DIP Episode 404 - The Floridly HY CXR Podcast

Okay, welcome everyone. My name is divine. This is episode 404 of the Divine Intervention Podcasts. And into these podcasts I'm going to be describing what I would like to call the pathophysiology of chest x-rays, the pathophysiology of chest x-rays. I know some of you may be like pathophysiology of chest x-rays, that's kind of weird, that's kind of bizarre. It's not like I'll be going into like deep pathophys, but maybe I should call this thinking about chest x-rays. Because the thing is so many people stress out about chest x-rays and they don't really need to do that. Most times on in-bim exams is not one factor that makes you get a question right is a combination of multiple factors that you put together in helping you arrive at an answer. So I will just say a few things about chest x-rays, actually a variety of things. Maybe let me see that way. That I'm really hoping that you find to be very helpful. Now before I delve into our conversation, if you're taking step two, seek your step three or complex level two or three, anytime within the next few days or next few weeks, I will strongly encourage you to consider the 20-hour course I offer. It's going to start this evening from 4 to 8 p.m. Pacific Standard Time. It'll be on Monday, Tuesday, Thursday, Friday and Saturday from 4 to 8 p.m. Pacific Standard Time over Zoom.

It's going to be 20 hours total and we will discuss internal medicine, Peds, Obidine, Psych, Neural, Surgery, Biostatistics, Ethics, Multi-Systems, Processes and the Soldiers, Communications, Healthcare Systems, things of that nature. And again, you know me, I'm not very big on just teaching a lecture. It's going to be almost entirely all key scenarios and I'm going to devote time to this awesome path of physiology so that you actually have the understanding. As you'll see, many things on the MBM is these days, depending on you understanding stuff, instead of you just blindly memorizing things. We're going to probably go over more than a thousand, not probably. We're going to go over more than a thousand different scenarios, right? That are very pertinent to the exam. Again, I've had many people that have taken these courses and they've done significantly well on their exams. So the thing is chest x-rays are not that hard. I mean, depends on the degree with which you need to know it. I mean obviously if you're a radiologist, your knowledge of chest x-rays is going to be significantly better than most, if not all people in medicine. The thing is many of these things will imagine you literally have to read like thousands of them to become proficient.

But the thing is if you're not a radiologist or whatever, there are just certain key things and obviously since this podcast is focusing on the USML Es, there are just certain key things to keep in mind with chest x-rays that can help you very significantly and answering them. The thing is if you follow some of the rules, I'm going to teach you today, you're probably going to be about 95% or more accurate with just dispatching most of the chest x-ray questions that you get. So let's start with a few basics about chest x-rays. Again, talk about some basics, talk about some pathologies. But the way I would discuss these pathologies, I really feel that if you really try to grasp everything I'm going over today, you're being good-ship. The key thing on exams is just recognizing what is common because many people try to memorize and learn all these esoteric images that they just end up not really ever needing on exams. So I will encourage you, try to learn the common things, remember common things are common and you'll be you'll be in good, in good shape. So again, I'll highlight something, try to give some commentary that I would really hope you can find to be helpful. Now, the first thing I would say about a chest x-ray is that as you listen to this podcast, just pull up an x-ray, pull up what is a normal chest x-ray, pull up what is a normal chest x-ray. The thing is, in a normal chest x-ray, some key critical things I'll say you want to try to identify.

You want to be able to identify the trick here. That's always very helpful. In fact, I'll just say there are some hot spots you should look at. Look at the trick here, right? It's like that thin black tube in the middle of the person's throat. Look at the trick here. Look at the epics of the lungs. Our friends at the Mbimis are amazing at hiding pathologies in the epics of the lungs. The epics of the lungs are the very top, right? So always think about those things. And then think about the Euric knob. The Euric knob is, so if you look at the left border of the heart, that's largely the left ventricle for the most part. If you look at the very top, you'll see like a little almost like the curve of an umbrella. That's the Euric knob. That's something you want to be aware of. Because obviously, if that Euric knob gets super wide, that tells you a few things. You may be thinking about anthrax in that situation. You may be thinking about a person having like a Euric dissection, things of that nature, right? So again, make sure you look at the trick here. Look at the costophonic angles. That's always a good thing to look at. At this sharp, they're supposed to be sharp, right? If they're not sharp, if they're very blunt, that tells you the person has fluid in their lungs, right? Just key critical things to kind of look at. And I'll give a lot of these tips that I would really hope you find to be helpful, right? So again, identify the trick here.

