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Everything’s Fine … Except His Spine
ANSWER
The chest radiograph shows an approximately 3-cm cavitary lesion in the right upper lobe. Such a lesion can indicate lung abscess, neoplasm, or tuberculosis.
Subsequent workup determined that he did, in fact, have tuberculosis, with involvement in his spine (known as Pott disease).
ANSWER
The chest radiograph shows an approximately 3-cm cavitary lesion in the right upper lobe. Such a lesion can indicate lung abscess, neoplasm, or tuberculosis.
Subsequent workup determined that he did, in fact, have tuberculosis, with involvement in his spine (known as Pott disease).
ANSWER
The chest radiograph shows an approximately 3-cm cavitary lesion in the right upper lobe. Such a lesion can indicate lung abscess, neoplasm, or tuberculosis.
Subsequent workup determined that he did, in fact, have tuberculosis, with involvement in his spine (known as Pott disease).
A 25-year-old man is admitted to your facility for a possible infection in his spine. He reports a two-week history of severe back pain with no history of injury or trauma. Imaging performed at an outside facility suggested compression and erosion of his vertebral bodies at the thoracolumbar junction, and the radiologist raised concern for possible osteomyelitis and diskitis.
The patient is otherwise healthy and denies any medical problems. He denies drug use of any form. Review of systems is significant for a three-month history of anorexia and night sweats but no fever.
Physical exam reveals a healthy-appearing male with normal vital signs. His heart and lung sounds are normal.
A chest radiograph is obtained (shown). What is your impression?
Getting Ahead of the Pain
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The image reveals a hypodense extra-axial fluid collection in the right frontoparietal region, measuring 8 to 10 mm in diameter. There is some mass effect and evidence of right-to-left shift. These findings are consistent with a subacute subdural hematoma, possibly secondary to the patient’s anticoagulant use. (The patient later recalled bumping his head a couple of months prior—but that may have been incidental.)
Arrangements were made for him at a local hospital where neurosurgical services were available. He underwent successful evacuation and was subsequently symptom free.
ANSWER
The image reveals a hypodense extra-axial fluid collection in the right frontoparietal region, measuring 8 to 10 mm in diameter. There is some mass effect and evidence of right-to-left shift. These findings are consistent with a subacute subdural hematoma, possibly secondary to the patient’s anticoagulant use. (The patient later recalled bumping his head a couple of months prior—but that may have been incidental.)
Arrangements were made for him at a local hospital where neurosurgical services were available. He underwent successful evacuation and was subsequently symptom free.
ANSWER
The image reveals a hypodense extra-axial fluid collection in the right frontoparietal region, measuring 8 to 10 mm in diameter. There is some mass effect and evidence of right-to-left shift. These findings are consistent with a subacute subdural hematoma, possibly secondary to the patient’s anticoagulant use. (The patient later recalled bumping his head a couple of months prior—but that may have been incidental.)
Arrangements were made for him at a local hospital where neurosurgical services were available. He underwent successful evacuation and was subsequently symptom free.
An 80-year-old man presents to urgent care for intermittent severe headaches. The pain is reportedly bifrontal, slightly worse on the right side than the left. He denies any recent injury or trauma, as well as symptoms including fever, chills, nausea, vomiting, and visual disturbance.
His medical history is significant for hypertension and hyperlipidemia. His current medications include prasugrel and aspirin.
On examination, you note an elderly male who is awake, alert, and oriented x 3. His vital signs are normal. His physical exam is overall normal, with no focal findings or neurologic deficits.
Noncontrast CT of the head is obtained at a local hospital. As you review the images, you see the following cut (shown). What is your impression?
When the Fix Fails
ANSWER
The radiograph shows an adequately positioned endotracheal tube. It also shows bilateral infiltrates, greater in the right than in the left lung.
A pigtail catheter is present, up high near the apex; despite this, a pneumothorax of moderate size remains on the right. The likely explanation is that the catheter is either not properly positioned or is kinked.
Prompt surgical consultation for new chest tube placement was obtained.
ANSWER
The radiograph shows an adequately positioned endotracheal tube. It also shows bilateral infiltrates, greater in the right than in the left lung.
A pigtail catheter is present, up high near the apex; despite this, a pneumothorax of moderate size remains on the right. The likely explanation is that the catheter is either not properly positioned or is kinked.
Prompt surgical consultation for new chest tube placement was obtained.
ANSWER
The radiograph shows an adequately positioned endotracheal tube. It also shows bilateral infiltrates, greater in the right than in the left lung.
A pigtail catheter is present, up high near the apex; despite this, a pneumothorax of moderate size remains on the right. The likely explanation is that the catheter is either not properly positioned or is kinked.
