay so have you memorized this so inhomogeneous would mean as heterogeneous same thing it just means that it is not completely white i'll give an example the cardiac opacity is completely white so it is homogeneous okay we will see how the homogeneous opacity looks like now these are clear cut you know diagnosed cases so i have just put this as a as a simple thing to remember how to talk about x-rays now if you see this x-ray go step-wise please first of all try to localize the truck here if you are able to localize the trachea excellent if you are not able to localize the trachea that's also excellent okay it doesn't mean that you are unable to make out x-rays it's relaxed it's fine just below the trachea there is a cardiac silhouette all right you know that there is a trachea and the heart and the trachea and the heart together comprise the mediastinum together comprise the so media sternum may move together it may move on one side or get pushed or pulled on the other side so what you need to know once you see the trachea is the heart in position or not or is it shifted to the right side how do we know whether it's shifted to the right side right para cardiac border is just just outside the spine okay the right paracardiac border is just away from the spine but in this particular x-ray you should be able to appreciate that the right pericardiac border is much more to the right side which means the heart seal out or the cardiac silhouette is shifted to the right some people may not be able to appreciate because they have not kept the normal x-ray in their mind so try to keep a normal x-ray in your mind and then put this x-ray image you will find that the x-ray is pushed the heart the cardiac silhouette is to the right now if you feel that the heart or the cardiac silhouette is to the right there has to be something which has pushed it heart cannot just move to the right by itself so there is something either something which is pushing it from the left to the right or something which is pulling it from the right itself so we take help of the next thing we have talked about the trachea we saw the heart now we take help of the diaphragm okay we take help of the diaphragm so what is seen in the diaphragm now you try to see the right diaphragm try to see the left diaphragm can you make out the left dome of diaphragm yes you can is it much less lower down than the normal presence yes it is almost two space below the left below the right dome of diaphragm it is come down so there is a diaphragm which is pushed down there is a heart which is pushed to the opposite side so we have finished talking about the trachea the heart and the diaphragm now we said now we have to talk about the lung fields so we compare the upper zone mid zone and the lower zone now if you see the x-ray and just compare leave the heart leave the trachea leave everything aside now there would be people who say this is a pneumothorax this is a whatever but i would be more eager for all the learners to go by a systemic approach systematic approach trachea heart diaphragm and if you see the zones then if you compare the upper zone mid zone lower zone the left upper zone mid zone lower zone as compared to the right appears more black it appears more black what is the word we use for a blackness it is called as hyper lucency we call it the left upper zone mid zone and lower zone or more hyperlucent as compared to the right side yes dr astha is right it's called hyperlucency so in this x-ray if you are to show this x-ray or if i am a student and i am told please describe this x-ray my description would be the cardiac siloed is shifted to the right the left dome of diaphragm is pushed down and there is a hyperlucency seen in the left upper zone mid zone and the lower zone this is the description so the examiner is going to ask me so what do you feel is the hyperlucency because of now i understand that hyperlucency means more more black more black means more air more air happens in a thoracic cage in two diseases one is in the pleura which is called a pneumothorax or it can be in the lung which can be a large bula bulla is a air filled cyst okay air filled cyst so it can be a large bula or a pleural air that is pneumothorax so this will be the way you will gradually gradually start thinking or interpreting x-rays okay it's all about how you can interpret the findings which are seen on the x-ray so for your understanding this would be just a hyperlucency in the left upper zone mid zone lower zone with shift of the mediastinum to the opposite side and the diaphragm being pushed downwards again i am trying to explain that the most common possibility in such an x-ray if it's in the pleura is a pneumothorax left sided pneumothorax air in the pleural cavity so if there is air in the pleural cavity and the air increases increases air it it pushes the lung immediately medially immediately immediately because the lungs are tied at the hilum they are like balloons which are tied at the hilum so when the plural air increases it pushes the lung smaller smaller smaller end the lung collapses or closes or atelectasis happens so the left lung is collapsed left lung is atelectasis and it is because of the compression of the lung caused by the air in the pleural cavity so it is called as a compression collapse there are many types of collapse but here we are just talking of a collapse occurring because of air in the pleural cavity so the air is compressing the lung so it's called as a compression collapse okay so if the entire lung is filled with a bula you may be not be able to really differentiate a pneumothorax from a large bula but only thing is that in a pneumothorax we'll be able to see the collapsed lung border lung margin in a bulla there won't be any collapse because the bullet is in the lung itself okay so obviously in this x-ray we can see there is a collapsed lung and there is air outside it so this becomes a left-sided pneumothorax so when i say collapse the collapse here is because of the air in the pleural cavity so we'll just move on to the next x-ray now you take your time don't be in a hurry this is not an exam obviously and this is not not thankfully there is no patient right now in front of you asking what is the diagnosis what do you feel it happens what is the what is there in the x-ray so take some time maybe another five seconds more think about it and then we will proceed with the discussion so those who have been able to you know sort of think about what's happening in this x-ray i would like to ask a simple question to all of them did you locate the trachea first