Make sure when you're looking at a chest x-ray, that the trick is literally in the middle. If you notice that the trick here is shifted in one direction or the other, then very likely the thing our friends at the end is trying to get it to pick is tension in the authorics, right? It is the most commonly tested pathology that deals with a tracheal deviation on exams, tension in the authorics. And obviously, if a person has a tension in the authorics, a smart thing to do is to do a needle decompression. Remember, sometimes instead of giving the term needle decompression, they'll give you the term needle thoracoste. So you do a needle decompression and that'll convert the tension in the authorics to an open new authorics. And then after that, you're going to do a chest tube. You're going to place a chest tube, right? That's a tube thoracoste. That's the next thing you're going to do in those circumstances. So again, that's one thing should focus on. And then another key thing to look at on a chest x-ray is the size of the heart, right? The thing is the size of the heart, again, can tell you if a person maybe has c-chef or they have like live-in-triple hypertrophy, stuff like that, right? It's something that's just very helpful, not just on exams, but it's also helpful clinically. Now a very decent rule of thumb that you can apply with this is draw a line from the midline of the chest x-ray to the end of the ribs on the left.

So I'm referring to the left in the anatomical position. So draw a line extending from the midline of the chest x-ray to the end of the ribs on the left in the anatomical position, right? Around where you're, you know, your left arm is basically, right? If the border of the heart extends more than halfway between these two lines, this person's heart is most likely enlarged, okay? If the border of the heart extends more than halfway between these two lines, the person's heart is most likely enlarged. And again, if you see that, we're worried about hypertrophy, you know, of the heart, right? Even cardiac tamponat. In fact, one other thing that we help with heart size is just looking at the heart from end to end, draw a line for that, and then draw a line from end to end from one side of the thoracic cavity to the other. If the heart is more than one half of that size, the person probably has cardiac enlargement. And don't forget, the most anterior section of chest x-ray is the right ventricle, right? A friend at the MBM is very good about giving these stab wounds, you know, person gets stabbed in the anterior chest is probably the right ventricle you're going to destroy. And then remember, the most posterior part of the heart is the left atrium. That's how this whole TE, transverse of a gelico-cardiogram, comes into play. That's why we TE is, right? A transverse of a gelico-cardiogram is more sensitive than a TE, there's a transphoracic echocardiogram, right?

So that TE gives you better imaging, right? Especially because, yes, don't get me around the right side of the heart-hospor problems, right? But the left side of the heart is where a lot of the action and pathologies arise from. You can see that thing very beautifully with a transverse of a gelico-cardiogram, okay? With a transverse of a gelico-cardiogram, transverse of a gelico-cardiogram. And really, if you're just looking at the heart, you know, just a normal chest x-ray, like a p-fail, right? Usually the border of the heart on the right side that you're just seeing is usually the right atrium. And then the border of the heart that is usually seen on the left side is usually the left ventricle, right? If you go higher above these things, that's why that's where you can see other things. Usually, above that left ventricle border, if you go up, right, to the very top, that's where you're going to see an eortic anob. Right? So let's say, for example, and I think I want to bring a concept here. One common question I get from people is, divine, how do I know when to pick between TTE and TE on Mbimix Amps? One of the smartest things you can do is only pick TTE is if TE is not an answer. As long as TE is an answer, it will almost always be a better answer than a TTE on an Mbimix Amps. That's just a nice simple rule of thumb to keep in mind for tests. It's something that is largely, not saying perfectly accurate, but is largely accurate on Mbimix Amps. Now that's one concept.

Now the second concept I want to discuss is paying attention to context. Context matters significantly on Mbimix Amps. Many people just ignore context. That's why, again, this is something I go over pretty extensively in my test against strategy scores. And also in my review courses, where you see people, they just say, oh, if I see this, it's always that. If I see this, it's always that. No. Many people just make that mistake and that's one bad habit that doing just making your study and all about flashcards can do to certain people. They just memorize certain things. They're just like, oh, this thing, whenever I see it, it's this pathology. This thing, whenever I see it, is this pathology. That's not a smart way to learn. That's not a smart way to take exams at all, right? Because many times that one thing you may have memorized, if a different kind of context is slapped on top of it, it'll be a completely different pathology. That is just the truth, right? Like for example, oh, is it's almost as ridiculous as a person saying, oh, if I see GVD, it means the person has congestive heart failure. No, it doesn't always mean. But you see some people, they take that mindset to exams, oh, define me if I see JVD, is it always congestive heart failure? No, it's not. Like literally, I can write a JVD question and it has nothing to do with heart failure and has everything to do with the person having like superior and a Kiva syndrome, right?

