User login
Woman with Abdominal Pain Following Severe Car Crash
ANSWER
The radiograph shows a comminuted fracture at the midshaft of the tibia. In addition, there is a comminuted fracture of the proximal tibial metaphysis extending to the tibia plateau. Also noted is a comminuted fracture of the distal femur metaphysis extending to the intercondylar notch
ANSWER
The radiograph shows a comminuted fracture at the midshaft of the tibia. In addition, there is a comminuted fracture of the proximal tibial metaphysis extending to the tibia plateau. Also noted is a comminuted fracture of the distal femur metaphysis extending to the intercondylar notch
ANSWER
The radiograph shows a comminuted fracture at the midshaft of the tibia. In addition, there is a comminuted fracture of the proximal tibial metaphysis extending to the tibia plateau. Also noted is a comminuted fracture of the distal femur metaphysis extending to the intercondylar notch
A 43-year-old woman is airlifted to your facility from an outlying area following a severe motor vehicle collision. Details are unclear, but there were known fatalities at the scene. Her primary complaints are abdominal pain and noted deformities of the lower extremities, according to the transporting medical personnel. On arrival, she is noted to be semi-arousable and is moving distal portions of all four extremities. Her heart rate is 150 beats/min, with a blood pressure of 80/40 mm Hg. She responds to initial fluid and volume resuscitation. She has no pertinent medical history. Her response to the fluid resuscitation is sufficient to stabilize her for transport to the CT scanner for additional imaging. Prior to the transfer, though, a portable radiograph of her right tibia is obtained. What is your impression?
Man Run Over By Vehicle
ANSWER
The radiograph shows some deformity within the mid-to-distal diaphysis of both the radius and ulna; however, no acute fracture is seen. This is most likely related to remote trauma.
Of note, closer to the elbow, there are some small avulsion fractures near the area of the lateral epicondyle. The patient was treated with a posterior splint and referred to orthopedics.
ANSWER
The radiograph shows some deformity within the mid-to-distal diaphysis of both the radius and ulna; however, no acute fracture is seen. This is most likely related to remote trauma.
Of note, closer to the elbow, there are some small avulsion fractures near the area of the lateral epicondyle. The patient was treated with a posterior splint and referred to orthopedics.
ANSWER
The radiograph shows some deformity within the mid-to-distal diaphysis of both the radius and ulna; however, no acute fracture is seen. This is most likely related to remote trauma.
Of note, closer to the elbow, there are some small avulsion fractures near the area of the lateral epicondyle. The patient was treated with a posterior splint and referred to orthopedics.
After accidentally being run over by a vehicle, a 54-year-old man presents to the emergency department for evaluation of pain in his elbow and left arm. He was leaning down behind the vehicle and was not seen when the driver backed up. The patient states that one of the tires went over his left shoulder and arm. Primary complaint is pain and decreased range of motion. He denies any significant medical history, except for medication-controlled hypertension and gallbladder surgery. His vital signs are stable. Exammination of the left arm demonstrates some abrasions and contusions over the shoulder and forearm, as well as some swelling over the elbow. The patient has good color, distal pulses, and sensation. There is localized tenderness over the elbow and midforearm. Flexion of the elbow is somewhat limited secondary to pain. Radiograph of the forearm is obtained and shown. What is your impression?
Man with Debilitating Back Pain
ANSWER
The radiograph demonstrates generalized degenerative changes. Of note are fairly significant destructive changes in the endplate at the L3-4 level. Such changes are generally consistent with osteomyelitis and diskitis.
On further questioning, the patient reported that when he was admitted previously, he was told that he had an “infection in his back” and was treated with IV antibiotics. This patient was again admitted for additional workup and treatment.
ANSWER
The radiograph demonstrates generalized degenerative changes. Of note are fairly significant destructive changes in the endplate at the L3-4 level. Such changes are generally consistent with osteomyelitis and diskitis.
On further questioning, the patient reported that when he was admitted previously, he was told that he had an “infection in his back” and was treated with IV antibiotics. This patient was again admitted for additional workup and treatment.
ANSWER
The radiograph demonstrates generalized degenerative changes. Of note are fairly significant destructive changes in the endplate at the L3-4 level. Such changes are generally consistent with osteomyelitis and diskitis.
On further questioning, the patient reported that when he was admitted previously, he was told that he had an “infection in his back” and was treated with IV antibiotics. This patient was again admitted for additional workup and treatment.
