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“Something Abnormal” on a Chest X-ray
ANSWER
The radiograph demonstrates a fairly large (4 x 6 cm) right paratracheal mass of unclear etiology. This type of finding warrants further evaluation with contrasted CT.
Fortunately for this patient, a subsequent study demonstrated a slightly enlarged thyroid gland. This correlated with the radiographic
finding.
ANSWER
The radiograph demonstrates a fairly large (4 x 6 cm) right paratracheal mass of unclear etiology. This type of finding warrants further evaluation with contrasted CT.
Fortunately for this patient, a subsequent study demonstrated a slightly enlarged thyroid gland. This correlated with the radiographic
finding.
ANSWER
The radiograph demonstrates a fairly large (4 x 6 cm) right paratracheal mass of unclear etiology. This type of finding warrants further evaluation with contrasted CT.
Fortunately for this patient, a subsequent study demonstrated a slightly enlarged thyroid gland. This correlated with the radiographic
finding.
You are doing preoperative orders on a patient scheduled for surgery tomorrow morning. The patient is a 75-year-old woman who was admitted with an acute left subdural hematoma after sustaining a ground-level fall. Her medical history is significant for hypertension and diabetes. Social history is unremarkable. She is neurologically intact except for occasional confusion and aphasia. She moves all her extremities well. As you review her lab results, one of the nurses mentions that the radiology department called about “something abnormal” on the patient’s chest radiograph. You pull up the patient’s portable chest radiograph on the computer to review. What is your impression?
Man Falls on Buttocks
ANSWER
There are degenerative changes present. Bilateral hip prostheses are noted. Within the coccyx, there is bone remodeling and angulation that are likely chronic and related to remote trauma or injury (arrow). Below this, some cortical lucency (circled) is noted, most likely consistent with an acute fracture. The patient was prescribed a nonsteroidal medication and a mild narcotic pain medication.
ANSWER
There are degenerative changes present. Bilateral hip prostheses are noted. Within the coccyx, there is bone remodeling and angulation that are likely chronic and related to remote trauma or injury (arrow). Below this, some cortical lucency (circled) is noted, most likely consistent with an acute fracture. The patient was prescribed a nonsteroidal medication and a mild narcotic pain medication.
ANSWER
There are degenerative changes present. Bilateral hip prostheses are noted. Within the coccyx, there is bone remodeling and angulation that are likely chronic and related to remote trauma or injury (arrow). Below this, some cortical lucency (circled) is noted, most likely consistent with an acute fracture. The patient was prescribed a nonsteroidal medication and a mild narcotic pain medication.
A 75-year-old man presents to the urgent care center for evaluation of pain in his buttocks after a fall. He states he was walking when his “legs gave out” and he hit the ground. He landed squarely on his buttocks, causing immediate pain. He was eventually able to get up with some assistance. He denies any current weakness or any bowel or bladder complaints. His medical/surgical history is significant for coronary artery disease, hypertension, and bilateral hip replacements. Physical exam reveals an elderly male who is uncomfortable but in no obvious distress. His vital signs are stable. He has moderate point tenderness over his sacrum but is able to move all his extremities well, with normal strength. Radiograph of his sacrum/coccyx is shown. What is your impression?
Thrown From Motorcycle
ANSWER
Several findings are evident from this radiograph. First, the quality is slightly diminished due to the patient’s size and artifact from the backboard. The patient’s mediastinum is somewhat widened, which is concerning for possible occult chest/vascular injury. There is some haziness within the left apical region suggestive of a hemothorax; no definite pneumothorax is seen. The left clavicle is fractured and displaced, and the left scapula is fractured as well.
ANSWER
Several findings are evident from this radiograph. First, the quality is slightly diminished due to the patient’s size and artifact from the backboard. The patient’s mediastinum is somewhat widened, which is concerning for possible occult chest/vascular injury. There is some haziness within the left apical region suggestive of a hemothorax; no definite pneumothorax is seen. The left clavicle is fractured and displaced, and the left scapula is fractured as well.
ANSWER
Several findings are evident from this radiograph. First, the quality is slightly diminished due to the patient’s size and artifact from the backboard. The patient’s mediastinum is somewhat widened, which is concerning for possible occult chest/vascular injury. There is some haziness within the left apical region suggestive of a hemothorax; no definite pneumothorax is seen. The left clavicle is fractured and displaced, and the left scapula is fractured as well.
