Ten 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—Are There Many Lung Lesions?), 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 30-year-old patient with epilepsy with high fever and chills for 5 days ( Figs. Q.1A and Q.1B ).

• 1

  There is an abnormality in the _____________ lobe.

• 2

  Describe the lesion in detail.

• 3

  On computed tomography (CT, not shown), an air-fluid level was visible on the axial and sagittal views only. Why?

• 4

  Diagnosis: Put the x-ray findings and history together for a logical diagnosis. (Answer on next page.)

Case 1

• 1

  Left upper lobe (LUL). It sits anterior to the major fissure.

• 2

  There is a mass or focal alveolar consolidation with a central cavity and an air-fluid level.

• 3

  In a supine patient, axial and sagittal images are perpendicular to the air-fluid level; the coronal is parallel to it.

• 4

  Diagnosis: This is a lung abscess in an epileptic patient who probably aspirated. Aspiration most often involves the gravity-dependent portions of the lung (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.” —John Wooden (former basketball coach at UCLA)

Case 2

History:

This is a young man with cancer ( Fig. Q.2 ).

Metal nipple markers have been placed to distinguish nipples, which sometimes show on x-rays, from real pulmonary nodules.

• 1

  Are there any nodules?

  • A

    yes

  • B

    no

  If so, where? _____________

  • A

    right upper lobe (RUL)

  • B

    right lower lobe (RLL)

  • C

    left upper lobe (LUL)

  • D

    left lower lobe (LLL)

• 2

  Are there any changes to suggest pleural effusion?

  • A

    yes

  • B

    no

• 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 2

• 1

  A. ; B. ; Yes, one rib below the right nipple marker, where the ribs cross, there is a subtle RLL pulmonary nodule. It could also be in the right middle lobe since the middle and lower lobes overlap on the frontal radiograph.

• 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 3

History:

This hypotensive patient is in the emergency department after a gunshot wound to the chest ( Fig. Q.3 ).

Identical paper clips mark the entrance and exit wounds.

• 1

  This radiograph is most likely _____________ and _____________.

  • A

    erect

  • B

    supine

  • C

    posteroanterior

  • D

    anteroposterior

• 2

  Describe the major radiologic findings.

• 3

  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.)

• 4

  Diagnosis: _____________