Dr. Pepe’s Diploma Casebook: Case 48 – SOLVED!

Diploma_casebook_case48

Dear Friends,

This week I am presenting images of a 49-year-old woman with abdominal pain and moderate distension. Examine the images below, leave your thoughts in the comments section, and come back on Friday for the answer.

What would be your diagnosis?

1. Hepatomegaly
2. Subpulmonary fluid
3. Diaphragmatic eventration
4. None of the above


PA view

Q2

Click here for the answer

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34 Responses to : Dr. Pepe’s Diploma Casebook: Case 48 – SOLVED!

  1. Genchi bari italia says:

    errore od orrore? Dr Pepes rivedi le immagini: il caso è stato già presentato dal Professore Caceres!!!!Aneurisma del tronco brachiocefalico!

    • genchi bari italia says:

      ….sollevamento cupola diaframmatica, con strie disatelettasiche, nonché sospetto di addensamento polmonare alla base polmonare dx,(con D-dimeri elevati?), farei un ecodoppler arto inferiore per escludere un TEP(trombo-embolismpo polmonare).

  2. sameh khodair says:

    The images I see is belonged to the case of the last week, I think that there is an error in loading the images ??

  3. Dr. Pepe says:

    Yes, there has been a big snafu. It will be corrected as soon as possible.

    Thank you calling it to my attention

  4. Dr. Pepe says:

    And you get your money back!

  5. sameh khodair says:

    I seen in the lateral film that the posterior costo-pherenic recess is obliterated by homogenous opacity rising upward this is associated with eccentric dome of the right diaphragmatic copula so subpulmonic effusion is highly considered, …just one look with ultrasonography will solve the problem

  6. gus says:

    is not so easy to say someone if there is sub pleural effusion because
    -Dome is not laterally displaced and we dont have straight edge on lateral view at the major fissure
    – we can see clearly the vascular shadows sub diaphragmatic.
    it was helpfull a decupitus view.

    the fact is that we have elevation of the right hemidiaphragm with subsegmental atelectasis
    no shifting of mediastinum
    and a small pleural effusion on the right costophrenic angle.
    a woman with abdominal pain and moderate distension.

  7. Dr. Ruhid says:

    Diaphragmatic eventration

  8. Marine says:

    1.pleuritis seq. Pulm dxt.
    2. Linear atelektasis lobulus inf. Pulm. Dxt.
    3. Diaphragmatic eventration

  9. Mark says:

    I agree with Gus’ initial assessment: a lack of lateral peaking of the right hemidiaphragm weakens the argument for a subpulmonary effusion. A right decubitus view would help to rule this in or out. Symmetric elevation of the hemidiaphragm is sometimes associated with phrenic nerve palsy, however, these patients are frequently asymptomatic making this unlikely here. Given our patient’s GI symptoms (abdominal pain and distention), I would seriously consider hepatomegaly secondary to hepatic carcinoma. But I don’t think one can definitively make this diagnosis based solely on these images. A CT would help. Looking forward to the answer 🙂

    • Dr. Pepe says:

      CT definitely helped in this case. I agree with your impression that the appearance of the elevated diaphragm is against subpulmonary effusion.

  10. sameh khodair says:

    ALL OF YOU AGAINST ME, OK……:)

  11. sameh khodair says:

    I seen that is not a typical subpulmonic effusion, but I suggested that is the possible diagnosis as the posterior costo-pherenic recess on the right side is obliterated and subpulmonic is often associated with free effusion, also the abdominal pain may be originated from basal pleurisy which may be associated with pleural effusion, However I see that ultrasonography is cheaper, rapid with no irradiation which may reveals that problem

  12. marta says:

    None of the above:)

  13. radioimager says:

    In the PA projection, the elevated right hemidiaphragm forms a round unbroken line arching from the mediastinum to the costal arch suggesting eventration, there is no Loss of the outline on lateral view ruling out pleural effusion, consolidation, however the unilateral right side eventration is extremely rare. There is some plate like Atelectasis on the ipsilateral side, and clinical history given by Dr. pepe indicating pathology below the diaphragm, a hepatic mass leading to hepatomegaly or Tumour of diaphragm (Lipomas – neurofibrimas, fibromas) could be considered.

    • Dr. Pepe says:

      Good discussion. CT on Friday.

      • radioimager says:

        Professor I forgot to mention metastasis as a cause of diaphragmatic elevation with particular reference to ovarian carcinoma and metastasis in these cases is not random. After initial implantation on the fallopian tube and to the contralateral ovary, then the most common sites for distant metastasis are the omentum and the peritoneum. The peritoneum beneath the right diaphragm and the small bowel mesentery are preferentially involved.

        • Dr. Pepe says:

          Good. Can you wait for the CT until Friday ?

          • radioimager says:

            NICE CASE PROFESSOR..REALLY TOUGH ONE !THE OVOID OPACITY IN THE LOWER LUNG IS CLUE TO DIAGNOSIS?BUT AT LEAST I THOUGHT SOME MALIGNANT PATHOLOGY BELOW THE DIAPHRAGM.BUT IF THE RADIOGRAPHS ARE PUT IN THE EXAM, DO WE NEED TO REACH THE EXACT DIAGNOSIS OR IS IT THE APPROACH THAT MATTERS??PARTICULARLY IN SUCH TYPE OF CASES.

  14. gus says:

    1 i like to know the nationality of the woman or if she had a trip in a tropical place (Amebic abscesses)
    2 if she had respiratory problems in the past, if is something new and if she has symptoms from respiratory system.
    if she was operate or if she had viral infection.
    (Phrenic Nerve Paralysis – unilateral side eventration)
    3 if she had ovary problem?(mets – ascites meigs syndrom)
    4 i need a extra Rx exams Breathe in-Breathe out and abdomen Rx.
    is too many?:)

  15. Dr. Pepe says:

    1. Spaniard. No
    2. No. No
    3. Yes
    4. No

  16. genchi bari italia says:

    metast endobronchiali?

  17. francesco says:

    There is some degree of atelectasis of medial (and also of the nearby territory) segment of inferior right lobe probably due to the “compression” made by a sub-phrenic patologic involvement (metastatic? abscess? other?).
    I choose answer 1 and 2 and wait for friday.

  18. Marcy says:

    I think I a late..Anyway, my considerations are:
    -Diafragm alteration (RDT, frenic nerve palsy)
    -Loss Volume Right lower lobe ( I see some blurring of the posterior right hemidiafragm, could represent colalpse?
    -Infradiafragmatic Process (hepatomegaly, liver tumor)

  19. gus says:

    great case!!!!

  20. WAEL KAMKOUM says:

    HEPATOMEGALY

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