A 57-year-old man is brought to your facility as a trauma code. He was riding a motorcycle on the highway, traveling approximately 45 to 50 mph, when the car in front of him abruptly stopped. He hit the car and was thrown from his bike. He believes he briefly lost consciousness but recalls emergency personnel tending to him. On arrival, he is awake and alert, complaining of pain in his neck, left arm, and left lower leg. Medical history is significant for borderline hypertension and a previous accident that resulted in an emergency laparotomy. Primary survey reveals stable vital signs: blood pressure of 157/100 mm Hg; heart rate, 110 beats/min; respiratory rate, 20 breaths/min; and O2 saturation, 98% with supplemental oxygen. Pupils are equal and reactive; there are slightly decreased breath sounds on the left side. Abdominal exam appears benign. There is decreased mobility and pain in the patient’s left upper and left lower extremities, although no obvious deformity is noted. Preliminary chest radiograph is obtained before the patient is sent for CT. What is your impression?
Clipped by an Oncoming Car
ANSWER
The image shows a comminuted and depressed fracture of the lateral tibial plateau. It is depressed approximately 6 to 7 mm. The patient was admitted, and orthopedic consultation was obtained. The patient subsequently underwent an open reduction and internal fixation of the fracture.
ANSWER
The image shows a comminuted and depressed fracture of the lateral tibial plateau. It is depressed approximately 6 to 7 mm. The patient was admitted, and orthopedic consultation was obtained. The patient subsequently underwent an open reduction and internal fixation of the fracture.
ANSWER
The image shows a comminuted and depressed fracture of the lateral tibial plateau. It is depressed approximately 6 to 7 mm. The patient was admitted, and orthopedic consultation was obtained. The patient subsequently underwent an open reduction and internal fixation of the fracture.
A 23-year-old man is brought in after being hit by a car. He was in the process of getting into his car when another vehicle coming from the opposite direction swerved into his lane. He tried to jump onto his hood to avoid the other car but was struck by the side mirror and landed on the ground. He is primarily complaining of left knee and lower leg pain. He denies any medical history. Primary survey appears to be stable except for scalp and facial lacerations. The patient is awake, alert, and oriented, and his vital signs are stable. His left lower extremity is in a splint immobilizer, placed by emergency medical personnel. There is a moderate amount of soft tissue swelling around the knee, which is exquisitely tender to palpation. The patient has limited flexion and extension of the knee due to pain. He is able to wiggle his toes, and distally in the leg and foot there appears to be no neurovascular compromise. Radiographs of the tibia are obtained. What is your impression?
Inmate Falls From Top Bunk
ANSWER
The radiograph demonstrates no acute osseous injury, such as fracture or dislocation. Of interest and note is increased sclerosis within both femoral heads, more so on the left versus the right side. Given the patient’s young age, such findings could be related to early avascular necrosis. His clinical symptoms certainly correlate. MRI or bone scan, as well as orthopedic evaluation, is warranted in such a case.
Fortunately, subsequent MRI of both hips did not show any avascular necrosis but rather osteoarthritic changes. The MRI of his spinal column was negative as well.
ANSWER
The radiograph demonstrates no acute osseous injury, such as fracture or dislocation. Of interest and note is increased sclerosis within both femoral heads, more so on the left versus the right side. Given the patient’s young age, such findings could be related to early avascular necrosis. His clinical symptoms certainly correlate. MRI or bone scan, as well as orthopedic evaluation, is warranted in such a case.
Fortunately, subsequent MRI of both hips did not show any avascular necrosis but rather osteoarthritic changes. The MRI of his spinal column was negative as well.
ANSWER
The radiograph demonstrates no acute osseous injury, such as fracture or dislocation. Of interest and note is increased sclerosis within both femoral heads, more so on the left versus the right side. Given the patient’s young age, such findings could be related to early avascular necrosis. His clinical symptoms certainly correlate. MRI or bone scan, as well as orthopedic evaluation, is warranted in such a case.
Fortunately, subsequent MRI of both hips did not show any avascular necrosis but rather osteoarthritic changes. The MRI of his spinal column was negative as well.
A 30-year-old man is transferred to your facility for evaluation of reported paraplegia after a fall. The patient is an inmate at a local prison. He states he was sleeping on the top bunk when he rolled over and fell off the bed, landing flat on his back on the concrete floor. He immediately started having severe back and hip pain and noticed that he could not move his legs. His primary complaint is severe bilateral hip pain. He was initially evaluated at an outside hospital, where CT of his head, cervical spine, and lumbar spine was negative for any acute pathology. He was sent to your facility for an MRI to rule out contusion or acute herniated disc. The patient denies any significant medical history, including back trauma. Currently, he reports no bowel/bladder issues or saddle anesthesia. On initial exam, he is awake, alert, and oriented, with normal vital signs. Musculoskeletal exam demonstrates a moderate amount of paraspinous tenderness and bilateral hip/pelvis tenderness. There is no instability detected, nor any leg shortening or rotation. He does have bilateral weakness in both lower extremities on the magnitude of 3-/5, although his exam seems limited due to the severity of his hip pain. Sensation is completely intact in both lower extremities. While the patient is awaiting his MRI, you order a portable pelvis radiograph, since none was performed at the outside facility. What is your impression?