So just encourage you to be very, very mindful of stuff like this on exams, right? So that's why you may notice this podcast, I don't necessarily have a slight deck for this specific podcast I'm making right now because I'm trying to give you the context. Many times, if you know the context behind the presentation, it doesn't really matter what they even give you on the chest X-ray. You can many times just kind of wiggle your way to the right answer. So let's say for example, they give you a question about a patient, the patient presents with a fever and a productive cough and then they show you a chest X-ray. Chances are pretty good that they are probably dealing with some kind of pneumonia, right? So instead of perseverating, perseverating, perseverating on the like, oh, okay, let me analyze every little part of this chest X-ray. You just ask yourself, okay, since this is likely a pneumonia, let me look at the distribution. Do I see like something that is one side, like one part in the lungs is well demarcated, it's well circumscribed. That's a low-bar pneumonia versus, hmm, do I see white stuff, white fluffy stuff going all over the lungs? And that's an interesting show in the morning. Literally just by doing that, you can arrive at an answer very quickly. You don't have to be going into knee deep, hardcore, detailed chest X-ray analysis, right?

So once you see something that's well circumscribed, it's like well marked out in a person that has like an acute onset fever and productive cough, that's probably going to be a low-bar pneumonia, right? So again, if you see any sort of white, because remember, when things are denser than, you know, things that describe that's radio dens, you know, when they're like really white on chest X-ray, right? They're obviously going to be denser than the air that is within the lungs. You see a lot of any sort of white well demarcated in the lungs. Think about a pneumonia, think about pneumonia. I remember the most common cause of the pneumonia is strep pneumonia, right? Again, make sure that you can decipher between typical and e-tipicoonomonies, right? Because in a typical pneumonia, again, the patient usually is going to be very toxic. They're going to have a productive cough, they're going to have high fever, they're going to have low-bar consolidation. When game-demy see low-bar consolidation, they mean white that is well circumscribed. And it's almost like that, it's only that part of the lungs that is just super, super affected. Most of the parts of the lungs are completely fine, right? But if you see a person that has a more indolent course, they have mild symptoms, right? But you look at the chest X-ray, you just see a diffuse pulmonary process, right? Like literally diffuse pulmonary process, that tells you it's probably going to be some kind of a typical pneumonia, right?

So really chest X-rays with pneumonia, just ask yourself, do you have a very localized, very well circumscribed process versus do you have a diffuse process? That diffuse process is going to be an typical pneumonia. That localized process is going to be a low-bar pneumonia, right? And also don't forget that, you know, the other kinds of pneumonia, there's like hospital acquired pneumonia, hospital acquired pneumonia are like super deadly, right? Most times when you get a hospital acquired pneumonia, it's staff warriors or pseudomonas that are kind of the culprit, right? So that's why many times you want to try like vancomaicin and dipraslin plus tizobactam, we can do vancomaicin plus cephepim or vancomaicin plus ceph tazidim, right? But again, so that's hospital acquired pneumonia, right? But cominhe acquired pneumonia many times is it's going to be strep pneumo. So again, the endimins can give you imaging, but then they're asking you for a specific bulk. Again, what's going to drive that specific bulk? You know, if they're kind, if you're taking step one, they will give you like all this wonderful information on, they'll give you all this wonderful information on gramsteen results, yeah, yeah, yeah, yeah, right? But first step two, step three, or even if you're taking the internal medicine boards, or family medicine boards, and you listen to this podcast, let me just give you imaging, but it's the context that is going to be your gramsteen essentially, right?

Is your context that is pretty much going to be your gramsteen, right? So, see, for example, they give you a question about a person that has been on prolonged steroid therapy, you know, they have like really bad asthma, they've been on oral steroids, or let's say it's a person that is immunocompromised, you know, a person that has HIV or whatever, right? And then they tell you that this HIV person has fever, they have cough, they have hypoxic, and then they show you a chest texture, to be honest with you, what else do you think they're going to show you a chest texture? You're going to see a diffuse process, you're going to see a diffuse process, that's going to be neosistise revedsy right there and there, right? Those are the things that we give the fancy term interstitial infiltrates, right? But again, it's the context that is the driver, right? So, remember, HIV patients though, don't get me wrong, they can get low-bar pneumonia, the most common cause in them will be strep pneumocrypt, but if you see interstitial infiltrates, that's going to be neosistise revedsy, right? That's going to be neosistise revedsy. Remember, neosistise revedsy, if your cd 4 count is under 200, we kind of try to perphylax you, we try methylpremsopharmethoxysol, and really that's actually the treatment of choice for neosistise revedsy.

