Dr. Pepe’s Diploma Casebook: Case 108 – The Wisdom of Dr. Pepe (Chapter 1) – SOLVED!

Dear Friends,

Today we’ll start the third part of The Beauty of Basic Knowledge series, entitled The Wisdom of Dr. Pepe, in which I intend to summarise my basic approach to chest interpretation. Here I am showing radiographs of a 27-year-old man with moderate cough.

As usual, check the images below, leave your thoughts in the comments section, and come back on Friday to find out the solution.


1. RML disease
2. Pleural effusion
3. RLL mass
4. None of the above

Click here for the answer


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    15 Responses to : Dr. Pepe’s Diploma Casebook: Case 108 – The Wisdom of Dr. Pepe (Chapter 1) – SOLVED!

    1. MK says:

      Good moorning!

      There is a loss of volume of the right hemithorax. The right cardiac border and the ipsilateral are bad defined.
      There is an increased vascularization proyected over the lower lobe with an increased tubular density. In the lateral view we can see a line typical of right hipoplasia.

      A pulmonary hipoplasia with a cimitar syndrome is a good option.

      • murzin says:


        MK has a point…

        I think the mass in the lower pole on right could represent extralobar sequestration.
        Vascularization seems to indicate PAPVR
        So: mixed congenital lesion combined of rgiht lung hypoplasia/ scimitar syndrome with pulmoary sequestration and PAPVR (bronchial atresia cannot be excluded)

        Can’t wait to see the answer.

    2. tr says:

      absence of the right atrial and right diaphragmiatic outline/border on the PA view, with crescent sign.
      lobulated structure over the right cardiophrenic angle on AP view that seems to be located over the anterior costophrenic recess on the lateral view.

      impression: right lower and middle lobe collapse with pleural effusion and morgagni hernia.


      • Jose Caceres says:

        Good imaginative answer. Wouldn’t you expect a triangular hilar-based shadow with lobar collapse?

    3. Yama says:

      1. small right lung
      2. rightward dextroposition of the heart
      3. tubular/serpiginous dilated opacity running from right hilum to below the diaphragm
      Dx – Scimitar syndrome

    4. Ren says:

      There is homogeneous opacity over the lower right hemithorax silhouetting the right hemidiaphragm and right hilum and a rising fluid level due to pleural effusion. Loss of volume of the hemithorax as indicated by the tracheomediastinal shift to the left. Hence collapse or agenesis to be considered. A Lobulated opacity in the right Cardiophrenic angle and abnormal vessel seen over the right lower lung suggests scimitar or venolobar syndrome.The mass may represent sequestration but I am unable to localize it in lateral view. Could this be loculated effusion.

      • Jose Caceres says:

        Remember what Dr. Pepe says: any opacity adjacent to the diaphragm maycome from below

    5. Elena says:

      Agenesia del pericardio

    6. genchi bari italia says:

      V. lenoci , 12

    7. genchi Bari italia says:

      ……magico “blugrana”….avevo previsto il risultato di Madrid ( il Barca ” sbanca ilReal)….proviamo a centrare la diagnosi…..a me sembra una patologia congenita, con ipoplasia del lobo inferiore, su base vascolare…..non vedo l’ilo vascolare di dx e l’opacita mi sembra di natura vascolare….pertanto anomalo ritorno venoso parziale , che si associa ad ipoplasia polmonare…..

    8. Jolanta says:

      Scimitar syndrome 9hypogenetic lung syndrome) with pleural effusion

    9. Jose Cáceres Sirgo says:

      In this case, the clue to the diagnosis lie in identifying the scimitar vein, which is a telltale sign of hypogenetic lung.

      Congratulations to all of you who made the diagnosis, led by MK, who was the first.