Elderly Woman Takes a Fall
ANSWER
The radiograph shows the lungs overall to be clear. There are some slight increased markings, perhaps suggestive of mild congestion, but no infiltrate or consolidation.
Of note is a small nodule within the middle portion of the left upper lobe that requires monitoring and further workup. Also, although it is incompletely imaged, there appears to be a fracture of the right humeral neck.
Additional imaging confirmed the fracture. Orthopedic consultation was obtained.
ANSWER
The radiograph shows the lungs overall to be clear. There are some slight increased markings, perhaps suggestive of mild congestion, but no infiltrate or consolidation.
Of note is a small nodule within the middle portion of the left upper lobe that requires monitoring and further workup. Also, although it is incompletely imaged, there appears to be a fracture of the right humeral neck.
Additional imaging confirmed the fracture. Orthopedic consultation was obtained.
ANSWER
The radiograph shows the lungs overall to be clear. There are some slight increased markings, perhaps suggestive of mild congestion, but no infiltrate or consolidation.
Of note is a small nodule within the middle portion of the left upper lobe that requires monitoring and further workup. Also, although it is incompletely imaged, there appears to be a fracture of the right humeral neck.
Additional imaging confirmed the fracture. Orthopedic consultation was obtained.
A 90-year-old woman is complaining of pain on the left side of her face, her chest wall, and right shoulder. Her family reports that she has fallen multiple times recently. On one occasion, there was brief loss of consciousness. History is significant for hypertension and osteoarthritis. Initial examination indicates she is awake, alert, oriented, and in no obvious distress. Vital signs are stable, and breath sounds are clear. There is tenderness on the left side of her face and decreased range of motion in her right shoulder, as well as localized tenderness. The hospitalist ordered a chest radiograph when the patient was admitted. What is your impression?
Hand Pain Following an Altercation
ANSWER
The radiograph shows moderate soft-tissue swelling with dislocation of the proximal interphalangeal joint. No definite fracture is seen. In addition, there are some metallic-appearing foreign bodies.
The patient was treated with closed reduction and splinting. He also received a referral to outpatient orthopedics for follow-up.
ANSWER
The radiograph shows moderate soft-tissue swelling with dislocation of the proximal interphalangeal joint. No definite fracture is seen. In addition, there are some metallic-appearing foreign bodies.
The patient was treated with closed reduction and splinting. He also received a referral to outpatient orthopedics for follow-up.
ANSWER
The radiograph shows moderate soft-tissue swelling with dislocation of the proximal interphalangeal joint. No definite fracture is seen. In addition, there are some metallic-appearing foreign bodies.
The patient was treated with closed reduction and splinting. He also received a referral to outpatient orthopedics for follow-up.
A 60-year-old man presents with a complaint of pain in his right fifth finger following an altercation. He is not sure exactly how the injury occurred, but he does recall that at one point his hand was twisted awkwardly. He denies any significant medical history. His vital signs are normal. Primary survey appears normal as well. On examination, you notice moderate swelling around the fifth finger of his right hand, which does appear to be slightly deformed. There are no obvious wounds or lacerations. He has moderate tenderness at the base of his finger. Range of motion is limited due to the swelling. Good capillary refill time is noted. The triage nurse already sent the patient for a radiograph of his finger (shown). What is your impression?
Is Headache a Sign of a Larger Problem?
Answer
The radiograph shows a masslike density within the left suprahilar and mediastinal region, most likely consistent with a carcinoma. Given the entire clinical picture, this patient likely has a primary lung carcinoma that metastasized to the brain.
Answer
The radiograph shows a masslike density within the left suprahilar and mediastinal region, most likely consistent with a carcinoma. Given the entire clinical picture, this patient likely has a primary lung carcinoma that metastasized to the brain.
Answer
The radiograph shows a masslike density within the left suprahilar and mediastinal region, most likely consistent with a carcinoma. Given the entire clinical picture, this patient likely has a primary lung carcinoma that metastasized to the brain.
A 60-year-old woman presents with a complaint of severe headache, hoarseness, and weight loss, which have worsened in the past few days. Her headache is bifrontal, and at times she rates its severity as 10/10. She is not aware of any medical problems, but she admits she doesn’t have a primary care provider due to lack of insurance. She has a 30-year history of smoking one to one-and-a-half packs of cigarettes per day. Family history is positive for cancer. On examination, you note that she is uncomfortable but in no obvious distress. Her vital signs are normal. She is able to move all four extremities well and is neurovascularly intact. She has no other focal deficits. Noncontrast CT of the head is obtained. It shows a large right frontal lesion with surrounding vasogenic edema. You also order a chest radiograph (shown). What is your impression?
