Dr. Pepe’s Diploma Casebook: Case 94 – A painless approach to interpretation (Chapter 1) – SOLVED!


Dear Friends,

This year I intend to discuss the basic principles of interpreting chest radiographs, under the heading, “The Beauty of Basic Knowledge”.

I plan to structure the discussion into three main parts, which will take us through the whole academic year:

Part 1. A painless approach to interpretation
Part 2. To err is human: how to avoid slipping up
Part 3. The wisdom of Dr. Pepe

This week’s case is the first chapter of my ‘painless approach to interpretation’. Interpreting chest radiographs is not difficult if we follow Confucius’ saying: “ A journey of a thousand miles begins with a single step”. As a clinical radiologist, my first step is to ask myself three questions:

a) Is there any visible abnormality?
b) It is intra or extrapulmonary?
c) What does it look like?

Today I’ll discuss the first question. Below you can see the chest radiographs of three different patients. Do you see any visible abnormality in any of them? Let me know in the comments section and come back on Friday for my answer.

CASE 1: 27-year-old woman with moderate cough

CASE 1: 27-year-old woman with moderate cough

CASE 2: 52-year-old man, pre-op for leg fracture

CASE 2: 52-year-old man, pre-op for leg fracture

CASE 3: 65-year-old man with moderate dyspnoea

CASE 3: 65-year-old man with moderate dyspnoea

Click here for the answer

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    18 Responses to : Dr. Pepe’s Diploma Casebook: Case 94 – A painless approach to interpretation (Chapter 1) – SOLVED!

    1. Borsuk says:

      Hello after holiday
      In 2 case there is round nodule projecting over anterior part of right VI rib.
      In 3 case there is obvious well circumscribed lesion in left lower lobe laying on diaphragm.
      In case 1 I cant find abnormality.

    2. Mauro says:

      Hello professor!

      In case 1 there seems to be blurring of the right cardiac border. It could be middle lobe consolidation, but pectus excavatum may also give this appearance. A profile x-ray might help.

      In case 2 I see a nodule projected on the lower third of the right lung, at the level of the 8th rib (posteriorly), or 6th rib (anteriorly). It is round, well circumscribed and could be pulmonary. It could be a nipple, too, although I don’t see anything on the other side. Maybe some more radiographs with nipple markers might help, or we could go straight to CT.

      In case 3 there is a lesion located in the posterior costophrening angle, possibly retrocardiac. Maybe a small Bochdalek hernia? Could be a lung tumor or pleural lesion as well. Moreover, it seems to me that the lungs are somewhat radiolucent, especially the left one. And I think there is a little hyperexpansion with elargement of the retrosternal clear space. Maybe COPD?

    3. Diogo says:

      In case 2 I’d add a right paratracheal lesion.

    4. 19Medicus83 says:

      Additionally to the comment of Mauro I would describbe a prominent right-sided mediastinal contour, possibly of vascular origin. I do not think that the x-ray is significantly verrotated because the trachea is in the midline. It could be an anomaly of the aortic arch, maybe a right-sided aortic arch. In the differential list would be coarktation.
      Best greeting.

    5. mk says:

      Case 1. Right cardiac silhouette is missing, probably because of something at medial lobe, such as consolidation. Pectus excavatum will be a good option too.
      Case 2. Peripheral nodule at right inferior lobe, and probably a partially calcificied nodule next to left hilum. Thickening of right paratracheal line.
      Case 3. Something proyected over lower posterior mediastinal.

    6. UFTM radiogroup says:

      Good morning, profesor:
      Case 1: we can’t define cardiac border correctaly, maybe because the heart is rotated by a pectus excavatum. We don’t think there is consolidation.
      Case 2: We think there is a right mediastinal bulging with extension to right paratracheal stripe. Vascular anomaly? Maybe there is no connection with the history of leg fracture.
      Case 3: We see a mass with pleural base posteriorly, possibly related to a hernia.

    7. M. A. Fahmy says:

      In the first case, blurring vision of the right cardiac border may suggest pectus excavatum, lateral view is advisable.

      In case number 2 there is a right para tracheal dense shadow with loss of the left aortic knob may represent right sided aortic arch, in addition to the the presence of a dense nodule in the right lower lateral zone ? metastases.

      In the third case what I see is mild hyperinflated lungs specially upper and mid zones with reduced pulmonary vascularity, the presence of large emphysematous bullae is a possibility, while that radiodense structure in the posterior left para spinal region; I see the posterior left hemi diaphragm is continuous so I do not think its a hernia, so it could be a nerve sheath tumour,, thank you

    8. Andrei says:

      1st case – pectus escavatum with concomitant changing of CXR appearance maybe consolidation of RML…need lateral view.

      2nd case – amputation of right hilum possible pulmonary embolism with enlargement of the upper mediastinum, may be vascular – check CT 🙁 or RX.

      3rd case – pulmonary scleroemphysema with a postero-basal ( LLL ) diaphragm opacity that might be either a transdiaphragm hernia or a fluid collection

    9. Andrey says:

      1 pectus excavatum
      2.right dose mediastinal widening maybe basilar abnormality
      3. Bohdalik hernia

    10. Julio says:

      In case 1 I would like to see the lateral view, because the right border of the heart might be slightly out of place, this could be due to wall deformity (pectus excavatum).

      Case 2 there is an increased density and enlargement of right paratracheal space although I can´t see tracheal displacement neither the aortic arch where it should be seen. This might be a vascular anomaly (Aortic arch developmental anomaly).

      Case 3 there is a round lesion seen in both projections and my best guess here is a diaphragmatic lobulation in the posterior left diaphragm.

    11. Jose Caceres says:

      Dear friends, thanks for participating. Most of you gave the right answers (cases were not too difficult, really 😉 ).
      See the discussion tomorrow and look at next week’s case. It is interesting.

    12. […] you may remember from Diploma Case 94, when I’m facing a chest radiograph I start by asking three […]

    13. […] Is there any visible abnormality? (Chapter 1) b) Is it intra or extrapulmonary? (Chapter 2) c) What does it look […]

    14. […] that we’ve looked at the three key questions to ask when facing a chest radiograph (chapters 1, 2 and 3), we move on to the interpretation of pulmonary […]