User login
Is Postop Lethargy Cause for Concern?
Answer
The radiograph shows a large cavitary lesion within the left mid-lung with evidence of an air fluid level. This finding is strongly suggestive of a postoperative abscess or empyema. Secondarily, there is some pleural thickening within the left lateral apex region. This can be suggestive of scarring or possibly a neoplasm.
The patient was admitted to the ICU for a sepsis workup, and Interventional Radiology was consulted to evaluate for CT-guided drain placement.
Answer
The radiograph shows a large cavitary lesion within the left mid-lung with evidence of an air fluid level. This finding is strongly suggestive of a postoperative abscess or empyema. Secondarily, there is some pleural thickening within the left lateral apex region. This can be suggestive of scarring or possibly a neoplasm.
The patient was admitted to the ICU for a sepsis workup, and Interventional Radiology was consulted to evaluate for CT-guided drain placement.
Answer
The radiograph shows a large cavitary lesion within the left mid-lung with evidence of an air fluid level. This finding is strongly suggestive of a postoperative abscess or empyema. Secondarily, there is some pleural thickening within the left lateral apex region. This can be suggestive of scarring or possibly a neoplasm.
The patient was admitted to the ICU for a sepsis workup, and Interventional Radiology was consulted to evaluate for CT-guided drain placement.
A 65-year-old man is transported to your emergency department from a local rehabilitation hospital. He is three weeks status post cardiac bypass surgery as well as “some other valve procedure.” In the past two to three days, staff members report, the patient has been less active and has not participated in therapy. This morning, he was found to be lethargic, and that is what prompted the call to 911. Examination reveals a lethargic male who has little verbal communication beyond moaning and groaning. His vital signs include a temperature of 36°C; blood pressure, 90/40 mm Hg; and heart rate, 135 beats/min. His O2 saturation is 90% on room air. Inspection of the patient’s chest reveals a recent, healing midline sternotomy incision. There is no overt redness or swelling. On auscultation, you note decreased breath sounds on the left side, with some coarse crackles. As you initiate your facility’s sepsis protocol order set, a stat portable chest radiograph is obtained. What is your impression?
When Trauma Changes the Picture
Answer
The radiograph has several findings. First, there are multiple fractures along the left lateral ribs. Second, there is a small left apical pneumothorax. Most significant, though, is an elevated left hemidiaphragm. There appears to be stomach or possibly bowel protruding into it.
Although a large hiatal hernia could yield similar findings, in the setting of trauma, one must be concerned about a traumatic diaphragmatic hernia. Subsequent CT of the chest, abdomen, and pelvis confirmed a defect within the diaphragm, with a significant portion of the stomach herniating into the left chest.
Surgical consultation was obtained. The patient was admitted and ultimately underwent surgical intervention to repair the problem.
Answer
The radiograph has several findings. First, there are multiple fractures along the left lateral ribs. Second, there is a small left apical pneumothorax. Most significant, though, is an elevated left hemidiaphragm. There appears to be stomach or possibly bowel protruding into it.
Although a large hiatal hernia could yield similar findings, in the setting of trauma, one must be concerned about a traumatic diaphragmatic hernia. Subsequent CT of the chest, abdomen, and pelvis confirmed a defect within the diaphragm, with a significant portion of the stomach herniating into the left chest.
Surgical consultation was obtained. The patient was admitted and ultimately underwent surgical intervention to repair the problem.
Answer
The radiograph has several findings. First, there are multiple fractures along the left lateral ribs. Second, there is a small left apical pneumothorax. Most significant, though, is an elevated left hemidiaphragm. There appears to be stomach or possibly bowel protruding into it.
Although a large hiatal hernia could yield similar findings, in the setting of trauma, one must be concerned about a traumatic diaphragmatic hernia. Subsequent CT of the chest, abdomen, and pelvis confirmed a defect within the diaphragm, with a significant portion of the stomach herniating into the left chest.