A 54-year-old man presents with a complaint of a two-week history of severe low back pain. He denies any injury or trauma. The pain is so severe that it limits his ability to walk. He states he had similar episodes earlier this year, some of which required him to be admitted to the hospital. His medical history is significant for hypertension, diabetes, and coronary artery disease. He admits to recently having subjective fever and chills, as well as some nausea. Physical exam shows a deconditioned male who is uncomfortable but in no obvious distress. He is afebrile, with a blood pressure of 92/57 mm Hg, a heart rate of 97 beats/min, and a respiratory rate of 20 breaths/min. He has mild tenderness to his lumbosacral area; no deformity, step-off, or crepitus is appreciated. He does have decreased range of motion in his lower extremities, although this may be a consequence of his back pain. While trying to pull up his previous medical records, you order some basic labwork and lumbar spine radiographs. Lateral lumbar spine radiograph is shown; what is your impression?
Woman with Foot Pain After Neurosurgery Service
ANSWER
The radiograph demonstrates mild soft-tissue swelling and an oblique, mildly displaced fracture of the distal fibula. In addition, there is a small bone density adjacent to the medial malleolus, which could represent either an unfused accessory ossification center or a sequela of prior trauma.
On closer questioning, the patient acknowledged that a few months prior, she had stepped in a hole and been treated for a “broken bone.” She had been in a cast for an undisclosed period of time; at a follow-up appointment, the cast had been removed and the bone had been declared “healed.”
A new orthopedic consultation was obtained prior to the patient’s discharge from the hospital, which resulted in placement of a short leg cast.
ANSWER
The radiograph demonstrates mild soft-tissue swelling and an oblique, mildly displaced fracture of the distal fibula. In addition, there is a small bone density adjacent to the medial malleolus, which could represent either an unfused accessory ossification center or a sequela of prior trauma.
On closer questioning, the patient acknowledged that a few months prior, she had stepped in a hole and been treated for a “broken bone.” She had been in a cast for an undisclosed period of time; at a follow-up appointment, the cast had been removed and the bone had been declared “healed.”
A new orthopedic consultation was obtained prior to the patient’s discharge from the hospital, which resulted in placement of a short leg cast.
ANSWER
The radiograph demonstrates mild soft-tissue swelling and an oblique, mildly displaced fracture of the distal fibula. In addition, there is a small bone density adjacent to the medial malleolus, which could represent either an unfused accessory ossification center or a sequela of prior trauma.
On closer questioning, the patient acknowledged that a few months prior, she had stepped in a hole and been treated for a “broken bone.” She had been in a cast for an undisclosed period of time; at a follow-up appointment, the cast had been removed and the bone had been declared “healed.”
A new orthopedic consultation was obtained prior to the patient’s discharge from the hospital, which resulted in placement of a short leg cast.
A 60-year-old woman is admitted electively to the neurosurgery service for a multilevel posterior cervical decompression and fusion. The procedure is completed uneventfully and without complication. The patient is admitted to the neurosurgical floor. In the middle of the night, you receive a call from the nurse stating that the patient is complaining of moderate pain and swelling in her left ankle and foot, which occurred after she got up to use the bathroom. The patient denies injuring herself. She complains of pain with weight-bearing. Since the pain is tolerable and pain medication has already been given, it is decided to assess the complaint later in the morning. On evaluation, the left foot and ankle are mildly swollen, with tenderness on the lateral aspect. There is minimal tenderness on the foot. Distal pulses and color are good. The calf is nontender. The patient’s medical history is significant only for mild hypertension. Radiographs of the left ankle are obtained. What is your impression?
Dehydration Leads to Incidental Finding
ANSWER
The radiograph demonstrates that the nasogastric tube is within a decompressed stomach. Normal gas pattern is noted within the bowel and colon.
Of note, however, are tiny calcifications within the right upper quadrant. This finding is suggestive of cholelithiasis—in this case, likely an incidental finding.
ANSWER
The radiograph demonstrates that the nasogastric tube is within a decompressed stomach. Normal gas pattern is noted within the bowel and colon.
Of note, however, are tiny calcifications within the right upper quadrant. This finding is suggestive of cholelithiasis—in this case, likely an incidental finding.
ANSWER
The radiograph demonstrates that the nasogastric tube is within a decompressed stomach. Normal gas pattern is noted within the bowel and colon.
Of note, however, are tiny calcifications within the right upper quadrant. This finding is suggestive of cholelithiasis—in this case, likely an incidental finding.
A 57-year-old man is admitted to your facility for weakness and dehydration. His medical history is significant for rectal carcinoma, diabetes, and hypertension. His family states that his oral intake has been progressively less in the past several weeks. The patient’s vital signs are stable. Overall examination demonstrates a weak, frail-appearing man with dry mucous membranes and no other acute abnormalities. Lab work reveals that his serum sodium level and BUN/creatinine ratio are slightly elevated. To facilitate hydration, administration of medications, and nourishment, placement of a nasogastric tube is ordered; this is done just prior to your arrival at the patient’s room during rounds. As per protocol, an abdominal radiograph is obtained, and the nurses ask you to check it to confirm placement. The radiograph is shown. What is your impression?