Although, remember if you're very hypoxic, so let's say your p little aO3 is less than 70, in addition to that TMPSMX, it'll probably be reasonable for you to get some kind of steroids, you know, get some kind of clinical steroid therapy, right? So again, just context, context, context, matter with pneumonia, right? Again, they can give you a HIV context for neosistise revedsy, they can give you a young person that has very mild symptoms with interstitial infiltrates, that's mycoplasma, right? You see an alcoholic, you see gram negative organisms in the hospital, that's going to be clapsilla, right? Or you see false million sputum, you're kind of thinking of an anaerobic, or you see birds, or whatever, you're thinking of chlamidophila, cdkey, right? Or they give you like new Mexico, like the southwestern part of the US, you know that you didn't exceed your mycosis, right? They give you a person that works with four animals, right? You're thinking of like Q-fever, coxilla, or an adi, right? You're thinking of a child that is less than two years old, right? That's going to be areas V, the respiratory sensitio virus, right? Or you see a newborn with pneumonia, right? You're thinking of group B strap, right? Strap it galactia, right? You're seeing humanifiers, uh, waterfall, business conference, that's going to be legionella, right? Again, these are just all clues they can give you, right?

You see a 65 versus a person less than 20 years old, that's tough for us, over 20 that's pseudomonas, these are all simple associations they can give you, or you see them see something about Kentucky Ohio, right? That's histoplasma capsule atom, these are all things our friends at the M.B. is just love to test, right? They love to test. So just make sure that you're learning your context, right? Well, let's see, they give you a question about an old person, pretty or smoke for a long time, they have hemoptysis, they've lost weight, and then they show you a chest X-ray, and you see like a density in the lungs, right? Again, notice I'm not going into like intense descriptors because those intense descriptors, you don't need them. If you're going into ideology, you will need them. But this, this podcast is not for people going into radiologists, people that try to crush the USMEL exams, right? When you see stuff like that, you know that is lung cancer, you see your pulmonary nodule, you know that is lung cancer, right? But the other things I give you like the smoking history and all those things, cannot point you in that direction, right? Or you see a person that are smoked, and then they give you like imaging, right? But they tell you that the person has GVD, why would a person that are smoked for a long time have GVD? I don't know, maybe because they have superior than a giver syndrome, right? That's what they are trying to go after with that exam question, right?

So again, don't overthink these things. I'm telling you this, one of the most common causes of people just watching their exams is just overthinking. Met students are professionals in overthinking, right? They are absolute professionals in overthinking. So you just need to be careful, you just need to be mindful of these things, right? You just need to be mindful of these things and you won't be led astray on exams, right? Or you may say, oh, divine, what if they are asking about a specific kind of lung cancer? Again, it all goes back to the context. It all goes back to the context. If a person has worked in a shipyard or in plumbing for a long time, right? And then you notice that while the edges of the chest texture are very thick, very, very thick edges, that's simple. That's going to be a misothelialma or that's going to be a stosis of some sort, right? So again, the context is very, very helpful, right? Or what if they give you a question about a person that has taken a long flight and then they show you a chest CT? It doesn't even matter what the chest CT is showing. It's going to be a PE. It's going to be a pulmonary ambulance, right? But again, someone like, ooh, divine, teach me how to analyze chest C Ts. But if you think about it, if they show you a chest CT and then you see something that looks like an inverted V, right?

That inverted V is the pulmonary artery and then you see block stuff inside it because think about it, who is going to be diagnosed in a PE by doing a CT of the chest without contrast? No, the MV is they're going to do contrast, right? Although sometimes they can elect not to, right? But you see block within the white contrast in the inverted V, that's a PE, that's a pulmonary and bulis. It's literally the pulmonary artery that you're trying to show you. But again, it's the context that matters. You see a person with sudden onset, shortness of breath, dyspnea, and you see them having risk factors. Let's say they are taking a surgeon containing no CP's, right? Or if they're taking a long flight, or if they're taking a long car ride, or they have a history of malignancy. Remember, people that have cancer, many of those will need to be on long-term hip-ray, right? Because they can get PE's as a result, right? You see a woman that smokes, you see a woman that has PCOS. These are all contexts, right? Fact of five, light it, right? Recent surgery, especially orthopedic surgery, right? Vascular surgery, orthopedic surgery and vascular surgery are like hot beds for people getting PE's afterwards, the person will be tired, he cardiac, the PCO2 will be low because they have a respiratory alkylosis, because they are blowing off a lot of PCO2, right? Or you see a person that has, they give you a chest X-ray, or chest CT, and a person that has a unilaterally swollen leg.