Surgical consultation was obtained. The patient was admitted and ultimately underwent surgical intervention to repair the problem.
A 75-year-old man is brought to your emergency center following a fall from his attic. He slipped and fell approximately 10 feet, landing on his left side. He did not hit his head and denies any loss of consciousness. His primary complaint is left-side chest wall pain. Medical history is significant for hypertension, diabetes, reflux, and atrial fibrillation. On primary survey, you note an elderly male who is somewhat uncomfortable but in no obvious distress. His vital signs are stable; O2 saturation is 98% on room air. The patient exhibits moderate tenderness along the anterior lateral aspect of his chest, as well as mild generalized tenderness in his abdomen. Good inspiratory effort is limited secondary to his pain. While you enter orders into the computer, a portable chest radiograph is obtained. What is your impression?
Shortness of Breath and Loss of Appetite
Answer
The radiograph shows several abnormalities: There is a moderate to large right pleural effusion, as well as a parenchymal density within the right lower lobe. In addition, several of the ribs have a mottled appearance.
All of these findings are highly suspicious for primary as well as metastatic carcinoma. The patient was admitted to the hospital for further workup.
Answer
The radiograph shows several abnormalities: There is a moderate to large right pleural effusion, as well as a parenchymal density within the right lower lobe. In addition, several of the ribs have a mottled appearance.
All of these findings are highly suspicious for primary as well as metastatic carcinoma. The patient was admitted to the hospital for further workup.
Answer
The radiograph shows several abnormalities: There is a moderate to large right pleural effusion, as well as a parenchymal density within the right lower lobe. In addition, several of the ribs have a mottled appearance.
All of these findings are highly suspicious for primary as well as metastatic carcinoma. The patient was admitted to the hospital for further workup.
An 80-year-old man presents with a complaint of acute shortness of breath. He says he has had difficulty breathing for the past two months, but the problem has worsened in the past two days. He reports experiencing dyspnea on exertion and denies fever or chills. He says he has had no appetite lately, adding that he’s lost about 20 to 30 lb in the past couple of months. Medical history is significant for atrial fibrillation, hypothyroidism, hyperlipidemia, and remote bladder cancer. He is a former heavy smoker who quit about 30 years ago. On initial assessment, you note an elderly male in mild respiratory distress. His vital signs are stable, except for his O2 saturation, which is 90% on room air. On auscultation, you note decreased breath sounds on the right and occasional wheezing. You order some preliminary lab work, as well as a chest radiograph. What is your impression?
Ladder Becomes Stairway to Urgent Care
Answer
The radiograph shows a compression deformity of the C6 vertebral body. In addition, there is a displaced fracture fragment along the anterior superior endplate. Alignment is adequate, with no evidence of subluxation. The disc space of C6-7 also appears slightly distracted, suggesting possible acute injury.
Given the clinical and radiographic presentation, this patient warranted further workup. He was admitted for CT and MRI of the cervical spine, which demonstrated disc herniation at both the C5-6 and C6-7 levels, as well as interspinous ligament injury.
The patient subsequently underwent a two-level anterior cervical discectomy and fusion. His symptoms resolved, and he was discharged home the next day.
Answer
The radiograph shows a compression deformity of the C6 vertebral body. In addition, there is a displaced fracture fragment along the anterior superior endplate. Alignment is adequate, with no evidence of subluxation. The disc space of C6-7 also appears slightly distracted, suggesting possible acute injury.
Given the clinical and radiographic presentation, this patient warranted further workup. He was admitted for CT and MRI of the cervical spine, which demonstrated disc herniation at both the C5-6 and C6-7 levels, as well as interspinous ligament injury.
The patient subsequently underwent a two-level anterior cervical discectomy and fusion. His symptoms resolved, and he was discharged home the next day.
Answer
The radiograph shows a compression deformity of the C6 vertebral body. In addition, there is a displaced fracture fragment along the anterior superior endplate. Alignment is adequate, with no evidence of subluxation. The disc space of C6-7 also appears slightly distracted, suggesting possible acute injury.
