 Hello everyone and a warm welcome to Indian Radiologist. This Sunday we will be taking a quick lecture on X-ray spotters and this one especially for those students and residents who have just joined Radiology. We know you should have been here eight months ago but it's never too late you can always subscribe to our YouTube channel that has more than 650 videos as of today. So we'd like you to be part of the Indian Radiology team and before we begin this series of spotters today a quick look at what Indian Radiologist has to offer this year. We start out with the masterclass series there are about four left in this year which include Fidel Echo with experts like Dr. Balu, Dr. Maaz Klansky and Dr. Alpana. We had the best imaging coming up this month later today with Dr. Shilpa Lard as the curator for this event. We also have two muscular skeletal programs with Dr. Sanjay Desai as well as Dr. Malini Lavande. There are three big ticket events also coming up especially the MRI course which is now in the 21st year. This is being run by Dr. Deepak Pakkar and it is a hybrid event with an option to attend this event both online as well as on site in Mumbai on 13th and 14th of August. We also have CT bus coming up with Dr. Dushan Sahani joining us from Washington USA and he will be conducting a series of lectures on abdominal imaging. This event again is an on site event which is being held in Mumbai at Hotel C Princess from October 29th to 30th. It's a weekend and all our conferences will have papers and poster presentations for residents as well as practicing consultants. Our big ticket event of course is Sonobas 2023 which is on the Jan weekend, Jan 6th to 8th and we have a huge galaxy of national stars as well as international stars which are coming to India for the first time since the COVID pandemic. All the links to these conferences are in the description below. So we hope you be part of the Indian radiologist fraternity and keep enjoying our lectures on YouTube as well as attending the various classes that we have on offer. Thank you. We begin with this x-ray. This is a chest x-ray AP view. It's a supine view and as we started with the previous x-ray spotters as well we just have to identify and see if the tube is in place or not. And as you can see it is really not in place because you can see the tip here at the distal end of the esophagus and actually it's very much lower down right here in the fundus. So you would need to call up the department the intensive care and just let them know that to push the tube inside a little more. And one more x-ray of tubes before we move to the actual cases and are all tubes in place. So once again if we see central line right here this looks fine coming in from the left jugular. We look at a riles tube coming in here and it's crossing down quite easily. We can see it going down below the diaphragm. This is likely to be in the fundus although we don't see the tip here but we can safely say that this looks fine but have a look at the endotracheal tube. You know it is supposed to shop short of the carina and just above it but here you can see it moving in almost placed in the right main bronchus right here. So once again do not wait and give the report and forget about it call up the intensive care and let them know of this problem. We move to our series and here is a chest x-ray of a patient who has come for a health checkup. So we can see here that the lung fields look clear the pleural spaces are normal so too the heart is looking good. So always always if the chest x-ray looks normal have a look at other subtle findings that you might miss. One we've been talking all along in the previous series also is to look at the bones but we don't see anything abnormal in the bones but also do look at the tracheal shadow and so when we see we look at it deviated and in fact there's a deviation caused by a little soft tissue density right here on the left side. So this happened to be actually a thyroid nodule which this patient had which was causing deviation of the trachea to the right side. So this is an important sign to look for in patients when you're seeing chest x-rays always a last look at the bones as well as the tracheal shadow. Our next case is over here again this is a simple spotter so once again clear chest clear pleural spaces the pony cage looks all right look at the trachea it looks nice and central with the carina right here but if you can look closely it's a little subtle but you can see a nice soft tissue density shadow here as well as on the other side this is separate from the breast shadow but within the breast is actually this happens to be a breast implant on both sides. And this is our next x-ray so the question here is are the pacemaker leads in position or not. So we can see two leads out here this is a post-CABG patient that we can say that based on the sternotomy sutures that we see here we can see the post-op clips as well right here and our pacemaker is here we can see two leads you've got to see the leads out here that need to be going down and into the right ventricle as well as the right atrium. So the position of a dual catheter is basically one lead stays in the right atrium and in fact you should see a hook there because that hook means that this is in place it should lie in the right atrial appendage whereas the second lead lies in the apex of the right ventricle so this is fairly well positioned. So we may see a single chamber lead where the tip lies at the apex of the right ventricle and of course a dual chamber like we saw in our case where the tip is in the apex of the right ventricle like we see here as well as a hook. So this is our next case and you got to have a look