Caceres’ Corner: Case No. 30 (Update: Solution)

Dear Friends,

Muppet has the silly notion that he is good at semiology and wants to test your interpretation skills with the following two cases.

Case 1 is an isolated lateral chest and the question is:

Which one is the right hemidiaphragm?

1. A
2. B
3. Can´t tell

Case 1: Which one is the right hemidiaphragm?

Which one is the right hemidiaphragm?

Case 2: does the patient have middle lobe disease?

1. Yes
2. No
3. Can’t tell

Case 2: does the patient have middle lobe disease?

Does the patient have middle lobe disease?

Hope you enjoy the challenge. Answer next Monday.

Click here for the answer to case #30

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    Aug 2012
    DISCUSSION 24 Comments

    24 Responses to : Caceres’ Corner: Case No. 30 (Update: Solution)

    1. Dr Hesham says:

      1 ans A
      2 ANS yes

    2. Livia says:


    3. Sabina says:


    4. Eric says:

      Case 1 – A
      Case 2 – NO

    5. Aby says:

      1. Right diaphragm is the one not seen completely on lateral CXR. So the answer is A.
      2. The patient has middle lobe disease.

      • Jose Caceres says:

        According to Dr Felson, my mentor, the right hemidiaphragm is the one that extends farther anteriorly, because the anterior portion of the left hemidiaphragm is obliterated by the cardiac shadow.
        Other criteria: the right one is higher and the left has the stomach bubble under it. So: which one is the right and which the left?

        • pedro manuel gil cruz says:

          el diafragma derecho se puede ver en toda su extension tambien segun mi mentor luego la respuesta es la qu se ve en toda su extension

          • pedro manuel gil cruz says:

            es un sindrome del lobulo medio en la pa pero no loes en la laterala de torax pues la densidad se situa ¡en el segemento anterosuperior del torax derecho, luego puede ser un sdme del lobulo medio masw afectacion del Lobulo superior anterior derecho

    6. Nataly says:

      1 A
      2 Yes

    7. m,basset says:

      Case 1 A

      Case B yes

    8. DAG says:

      1. A
      2. No

    9. Genchi Bari Italia says:

      L’emidiaframma dx è A per 3 motivi:Il sx è contrasegnato dalla bolla gastrica;il dx è piu’ alto del sx; il grado di opacità del diaframma dx( in ll sx) è meno denso del sx.Per il 2 quesito: non si tratta di s: del lobo medio, perchè in LL l’opcità non è fusiforme e sospesa tra mediastino superiore ed inferiore. Tuttavia il segni della ” silhouette” cardiaca ,” cancellato” in AP ci dice che siamo nel mediastino medio: io penso allora o ad un esito di mediastinite o agli esiti di lobectomia inferiore.

    10. Alice says:

      1. A – unless there is dextrocardia (with the visceral organs where they usually are?)
      2. Yes – there is a consolidation with smooth margins (the fissures?) in the lateral.

      • Alice says:

        I meant to say A is probably the right hemidiaphragm, either because there is dextrocardia or… because Muppet’s teaching point is that the criterion of the anterior extension is not always correct?
        I’ve already wrecked my brain over these cases.
        Scimitar Syndrome as mentioned by Mm seems a very good idea.

    11. Mm says:

      I think the right hemidiaphragm is A. The anterior portion of the right hemidiaphragm is obliterated
      by the cardiac shadow because the heart is located to the right (dextrocardia).
      Considering that a lateral chest radiograph is taken with the patient’s left side of chest held against the x-ray
      cassette, this x ray shows a poorly defined borders and magnified cardiac shadow, supporting dextrocardia

    12. Mm says:

      CASE 2.
      ANSWEAR: NO.
      You might think I’m crazy but I believe this case is a scimitar syndrome.

      The lateral view shows a vertical retro-sternal band and elevation of the right hemidiaphragm. As was said in case 6: these findings are very suggestive of hypogenetic lung syndrome, secondary to congenital absence of one or two lobes of the lung. It almost always occurs on the right side. About 80% of the patients have anomalous venous drainage of the lower lobe (scimitar syndrome)
      The front view shows a vessel cursing obliquely towards the inferior vena cava.

      • Jose Caceres says:

        You are not crazy and your answer is correct. Muppet very happy!
        Good thinking in case 1

    13. Radost says:

      Case 1: A
      Case 2: No

    14. RadLex says:

      Case 1:
      A is right hemidiaphragm – higher and inserts anteriorly.
      B is left hemidiaphragm. BUT heart is not sitting on the left hemidiaphragm – this is due to dextrocardia.
      Situs solitus is present however.

      Case 2:
      Scimitar syndrome (TAPVR + hypogenetic right lung).

    15. makuna says:

      i think it is impossible to differ which of them is right or left hemidiaphragm. and there is no middle lobe disease .

    16. hassan says:

      1- A
      2- yes