Dr. Pepe’s Diploma Casebook: Case 98 – A painless approach to interpretation (Chapter 5) – SOLVED!


Dear Friends,

Today we are moving to a new chapter in the Painless Approach to Interpretation, addressing what to do when the chest radiograph does not show an obvious abnormality.

For this purpose I am presenting the PA and lateral radiographs of a 57-year-old man with a chronic cough. What do you see?

Examine 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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    42 Responses to : Dr. Pepe’s Diploma Casebook: Case 98 – A painless approach to interpretation (Chapter 5) – SOLVED!

    1. Mauro says:

      I see two rounded calcifications located in the soft tissues of the right hemithorax, laterally. I also see some linear hyperdensities which seem to be in the periphery of the right lung, lower third. Did this patient undergo any surgery?

    2. MK says:

      There are some straights metallic opacities in the right soft tissues and proyected over the lung. Is no surgery history we can think about acupuncture needles.
      The PA view is poorly inspired with a prominent right hilum, but I can find anything eles in the lung fields. Perhaps we can recomended a high resolution CT for studing the chronic cought Ifara others clínicas causes have been excluded

    3. MK says:

      Sorry, ….CT for studing the chronic cought if others clinical causes have been excluded.

    4. Dr Tariq says:

      Subcutaneous short linear opacities, right chest; queries iatrogenic/ parasitic infection
      Mild thoracic spondylosis
      Thickened left oblique fissures

    5. Bs says:

      Middle lobe atelectasis

    6. Sakanyan Mari says:

      right hemitorax

    7. Sakanyan Mari says:

      right hemitorax

    8. Moises botello says:

      Les a gradesco mucho por su pagina y los casos son muy interesantes

    9. Moises botello says:

      Les a gradesco por su pagina y sobreto por los casos son muy interesantes

    10. Pio says:

      In my opinion, the left hemithorax is hyperlucent with signs of oligaemia. Asymmetry of hila, structures of left hilum are poorly seen. Maybe some vascular anomaly (for example hypoplasia of left pulmonary artery) or pulmonary embolus. I think also that there are some discrete atelectatic parts of lingula.

    11. Rv says:

      Subsegmental collapse in lingula
      Additional radiopaque shadow in right lower zone

    12. Olena Hural says:

      There is obvious decrease of right hemithorax and the diaphragm relaxation on the right (trauma, e.g. fall in anamnesis or partial lung resection – this could explain metallic shadows on the right)

      On lateral view there is thickend pleura in great fissure with the obliteration of anterior sinus also due to pleural thickening – post inflamatory changes?

      There is also a tube-like lucent space on the cardiac shadow and is following to the abdomen level – something wrong with esophagus? the early stage of achalasia?

      There should be the air in stomach visible on the left side both on PA and lateral view, which in this case is not seen.
      I think also about esophageal defect replacement with the part of intestine or possible gastrectomy

    13. Mahmoud says:

      There is left retrocardiac opacity, ct is of help for further evaluation.

    14. MK says:

      Second round:

      The left ventricle is increased in size in the PA and Lateral view.
      In the lateral view there is a haziness of the anterior clear space, so a dilatation of the ascending aorta will be an option (aortic valve stenosis?). Mayor fissure is thickened.
      The right hilum is increased respect to the opposite.

    15. Maria-Cristina Andrei says:

      I think surgery for right breast cancer and pulmonary changes after radiation.

    16. MK says:

      Another causes of hiperlucency hemithorax without air trapping and surgery history are: pulmonary artery agenesis/hypoplasia, wall chest anomalies, technical rotational factors.

      Foreign body without air traping is possible?

      Me rindo….

    17. genchi bari italia says:

      ….stimatissimo Maestro……il problema è a sx, ove il polmone è ipertrasparente perchè in compenso funzionale alla estrema atelettasia del lobo inferiore…profilo cardiaco e diaframma a margini “flou” quale segno indiretto…..

    18. Nacer says:

      left hilum is poor, and hypertransparency in left side.
      pulmonory left artery atrésia

    19. Dr Pepe says:

      At this time of the week I have to point out the marked downward displacement of the left hilum, indicative of LLL collapse with compensatory increased lucency of LUL. Congratulations to Genchi Bari for his diagnosis.

      • Marco says:

        Professor, quick question. Is the right hemidiaphragm on the PA an example of eventration? Thanks for the great case 🙂

    20. Nacer says:

      hypertransparancy in the left side with poor hilum

    21. Genchi Bari Italia says:

      …..goals !!!!!! Professore son quelli che mancano al Bari…..ancora una prestazione deludente….Il Barca e’ sempre galattico!!!!

    22. Yvette says:

      Good evening, Dear Doctor.
      Right hemithorax with small volume reduction.
      left hemithorax is hyperlucent, left hilum is smaller.
      We are not able to see the left diafragmae dome( siluette sign). Behid the heart there is visible slight triangle opacity without any particular coresponding changes in lateral view.
      I woud say it is LLL collaps with compensatory distension the rest of the left lung parenhyma. The most common cause is tumor, chronic inflamatory changes, foregin body in segmental bronchus.

    23. Mk says:

      And what happen with the metallic densities?

      • Dr Pepe says:

        Don’t have the foggiest idea! Sometimes you cannot explain everything.
        But you should not center in the metallic densities and because of them overlook a descended hilum

    24. MK says: