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.
Findings: supine AP film shows a congenital rib malformation with a pseudoarthrosis between the first and the third right ribs (A, B, yellow arrow). The main finding is a line parallel to the right rib cage that raises the possibility of a pneumothorax. Diagnosing a skin fold is easy because vessels are crossing the line (circle in B) and especially because the minor fissure crosses the line and reaches the chest wall (A, B, red arrow). If a pneumothorax were present, the fissure would stop at the border of the lung.
Despite the obvious findings in the AP film, an expiratory film and a CT were performed. Both of them failed to demonstrate a pneumothorax.
Final diagnosis: skin fold mimicking pneumothorax.
Congratulations to Gus, who was the first to give an explanation of the findings.
Teaching point: paying attention to basic findings is crucial to making the correct diagnosis. In this case it would have saved valuable time and money.
