 Hello, everyone. I'm Dr. Sanjeev Mani from Indian Radiologist. Today we start a new section that of spotters and what better spotters to start with than with the X-ray chest. We know X-ray chest are important for us whether you are an MBBS student, MD radiology or MD medicine, as well as in our day-to-day practice. So what we are going to do is a quick rapid file testing of your abilities and your skills. Some are going to be very easy, but some are a little twisted. So I hope you enjoy this. Thank you. So we have a collection of about 10 to 12 spots. Pretty simple ones actually to begin with the series. And what we are going to do is show a spot for about 5-10 seconds and then proceed with the diagnosis and a very brief discussion. Not more than 40 to 60 seconds per X-ray. So we should be done in about 10 minutes. So this is the first X-ray. This is chest X-ray of a child with fever. So what we see here is multiple tiny nodules scattered across the lung. Those in reporting in India it's very simple diagnosis. This is nothing but millery modeling. And the causes of this in our country especially is the one and only millery tuberculosis which is because of hematogen is spread. But the other causes also usually sarcoid is a very close second. And also hypersensitivity nemonitis can give rise to a picture such as this. In the elderly you are looking at malignant disorders like bronchoalveolar carcinoma. And also hematogenist metastasis from carcinoma of the thyroid, kidney or even lymph angiotic carcinomatosis. Some other cause of millery shadows can include pneumoconiosis although those nodules will be slightly larger and silicosis and pulmonary cirrhosis. Now what we have to understand is the difference between millery modeling as well as pulmonary nodules, pulmonary micro nodules and pulmonary masses. Now millery modeling is basically a lesion that is up to 2 millimeters. Anything more than 2 millimeters to up to 7 millimeters is usually classified as a pulmonary micro nodule. Nodules are characterized by lesions that lie in the dimensions between 7 millimeters and 30 millimeters. And beyond 30 millimeters those lesions are usually called pulmonary masses. So this is the differentiation based on the sizes and this is the case of millery modeling. We move to case 2. Again pretty simple what you can see is a soft tissue density shadow seen in the right claustrophrenic angle. It's blunting the claustrophrenic angle and moving up to the axilla. We also see a biconvex soft tissue density shadow here which is nothing but fissural effusion. So the diagnosis here is pretty simple. It is a right sided pleural effusion with fluid lying in the fissure as well. Now the causes of pleural effusion may be asked and it's pretty simple. This is usually heart failure or heart disease. Also of course liver and kidney diseases can give rise to pleural effusions. These are usually transutates that we come across. Now the fluid that comes is usually on the right side. Other conditions such as pneumonia or consolidations can give rise to a small synpneumonic effusion as well. Tuberculosis of course is the major cause and even if you see one sided pleural effusion you have to think of tuberculosis as a diagnosis. And that patient will usually be subjected for a pleural tapping. So what we see is dense calcific areas seen at the right claustrophrenic angle. The claustrophrenic angle is blunted. You can see that calcification extending upwards as well. You can also see a little streak of calcification here on the left side. So this is pleural calcification. So the causes of pleural calcification are usually hemothorax, pyothorax and pima as well as tuberculosis effusions. Rarely met from osteosarcoma can also give rise to pleural calcification. We go to our next case now. So what we see here are dense plaques seen on both sides, both in the right and the left. The claustrophrenic angles are incidentally spared in this condition here. And you see a classic pattern which is known as the holly leaf pattern. So these are asbestosis plaques. Now we have to remember that there is a long interval between the initial exposure to asbestosis and the development of asbestosis related diseases. Especially you have to ask for history for people working in mines and also those in the fiber cement industry. Asbestosis exposure can result in asbestosis, mesotheliomas as well as lung cancers. Now these pleural plaques are usually asymptomatic but are a marker of asbestosis exposure indicating greater risk of developing pulmonary fibrosis or asbestosis related malignancies. This is our next case. This patient has come for a pre-op evaluation. So what we can see is a shadow seen at the right. Cardiophenic angle. You can see this little triangular structure. You note that this is not really a true soft tissue density shadow. When we talk of densities we look at air densities as we can see here. We look at soft tissue densities like that of the heart or any lesion that we may see in the lung. We also look at calcific densities like how we saw in the pleural calcification on the asbestosis of plaques. But this is a little less denser than a soft tissue density and this is actually fat. So this is nothing else but a pericardial fat pad. Now you have to understand the difference between epicardial fat and pericardial fat. Now epicardial fat lies between the myocardium and the visceral pericardium whereas pericardial fat is adherent and external to the parietal pericardium. Usually we see it as a faint capacity which resembles fat density at the cardiophenic angle usually on the right side. Differentials for this can be pericardial cysts or sometimes a true lipoma. Sometimes a Morgagni hernia can also give rise to a similar picture. Next case. So what we see here is an inhomogeneous airspace consolidation noted in the right upper and mid-zone. If you look at this lesion closely by magnifying this area you can see a wedge shape structure. So this resembles what a consolidation would look like limited by the fissure. But you also see an air fluid level right here. You can see the air pocket here and fluid here. So immediately you are looking at