at it and look what the answer is. So once again this is post-CABG so you can see post sternotomy sutures you can see the pacemaker out here on the left chest wall you can see two leads again you can see one here in the right atrium as well as the other one at the apex of the right ventricle these look to be in place but have a look at another finding here you can see a linear dense calcified area running almost parallel to the plural margin so this happens to be plural calcification. So plural calcification usually results secondary to hemothorax thoracic empymer and also tuberculosis plural effusion you can see plural calcification as a result of exposure to asbestos fibres but those are usually plural plaques and they're usually free of the claustrophantic angles we also see them in post-radiation therapy this happens to be our next x-ray so once again you can see clear lung fields you can see a normal heart the tool spaces are clear there's no effusion you can see a normal pony cage like we said have a look at the trachea before you sign out it looks fine but also look at the abdomen so abdomen usually is featureless you may see a scattered bowel loop here or there and of course you need to see the funding bubble but have a look at this you see dilated loops these look like judgment loops dilated and this is not normal so once we saw this x-ray we ordered a abdomen x-ray and as you can see you can see multiple effluid levels there's no pneumo peritoneum this is a case of small bowel obstruction and we ordered a cp scan next we can see multiple dilated loops all across you can see presence of acitis over here in the paracolic gutters on either side you can see dilated bowel loops with small bowel feces sign and the colon is empty as we go back once again you will be seeing nice thickened enhancing wall suggestive of a stricture this happened to be a tuberclean stricture which has caused a small bowel obstruction and that was first visible on the x-ray so many a time it's important to know history unfortunately when we have chest x-rays we don't always get the history you get a big pile and you get about going to report it as fast as you can so a little bit of attention to detail as far as the history is important because it can help us get a strong solid diagnosis of right from the x-ray chest itself so we come to our next x-ray this is a case 8 so this is a true spotter in the sense that something like this might be up in the spotter series in your exams and once again got a look everywhere so once again we start looking we look at the lungs in the zigzag fashion or up down and down up as you wish to the lung feels look absolutely normal so to the heart and the plural spaces but we have a couple of findings one that you see some clips which are post-operative clips in the right axilla and immediately you got to think of some surgery that's been performed here and if you start looking at the soft tissues as well you can see that the right breast shadow is missing and you can see the left shadow here but there is no right-sided breast shadow so this is a right mastectomy because of CA breast and you can see the absent right breast shadow as well as the post-op clips out there and we come to our next x-ray again this is a portable x-ray taken in the ICU and it was taken in sitting position as we do insist for x-rays done in the ICU in our hospital so once again look at the lung feels look at the heart so you will get that apparent cardiometalline even though the patient's in sitting position because of the AP view of the radiograph and firstly we come to the tubes the endotrivial tube looks little fine maybe a little high but it's just fine and so to the central line there is some blunting here of the left costofrenic angle and if we look at the retro cardiac shadow okay you can see the presence of an air bronchogram so once you see the presence of an air bronchogram here you are actually thinking of a consolidation in the left lower low so this is an important finding the key here is to look at retro cardiac shadow and to look for an air bronchogram or a collapsed left lung as the case might be once we saw this the patient was breathless the PO2 was falling we went on to do a CT scan of this patient as we see the CT scan of course we can see the pleural effusion out here as well as the airspace consolidation right there we will also switch to lung window and in the lung window again you can see the pleural fluid as well as the consolidation that is seen in the vingula as well as the left lower low so the echo message from the CT is that always look at the retro cardiac space do not miss any collapse of consolidation behind the heart and we come to our last case this an 80-year-old female who was gifted a health checkup by her daughter who's staying in the United States so this lady was insistent saying well nothing's wrong with me but unfortunately one test led to another and what we can see here are very subtle soft tissue density lesions seen in the chest on both sides you can see it in the lungs in the left lower zone and the mid zones just soft tissue density shadows rather ill-defined and you can see one more over here in the right lower zone so once we saw this we are thinking of metastatic lesions and we had to really convince her to get a CT scan done and when we run the CT scan so we can see the lung windows as well as the chest but when we come to the lung windows you can see clearly nodules of various size scattered in both lungs and these happen to be metastatic lesions and we see the arterial study out here on the left and we can see medecinal lymph nodes as well as a large neoplastic mass lesion was observed in the left breast