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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?
Construction Worker Falls From Scaffolding
ANSWER
The radiograph shows an acute, comminuted fracture of the scaphoid bone. The patient was placed in a thumb spica splint and sling. He was instructed to follow up in one to two days with the hand surgeon who was on call, with anticipation of subsequent open reduction and internal fixation.
ANSWER
The radiograph shows an acute, comminuted fracture of the scaphoid bone. The patient was placed in a thumb spica splint and sling. He was instructed to follow up in one to two days with the hand surgeon who was on call, with anticipation of subsequent open reduction and internal fixation.
ANSWER
The radiograph shows an acute, comminuted fracture of the scaphoid bone. The patient was placed in a thumb spica splint and sling. He was instructed to follow up in one to two days with the hand surgeon who was on call, with anticipation of subsequent open reduction and internal fixation.
A 45-year-old construction worker is brought to your facility for evaluation following a fall. He was at a job site, standing on scaffolding approximately 20 feet above the ground, when he accidentally fell. He does not remember for sure, but he thinks he landed on his face. He did briefly lose consciousness. He is complaining of right-side facial pain and right wrist pain. His medical history is unremarkable. The physical exam reveals stable vital signs. The patient appears somewhat uncomfortable but is in no obvious distress. There is a moderate amount of periorbital soft-tissue swelling around his right eye, with moderate associated tenderness. Pupils are equal and react well bilaterally. Examination of the right wrist shows a moderate amount of soft-tissue swelling. The patient is unable to flex or extend his wrist due to pain. Good pulses and capillary refill of the nail beds are noted. There is also moderate tenderness along the base of the first metacarpal. Radiograph of the right wrist is shown. What is your impression?
Woman Assaulted on Street
The chest radiograph demonstrates a massive amount of soft tissue and subcutaneous emphysema extending from the neck down through the chest and into the lower chest/upper abdomen. In addition, there are several fractured posterior ribs bilaterally. No large pneumothorax or pneumomediastinum is noted.
Because of the extent and mechanism of injury, CT of the chest, abdomen, and pelvis had already been ordered. Arrangements were also made for the patient to be admitted to the ICU for closer observation.
The chest radiograph demonstrates a massive amount of soft tissue and subcutaneous emphysema extending from the neck down through the chest and into the lower chest/upper abdomen. In addition, there are several fractured posterior ribs bilaterally. No large pneumothorax or pneumomediastinum is noted.
Because of the extent and mechanism of injury, CT of the chest, abdomen, and pelvis had already been ordered. Arrangements were also made for the patient to be admitted to the ICU for closer observation.
The chest radiograph demonstrates a massive amount of soft tissue and subcutaneous emphysema extending from the neck down through the chest and into the lower chest/upper abdomen. In addition, there are several fractured posterior ribs bilaterally. No large pneumothorax or pneumomediastinum is noted.
Because of the extent and mechanism of injury, CT of the chest, abdomen, and pelvis had already been ordered. Arrangements were also made for the patient to be admitted to the ICU for closer observation.
A 40-year-old woman is brought in by EMS for evaluation of injuries secondary to being assaulted. She was out walking late last night when she was approached by two men who pushed her to the ground and began punching and kicking her repeatedly on her face, chest, and back. She is primarily complaining of chest wall and back pain. Her medical history is significant for hypertension, diet-controlled diabetes, and “some sort of heart problem” for which she takes medication. Surgical history is significant for hysterectomy, cholecystectomy, and appendectomy. She smokes more than a pack of cigarettes per day and consumes at least a six-pack of beer daily. Initial exam shows an anxious female who appears somewhat uncomfortable but is in no obvious distress. Her vital signs are as follows: blood pressure, 130/88 mm Hg; pulse, 120 beats/min; respiratory rate, 22 breaths/min; and O2 saturation, 100% on room air. Physical exam reveals extensive facial/periorbital swelling, as well as swelling in the neck. Some splinting is noted. There is extensive crepitus noted within the soft tissue of the face, neck, and chest wall. Also, there is moderate tenderness bilaterally over the ribs. Chest radiograph is obtained (shown). What is your impression?
Competitive Swimmer With Hip Pain
ANSWER
The radiograph demonstrates no evidence of an acute fracture or dislocation. Normal gas/stool pattern is present. Essentially, this radiograph is normal.