a cavity with fluid or a lung abscess. And if we do a CT as we did here we can see the consolidation right here and it's a bit of air bronchogram but you can clearly see an air fluid level right here. That's the air pocket with the negative attenuation values and that is the fluid pocket. So these are lung abscess and the causes of lung abscess are several. Common ones being infective especially aspiration and elderly and usually those infections are anaerobic infections. Tuberculosis can be the major cause of lung abscess and when you see this picture sometimes it's hard to tell whether it's tuberculosis or infection. And what you would need to do is stick in a needle, remove some fluid and send it for cytology and gene expert and you would be getting a definite diagnosis. Tumors such as swarmicell carcinoma can also cavitate and give rise to cavity with the fluid level inside those lesions of course. The cavities will be thick walled and irregular. Underlying lung diseases such as bronchitis, cystic fibrosis, contusions and even infarcts that get infected give rise to a lung abscess. This is again an ICU radiograph and what we see again is a similar picture but on a much more severe scale. We can see different patterns here. You can see destruction of lung on the right side. You can see formation of a cavity here in the upper lobe and you can see a cavity in the mid zone as well here. You can see dense lesions in both mid zones as well as the lower zones. What I interest was this little soft tissue shadow that we thought could be representing some material within the cavities. So we subjected this patient to a CT scan. We see CT scans done in the supine position here and you can actually see some opacification seen within the cavity that actually moves its mobile as you check the prone scan. It has moved downwards and hence this is a fungal ball and fungal ball in a cavity is pretty common and diagnosis is aspergilloma. Now this is a patient who has history of tuberculosis in the past and has presented with persistent cough. What we see here is destruction and loss of lung volume on the left side. You can see that the lung is totally destroyed and replaced by cystic areas. You can also see a pulling effect that has been created. So you can see a cardiomedicinal shift to the same side. So you can see the heart has moved totally to the left leaving the spine there. You can see the trachea that's moved to the left. The left dome of diaphragm is raised and not very discernible but you can see these bronchiatric shadows extending down in the lower lobe. So this is just destroyed lung with loss of lung volume and stigmata which suggests fibro bronchiatric changes which are secondary to pulmonary tuberculosis. You also have to note that the right lung is looking quite clean. It is showing compensatory hyperinflation with a little bit of lung moving across towards the left side. So a 55 year old patient was presented with cough. So what we can see is a bi-lobed mass lesion. You call it a mass lesion because more than 3 cm and I'm calling it a mass lesion because I don't see any air bronchogram with this lesion. It is not bed shaped. It is lobulated. It has got a convex border. It's reaching up to the apex. It's reaching up to the pleural margins. It's pushing on the trachea, pushing it slightly to the opposite side and when you see a soft tissue shadow with rounded margins absent air bronchogram, you're looking at mass lesions and the next thing you've got to do is a CT scan and that's what we did and the CT showed a mass over here and subsequent investigation with the PET CT showed this to be a metastatic lesion from a CA colon. So this is an x-ray taken in the COVID ICU. What we see here of course are typical COVID lesions that we've been seeing all along in the last 18 months. We can see consolidation pictures seen in both lungs, more so on the right side but we've got to train our eyes to see beyond the lungs. So of course we saw pleural lesions in this video today but we also need to look at the bones and what you can see is a calcific lesion and it's a little lobulated and you can see it arising probably from the scapula or the rib. This patient actually incidentally came down for a CT scan and when we did the CT scan what we can see is very clearly this lesion is arising from the scapula. So dense solid sclerotic lesion arising from the scapula, little lobulated but very smooth and this happened to be a scapula osteocontroma. Our next case is a patient with a chest x-ray, a chest x-ray PA view who actually came for some trauma and a PA view was asked for by the GP so we said no we need to do an oblique and we did an oblique x-ray of course over here and this patient had a couple of fractures which will not be so evident to you now so I'm just going to zoom up this image right now and what we can see is a couple of subtle fractures we can see that here and we can see it here but what is also important is that when we look at the breast tissue shadow on the left side we can see a subtle opacity within it it's almost a biconvex lesion and hence this patient was then subjected to mammography which was a very smooth lesion and eventually we did an ultrasound as well which demonstrated a very smooth lesion indeed with a fluid level but it also had a small solid nodule right here this patient's subsequent histopath revealed this to be a neuroplastic lesion on this x-ray we can see is again an ICU x-ray and every time you're seeing tubes and lines you actually got to trace where the tube is coming from and where it's ending so this is a very simple one but we'll be showing a few more in subsequent tutorials and what you can see here is the endotracheal tube and this tube is reaching out into the right-wing bronchus so you need to make a quick call to the intensivus or the sister in charge or the doctor whoever is picking the phone up and just let them know that they need to reposition the endotracheal tube well that's it from me for this tutorial I do hope you enjoyed it and if you did I would like you to please share or comment in the box below and I look forward to seeing you again next month bye bye