Dr. Pepe’s Diploma Casebook: Case 100 – A painless approach to interpretation (Chapter 7) – SOLVED!


Dear Friends,

Today I present the seventh chapter of the Painless Approach to Interpretation, which also happens to be case number 100 of Dr. Pepe’s Diploma Casebook. It makes me very proud to have shared with you one hundred cases and hope they have been useful.

Showing chest radiographs of a 47-year-old woman with mild fever and chest pain.

What do you see? Check the images below, leave me your thoughts in the comments section and come back on Friday for the answer.



Click here for the answer

Be Sociable, Share!

    32 Responses to : Dr. Pepe’s Diploma Casebook: Case 100 – A painless approach to interpretation (Chapter 7) – SOLVED!

    1. Dr Pepe says:

      Where is everybody?

    2. Jolanta says:

      Opacity below the right cardiophrenic angle,opacity in the left costophrenic angle.

    3. Olena Hural says:

      Mitral shape of the heart suggests mitral stenosis/insufficiency.

      • Olena Hural says:

        On lateral view slightly inhomogeneous shadow in left lower lobe – ddx: inflammation/hypoventilation left lower lobe

        • Olena Hural says:

          Or probable inflammation of the heart – endocarditis

          • Dr Pepe says:

            Can you diagnose endocarditis in the plain film?

            • Olena Hural says:

              Of course, no, but the combination of clinical data and the plain film information make me to think about ddx and further diagnostic algorithm. The laboratory data and heart USD needed

            • Olena Hural says:

              Of course, no. But the combination of clinical data and the plain film information make me to think about the ddx and the next steps of diagnostic algorithm. The laboratory data and heart USD needed

            • Olena Hural says:

              I meant I can not diagnose endocarditis directly on plain film but indirectly

    4. Mahmoud says:

      Irregularity and erosions along vertebral endplates of lower thoracic vertebra, may represent discitis
      There is also minimal opacity in base of left lung

    5. Soledad says:


      • Dr Pepe says:

        I don´t believe pericarditis can be dignosed in the plain film, unless a pericardial fat sign is present (and it is not in this case)

    6. Soledad says:

      cardiac sillhouete is enlargement

    7. Mk says:

      The heart is enlarged, cardiomegaly. I cant delimitate the aorto-pulmonary window. In the lateral view there is an opacity posterior to the left atrium and silhouette sign with the right hemidiaphragm is present.
      Increased density at the level of the left principal bronchious.
      Alveolar opacity near to the left costophrenic angle.

      Cardiac pathology? Endo-pericarditis with alveolar opacities.

    8. reena gupta says:

      There is some increased inhomogeneous opacity in the left lower zone adjacent to the left costophrenic sulcus. This may represent a developing focus of consolidation in the context of patient symptoms.
      Heart size appears normal.
      There are degenerative discovertebral changes seen as osteophytes and lower thoracic facetal hypertrophy particularly at D11 -D12 vertebral level

    9. Sht says:

      RV enlarged.
      Eso dilated – ?achalasia (narrowing seen in lat)
      Focal erosion lt clavicle

    10. Sht says:

      Hpt fits erosion and gerd (eso narrowing) but rvh?

    11. reena gupta says:

      right ventricle appears hypertrophic on lateral xray. vasculits needs to be excluded.

    12. sht says:

      now seeing on proper pc becoming more confused!

      Soft nodule right paratracheal region near apex.
      Small wedge opacity left base peripherally.
      Erosion inferior border left clavicle.
      Not achalasia, but unconvinced GE junction normal

    13. Dr.Hemanth.S says:

      An opacity is noted in the left base. Osteoporotic changes are seen in the vertebra. Pruning of the pulmonary artery noted. On consideration with chest pain,Pulmonary embolism cannot be ruled out.

    14. Yvette says:

      there is an opacity in the right apex and lobulated mass adjacent to the vertebral column – in posterior mediastinum.
      Also the right paraspinal line has abnormal bulge at the level of the right hilum – mass in the paraspinal space?
      Below the right hilum there is also opacity but with no siluette sign , it sugests ( together wirh lat. view)pulmonary inflamatory changes or athelectasis in PS7 and 10 due to the posterior mediastinal mass.

    15. MK says:

      There is a thickening/increased linear opacity at the level of the right inferior paravertebral line, and if we compare with the lateral view, perhaps the diaphragm sillhoutte`s sign is because of an atelectasis of the RLL. The carina level is displaced towards the right side.

      Alveolar opacity near to the left costophrenic angle.

    16. genchi bari italia says:

      …Galactico Professore…..vi è una area di disomogeneo addensamento parenchimale in sede paracardiaca basale sx, con velatura del seno costovertebrale, da piccolo versamento pleurico reattivo….il tutto spiega la febbre ed il dolore toracico….ma,ma, ma non vedo il primo arco superiore d della silhouette mediastinica, riferibile all’arco ascendente della ‘aorta…..pertanto due patologie….una riferibile alla patologia attuale e l’altra “incidentale”, di natura vascolare….aspettando la TC un caro saluto da Bari…..

    17. ZHW says:

      Linear atelectasis left costophrenic angle.
      Peribronchial opacity in the left lower lobe with loss of the retro cardiac black space on the lateral in keeping with alveolar opacity secondary to infection.
      Note sure about the next bit …. The main pulmonary outflow tract is prominent. The heart is not enlarged so no evidence of a shunt. Consider pulmonary valve stenosis. Given this and the lung opacity consider sub acute bacterial endocarditis involving pulmonary valve.

    18. ZHW says:

      Thanks you are right. I’d report it as pneumonia in my day job but thought there must be an added twist? I definitely wouldn’t have suggested pulmonary valve stenosis in my day job!

    19. […] to complete the checklist for the lateral chest radiograph. In addition to the regions described in Diploma Casebook case 100, we should examine the following areas, most of which are hidden in the PA […]