Given the clinical and radiographic presentation, this patient warranted further workup. He was admitted for CT and MRI of the cervical spine, which demonstrated disc herniation at both the C5-6 and C6-7 levels, as well as interspinous ligament injury.
The patient subsequently underwent a two-level anterior cervical discectomy and fusion. His symptoms resolved, and he was discharged home the next day.
A 30-year-old man presents to an urgent care clinic for evaluation of neck pain secondary to an injury he sustained earlier in the day. He was at a construction worksite, on a ladder, approximately eight to 10 feet above the ground. He went to step onto an adjacent ladder and missed. His chin and face struck one of the rungs, and his head went back. Amazingly, he was able to maintain his balance, holding onto the sides of the ladder, sliding down the front, and landing on his feet. He immediately began to experience neck pain, as well as numbness and tingling in both arms (worse on his left side). He was placed in a rigid collar upon arrival to the facility. Medical history is unremarkable except for tobacco use. Vital signs are normal. Physical exam demonstrates some neck pain within the paraspinous muscles. There is some mild midline tenderness within the cervical spine. Of note, the numbness and tingling seem to be worst in his index finger and thumb. You obtain a cervical spine radiograph; the lateral view is shown. What is your impression?
Patient Has No Complaints, But Family Is Concerned
ANSWER
The radiograph shows diffuse osteopenia and spondylosis. Of note is a moderate to severe compression deformity of the T8 vertebral body. However, by plain radiograph, it is age indeterminate as to its acuity. For definitive diagnosis, MRI without contrast is required to assess for marrow edema, which then suggests an acute fracture.
This patient was admitted for further workup. MRI was ultimately obtained and revealed marrow edema within that vertebral body. She was treated with a rigid custom-made brace.
ANSWER
The radiograph shows diffuse osteopenia and spondylosis. Of note is a moderate to severe compression deformity of the T8 vertebral body. However, by plain radiograph, it is age indeterminate as to its acuity. For definitive diagnosis, MRI without contrast is required to assess for marrow edema, which then suggests an acute fracture.
This patient was admitted for further workup. MRI was ultimately obtained and revealed marrow edema within that vertebral body. She was treated with a rigid custom-made brace.
ANSWER
The radiograph shows diffuse osteopenia and spondylosis. Of note is a moderate to severe compression deformity of the T8 vertebral body. However, by plain radiograph, it is age indeterminate as to its acuity. For definitive diagnosis, MRI without contrast is required to assess for marrow edema, which then suggests an acute fracture.
This patient was admitted for further workup. MRI was ultimately obtained and revealed marrow edema within that vertebral body. She was treated with a rigid custom-made brace.
An 80-year-old woman presents to the emergency department for evaluation. Her family reports that she has baseline dementia and resides in an assisted living facility. Staff there report that recently the patient has fallen multiple times. The patient herself does not voice any specific complaints, but her family has noticed she is not as active or walking as much as usual. Medical history is significant for mild hypertension. On physical exam, you note that the patient is awake and alert but oriented only to person. Her vital signs are stable. Primary and secondary survey do not demonstrate any obvious injury or trauma. You order some basic blood work, as well as some imaging studies—including thoracic and lumbar radiographs. The lateral thoracic radiograph is shown. What is your impression?
Secondary Survey of Trauma Patient
ANSWER
The radiograph shows a slightly displaced fracture of the distal fourth metacarpal head. No other injuries are present.
The patient’s hand was left in the splint, and orthopedic evaluation was obtained.
ANSWER
The radiograph shows a slightly displaced fracture of the distal fourth metacarpal head. No other injuries are present.
The patient’s hand was left in the splint, and orthopedic evaluation was obtained.
ANSWER
The radiograph shows a slightly displaced fracture of the distal fourth metacarpal head. No other injuries are present.
The patient’s hand was left in the splint, and orthopedic evaluation was obtained.
