Dr. Pepe’s Diploma Casebook: Case 79 – SOLVED


Dear Friends,

I would like to start the fourth season with an easy case. Showing pre-op radiographs for facial surgery of a 31-year-old woman. Check the images below, leave me your thoughts in the comments section, and come back on Friday for the answer.

1. Carcinoma of the lung
2. Subpulmonary fluid
3. Aspiration pneumonia
4. None of the above



Click here for the answer

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    19 Responses to : Dr. Pepe’s Diploma Casebook: Case 79 – SOLVED

    1. gus says:

      Right middle and probable lower lobe atelectasis -/+ small pleural effusion.
      Right hilum bulky with irregular thickening of main bronchial walls.
      i think 1

    2. Ryan says:

      I would like to choose subpulmonary fluid, but seeing the lateral film the ‘fluid’ is not in dependent position. Does not seem to be carcinoma. Aspiration pneumonia i dont think so to be so well defined. Maybe 4?

    3. Borsuk says:

      I agree with Gus. There is RML atelectasis with silhouette sign of right heart border and medial part of diaphragm. Also mediastinal shift to the right is seen.
      Answer nr 1 is best choice.

    4. Lola la Piconera says:

      There is a right lower lobe atelectasis and for that reason the posteror portion of the right hemidiaphragm is blurred. The RML seems to me normal. RLL bronchus is narrowed and seems like beaded and posterior wall thickening in the lateral view. There can be hilar calcified lymph nodes and left pleural calcification. For me there is no clear evidence of very enlarged right hilar lymph nodes regarding the lateral view. Patient is young. I would compare with previous looking for the chronicity of the RLL loss of volume. If it is new I would do a CT for ruling out a bronchial carcinoma or a foreing body. If it is old I would go for an old TB causing RLL bronchus stenoses or a right lower lobe hypoplasia. If there are not previous chest x rays I would do a CT because there is a possibility of lung cancer

      • Dr. Pepe says:

        Nice discussion. Will give you a hint: satisfaction of search.

        • Lola la Piconera says:

          Then I see the right hilum is well possitioned which shouldnt be in a RLL athelectasis. Could it be a mass in the right lower portion either pulmonary or pleural a fibrous mesothelioma for example?

    5. devjani says:

      Rt lower lobe consolidation collapse. The lower vertebrae in the lateral image are whiter than the upper ones. With subpulmonary effusion.

      ?Rt middle lobe consolidation – the triangular opacity on the lateral image.

    6. Iffat Rehman says:

      2 subpulmonic fluid. US correlation suggested.

    7. genchi bari italia says:

      iperchiarezza del polmone dx, in relazione ad iperventilazione vicariante da atelettasia del lobo polmonare inferiore dx e versameNto pleurico. lieve attrazione omolaterale dell’ombra cardiomediastiNIca e scarsa definizione dell’ilo…A SX .sembrano evidenziarsi due tenui opacità in campo polmonare superiore.

    8. Dr. Pepe says:

      So far, nobody is looking at the whole film.

      • genchi bari italia says:

        il bronco principale di dx è irregolarmente distorto, ristretto e non sede….è chiaro che una TC, con ricostruzioni sul piano coronale chiarirà tutta la patologia…

    9. Aloria says:

      Opacity in the left lung?

    10. gus says:

      rib metastasis?

    11. ilorio says:

      a nodular well circumscribed opacity in the left middle lung zone suggestive of ? lung CA. there is also RLL collapse.

    12. Dr. Pepe says:

      Before the answer is posted, I want to congratulate Gus, who was the first the mention the correct diagnosis and the one that discovered the rib metastases.

    13. genchi bari italia says:

      …l’irregolarità e stenosi del bronco principale era stato segnalato, così pure la sospetta opacità in campo polmonare superiore di sx….oltre naturalmente al collasso del lobo polmonare inferiore dx…