Post PICC Placement
ANSWER
The radiograph demonstrates a right PICC line terminating at the superior vena cava. There is no evidence of pneumothorax.
Of note, however, is a large oval density within the right upper lobe, measuring 4.5 x 7 cm. This lesion could represent a loculated mass such as an abscess or hematoma. Further workup with additional imaging is warranted.
The working theory on this patient was that the density likely represented abscess or infection. Contrast-enhanced CT of the chest suggested likely abscess. The patient then underwent successful CT-guided needle biopsy, which returned positive results for Cryptococcus.
ANSWER
The radiograph demonstrates a right PICC line terminating at the superior vena cava. There is no evidence of pneumothorax.
Of note, however, is a large oval density within the right upper lobe, measuring 4.5 x 7 cm. This lesion could represent a loculated mass such as an abscess or hematoma. Further workup with additional imaging is warranted.
The working theory on this patient was that the density likely represented abscess or infection. Contrast-enhanced CT of the chest suggested likely abscess. The patient then underwent successful CT-guided needle biopsy, which returned positive results for Cryptococcus.
ANSWER
The radiograph demonstrates a right PICC line terminating at the superior vena cava. There is no evidence of pneumothorax.
Of note, however, is a large oval density within the right upper lobe, measuring 4.5 x 7 cm. This lesion could represent a loculated mass such as an abscess or hematoma. Further workup with additional imaging is warranted.
The working theory on this patient was that the density likely represented abscess or infection. Contrast-enhanced CT of the chest suggested likely abscess. The patient then underwent successful CT-guided needle biopsy, which returned positive results for Cryptococcus.
A 31-year-old man is admitted to your facility with presumed cryptococcal meningitis. He has a one-month history of progressively worsening headaches, malaise, weight loss, and blurred vision. A lumbar puncture demonstrates an extremely elevated opening pressure and yields samples that are positive for Cryptococcus on microscopic examination. The patient denies any significant medical history. Specifically, there is no history of HIV, which was confirmed by recent serologic testing at another hospital. As a result of poor peripheral access and with anticipated need for lengthy IV antifungal therapy, a PICC (peripherally inserted central catheter) line is ordered. It is placed without incident at the bedside, and as per protocol, a post-placement portable chest radiograph is obtained. What is your impression?
Man Thrown From All-Terrain Vehicle
ANSWER
The image shows several things. First, there is a well-corticated lucency through the base of the odontoid process. This most likely represents what is referred to as an os odontoideum (congenital spinal variant). The other possibility is that it could be an old odontoid fracture with nonunion.
In addition, there are superior end-plate fractures noted in C6, C7, T1, and T2. However, no definite fracture lines are evident, suggesting these are subacute or old injuries. MRI can be performed to differentiate old versus new fractures; in this case, it was determined these were old.
ANSWER
The image shows several things. First, there is a well-corticated lucency through the base of the odontoid process. This most likely represents what is referred to as an os odontoideum (congenital spinal variant). The other possibility is that it could be an old odontoid fracture with nonunion.
In addition, there are superior end-plate fractures noted in C6, C7, T1, and T2. However, no definite fracture lines are evident, suggesting these are subacute or old injuries. MRI can be performed to differentiate old versus new fractures; in this case, it was determined these were old.
ANSWER
The image shows several things. First, there is a well-corticated lucency through the base of the odontoid process. This most likely represents what is referred to as an os odontoideum (congenital spinal variant). The other possibility is that it could be an old odontoid fracture with nonunion.
In addition, there are superior end-plate fractures noted in C6, C7, T1, and T2. However, no definite fracture lines are evident, suggesting these are subacute or old injuries. MRI can be performed to differentiate old versus new fractures; in this case, it was determined these were old.
A 57-year-old man is transferred to your facility after being thrown from an all-terrain vehicle. He was not wearing a helmet and was documented to have loss of consciousness. Upon arrival, his primary complaint is severe headache. He gives no significant medical history. Initial assessment shows a male on a backboard with full cervical spine immobilization. His Glasgow Coma Scale score is 14, with a blood pressure of 130/83 mm Hg and a heart rate of 87 beats/min. He has several abrasions on his face, but his pupils are equal and react well. His heart and lungs appear to be clear and the abdomen is benign. He is able to move all extremities well, with no obvious neurovascular compromise. After removal from the backboard, he is sent to the radiology department for multiple scans. A static sagittal image from CT of the cervical spine is shown. What is your impression?
Man Presents with Altered Mental Status and Confusion
ANSWER
The chest radiograph demonstrates a fairly large right hilar mass with an associated right upper lobe infiltrate. This finding is very worrisome for a bronchogenic carcinoma.
Subsequent CT of the brain also demonstrated a right parietal mass. Thus, this lung lesion is most likely a primary neoplasm with metastatic involvement.