You are assisting in the evaluation and management of a trauma patient who was brought to your facility earlier today, following a motor vehicle collision. He is estimated to be in his 30s and is presumed to have been ejected, as he was found outside the vehicle. He was intubated in the field, and primary survey and resuscitation have been completed. History is otherwise unknown. The patient’s vital signs are currently stable. As you perform your secondary survey, you note that his right hand and wrist appear to be moderately swollen. He has been placed in a splint. You order a radiograph of the hand. What is your impression?
Revenge of the Deer Stand
ANSWER
The radiograph shows a fracture of both the distal radius and distal ulna. The patient was placed in a splint and referred to orthopedics for outpatient follow-up.
ANSWER
The radiograph shows a fracture of both the distal radius and distal ulna. The patient was placed in a splint and referred to orthopedics for outpatient follow-up.
ANSWER
The radiograph shows a fracture of both the distal radius and distal ulna. The patient was placed in a splint and referred to orthopedics for outpatient follow-up.
As you begin your shift, knowing deer season has started in your area, you wonder how long it will be before you see your first deer stand casualty of the day. With your first patient, you wonder no more: A 30-year-old man presents for evaluation of right wrist pain after falling from his deer stand. He says one of the straps holding the stand broke, causing him to fall forward and land on his outstretched hands. His medical history is unremarkable. Inspection of the right wrist shows no obvious deformity. No significant swelling is present. There is decreased range of motion and localized tenderness over the radius and ulna. Good pulses and capillary refill are noted. You obtain a radiograph of the wrist. What is your impression?
What’s Wrong With This Picture?
ANSWER
The radiograph shows an enteric tube passing through the gastrointestinal tract. However, it extends low into the left lower quadrant, loops around the right lower quadrant, and then heads up toward the left upper quadrant. Such a course is atypical and concerning for displaced position.
The radiologists concurred, and it was decided to instill some water-soluble contrast and repeat the KUB for further evaluation. That image is shown here. Note that the contrast does not appear to be in the stomach, as no gastric folds are visible. It accumulates in the left upper quadrant, under the diaphragm. Such a finding is concerning for possible gastric perforation.
The tube was promptly withdrawn, and urgent surgical consultation was obtained.
ANSWER
The radiograph shows an enteric tube passing through the gastrointestinal tract. However, it extends low into the left lower quadrant, loops around the right lower quadrant, and then heads up toward the left upper quadrant. Such a course is atypical and concerning for displaced position.
The radiologists concurred, and it was decided to instill some water-soluble contrast and repeat the KUB for further evaluation. That image is shown here. Note that the contrast does not appear to be in the stomach, as no gastric folds are visible. It accumulates in the left upper quadrant, under the diaphragm. Such a finding is concerning for possible gastric perforation.
The tube was promptly withdrawn, and urgent surgical consultation was obtained.
ANSWER
The radiograph shows an enteric tube passing through the gastrointestinal tract. However, it extends low into the left lower quadrant, loops around the right lower quadrant, and then heads up toward the left upper quadrant. Such a course is atypical and concerning for displaced position.
The radiologists concurred, and it was decided to instill some water-soluble contrast and repeat the KUB for further evaluation. That image is shown here. Note that the contrast does not appear to be in the stomach, as no gastric folds are visible. It accumulates in the left upper quadrant, under the diaphragm. Such a finding is concerning for possible gastric perforation.
The tube was promptly withdrawn, and urgent surgical consultation was obtained.
A 90-year-old woman, admitted for altered mental status, just had a nasogastric tube placed to facilitate nutrition and medication delivery. The ICU nurse asks you to review an abdominal radiograph to confirm correct placement, since several attempts by various hospital personnel were required before they felt they had the tube in place. The patient is otherwise currently stable, per the nurse’s report. Her vital signs are stable, and she will arouse to minimal stimulation, although she continues to demonstrate confusion. Portable KUB radiograph is shown. What is your impression?
