 Hello everyone and welcome once again to Indian Radiologist. Firstly, I want to thank all your subscribers and viewers for having faith in us and staying with us for the last three years. In these last three years we've had more than 28,000 subscribers with us and we've been growing. So we have no one but you to thank for our development on this channel. So we start once again this Sunday with another series of X-ray spotters. This is the second series, the first one I've done about a month ago. So those of you who have not seen that one, you can just go back and watch it right here. And for those who've seen that one and are coming back for this second series, well welcome back. And we start with the last X-ray of the first series and here it is. So what we have is an portable X-ray done in the intensive care setting and as we discussed earlier, we have to look out for every tube, okay? We have to see the end of the tube where it ends and also if you can see the other end of the tube in this frame or in this projection. So we can see here the endotracheal tube very clearly coming down, but it's not stopping at the carina as it should. It is moving down and is in the right main bronchus. So this is an absolute red flag. You need to call the intensivist or the doctor, the nurse and tell them that this needs to be withdrawn. We start with our first X-ray of the series and this again is an X-ray taken in the ICU. So this is a COVID patient actually and what we could see of course are those peripheral shadows that we've been seeing for all of the last 18 months. We can see these soft tissue density shadows in the peripheral aspects of both mid zones as well as lower zones. Now if we start tracing the tubes that we can see on this radiograph, what do we see? We can see here the central line is ending quite correctly as it should, but we see another tube here and this is the right tube. We can see the nasogastric tube tip which is led which allows us to see it on the radiograph and this is not where it should be. We should see that tip somewhere here in the fund list very confidently. So this tip has lodged in the midisophagus again a big red flag and you need again to call up the intensivist and tell them what the problem is. So we have to be very off the Ryals tube. You must see the tip off that Ryals tube very clearly in the fundus of the stomach or in the stomach proper. Sometimes it can be a problem with newborns especially when you're taking X-rays in the NICU or the PICU and here's one of them. So what you could see is that I can see a nasogastric tube right here. However, I'm not so sure where the tip is. I cannot see it in this fundus. So what should I do? Should I let it go or should I say you know hold on. I'm not so sure that you should be very sure where the tip of that nasogastric tube is. It's a small thing but it's very important and here again you can see it very clearly nicely ending up in the stomach. So this was about nasogastric tubes. The tube can get displaced and may not be in the correct position and it is our job to find out where the end is and if it has been correctly placed. Whether you see it on X-rays, whether you see it on a CT scan. This is our next radiograph. So what we see here is of course a postoperative X-ray but you've got to know what it is. And this is a pneumonectomy and how can you tell? So you can tell a pneumonectomy by absence of air markings in this lucent area. So you know that there is an air fluid level here. Don't mistake it for a hydronomothorax and say that it's a hydronomothorax. It's not and there are other features that help guide us. And these are the features that we can see. You've got to see an air fluid level very clearly. You see resected ribs usually it's the fifth or the sixth rib on that same side. You will also see if you look carefully surgical clips right here. You can see them here. So the surgical clips seen at the high limb. And of course when you look carefully as time goes by you will happen to see there's hyperinflation occurring off the opposite side of the lung and the lung actually comes towards the right side. Like for example in this X-ray you will expect as you take progressive X-rays of this patient you will see hyperinflation off the left-sided lung. And gradually the fluid level on the operated size will keep increasing till it fills up. So we have the next radiograph here and this one was a little tricky for us. When it came to us this patient came with a bit of breathlessness and history of surgery. So have a look at this radiograph and we have an explanation as well as a CT scan for you. So when we first saw this X-ray we thought well it's post lobectomy and you see resected ribs on this side. But we also felt these look like bullets and also noting that the patient was breathless. We decided to do a CT scan for this patient. So here's our CT scan what can you see you can see this loculated pneumothorax. But you can also see a clear communication with the right lower low bronchus. You can see that pneumothorax here and if we just go back and forth and you go on the same lung windows as well. Once again you can clearly see that communication right there. So this is a case of a broncoplural fistula. Once again the coronal plane resected ribs here on the right side. Here's the broncoplural fistula with the loculated fluid seen. So what are the causes of broncoplural fistula? They most commonly