Dr. Pepe’s Diploma Casebook – All you need to know to interpret a chest radiograph – First Session – CASE 147 – SOLVED

There are some things which cannot be learned quickly, and time, which is all we have, must be paid heavily for their acquiring. They are the simplest things; and, because it takes a man’s life to know them, the little new that each man gets from life is very costly and the only heritage he has to leave

Dear friends, this quote from Ernest Hemingway serves as introduction to the next series of webinars. From October to March I intend to give a webinar every two weeks describing my basic approach to interpreting the chest radiograph. The subject is ample, and will continue with a second series in 2021.

To start, I am showing a preoperative PA chest radiograph for varices in a 60-year-old woman. The chest was read as normal, but there is an abnormality, difficult to detect.
Do you see it?

The answer was given during a webinar. You can watch the webinar here

Click here to see the answer

Findings: PA radiograph shows a small nodule overlapping the left cardiac border (A-B, arrows). The nodule was overlooked, and the chest was read as normal.

A chest radiograph taken four years later shows a marked increase in size of the nodule (C, arrow). Enhanced axial CT shows a non-enhancing low-density nodule (-30 H.U.)
(D, arrow). Needle biopsy confirmed the diagnosis of hamartoma.

Final diagnosis: Pulmonary hamartoma, overlooked in the initial film
 
Congratulations to Uve, who discovered the nodule with a little help.
 
Teaching point: Remember that overlooking visible findings accounts for 50% of our errors. Using checklists is an excellent way to change an error into a discovery.

8 thoughts on “Dr. Pepe’s Diploma Casebook – All you need to know to interpret a chest radiograph – First Session – CASE 147 – SOLVED

  1. Greetings,
    there is carinal widening with marked narrowing of proximal part of oesophagus. this is suspicious of subcarinal mass as I do not see any signs of left atrial enlargement.
    Finding can be confirmed by lateral chest X-ray . if this is new patient needs further evaluation by a CT CHEST.

  2. “Trying my luck”… I think that there is a decrease in proximal caliber of the main left bronchus…

    1. Good! You are right. The nodule was missed by the radiologist who read the film. Follow-up and CT on Friday.

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