Oh, Deer! Accident Leaves Man in Pain
ANSWER
The radiograph shows a nondisplaced fracture of the proximal fibular head. No other fractures are evident. There is some evidence of soft-tissue injury and edema over the tibia.
An orthopedics consultation was obtained, with the presumption that the fracture would be nonsurgically managed.
ANSWER
The radiograph shows a nondisplaced fracture of the proximal fibular head. No other fractures are evident. There is some evidence of soft-tissue injury and edema over the tibia.
An orthopedics consultation was obtained, with the presumption that the fracture would be nonsurgically managed.
ANSWER
The radiograph shows a nondisplaced fracture of the proximal fibular head. No other fractures are evident. There is some evidence of soft-tissue injury and edema over the tibia.
An orthopedics consultation was obtained, with the presumption that the fracture would be nonsurgically managed.
A 50-year-old man is brought to your facility by EMS personnel for evaluation after a motor vehicle crash. He was an unrestrained driver who swerved suddenly to avoid hitting a deer that jumped in front of him. He lost control of his vehicle, which rolled over several times and eventually landed in a ditch. His airbag deployed. The patient’s primary complaint is neck and right leg pain. His medical history is essentially unremarkable. He is awake, alert, and oriented, with stable vital signs. Primary survey shows a large laceration of his right leg over the tibia, with extensive soft-tissue injury and loss through the muscle. He has good range of motion in his knee, with no evident pain or swelling. His ankle and foot also show no injury and appear to be neurovascularly intact. You obtain a radiograph of the right tibia. What is your impression?
Elective Craniotomy Results in Respiratory Distress
ANSWER
The radiograph shows complete opacification of the left hemithorax. The differential includes total atelectasis of the lung, mucus plug within the left bronchus, or possible blood or fluid collection. Of note, the patient has a catheter within the left subclavian vein, the distal tip of which appears to be in an unusual location. In this case, it was determined that the displaced catheter tip, resulting in hemothorax, was the etiology. The line was removed, and urgent cardiothoracic consultation was obtained. A left chest tube was promptly placed, with a resultant 2 L of immediate output. The patient improved clinically as well.
ANSWER
The radiograph shows complete opacification of the left hemithorax. The differential includes total atelectasis of the lung, mucus plug within the left bronchus, or possible blood or fluid collection. Of note, the patient has a catheter within the left subclavian vein, the distal tip of which appears to be in an unusual location. In this case, it was determined that the displaced catheter tip, resulting in hemothorax, was the etiology. The line was removed, and urgent cardiothoracic consultation was obtained. A left chest tube was promptly placed, with a resultant 2 L of immediate output. The patient improved clinically as well.
ANSWER
The radiograph shows complete opacification of the left hemithorax. The differential includes total atelectasis of the lung, mucus plug within the left bronchus, or possible blood or fluid collection. Of note, the patient has a catheter within the left subclavian vein, the distal tip of which appears to be in an unusual location. In this case, it was determined that the displaced catheter tip, resulting in hemothorax, was the etiology. The line was removed, and urgent cardiothoracic consultation was obtained. A left chest tube was promptly placed, with a resultant 2 L of immediate output. The patient improved clinically as well.
A 60-year-old woman undergoes an elective craniotomy for clipping of a nonruptured aneurysm. The perioperative course is uneventful, and the aneurysm is clipped without complication. The patient is extubated and sent to the recovery room. Within 30 minutes, you are notified by the nurse that the patient is experiencing moderate respiratory distress. There are no neurologic deficits. Her medical history includes hypertension, hypercholesterolemia, and coronary artery disease, with previous stenting. Preoperative medical and cardiac clearance for the craniotomy had been obtained. Examination reveals the patient to be in a postanesthetic state, with mild-to-moderate dyspnea and tachypnea. She appears to be moving all of her extremities well. Her O2 saturation is 92% on 100% oxygen via a nonrebreather mask. Her breath sounds are significantly diminished on the left side. A stat portable chest radiograph is obtained. What is your impression?