Prompt surgical consultation for new chest tube placement was obtained.
A 60-year-old woman is transferred to your facility from an outside hospital for tertiary care. She was reportedly at home with family when she suddenly collapsed and became unresponsive. She was taken to a nearby hospital, where she was resuscitated, stabilized, and urgently sent to your facility for possible cardiac intervention.
You assess the patient immediately upon arrival;with no family present, history is limited to the chart. You note an intubated female on mild sedation. Her vital signs include a temperature of 37.0°C; blood pressure, 130/80 mm Hg; heart rate, 70 beats/min; and O2 saturation, 98% on 100% FiO2.
The heart rate monitor shows sinus rhythm. A right chest tube is in place. Auscultation reveals bilateral rhonchi.
Portable chest radiograph is obtained (shown). What is your impression?
Birthdays, Booze, and … Broken Bones?
ANSWER
The radiograph shows two fractures: one within the distal ulna and one within the fifth metacarpal. On closer examination, you can see that a bony callous surrounds each of the fracture lines, making these injuries more likely to be subacute or remote than acute.
Review of the patient's electronic health record showed he had presented three months earlier for a left hand and wrist injury, at which time an acute fracture was diagnosed. Nonetheless, he was placed in a splint and referred to orthopedics for outpatient follow-up.
ANSWER
The radiograph shows two fractures: one within the distal ulna and one within the fifth metacarpal. On closer examination, you can see that a bony callous surrounds each of the fracture lines, making these injuries more likely to be subacute or remote than acute.
Review of the patient's electronic health record showed he had presented three months earlier for a left hand and wrist injury, at which time an acute fracture was diagnosed. Nonetheless, he was placed in a splint and referred to orthopedics for outpatient follow-up.
ANSWER
The radiograph shows two fractures: one within the distal ulna and one within the fifth metacarpal. On closer examination, you can see that a bony callous surrounds each of the fracture lines, making these injuries more likely to be subacute or remote than acute.
Review of the patient's electronic health record showed he had presented three months earlier for a left hand and wrist injury, at which time an acute fracture was diagnosed. Nonetheless, he was placed in a splint and referred to orthopedics for outpatient follow-up.
A 60-year-old man is brought to your facility emergently for decreased consciousness secondary to alcohol intoxication. He is somewhat incoherent, but from what you gather, he was attending a birthday celebration. He does not know how much he drank.
The patient complains of a headache and pain in his left wrist. You ask if he fell or was assaulted, but he does not respond. His medical history is otherwise unknown.
His initial vital signs are stable, and primary survey does not show any major injuries. He appears to spontaneously move all four extremities.
Closer examination of his left wrist shows no deformity or swelling, but the dorsolateral aspect of his hand is tender. Radiograph of his left wrist is obtained (shown). What is your impression?
Haste Makes Waste
ANSWER
The chest radiograph shows an endotracheal tube within the right main stem bronchus. There is no evidence of any other acute pathology (eg, fracture, contusion, pneumothorax).
The tube needs to be withdrawn so that it sits just above the carina (see arrow). If not promptly addressed, incorrect placement of an endotracheal tube can lead to complications, including hypoxemia, pneumothorax, atelectasis, or complete collapse of the left lung.
ANSWER
The chest radiograph shows an endotracheal tube within the right main stem bronchus. There is no evidence of any other acute pathology (eg, fracture, contusion, pneumothorax).
The tube needs to be withdrawn so that it sits just above the carina (see arrow). If not promptly addressed, incorrect placement of an endotracheal tube can lead to complications, including hypoxemia, pneumothorax, atelectasis, or complete collapse of the left lung.
ANSWER
The chest radiograph shows an endotracheal tube within the right main stem bronchus. There is no evidence of any other acute pathology (eg, fracture, contusion, pneumothorax).
The tube needs to be withdrawn so that it sits just above the carina (see arrow). If not promptly addressed, incorrect placement of an endotracheal tube can lead to complications, including hypoxemia, pneumothorax, atelectasis, or complete collapse of the left lung.
A woman who looks to be 30 years old is brought to your facility as a trauma code following a car accident. She was a restrained driver, traveling at a high speed when she lost control of her vehicle and hit a retaining wall.
When first responders arrived, the patient had extricated herself but demonstrated a decreased level of consciousness, severe respiratory distress, and a Glasgow Coma Scale score of 7. She was intubated at the scene by emergency medical personnel.
On evaluation, you note a young, intubated, unresponsive female. Her blood pressure is 90/50 mm Hg; heart rate, 90 beats/min; and O2 saturation, 100%. Rapid primary survey shows
A portable chest radiograph is obtained (shown). What is your impression?