The patient most likely has an acute strain of her hip quadriceps or flexor. On occasion, severe enough strain injuries can cause a slight avulsion fracture within the hip at the muscle origination point. These can sometimes be evident on plain films.
ANSWER
The radiograph demonstrates no evidence of an acute fracture or dislocation. Normal gas/stool pattern is present. Essentially, this radiograph is normal.
The patient most likely has an acute strain of her hip quadriceps or flexor. On occasion, severe enough strain injuries can cause a slight avulsion fracture within the hip at the muscle origination point. These can sometimes be evident on plain films.
ANSWER
The radiograph demonstrates no evidence of an acute fracture or dislocation. Normal gas/stool pattern is present. Essentially, this radiograph is normal.
The patient most likely has an acute strain of her hip quadriceps or flexor. On occasion, severe enough strain injuries can cause a slight avulsion fracture within the hip at the muscle origination point. These can sometimes be evident on plain films.
A 17-year-old girl presents for evaluation of severe pain in her left hip. She is a competitive swimmer; earlier in the day, she was at practice doing dry land (out of the water) activities/exercises. Having completed a series of stretches and warm-up exercises, she and her teammates proceeded to do sprints. During one of these sprints, she immediately felt a “pop” in her left hip followed by severe, debilitating pain in that hip and thigh. Medical history is otherwise unremarkable. Physical exam reveals that it is extremely painful for the patient to bear weight on the affected leg. There is moderate-to-severe tenderness over the lateral hip. Some swelling is noted; no bruising is present. Distal pulses are good, and motor and sensation are intact. Radiograph of the pelvis is obtained (shown). What is your impression?
A Different Source of Elbow Pain
ANSWER
The radiograph shows no obvious fracture or dislocation. However, there are two small, radiopaque densities noted within the soft tissue. These are most likely consistent with broken glass pieces.
When the laceration was irrigated and the wound probed, the glass bits were found and removed prior to wound closure.
ANSWER
The radiograph shows no obvious fracture or dislocation. However, there are two small, radiopaque densities noted within the soft tissue. These are most likely consistent with broken glass pieces.
When the laceration was irrigated and the wound probed, the glass bits were found and removed prior to wound closure.
ANSWER
The radiograph shows no obvious fracture or dislocation. However, there are two small, radiopaque densities noted within the soft tissue. These are most likely consistent with broken glass pieces.
When the laceration was irrigated and the wound probed, the glass bits were found and removed prior to wound closure.
A 30-year-old man is brought to your facility after being in a motor vehicle collision. He was an unrestrained driver who lost control of his vehicle, went off the road, and hit a tree. Emergency personnel on the scene indicated there was moderate damage to his vehicle, including a broken windshield, and no air bag deployment. The patient is complaining of right shoulder, chest, hip, and left elbow pain. His medical history is unremarkable. His vital signs are normal. On physical examination, he has superficial lacerations on his forehead, face, and both forearms. Bleeding from all wounds is controlled. Palpation reveals some bruising of the right shoulder, chest, right hip, and left elbow; no obvious deformity or neurovascular compromise is noted. Multiple radiographs are ordered; the left elbow is shown. What is your impression?
Woman With Hip Pain After Car Accident
ANSWER
The radiograph demonstrates evidence of contrast material within the bladder. There is evidence of fixation of an old subcapital femoral neck fracture on the left.
There is an acute, mildly displaced right intertrochanteric fracture of the right hip. The orthopedic service was consulted, and plans were established to subsequently fix this fracture surgically.
ANSWER
The radiograph demonstrates evidence of contrast material within the bladder. There is evidence of fixation of an old subcapital femoral neck fracture on the left.
There is an acute, mildly displaced right intertrochanteric fracture of the right hip. The orthopedic service was consulted, and plans were established to subsequently fix this fracture surgically.
ANSWER
The radiograph demonstrates evidence of contrast material within the bladder. There is evidence of fixation of an old subcapital femoral neck fracture on the left.
There is an acute, mildly displaced right intertrochanteric fracture of the right hip. The orthopedic service was consulted, and plans were established to subsequently fix this fracture surgically.