Guys, what do you think the guys and girls, what do you think they're trying to test? It's a PE, right? It's a PE. I'm just trying to, I will say, I'm kind of wondering, this podcast, like, my main goal here is just to show you that. Many and many questions are not that hard if you just stop over thinking and if you're just logical and rational and unemotional in your analysis, right? Or let's say they give you a question about an African-American female, right? Or they give you a question about a female, they won't, they don't, let's say they don't even mention African-American, right? And she has shortness of breath, she has like cough, she has hypercalsemia. It doesn't matter what the chest X-ray they're showing you literally shows, it literally doesn't matter, right? But that's going to be structural doses. Many times if they show you the chest X-ray, you'll see a diffuse process in the lungs. And you'll notice that the sides of the, because remember, the heart has a bulge, you know, like, you see the middle of the lungs, there's a bulge which represents the heart. But if you go above that bulge, and you notice that, wow, the sides of this media sign on look very buggy, those are lymph nodes they're showing you. Like, literally, in fact, maybe this podcast is like, I don't know, I feel like I've been deciding on different topics for this podcast, descriptive radiology, right?

Many times if you just look up a picture of these pathologies, as I'm describing them, you'll be like, oh, that's what divine is talking about, right? This is a pretty clear case of sarcoidosis, highly lymphatic anopathy, intestinal fibrosis, African-American females, right? Think I'm also a coidosis, it's one of those things that they love, love, love, love to test on exams, right? Remember, in sarcoid you have all these non-case eating granulomas, I'm sure it's steroids. The macrophages, the fact that you have a granuloma means that they have macrophages there. Those macrophages, they make a lot of vitamin D because they express one alpha hydroxylis. When you have hyper vitamin Noses D, you're going to get hypercalcemia as a result of that, right? You're going to get hypercalcemia as a result of that. You're going to get restrictive long disease, right? From sarcoidosis. Or they give you a question about a person that has a history of COPD. And they have, or a person that is a young guy, is like in his 20s or early 30s. And they notice that he has this sodium oceas sharpness or breath, right? And they show you a chest x-ray again, it doesn't matter what the chest x-ray is. Chases are, this person has a simple pneumothorax, right? Essentially this person has ruptured or popped an apical bleb. Remember, those blebs and bullying the lungs are very common in COPD patients, right? But it's also common in like a tall thing young male, especially one that smokes, right?

You're going to get those apical blebs in the lungs, right? That's a simple pneumothorax. Obviously for that, you're going to do a chest tube. You're going to place a chest tube. Another thing you may see for that on exams is the term a tube-thura costum, right? A tube-thura costum, right? And I guess maybe one tool I can give that can help you with, because the tension in the mothoracies, most times people can analyze it pretty easily. You notice that while the trick is like super deviated, right? That tells you all you need to know. But, you know, for a simple pneumothorax, one thing that I found to be helpful with chest x-ray is especially for met students, you know? On exams, when they give you a chest x-ray question, just get into the habit of starting from the edge, start from the edge of the chest x-ray. And then look for a straight line. Like really the way, in fact, let me see this. Let me see two things. One is helpful to look at a chest x-ray from the edge and from the middle and analyze it in both directions and look at the top of the chest x-ray. Literally by doing just these four things. So let me tell you four things you should always look at a chest x-ray. Look at the middle, look at the trickier area, look at the middle, look at the edges, right? Look at the tops, the AP Cs, and look at the cost of frantic angles. Those are the four places that friends at the NBM is love to invest most of their efforts.

So again, look at the middle, look at the edges, look at the cost of frantic angles, and look at the AP Cs, right? If you do that, it's almost like a four corners approach. Middle, edges, bottoms, right? Those are the cost of frantic angles and tops. Those are the AP Cs. If you do those things, you'll catch a lot of pathologies that classically show up on exams that people miss, right? So how would you know that a person has a simple new motorics? Well, the thing is if you look from the edge of the chest x-ray, you'll notice that there's a straight line somewhere and it's almost like a straight line with two things on either side, with something different on either side. On one side, you'll notice that wow, one side is really white of the line. And then you notice that the other side of the line is really dark. The longs, right? The pneumothorax, airs deposited in the plural cavity, right? That plural cavity, the visceral plural that you're seeing is what is the straight line. And then on one side is gas, that's the dark part. On one side is long that is being squished. That long that normally is dark is going to look very white. Why does it look very white? Because now it's being squished pretty heavy. So again, look at, really, even this is just a rule of imaging, right? The good thing is, you know, God has largely blessed us with two of everything. Look at one side, don't look like the other side. There's probably something wrong going on going on, right?

