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

Dear Friends,

Today I am presenting the leading case of the second webinar. The PA radiograph belongs to a 62-year-old man with hemoptysis.

Is the radiograph abnormal?
If so, what do you see?

Starting this week, I have decided to stop giving live webinars. They will be recorded and published at the end of the week, together with the answer to the case. You can see the first session here

Click here to see the answer

Findings: PA chest radiograph shows convexity of the aorto-pulmonary window (A, arrow) and an opacity in the upper left hilum (A, red arrow). The findings were not present in a film taken three years earlier (B, circle) and suggest a pulmonary process with mediastinal adenopathy.

Findings were overlooked and the chest was read as normal. Six months later the patient returned with acute right chest pain. PA chest shows two triangular pleural-based opacities (C, arrows) suggestive of Hampton’s humps. The convexity at the APW is larger (C, green arrow) and the hilar opacity has increased in size (C, red arrow).

Coronal CT shows the typical appearance of pulmonary infarcts at the right lung base (D, arrows). There is large adenopathy at the APW (D, green arrow) accompanied by a lung mass (D, red arrow).

Final diagnosis: carcinoma of the lung with mediastinal metastases and associated pulmonary infarcts.
 
Congratulations to S, who made a brilliant diagnosis.
 
Teaching point: Remember the importance of checklists. If a checklist had been used in the initial radiography, a CT would had been taken and the tumor would had been discovered earlier

If you would like to learn more about this subject, check the webinar Prof. Cáceres recorded explaining this cases and others! You can also check the first webinar here.

Emergency #8 – Long case

83-year-old man with:
* Painful swelling in the right groin
* No fever
* Nausea but no vomiting, difficulty passing stools
* Swelling not reducible

What do you see? Is it an incarcerated inguinal hernia?

Click here to see the images


Click here to see the answer

Imaging findings

* Right-sided inguinal hernia with intestines inside
* Mechanical small bowel obstruction proximal of hernia
* Normal enhancement of the bowel wall

No signs of ischemia.

Differential diagnosis

Mechanical small bowel obstruction: Adhesions/bands–volvulus–internal hernia–obstructing tumour/tumoural implants–other hernia’s–congenital or acquired stenosis

Groin swelling: Adenopathy–femoral hernia–psoas abscess–retracted testicle

Management

If no signs of ischemia are present:
* Careful manual reduction attempt
* If not successful: emergency surgery (risk of strangulation)

If signs of ischemia are present:
* Emergency surgery

Key points

Incarceration only means the hernia is not reducible and does not say anything about the content. An incarcerated inguinal hernia can also contain abdominal fat without bowel loops

Incarcerated hernia can turn into strangulated hernia and lead to small bowel obstruction

Carefully inspect the enhancement of the implicated loop of small bowel

Lack of enhancement is an early sign of ischemia (strangulation) and an indication for urgent surgery

Get free registration for ECR 2019!

ECR 2019 will be the 25th to take place in Vienna, and to celebrate this very special anniversary, all European Diploma in Radiology (EDiR) candidates who succeed in an upcoming examination in 2018 and submit an abstract for ECR 2019 can attend the meeting free of charge*

* Please note that fees already paid (reduced congress fees at national events, etc.) and congress payments made after attending a diploma course (also not through third party) will definitely not be refunded by the ESR!

** Successful candidates of the EDiR examination at ECR 2018 are not eligible to benefit from this promotion

EDiR: Question of the day: #3

We dare you to solve one of the hardest questions of the EDiR examination!
The European Board of Radiology raffles amongst the winners an examination place for the EDiR that will take place at the ECR 2019.
The registration for the ECR 2019 is also included!

73-year-old male. Referred for macroscopic haematuria. He was taking anticoagulants and there were stones in the right kidney. Axial US image of the bladder was performed. Which of the following could cause the appearance seen on these images?

Please, click here to enter your answer. Solve the question before 13:30.

Winner will be announced here, on the EBR blog, at 14:00.

Good luck!

EDiR: Question of the day: #2

We dare you to solve one of the hardest questions of the EDiR examination!
The European Board of Radiology raffles amongst the winners an examination place for the EDiR that will take place at the ECR 2019.
The registration for the ECR 2019 is also included!

Regarding SAPHO (synovitis, acne, postulosis, hyperostosis and osteitis) syndrome: Which of the following statements are correct?

Please, click here to enter your answer. Solve the question before 13:30.

Winner will be announced here, on the EBR blog, at 14:00.

Good luck!