The Not-So-Routine Physical
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The radiograph shows a moderate-size mass, measuring about 5 × 3 cm, at the medial portion of the right upper lobe, within the paratracheal region. This lesion should be treated as a neoplasm until proven otherwise. Contrast-enhanced CT is warranted, as well as prompt referral to a cardiothoracic surgeon.
ANSWER
The radiograph shows a moderate-size mass, measuring about 5 × 3 cm, at the medial portion of the right upper lobe, within the paratracheal region. This lesion should be treated as a neoplasm until proven otherwise. Contrast-enhanced CT is warranted, as well as prompt referral to a cardiothoracic surgeon.
ANSWER
The radiograph shows a moderate-size mass, measuring about 5 × 3 cm, at the medial portion of the right upper lobe, within the paratracheal region. This lesion should be treated as a neoplasm until proven otherwise. Contrast-enhanced CT is warranted, as well as prompt referral to a cardiothoracic surgeon.
A 60-year-old woman wants to establish care as a new patient at your clinic. She presents for an annual physical and has no current complaints.
Her medical history is significant for hypertension and remote uterine cancer, which was treated with a hysterectomy. She does report smoking a half-pack to one pack of cigarettes per day for “about 30 to 40” years.
Vital signs are normal. Overall, the complete physical examination yields no abnormal findings. Routine bloodwork, 12-lead ECG, and a chest radiograph are ordered. The last is shown. What is your impression?
When It All Comes Crashing Down
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The radiograph shows that the patient is intubated. The lungs are clear overall. There is a fractured, slightly displaced left clavicle. Of concern, though, is the widened appearance of the mediastinum. In patients with blunt chest trauma, there should be a high index of suspicion for a great vessel injury, warranting a chest CT with contrast for further evaluation. Fortunately, in this patient's case, CT was negative.
ANSWER
The radiograph shows that the patient is intubated. The lungs are clear overall. There is a fractured, slightly displaced left clavicle. Of concern, though, is the widened appearance of the mediastinum. In patients with blunt chest trauma, there should be a high index of suspicion for a great vessel injury, warranting a chest CT with contrast for further evaluation. Fortunately, in this patient's case, CT was negative.
ANSWER
The radiograph shows that the patient is intubated. The lungs are clear overall. There is a fractured, slightly displaced left clavicle. Of concern, though, is the widened appearance of the mediastinum. In patients with blunt chest trauma, there should be a high index of suspicion for a great vessel injury, warranting a chest CT with contrast for further evaluation. Fortunately, in this patient's case, CT was negative.
A 40-year-old construction worker was remodeling a home when the roof collapsed. The patient’s head, face, and chest were reportedly struck by a large metal support beam. He was taken to a local facility, where he was found to have decreased level of consciousness and was combative. He was intubated for airway protection and sent to your facility for tertiary level of care.
History is limited. On arrival, you note a male patient who is intubated and sedated. His blood pressure is 90/60 mm Hg and his heart rate, 130 beats/min. A large laceration on his forehead and scalp has been primarily closed. His pupils are unequal, but both react. Neurologic exam is limited secondary to sedation.
As you complete your primary and secondary surveys, a portable chest radiograph is obtained (shown). What is your impression?
From Revved Up to Banged Up
ANSWER
There is significant diastasis of the pubic symphysis, measuring nearly 4 cm. No obvious fractures of the hip or pelvis are seen, but there is malalignment of the rami. There is also evidence of a proximal right femur fracture, although this area is not fully imaged.
Such radiographic findings are typically referred to as an open book pelvic fracture. Usually the result of a shear injury, these fractures are not uncommon and carry an increased risk for pelvic vascular injury.
Emergent orthopedic and vascular consults were obtained, and the patient was placed in a pelvic binder to help reduce the distraction and tamponade any potential vascular injuries.
ANSWER
There is significant diastasis of the pubic symphysis, measuring nearly 4 cm. No obvious fractures of the hip or pelvis are seen, but there is malalignment of the rami. There is also evidence of a proximal right femur fracture, although this area is not fully imaged.
Such radiographic findings are typically referred to as an open book pelvic fracture. Usually the result of a shear injury, these fractures are not uncommon and carry an increased risk for pelvic vascular injury.
Emergent orthopedic and vascular consults were obtained, and the patient was placed in a pelvic binder to help reduce the distraction and tamponade any potential vascular injuries.
ANSWER
There is significant diastasis of the pubic symphysis, measuring nearly 4 cm. No obvious fractures of the hip or pelvis are seen, but there is malalignment of the rami. There is also evidence of a proximal right femur fracture, although this area is not fully imaged.