These are just all simple rules that can help you with chest x-rays and just radiology in many parts of the body. Right? So again, keep these things in mind. And you know, usually when people have like pneumothoracies, they'll have like absent breath sounds, they'll have hypers and anastropocution, right? Again, they give you those things. You don't probably don't even need to look at a chest x-ray. You really know what you're dealing with, right? Or let's say they give you a question about a person with, I'm literally just trying to use different cases here. A person who are penetrating trauma to the chest, right? And then you notice that, hmm, in the tops of the lung, especially in the middle, just above the heart, you notice all these black lines, these black straight lines, all these black curved lines. That tells you that this person probably has no immediate stina, right? Again, the context is going to be all that matters here. The person just got an EGD with biopsy or they just got a numatic dilution. I don't know, maybe they just rupture their soft August, right? Or it can be a person that has a zenchrist diverticulum. And then you decide to do an EGD. Again, you profess their soft August. That's how they got a trouble. Or when a person has like scream or cell cancer of their soft August, those things love to also reach that can cause the person to have a soft agio rupture, right? So again, these are just all things.

So you see a person again, they have syndrome like a severe retching, eating the sovere patient, visual hyperimessing, gravity, those are always the contest those things on exams, right? Or they give you a question about a smoker. I noticed that man, this chest X-ray looks really large and long. I think I like man, this person, like it's almost like a very burned chest X-ray, right? Too much radiation, pasta, like you see a lot of dark and the persons lungs are very long, right? When you see stuff like that, that tells you all you need to know, that's long hyperinflation, presence in fissima. But if they decided to give you that same image, and a person that you know smoked only for like 10 years, they're in their 40s, and you see elevated LF Ts, that tells you all you need to know, the person has a panel of acetylum fissima, they have a phone and type trips in deficiency, right? So again, these are all simple things, right? You can keep, you should keep your mind on exams. Or let's say they give you a question about a young child. Let me tell you this, my handy dandelion, whenever they give you chest X-rays and very young kids, like kids that are single digits in age, always look at the throat. Most times when the NBM is at giving chest X-ray questions for young kids, look at the throat, look at the throat. If you see what looks like a wine bottle in the throat, right?

The wine bottle sign, sometimes we call that the steeple sign, that's going to be a person that has a group, right? Although our friends at the NBM is instead of putting the term group, the occasionally can put the other name, right? A derivative answer, like laryngo tricubron chidis, laryngo tricubron chidis, this will have the barking, the cell-like cough, right? That's group, that's usually caused by the parian influenza virus, right? Well, let's say for example, they give you a question about a person that's an alcoholic or has like a neuromuscular disorder, publicity, have like, ALS or whatever. And then they tell you that even a Parkinson's disease patient can have this problem. And then they tell you, they show you a chest CT, right? Or chest X-ray. And then you notice that there is an area of dark and right below that area of dark, you notice that there is like a straight line, right? Well, this is not in the vertical plane, it's, it's not in the horizontal plane, right? So you notice a dark, right? A dark, and then you see a straight line below that dark. And you see it's like well carved out, that's that's a long abscess. Literally, that thing you're seeing is an air fluid level. Air fluid levels look the same thing everywhere. Literally, the, the name tells you how you need to know air, fluid level. Well, air is less dense, so you should arise, right? So you're going to see dark on top and a straight line and then white on the bottom.

The white on the bottom is fluid. It's more dense, it's more radio dense, it's going to be white. The stuff at the top is dark. That's all you need to know. The person has a long abscess. Many times when people have long abscesses, right? You think about anerobs, bacteriories, fused of bacterium, prevohtela, stuff like that, right? And remember, those abscesses, you know, sufferers can cost them as well. And those things respond beautifully to clean the mice. Clean the mice is actually pretty good because it's very effective against MRSA when it also covers anerobs beautifully, right? Covers anerobs beautifully. And again, you notice that, wow, a person's cost of any cangels are very blocked, right? If you notice that it's both sides, right? Usually you're thinking about a CHF exacerbation or CHF of some sort. But if you notice that, wow, this person has been a smoker or they've worked at like a steel company or shipyard or whatever. They notice they have this big, massive, nasty plural of fusion on one side. That person probably has malignancy, right? Many times when you see you need lateral plural of fusions on NBM Es, it's usually one of three things. It can be TB. Again, the context will tell you like, oh, TSE agent, person that's in the present system, immunocompromised, right? That can be TB. Or it can be a person that has smoked, has been losing weight blah, blah, blah, blah. That's going to be a person that has a long cancer.

