Dr. Pepe’s Diploma Casebook: Case 106 – To err is human: how to avoid slipping up (Chapter 5) – SOLVED!

Dear Friends,

This week I’m continuing with another chapter of “To err is human”; and today I am presenting chest radiographs of a 64-year-old man. These images were taken one month after a myocardial infarction.

Check the images carefully, leave your thoughts in the comments and come back on Friday for the answer.

1. Aortic elongation
2. Aortic dissection
3. Aortic aneurysm
4. Any of the above

Click here for the answer

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    22 Responses to : Dr. Pepe’s Diploma Casebook: Case 106 – To err is human: how to avoid slipping up (Chapter 5) – SOLVED!

    1. Mk says:


      there is an evident elongation of the descending aorta with an increased size (aneurysm dilatatation of the aorta), but with the Rx I can´t excluded a dissection.

      The left hilum is increased in size and density, perhaphs because of an increased pulmonary artery.

    2. MP says:

      4. Any of the above.

      The descending aorta is definitely elongated and widened. Chest pain is usually present with dissection, but it cannot be ruled-out based on this radiograph.

    3. genchi bari italia says:

      ….professore…..la risposta dovrebbe essere la 4: …con la radiografie standard osserviamo l’allungamento “sigmoide” di tutta l’aorta,,,la sua evidente dilatazione nel tratto discendente( confronto con l’aorta ascendente) …ma in tutta onestà non riesco a fare dd tra l’aneurisma, la dissezione o l’ematoma intramurale…..ci sarebbe tutta una clinica, di emergenza nel caso di dissezione…oltre naturalmente a segni di insufficienza del ventricolo sx, con scompenso del piccolo circolo e versamento pleurico….però siamo qui per imparare ed aspettiamo che il “galactico” ci illumini….

    4. Ale says:

      Elongation of descendent aorta with appearance serpiginous.
      Aortic Aneurysm in proximal descendent aorta.
      It seems to me that there is a change of caliber in the distal thoracic aorta, but it may be because of the tortuosity.
      Left Ventricle rounded outline, apex sligth up.
      Diffuse osteopenia.

    5. Olena says:

      This is aortic elongation due to the old age.

    6. Sam ngeno says:

      Any of the above

    7. ksh says:

      1+2+3 😀
      + trachea shifted to the right

    8. 19Medicus83 says:

      Elongated thoracal aortic with probable ektatic/aneurysmatic aortic descendens (seems to more than 3,5cm in diameter). Slight shift of the trachea to the right. There is kinking of the aorta in the thoraco-abdominal junction. Aortic aneurysm cannot be rouled out by this chest x-ray as already mentioned. Both hila and lungs are normal.
      So for me any of the above is the correct answer.

      • Dr Pepe says:

        Perhaps we have a semantic problem: to
        me, an elongated aorta is tortuous but has a normal caliber. In this patient, as you rightly say, the descending aorta is dilated. According to my criteria (not universal, of course), the correct answer cannot be any of the above.

        • 19Medicus83 says:

          Thank you for this advice. I have to admit that until now I used the term elongated to describe the aortal appearance not keeping in mind the caliber, which could be normal or ectatic/aneurysmatic.
          Therefore, three: aortic aneurysm.

          • Dr Pepe says:

            Actually, you are right calling the aorta elongated, because most of the times the inner wall is not visible and it cannot be determined whether or not there is dilatation. The case presented is the rare one in which you can see both walls and determine that there is dilatation.

    9. DE says:

      Elongated aorta, which also shows an increased diameter, consistent with aortic aneurysm.
      Shift of the trachea to the right.

      I believe an aortic disection cannot be excluded with this XRay and the patient’s symptoms should be considered.

    10. genchi Bari italia says:

      …carissimo professore…..ti pongo una domanda e ti faccio una osservazione….la brusca differenza di calibro tra aorta ascendente e discendente poteva sospettare anche un esteso ematoma intramurale?…..di fronte all’ rx , anomalo, la diagnosi di certezza poteva essere fatta solo con la Tc, nella dd tra queste due patologie?…..ti seguo sempre con interesse e penso che i 2 punti di distacco possano sempre essere recuperati!