Such radiographic findings are typically referred to as an open book pelvic fracture. Usually the result of a shear injury, these fractures are not uncommon and carry an increased risk for pelvic vascular injury.
Emergent orthopedic and vascular consults were obtained, and the patient was placed in a pelvic binder to help reduce the distraction and tamponade any potential vascular injuries.
A man, approximately 60 years old, is brought to your facility as a trauma code following a vehicular accident. He was riding a motorcycle when he crashed into another vehicle and was thrown off. Emergency medical personnel report that the patient has obvious head, facial, and extremity trauma. Due to decreased level of consciousness, he was intubated en route. History is otherwise unknown.
Upon arrival, he has two large-bore IVs in place, with fluids going wide open. Despite that, his systolic blood pressure is 90 mm Hg and his heart rate is in the range of 150-160 beats/min. The massive transfusion protocol has been initiated to aid in the aggressive resuscitation efforts.
Portable radiographs of the chest and pelvis are obtained; the latter is shown. What is your impression?
The Man With No Medical History
ANSWER
The radiograph demonstrates no acute fractures or pneumothorax. Of note is a right upper lobe infiltrate, which is a rounded cavitary lesion measuring approximately 4 cm. The differential includes pulmonary malignancy, active or previous pulmonary infection (eg, tuberculosis), or pneumatocele. Further evaluation with CT and a pulmonary consultation was coordinated.
ANSWER
The radiograph demonstrates no acute fractures or pneumothorax. Of note is a right upper lobe infiltrate, which is a rounded cavitary lesion measuring approximately 4 cm. The differential includes pulmonary malignancy, active or previous pulmonary infection (eg, tuberculosis), or pneumatocele. Further evaluation with CT and a pulmonary consultation was coordinated.
ANSWER
The radiograph demonstrates no acute fractures or pneumothorax. Of note is a right upper lobe infiltrate, which is a rounded cavitary lesion measuring approximately 4 cm. The differential includes pulmonary malignancy, active or previous pulmonary infection (eg, tuberculosis), or pneumatocele. Further evaluation with CT and a pulmonary consultation was coordinated.
Following a motor vehicle collision, a 60-year-old man is brought to the emergency department via ambulance. He was an unrestrained front-seat passenger in a vehicle that lost control on the roadway and went into a ditch. The patient complains of headache, chest wall pain, and left arm pain. He does not believe he lost consciousness.
He denies any medical history and adds that he does not seek regular medical treatment. He admits to tobacco use and frequent alcohol use.
On physical exam, you note an elderly-appearing male in no obvious distress with a Glasgow Coma Scale score of 15. His vital signs are all within normal limits. Other than slight swelling on the left side of his head, tenderness in the anterior chest wall, and pain in his left humerus, his exam is normal.
You order trauma lab tests and appropriate radiographic studies; a portable chest radiograph is completed (shown). What is your impression?
Woman’s Weakness is Worsening
ANSWER
The radiograph shows a large, hyperdense mass within the left hilum. A second hyperdense mass is seen within the left upper lobe. Both are concerning for neoplastic processes and warrant further evaluation with contrast-enhanced CT.
Although thorough work-up and biopsy is needed, the presumptive diagnosis is a primary lung mass with likely metastasis to the brain.
ANSWER
The radiograph shows a large, hyperdense mass within the left hilum. A second hyperdense mass is seen within the left upper lobe. Both are concerning for neoplastic processes and warrant further evaluation with contrast-enhanced CT.
Although thorough work-up and biopsy is needed, the presumptive diagnosis is a primary lung mass with likely metastasis to the brain.
ANSWER
The radiograph shows a large, hyperdense mass within the left hilum. A second hyperdense mass is seen within the left upper lobe. Both are concerning for neoplastic processes and warrant further evaluation with contrast-enhanced CT.
Although thorough work-up and biopsy is needed, the presumptive diagnosis is a primary lung mass with likely metastasis to the brain.
A 65-year-old woman is transferred to your facility for evaluation of left-side weakness she has been experiencing for more than two months. She states that it is worsening with time but denies any other symptoms. Outpatient MRI of the brain, obtained by the referring provider, is reported to show a right parietal mass with surrounding edema.
Medical history is significant for hypertension, diabetes, and hypercholesterolemia, which are controlled with medication. The patient reports smoking nearly two packs of cigarettes daily for at least 30 years.
Physical examination reveals normal vital signs and no apparent distress. The patient does have left hemiparesis; her left upper extremity is approximately 4/5 throughout, and her left lower extremity is approximately 2/5 throughout. The exam is otherwise normal.
As you review her admission lab results, you note that a chest radiograph was obtained (shown). What is your impression?