Or you can see like a more acute onset, right? The person has like rebatchest pain and you have a immunolateral plural of fusion. Usually the plural of fusion on NBM Es is going to be on the left. That tells you all you need to know. That person has aortic dissection. And if you look at that fancy shmancy, aortic knob that I just mentioned, you notice that, hmm, it's wide. Whenever you see a wide aortic knob, you're thinking about a wide intermediate sign. The person probably has aortic dissection or they have hemorrhagic mediastonitis as a result of anthrax, right? Or let's say for example, they give you a question about a person that has had a very severe illness. They've had like acute pancreatitis or they drowned or they had like very major emergency surgery. And then you give your chest X-ray, you see the whole lung is white. You don't have to think too hard. That person has ERDS, right? That person is going to be profoundly hypoxic, right? The person is going to be profoundly hypoxic. That's going to be ERDS. That's going to be ERDS, right? That's going to be ERDS, right? So just kind of think of all these things. And you may notice that in the medias sign, them, most of the lines points downwards. Those lines are like lymph nodes and lot nuts and pulmonary vessels, right? Most of them are, you know, less common pulmonary vessels. Most of those lines point downwards, right? In the middle of the chest.

But if you notice that many of those lines are pointing upwards, that's what's called sephalization. What do you think the term came from? Well, sephalization, sephalumins head. So those lines that are supposed to be pointing downwards are your pulmonary vessels, the point upward because the engorges we blot. That's pulmonary gema, right? That's pulmonary gema. Usually you're going to see that in the CHF exacerbation or present that has like really badly compensated a CHF, right? Well, let's say they give you a question about a person. I mean, they can literally make many questions from this. Ooh, this person has a issue of an arrhythmia, should it be with a mutor room or this person has a rheumatoid arthritis and you've been on long-term therapy, aka methyl tracksuit or, hmm, this person has just had chemo, like many cycles of chemo and his biosophane or blyomycin or whatever, right? And then you notice that the person's lungs look very patchy and white. That tells you all you need to know. The person has a diopathy bone nerve fibrosis, right? You're going to see the honeycomin powder, right? You're going to see the honeycomin powder. So I think I'm going to just go ahead and stop here. I feel like I've kind of hit a lot of the very high-yoda pathologies. But again, I promise you, if you just listen to this podcast and understand what I've just said, maybe look up some of these examples just to get some more correlation for yourself.

You'll see that a lot of this stuff I've talked about is going to be super high-yod for your test and you're going to see that chest x-rays and all that. But as I do at the end of every podcast and I'll talk about a life lesson at the end here as well, I brought for one or one tutoring for the USMEL exams. Step one, step two, seek is step three, complex level one, two, and three. Just don't tutor OMM. That's the one major thing I don't do. And then I offer this review courses, I have a bio-statistics course, a bootcamp. It's four hours long. I have an MBA me testing and strategy course. It's two and a half hours long. I have a 20 hour step two, seek is step three, complex level two, and three review course. And then I have a You Tube channel. It's called Divine Intervention USMEL podcast and videos. I'm going to be making changes to that You Tube channel. Just to increase access to my podcasts. I've actually kind of put things in place and I'm trusting God that some find within the next few days you're going to start seeing changes. You're going to start seeing changes in our You Tube channel. So go ahead and subscribe so that you can see those changes when they happen. It's called Divine Intervention USMEL podcast and videos. And then I also have these podcasts on Apple podcasts on Google podcasts and Spotify, at least the most for 1,150. If you want everything from the very beginning, just go to the website, divineinterventionpodcasts.com.

Everything from episode one, all the way to this episode, episode 104 is right on there. Even a simple thing you can do is just do a Google search for the, let's say for example, you have a problem. You're like, I want to learn about chest X-rays. Just do a Google search, chest X-rays, divine intervention. You'll very likely pull up a podcast that I have on that topic. Or if you go on my website and you click on exam topics list, that will take you to a Google spreadsheet where I break things down step one, step two, seek is step three, break things down by subject, by discipline. I give it a suggested podcast. And then you can just stick that name on. Let's say, oh, you want to look at OBGYN, which I think is episode 22, just go on Google, episode 22, OBGYN, divine intervention. Boom. And you're going to see, see pop up. But again, I will strongly encourage you sign up if you know, if you have a Word Press account, you can subscribe to my podcast. You get an email notification whenever I make a new podcast. But I will strongly encourage you. I'm saying this very strongly. If you can, subscribe to my You Tube channel, divine intervention, USMLE podcast and videos. It's really going to help you. You're going to see some changes coming to that You Tube channel. Very soon by the grace of God. And then finally, I also help with ERA's applications, right? You know, personal statements, rec letters, supplemental applications. I help with all these things.