A 55-year-old woman is transferred to your facility with injuries sustained in a motor vehicle collision. She was an unrestrained front-seat passenger in a vehicle that rear-ended another vehicle. There was no airbag deployment, and the patient believes she struck her face on the windshield. At the outside facility, it was determined that she had a cervical fracture and facial fractures. Upon arrival at your facility, she is complaining of bilateral hip pain as well. Her medical history is significant for coronary artery disease, several myocardial infarctions, hypertension, and stroke. She has a pacemaker. Six months ago, she had an open reduction internal fixation of her left hip for a fracture she sustained in a fall. Primary survey reveals a female who is uncomfortable but alert and oriented. Vital signs are normal. She has some facial swelling and bruising. Her heart and lungs are clear; abdomen is benign. She is able to move her upper extremities with-out any problems. She has limited movement of her lower extremities due to pain in her pelvis. She is able to move both feet and toes, and distal pulses and sensation are intact. No obvious leg shortening is noted. A portable radiograph of the pelvis is obtained. What is your impression?
Child hit by car
ANSWER
The chest radiograph demonstrates no acute abnormalities within the lungs, ribs, or chest. Of note, there are two radiodensities consistent with teeth, which are presumed to be in the patient’s stomach (most likely secondary to being swallowed following trauma to his face). Upon reexamination, it is noted that the child’s two front incisors are missing, with minimally bleeding sockets. Other than reassurance, no specific intervention was required.
ANSWER
The chest radiograph demonstrates no acute abnormalities within the lungs, ribs, or chest. Of note, there are two radiodensities consistent with teeth, which are presumed to be in the patient’s stomach (most likely secondary to being swallowed following trauma to his face). Upon reexamination, it is noted that the child’s two front incisors are missing, with minimally bleeding sockets. Other than reassurance, no specific intervention was required.
ANSWER
The chest radiograph demonstrates no acute abnormalities within the lungs, ribs, or chest. Of note, there are two radiodensities consistent with teeth, which are presumed to be in the patient’s stomach (most likely secondary to being swallowed following trauma to his face). Upon reexamination, it is noted that the child’s two front incisors are missing, with minimally bleeding sockets. Other than reassurance, no specific intervention was required.
A 6-year-old boy is brought to your facility by ambulance after being hit by a car. The child was apparently riding his bike when a slow-moving vehicle turned onto the street and accidentally bumped him, knocking him to the ground. He was not wearing a helmet. The child is crying but somewhat consolable. His medical history is unremarkable. On initial assessment, he is awake, crying, and moving all of his extremities spontaneously. His vital signs include a temperature of 36.3°C; blood pressure, 149/72 mm Hg; pulse, 110 beats/min; and respiratory rate, 22 breaths/min. Physical examination reveals several abrasions to his face, nose, and lips. Otherwise, he is normocephalic. His pupils are equal and react appropriately. Heart and lung sounds are clear, and the abdomen appears benign. You order some preliminary labwork and CT of the head. In addition, a portable chest radiograph is obtained (shown). What is your impression?
Foot Pain Following a Car Crash
The radiograph demonstrates an acute fracture of the second, third, and fourth distal metatarsals. The third and fourth are mildly impacted.
In addition, there is a deformity noted within the medial cuneiform, strongly suggestive of a fracture. This was later confirmed by CT. Orthopedic consultation was obtained.
The radiograph demonstrates an acute fracture of the second, third, and fourth distal metatarsals. The third and fourth are mildly impacted.
In addition, there is a deformity noted within the medial cuneiform, strongly suggestive of a fracture. This was later confirmed by CT. Orthopedic consultation was obtained.
The radiograph demonstrates an acute fracture of the second, third, and fourth distal metatarsals. The third and fourth are mildly impacted.
In addition, there is a deformity noted within the medial cuneiform, strongly suggestive of a fracture. This was later confirmed by CT. Orthopedic consultation was obtained.
Following a motor vehicle collision, a 60-year-old woman is brought in by emergency medical transport. She was a restrained driver in a vehicle that went out of control, hit a tree, and ended up in a ditch. There was a prolonged extrication time (> 30 minutes) due to extensive damage to the front of the vehicle. On arrival, the patient is awake and alert, complaining primarily of pain in her left hip and right foot. Her medical history is unremarkable. She has an initial Glasgow Coma Scale score of 15. Her vital signs are: blood pressure, 154/100 mm Hg; pulse, 108 beats/min; respiratory rate, 16 breaths/min; and O2 saturation, 100% on room air. Primary survey is otherwise unremarkable. A series of radiographs are ordered; that of the right foot is shown. What is your impression?