ANSWER
The chest radiograph demonstrates a fairly large right hilar mass with an associated right upper lobe infiltrate. This finding is very worrisome for a bronchogenic carcinoma.
Subsequent CT of the brain also demonstrated a right parietal mass. Thus, this lung lesion is most likely a primary neoplasm with metastatic involvement.
ANSWER
The chest radiograph demonstrates a fairly large right hilar mass with an associated right upper lobe infiltrate. This finding is very worrisome for a bronchogenic carcinoma.
Subsequent CT of the brain also demonstrated a right parietal mass. Thus, this lung lesion is most likely a primary neoplasm with metastatic involvement.
A 59-year-old man presents to your facility for evaluation of altered mental status and confusion that have progressively worsened in the past two months. He denies any injury or trauma. He states he has had associated headaches and dizziness. He denies any weight loss, shortness of breath, or malaise; however, he himself is able to notice that his mentation has “not been right.” His medical history is significant for mild hypertension and hyperlipidemia, both of which are well controlled. He discloses a 50–pack-year history of cigarette use. Physical exam reveals a male in no obvious distress but complaining of a moderate headache. His vital signs are stable. His oxygen saturation is 97% on room air. Breath sounds appear clear. The neurologic exam shows no focal deficits. You order noncontrast CT of the head, as well as a chest radiograph. The chest radiograph is shown. What is your impression?
Elderly Man with Headaches and Weakness
ANSWER
The chest radiograph demonstrates evidence of previous sternotomy. No evidence of acute infiltrate is noted.
However, there is a prominence within the left hilar region. This finding is strongly suggestive of neoplasm until proven otherwise. The patient was promptly referred for CT of the chest, abdomen, and pelvis, which confirmed the lesion. Subsequent CT-guided biopsy was performed.
ANSWER
The chest radiograph demonstrates evidence of previous sternotomy. No evidence of acute infiltrate is noted.
However, there is a prominence within the left hilar region. This finding is strongly suggestive of neoplasm until proven otherwise. The patient was promptly referred for CT of the chest, abdomen, and pelvis, which confirmed the lesion. Subsequent CT-guided biopsy was performed.
ANSWER
The chest radiograph demonstrates evidence of previous sternotomy. No evidence of acute infiltrate is noted.
However, there is a prominence within the left hilar region. This finding is strongly suggestive of neoplasm until proven otherwise. The patient was promptly referred for CT of the chest, abdomen, and pelvis, which confirmed the lesion. Subsequent CT-guided biopsy was performed.
A 71-year-old man presents with complaints of headaches and weakness that have been ongoing for almost a month. He denies any fever, nausea, or vomiting. He has noticed an occasional cough and denies any weight loss. The patient has an extensive history of coronary artery disease, hypertension, and hyperlipidemia. History is also significant for coronary artery bypass grafting. He denies any history of smoking. The man is afebrile, and the rest of his vital signs, including pulse oximetry, are within normal limits. Physical exam shows an elderly, ill-appearing man in no obvious distress. Breath sounds bilaterally are clear. You order a chest radiograph along with some bloodwork. The chest radiograph is shown. What is your impression?
Car Accident and a Language Barrier
ANSWER
The radiograph shows an obvious deformity in the distal humerus consistent with an old fracture with chronic malunion. There is no evidence of a superimposed acute fracture.
Once family and interpreters became available, it was elicited that the patient, who is originally from Nepal, did sustain a childhood injury and broke his right arm. No acute intervention was required.
ANSWER
The radiograph shows an obvious deformity in the distal humerus consistent with an old fracture with chronic malunion. There is no evidence of a superimposed acute fracture.
Once family and interpreters became available, it was elicited that the patient, who is originally from Nepal, did sustain a childhood injury and broke his right arm. No acute intervention was required.
ANSWER
The radiograph shows an obvious deformity in the distal humerus consistent with an old fracture with chronic malunion. There is no evidence of a superimposed acute fracture.
Once family and interpreters became available, it was elicited that the patient, who is originally from Nepal, did sustain a childhood injury and broke his right arm. No acute intervention was required.
You are asked to see a 41-year-old man complaining of right upper arm pain. He was brought in by EMS from a reported single-vehicle crash, in which he was one of approximately 15 people traveling in a van. The patient speaks little to no English, and details of the accident are sketchy. Best as can be ascertained, the vehicle either went out of control or was hit and ran off the road. There were known fatalities at the scene. Due to language barriers, history is limited. Physical exam shows a middle-aged Asian man who appears quite uncomfortable. He indicates he is hurting in his chest, back, and right arm. His vital signs are normal, and primary survey appears stable, with the patient having multiple abrasions on his face and whole body. Examination of his right arm shows multiple abrasions with some bruising and swelling, as well as a deformity just above the elbow. The patient is able to slowly move his wrist and fingers. Distal pulses and sensation appear intact. Radiograph of the right humerus is shown. What is your impression?
