Caceres’ Corner Case 91 (Update: Solution)


Dear Friends,

This time I want you to make an easy diagnosis in the case of a 79-year-old woman who was found unconscious at home. Supine chest film obtained on admission. Is the chest abnormal? What do you see?

Examine the image below, leave your thoughts and diagnosis in the comments section and come back on Friday for the answer.

79-year-old woman, supine chest

79-year-old woman, supine chest

Click here for the answer to case #91
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    Apr 2014
    DISCUSSION 26 Comments

    26 Responses to : Caceres’ Corner Case 91 (Update: Solution)

    1. genchi bari italia says:

      ….pn-torace dx…..possibile che la diagnosi sia così facile? frattura 3 costa dx ?….

    2. gus says:

      Pneumothorax on the right? or pseudo pneumothorax? Could bed sheet fold mimicking pneumothorax?(Supine chest film )
      I am not sure if there is a fracture on the 1-3 ribs on the right or is a displasia of cervical rib (pseudarthrosis).
      (Thoracic outlet syndrome)?

    3. gus says:

      Should be not? 🙂

      • Jose Caceres says:

        Yes, you should be more assertive. Remember: “an expert is someone who make mistakes with confidence”

    4. gus says:

      i think is pseudo pneumothorax!!!!!! It has a lot of confidence that? 🙂

    5. Lola la Piconera says:

      Firsts three ríbs on the right are abnormal. Some of them are forked showing pseudoarticulations. Heart shilouette is enlarged but this finding can be normal on supine. There is a skin fold on the right hemithorax as Gus said.
      There are some linear opacities on the lower aspect of the left lung that can be due to linear athelectasis.
      Left lung is a bit less dense than the right one. Also there are more vessels on the right lung than on the left. This finding can be due at less partaly to slight rotation of patient. However I think it can be true. I would consider a PE as a pdiagnostic posibility in this patient. Am I wrong?

      • Jose Caceres says:

        As you say, probably rotation accounts for the slight diiference in opacity of both lungs. Patient did not have PE.

    6. Jose Caceres says:

      Now that we have a menage a trois (two against and one in favour).
      would you do expiration film to prove/disprove your diagnosis? And/or CT?
      Should inform you that the patient was awake at the time that the AP film was taken.

    7. gus says:

      No…. is pseudo pneumothorax.

    8. gus says:

      If the patient has pneumothorax symptoms the best method to see a small pneumothorax is CT but that hyperlucent part on the right is not.
      Supine pneumothorax has different distribution plus the minor fissure extended through hyperlucent area to thoracic wall

    9. Lola la Piconera says:

      I wouldn´t do any other imaging test. I would go to see her chest trying to found out for example if he is very thin.

      As you say the patient was awake at the time of taking the PA view I would ask him about any chest pain or dyspnea.

    10. Laurens says:

      Maybe it is a combination of pseudo pneumothorax and pneumothorax. I agree that the vertical line near the lateral chest wall on the right is a skin fold. I suspect pneumothorax because of possible double diaphragm sign on the right.
      As for ribs -I would say there is articulation between first and second rib (which are bifid).

    11. genchi bari italia says:

      …la domanda del professore è chiara…cosa farei in caso di sospetto pn-torace? il problema si pone ovviamente x “piccoli” pn-toraci in cui la radiografia tradizionale può essere “muta”…farei l’ecografia “beside ultrasound” ricercando i segni ecografici del Pntorace: Perdita dello “silding” pleurico e presenza del “double sign”…

    12. Anna says:

      Firstly I was sure that it is a skin fold mimicked a pneumothorax in the right lung and nothing abnormal except an enlarged heart is not seen. But this “skin fold” is strange, it is too much similar to the lung shape and in the right lung apex it is detected additional line of the possible pneumothorax. But in the lung’s bases pulmonary vascularity is good seen, what I’m not expecting to see in pneumothorax. So, I don’t know. In my report I would recommend chest CT for exclusion of right sided pneumothorax.

      • Jose Caceres says:

        There is a finding that helps to eliminate neumothorax and therefore eliminates doing CT.

        • Anna says:

          Yes, it’s obvious now, interlobular fissure is seen, no pneumothorax. “Easy case” as you said at the beginning 🙂

    13. Laurens says:

      Lung vasculature extends beyond the line of the skin fold.

    14. Dr malik says:

      Aortic calcification
      Intravertebral disc heights are decreased in thoracic region