follow a lung resection. This is the most common cause with a reported incidence of almost 1.5 to 28% after pulmonary resection. There are other causes also such as tuberculosis. Sometimes it can be itrogenic during tube insertions as well as a tumor extension or tumor necrosis following chemotherapy or radiation. We run through a couple of quick spotters that are just spotters. So here's one. Okay you must have all got this by now. This is just a simple old healed left clavicular fracture. Now this is really insignificant we feel it's old it's healed but sometimes this can come back to bite you. You might miss this and the patient may come back with some x-ray the next day and say you know what you had diagnosed this like three years ago. So you end up feeling really stupid this does happen once in a while. So you just got to be very look at the bones keep looking at the bones in the x-ray. So when you have a normal pattern of watching x-rays some people do a zigzag pattern for the lungs some go inside out some go outside in whatever your style. Eventually the last look always try to look at the scapulae look at the clavicles and look at the ribs you will end up finding something. Well this is our next radiograph. Okay so this would seem like just simple pleural effusion right you'll say okay pleural effusion on the right side and it's out. But like I said last look always keep looking at the bones have a look at the scapulae have a look at the clavicles have a look at the ribs and if you look at the ribs nicely. You can see a couple of cracked ribs over there you can see rib fractures instantly you will say why are the ribs fractured with pleural effusion you're looking at some sort of trauma. Here we go. So we see this CT scan you can see a lot of fluid out there as well as the rib fractures right there. A bit of air pocket also seen in that pleural fluid and some more rib fracture so always remember always look at the bones towards the end. Next case. So this is a patient where undergoing a lumpectomy turned out to be malignant but she did not follow up for radiation. She tried alternate therapy and soon enough within about six to eight months she came gasping to a hospital with this large pleural effusion. So she was tapped immediately in the the casualty itself and kept in the ICU next day. It filled up once again it's quite a bit of fluid once again so a decision was taken that we need to put a pigtail or an ICD patient was pretty bad could not withstand any sort of even minor surgery. So we took a quick decision here to put a pigtail on bedside setting in the ICU. So we had the pigtail put nice and clean it was direct puncture style. You can also see a large airspace consolidation involving the right lower side but you can see the amount of fluid that had gone two liters went in the first 15 minutes and subsequently even the consolidation did clear up. Eventually the patient was convinced and agreed to go for radiation therapy. This is our next x-ray. So again you should get this by now. This is the azygous lobe or the azygous fissure as we call it. So what is the azygous lobe? Now this is formed during embryological development when the right posterior cardinal vein aberrantly migrates through the upper lobe of the right lung rather than over the apex. As a result two pleural layers get carried down through the right upper lobe creating a fissure known as the azygous fissure. So our next radiograph. The x-ray with some soft tissue density opasties noted in the left mid and lower zone. But like I said you need to see the bones either at the beginning or at the end. So if we have a look at the bones here we can see the ribs and they look just fine. We can have a look at the clavicle. The clavicle is fine and so to the left scapula. But if you look at the right scapula what we see is a dense clerotic lesion involving the spine of the scapula. So this dense clerotic lesion in a 70 year old male should raise your antenna to a couple of diagnosis. The most common one being that of a metastatic lesion from a prosthetic cancer. A PSA was done for this patient it turned out to be sky high it was about 70. And we ran a CT scan on the patient to confirm this lesion. Of course we could see very clearly this dense clerotic lesion involving almost the entire scapula. The spine as well as the denoid cavity. Our last case of the day. So once again dense sclerotic bones. This is a child as you can see. This is uniform increased bone density. And the first and only diagnosis that you can think of in a child is marble bone disease or osteopetrosis or Albus Schoenberg disease. And what happens in this condition is that the bones become sclerotic and thick. But they are quite weak and brittle because of deficiency of osteoplasts. In adults you will think of osteoblastic meds. Prostatic cancer and breast cancer usually can give rise to this. Fluorosis but fluorosis would be generalized. You would also get ligament calcification and fluorosis. Pajus disease. But once again in Pajus disease there will be some change in the bony architecture. And of course myelosclerosis and renal osteodistrophy. Whereas in a child you will be looking at osteopetrosis. Okay friends so that is it from me now for this session of x-ray spotters. I hope you enjoyed it and if you did I would like you to please like, comment or share this video. Thank you and see you back once again on Indian Radiologist. Bye bye.