So if that's something you're interested in, again, I've been on an admissions committee for a year. I've worked with tons of residents. Some of them are actually now attendants. If you're interested in any of these things, just shoot me an email. I'll give you some more information. Again, I have a very good track record with a very large number of disciplines, with a very large number of disciplines. So that's something I think you'd find to be extremely helpful. And then finally, I have a new website called divineinterventionallifelessons.com. It's many people love these life lessons. I give at the end of my podcast. So I said I'll start a Bible based website. You know, many of you know I'm a Christian. I have this Bible based website where just topics that I know affect humanity. Just a lot of problems that people face. I've made podcasts on those I make about two every week. In fact, right now we have about more than 100 podcasts. Most of them about 10 to 20 minutes long. You know, I use a Bible verse many times to illustrate a concept. And then I kind of talk about it in light of problems we face as humans right now. And then the final thing I will just say, so go on, that's divineinterventionallifelessons.com. There's actually an Apple podcast for it. It's called the divineinterventionallifelessons podcast. And then the final thing I will say, the life lesson for today is don't slander. Don't slander. That's just the thing.

I feel like we're getting to a season of med school, you know, with Eras can I'm boiling over where people start slandering other people. That's not a smart thing to do. That's not a smart thing to do. You don't build yourself up by literally tearing other people down. Many medical students do it, right? Even some other people have definitely made that mistake in my life as well. I'm not going to stand here and be like this perfect person. No, I've definitely made that mistake. Right? So just don't tear other people down. You know, you're not going to be more popular by destroying other people. And again, remember you reap what you sow, right? If you slander other people, then other people will slander you at some point in the future. That's just the truth, right? So don't be that kind of individual, right? It's not honest. It's not honorable. Take the higher road. You're not going to increase your chances of matching at a program because you're slander than other person, right? Don't spread falsehood about people. Don't destroy people's repetitions. I feel like we live in a world. You hear this whole concept of cancel culture. That thing is a very terrible mindset to have. Well, I'm going to cancel this person. I'm going to cancel this person. You're counseling people. You yourself will be canceled in the future, right? Cancell culture is just not a smart thing, right?

You don't have to like, even if you don't agree with someone on something, you don't, you don't have to go on this war path of destroying them, destroying their destiny because many times when people don't think about the repercussions of some of the things they do, you know, when you go on, just spread slander about a person in public, you don't know you may literally be destroying their family, destroying their marriage. How would you feel if someone came out of the woodworks and destroyed your family, destroyed your own marriage? Again, do is the golden room. Do on to others as you like to be done. Would you want someone to come and just spread things because you see some people, they spread rumors about people online or whatever and then those people's marriages never the same again, right? Or those people may have young kids and you absolutely destroy their lives, they can go out in public or whatever because you have in quotes, can't show them. This is something I'm actually really passionate about. If you do not agree with someone on something, that's fine, but don't go to the, oh, because I don't agree with you and because you don't agree with me, I'm going to destroy you, going to wreck your destiny, that's an evil mindset, that's an evil mindset, but it's a thing that is very prevalent in the world today and many people support it, but it's a terrible with a humble conflict.

If you don't agree with someone, why don't you see with the person and engage in reasonable conversation? And again, the fact that someone doesn't agree with you doesn't mean that they are evil people, right? So I'll encourage you, stop spreading slander, stop destroying other people's reputations and I really pray that all will be well with you. So thank you for listening to me today. Until next time, have a wonderful rest of your day and God bless you. For those that made the review course, I'll see you later. Thank you.

The mediastinum/trachea (middle), the lung apices, the costophrenic angles, and the lateral edges.

Tension pneumothorax.

Needle decompression (or needle thoracostomy), followed by chest tube placement.

Pulmonary edema, typically associated with CHF exacerbation.

Lobar pneumonia shows well-demarcated/circumscribed consolidation; atypical pneumonia shows diffuse infiltrates.

Pneumocystis jirovecii pneumonia (PCP).

A straight line separating dark air from white/opaque lung tissue.

It suggests potential aortic dissection or hemorrhagic mediastinitis (e.g., anthrax).

The expression of 1-$\alpha$-hydroxylase leading to excessive production of active Vitamin D.

A straight line (visceral pleura) separating dark air (pneumo) from white/compressed lung tissue.

The presence of a lung abscess or empyema; air is less dense (dark), and fluid is more radio-dense (white).

Bilateral hilar lymphadenopathy, often accompanied by restrictive lung disease and hypercalcemia.

Atypical pneumonia (e.g., Mycoplasma).

The presence of a straight line separating air in the pleural space from compressed lung tissue.

It suggests potential aortic dissection or hemorrhagic mediastinitis (e.g., anthrax).

The expression of 1-$\alpha$-hydroxylase leading to excessive production of active Vitamin D.

A straight line (visceral pleura) separating dark air (pneumo) from white/compressed lung tissue.

The presence of a lung abscess or empyema; air is less dense (dark), and fluid is more radio-dense (white).

Bilateral hilar lymphadenopathy, often accompanied by restrictive lung disease and hypercalcemia.

Atypical pneumonia (e.g., Mycoplasma).

The presence of a straight line separating air in the pleural space from compressed lung tissue.