of all that's my always my first question and every time i would want to know if the answer is yes or no have you been able to see the truck yet so definitely the trachea is seen in this x-ray and i will tell you where the trachea is seen try to see the right clavicle okay try to see the right clavicle the medial end of the right clavicle you can see near the middle end of the right clavicle you will see a slanting gray line slanting gray line okay it is towards the right towards its almost coming to the right clavicle medial end of the right clavicle it's a slanting gray line gray line is because it's air in the trachea so there is a trachea which is seen definitely it is seen and it is actually almost at an angle towards the right clavicle so that is the trachea so in this x-ray if we go systematically you can see the trachea is to the right the left heart border is seen right hard border is not seen so we don't know where is the right hard border but more probably that the right hard border is gone to the right because the left hard border is hardly on the left side but at this moment we'll stick to only one thing i can see the trick i don't know about the heart that's fine so the right the trachea is to the right side we can't see the right dome of diaphragm so i don't know what's happening on that side so let's keep at that only i can only and only see that the right side trachea is to the right so let's see what is happening in the lungs compare the upper zone mid zone and lower zones when you compare these zones on either side you can actually see that the upper zone on the right side is opaque as compared to the left upper zone right mid zone is opaque as compared to the left mid zone right lower zone is opaque as compared to the left lower zone so there is an opacity in the upper zone mid zone lowers on on the right side as compared to the left zone here the left lung now when we talk of opacity we need to know whether it is just go through those points which i said whether it is localized whether it is homogeneous or with or without shift of the mediastinum okay so we'll answer these three questions is it localized it is completely opaque so there is nothing like a small localization it is the entire right hemi thorax here we use the word right hemithorax is completely opaque completely opaque is it homogeneous yes it is homogeneously opaque okay so there is no nothing like a border to its completely homogeneously opaque is it is it causing a pull of the mediastinum yes it is causing a pull of the mediastin so we have got all the answers now there is a pull of the mediastinum there is something in the right hemithorax which is completely opaque opaque means either solid or liquid that also we know because black means air white means solid or liquid so can it be liquid if there is liquid on the right side of the lung the lung would be pushed to the opposite side so that is not happening so it is not liquid so that means that the entire right lung is closed because there is no air in the right lung the all the air has gone away so the tissue has come close together and now what you can see is only and only the tissue in the lung or the lung tissue so this would classify as a collapse of the right lung collapse of the right lung okay in simple word it would be just a closure of the lung on the right side so all the air has gone away what is left is only the lung tissue lung tissue without air looks white so it is a complete collapse of the right lung okay so it is something which is pulling and that's why we are calling it a collapse if it would have been a tumor say someone says one of you may say but why don't so why don't we think it's a solid growth solid growth is also tumor so it will look white if it grows and grows and grows it may actually push the heart to the opposite side okay so this is at this moment we can just say it seems to be a right lung collapse now there are differential diagnosis there are causes which we will discuss for five minutes uh so what could be the cause let's assume that i am that we are all corrected yeah okay this is a collapse only why should there be a collapse in a patient now collapse means if you remember and heard me correctly some time back when we were talking of pneumothorax and the lung collapsing i used the term compression collapse okay the lung was getting compressed now imagine that there is a bronchus okay there's a bronchus but there is a growth in the bronchus there is a tumor or a growth in the bronchus and this growth it closes the airway it closes the bronchus once it closes the bronchus the lung which is distal to it will collapse because there is no air entering into the lung for the lung to function it has to open take in air exhale it has to function but now there is a blockage so no air is entering so that growth in the bronchus could have led to a right lung collapse it could have led did you see the growth we have not seen the growth can you see the tumor no we can't see the tumor so on x-ray what is the possibility right sided collapse if it is because of a tumor which is blocking the bronchus then it is called obstructive collapse remember in pneumothorax we said compressive collapse now we are talking about obstructive collapse so this could be an obstructive collapse all right there are of course now this we just discussed the cause but there are differential diagnosis can it happen that the person survives on one lung very much it can happen so this could be a differential diagnosis a genesis of the right lung means the patient never had a right lung so there was nothing but fibrous tissue thick tissue and it just kept the trachea to the right the lung was not there so it could be a genesis of the lung which also means that if the patient has been operated and his right lung has been removed which is called pneumonectomy the x-ray would look similar so a genesis of the lung pneumonectomy obstructive collapse all could be possibilities in this patient okay this could be possibilities and the most and the most sensitive aspect of x-ray reading is history taking without history taking to see an x-ray and just to say this is what i feel is like half the job done it doesn't mean or serve the purpose all right so you need to have a history but in this particular x-ray it could be a genesis it could be pneumonic domain it could be obstructive collapse all right this would be the terminologies we need to use in this x-ray so good night everyone thanks a lot for your time thank you thank you so much bye bye

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