A Dozen Great Cases
Challenge
Each case tests your ability to apply the fundamental principles we have just gone over and over.
Suggestions
- 1.
Read the history.
- 2.
Evaluate the x-ray with your routine scanning pattern (ATMLL), making all the pertinent observations.
- 3.
Then, and only then, answer all questions before you turn to the answers.
Beware of “satisfaction of search.” There is a tendency when reading x-rays to be so thrilled that you have actually found an abnormality that you then relax your search. Don’t! Many patients have several abnormalities that you can combine to arrive at a diagnosis.
Case 1
History:
This is a young man with cancer ( Figure Q-1 ).
Metal nipple markers have been placed to distinguish nipples, which sometimes show on x-rays, from real pulmonary nodules. (Answer on next page.)
- 1.
Are there any nodules?
- A.
yes
- B.
no
If so, where? _____________
- A.
RUL
- B.
RLL
- C.
LUL
- D.
LLL
- A.
- 2.
Are there any changes to suggest pleural effusion?
- A.
yes
- B.
no
- A.
- 3.
What type of surgery has the patient had? ____________ (Hint: Is anything missing?)
- 4.
Diagnosis: Can you combine the history and x-ray findings to suggest a diagnosis? _____________
Case 1
- 1.
A. ; B. ; Yes, below the right nipple marker, where the ribs cross, there is an RLL pulmonary nodule.
- 2.
B. No. The costophrenic angles are sharp. The stomach bubble sign is absent. Diaphragms are normally shaped.
- 3.
The right shoulder has been amputated. A systematic approach helps avoid embarrassing misses.
- 4.
Diagnosis: Patient had a shoulder amputation. The nodule is most likely a pulmonary metastasis. The amputation was for osteosarcoma.
“Intuition is the source of scientific knowledge.” —Aristotle
“Aristotle could have avoided the mistake of thinking that women have fewer teeth than men by the simple device of asking Mrs. Aristotle to open her mouth.” —Bertrand Russell
Case 2
History:
This is a 30-year-old epileptic with high fever and chills for 5 days ( Figures Q-2A and Q-2B ).
- 1.
There is an abnormality in the _____________ lobe.
- 2.
Describe the lesion in detail. _____________
- 3.
The arrow points to a(n) _____________.
- 4.
Diagnosis: Put the x-ray findings and history together for a logical diagnosis. _____________
Case 2
- 1.
right upper lobe (it sits anterior to the major fissure and above the minor fissure)
- 2.
There is a mass or focal alveolar consolidation with a central cavity, air-fluid level.
- 3.
air-fluid level
- 4.
Diagnosis: This is a lung abscess in an epileptic who probably aspirated during a seizure. Aspiration most often involves the gravity-dependent portions of the lung in a supine patient (posterior segments of the upper lobes and the superior and posterior basal segments of the lower lobes). Tuberculosis, another reasonable possibility, is usually more indolent.
“It’s what you learn after you know it all that counts.” —Earl Weaver
Case 3
History:
This hypotensive patient is in the emergency department after a gunshot wound to the chest ( Figure Q-3 ).
Identical paper clips mark the entrance and exit wounds.
- 1.
This radiograph is most likely _____________ and _____________.
- A.
erect B. supine
- C.
PA D. AP
- A.
- 2.
Describe the major radiologic findings of the left hemithorax. _____________
- 3.
The mediastinum is _____________ .
- A.
shifted right
- B.
shifted left
- C.
not shifted
- A.
- 4.
The police tell us that he was shot from the front. Is the entry wound midline or left-sided? (Remember, they are identical paper clips.) _____________
- 5.
Diagnosis: _____________
Case 3
- 1.
B. supine and D. AP—patient is hypotensive
- 2.
The left hemithorax is opaque. The partially aerated lung is barely visible medially.
- 3.
A. shifted right (contralateral side)
- 4.
Left-sided. This is an AP supine film, so the anterior clip would be magnified. Because identical paper clips were used, the bullet must have entered the left chest (magnified clip) and exited in the midline.
- 5.
Diagnosis: Left hemothorax from gunshot wound. Increased pressure in left hemithorax causing contralateral mediastinal shift.
“Why shouldn’t truth be stranger than fiction? Fiction has to be believable.” —Mark Twain
Case 4
History:
Young male with chest trauma.
Admission chest x-ray ( Q-4A ) and CTs ( Figures Q-4B through Q-4C ), taken a few hours later.
- 1.
← indicates ___________.
- 2.
↓ indicates ___________.
- 3.
→ indicates ___________.
- 4.
∧ indicates ___________.
Case 4
- 1.
← on both the chest x-ray and the CT show the mediastinal pleural reflection, indicating a pneumomediastinum.
- 2.
↓ shows a small apical pneumothorax.
- 3.
→ delineates subcutaneous emphysema dissecting through the soft tissue and muscle planes.
- 4.
∧ shows the tracheostomy tube in the trachea.
Case 5
History:
This is a 50-year-old woman with pain on inspiration.
Figure Q-5A is a baseline image obtained 10 months earlier. Figure Q-5B is the current image.
- 1.
In Figure Q-5A , the _____________ lung is more radiolucent.
- A.
right
- B.
left
Explain the discrepancy. _____________
- A.
- 2.
Ten months later, there have been striking changes ( Figure Q-5B ). The cardiac size (cardiac silhouette) is _____________,
The pulmonary vessels _____________.
- A.
show cephalization
- B.
are normal
- A.
- 3.
The _____________ costophrenic angle(s) is (are) blunted.
- A.
right
- B.
left
- C.
right and left
- A.
- 4.
Diagnosis: Combining the history and your radiographic observations, the current image shows _____________ and _____________, most likely caused by _____________.