Is Spreading Pain Due to Injury?
Answer
The radiograph shows a right apical mass. This clinical and radiographic presentation is strongly suggestive of a Pancoast tumor. Such lung masses (typically non–small cell carcinomas) can cause brachial plexus compression when they progress, which results in thoracic outlet obstruction and symptoms similar to those seen in this patient.
The patient was admitted by a hospitalist service, and further imaging did confirm the presence of a lung mass, as well as extension to the chest wall and cervicothoracic portion of the spinal canal. CT-guided biopsy of the mass is pending.
Answer
The radiograph shows a right apical mass. This clinical and radiographic presentation is strongly suggestive of a Pancoast tumor. Such lung masses (typically non–small cell carcinomas) can cause brachial plexus compression when they progress, which results in thoracic outlet obstruction and symptoms similar to those seen in this patient.
The patient was admitted by a hospitalist service, and further imaging did confirm the presence of a lung mass, as well as extension to the chest wall and cervicothoracic portion of the spinal canal. CT-guided biopsy of the mass is pending.
Answer
The radiograph shows a right apical mass. This clinical and radiographic presentation is strongly suggestive of a Pancoast tumor. Such lung masses (typically non–small cell carcinomas) can cause brachial plexus compression when they progress, which results in thoracic outlet obstruction and symptoms similar to those seen in this patient.
The patient was admitted by a hospitalist service, and further imaging did confirm the presence of a lung mass, as well as extension to the chest wall and cervicothoracic portion of the spinal canal. CT-guided biopsy of the mass is pending.
A 53-year-old woman presents with complaints of right-side chest wall, neck, and shoulder pain. Her symptoms started two months ago, when she says she injured herself while doing yard work. She initially self-treated but subsequently went to various emergency departments and walk-in clinics on several occasions; no definitive diagnosis was established. Recently, she has noticed increasing weakness in her right arm and hand as well. Medical history is significant for hypertension. Family history is remarkable for non-Hodgkin’s lymphoma (mother). Social history reveals that the patient is a smoker, with a pack-a-day habit for at least 40 years. On physical exam, you note normal vital signs. The patient has good range of motion in her extremities; however, the strength in her right upper extremity is significantly diminished. Her deltoid, biceps, triceps, and hand grip are all about 2/5. She also notes a paresthesia along her right anterior chest wall, although sensation is intact. Chest radiograph is ordered (shown). What is your impression?
Neck Pain With No Palpable Tenderness
ANSWER
The image shows an acute fracture at the base of the odontoid with evidence of posterior displacement of the fracture fragment. Such fractures are typically unstable.
In addition, there is evidence of a fracture and subluxation at the C4/C5 level. However, given the degree of sclerosis and chronic changes present, this finding is likely an old one.
The patient was maintained in a collar on bedrest. Subsequently, he underwent odontoid pinning to stabilize the fractures.
ANSWER
The image shows an acute fracture at the base of the odontoid with evidence of posterior displacement of the fracture fragment. Such fractures are typically unstable.
In addition, there is evidence of a fracture and subluxation at the C4/C5 level. However, given the degree of sclerosis and chronic changes present, this finding is likely an old one.
The patient was maintained in a collar on bedrest. Subsequently, he underwent odontoid pinning to stabilize the fractures.
ANSWER
The image shows an acute fracture at the base of the odontoid with evidence of posterior displacement of the fracture fragment. Such fractures are typically unstable.
In addition, there is evidence of a fracture and subluxation at the C4/C5 level. However, given the degree of sclerosis and chronic changes present, this finding is likely an old one.
The patient was maintained in a collar on bedrest. Subsequently, he underwent odontoid pinning to stabilize the fractures.
A 65-year-old man presents with neck pain following a fall. Earlier this evening, he says, he fell off his porch (approximately four feet in height) and hit the top/front of his head on the ground. He denies any loss of consciousness, adding that he only came in for evaluation at the urging of his family. The patient denies any extremity weakness or paresthesias. He also denies any significant medical history, although his sister, who has accompanied him, states that he drinks alcohol “regularly and heavily.” Physical examination reveals a man who appears much older than his stated age and is uncomfortable, but not in obvious distress. His vital signs are normal. He is currently wearing a hard cervical collar. There is no palpable tenderness posteriorly along his cervical spine. He is able to move all of his extremities well. His strength is good, and his sensation is intact. A lateral radiograph of the patient’s cervical spine is shown. What is your impression?
