Dr. Pepe’s Diploma Casebook: Case 105 – To err is human: how to avoid slipping up (Chapter 4) – SOLVED!

Dear Friends,

Continuining with the next chapter of “To err is human”, I present PA radiograph of a 45-year-old woman with chest pain and mild fever.
How many significant findings do you see?

1. One
2. Two
3. Three
4. Four

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

Click here for the answer

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    Mar 2017
    DISCUSSION 17 Comments

    17 Responses to : Dr. Pepe’s Diploma Casebook: Case 105 – To err is human: how to avoid slipping up (Chapter 4) – SOLVED!

    1. MK says:

      Good morning!!!

      I think that there are 2 abnormal findings: the right hilum is increased in size and density, with a nodular appearence. Also I see a horizontal increased density area proyected over the RUL (the first idea is a mucus plug).

    2. Mauro says:

      I see a nodule on the right lung, the right hilum is enlarged, there is an irregularity in the upper portion of the left hilum, associated with a small linear and vertical opacity. And I also think there is a very small lung nodule just above the left hilum.
      Four findings, then.

    3. tr says:

      1- enlargement of the right pulmonary artery (Fleishner sign).
      2- oligaemia in the right mid and lower zones compared with the left (Westermark sign).
      3- faint wedge- shaped opacity over the right mid zone (Hampton sign).
      4- abrupt cutoff of the pulmonary artery branches over the right mid zone (knuckle sign).

      my suggestion is right pulmonary artery embolism.


    4. m.saoud says:

      i thimk there is only one abnormality which is enlargment of the right hilum.

    5. ania says:

      1) widened paratracheal line,
      2) enlarged right hilum,
      3) opacity projected over the anterior part of IVth rib
      4) linear opacity near the pulmonary trunk

    6. ren says:

      1.enlarged right hilum with nodular opacities and few nodular bopacities in left hilum as well? lymphnodes
      2. Few opacities in right mid /lower zones ?linear opacity in right mid zones. these may represent mucous impacted bronchi/ infective nodules.
      3. haziness in bilateral lower zones left>right

    7. pepita says:

      Prominent rignt hilum could be consistent with right pulm.a. embolism, and opacity in the perifery of the middle zone infarction, anamnestic sign is mild fever, maybe septic emboli?
      Also could be pneumonic infiltration with hilar adenopathy, but the case should be complex, so..

      • pepita says:

        I can also see faint soft tissue shadow in the left upper zone near the aortic knuckle between posterior parts of the 5th and 6th rib

    8. genchi bari italia says:

      ….gentilissimo Prof…..ci sono due segni evidenti….iperplasia ilo dx ed opacità ground-glass in campo medio omolaterale…..vi è poi un terzo segno,….l’ispessimento della linea paratracheale e mediastinica, bilateralmente, che potrebbe essere di natura adenopatica….il quarto segno potrebbe essere l’immagine aerea, ipertasparente nell’ambito dell’ilo dx iperplastico(broncocele?)…..in caro saluto ….

    9. genchi bari italia says:

      …grazie Prof…..possiamo dire che il Bari è andato vicino al goal ?

    10. jose caceres says:

      Dear friends, the aim of this case was to explore satisfaction of search. Of all the responders only two (ania and genchi bari) mentioned the enlarged paratracheal line, which reinforced the presence of adenopathy and the likely diagnosis of malignancy.

    11. Dr ahmad al ani says:

      Dear my question
      Why this case pospond for 3 months later

      • jose caceres says:

        This case was initially diagnosed as infection and treated as such. The next radiograph was taken two months later as well as the CT. I chose the radiograph at three months because the changes were more obvious. Still, a two month delay is significant. Perhaps the patients’ symptoms improved or she missed an appointment with his doctor

    12. ren says:

      Thanks professor. indeed an eyeopener. I have a doubt. How do we differenciate thickened paratracheal stripe from the shadow of SVC, on occasions i have reported it as thickened paratracheal stripe and others have refuted terming it as simply vascular shadow.

      • jose caceres says:

        This a difficult question. Will write to your mail with one image of each, giving you my approach