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Cough and Back Pain in a Man With COPD
ANSWER
The radiograph shows some evidence of hyperinflated lungs, consistent with COPD. There is a small right effusion evident.
Of note is a superior mediastinal mass, which is causing right-sided and anterior displacement of the intrathoracic trachea. The differential includes possible adenopathy related to a carcinoma or a substernal goiter. Further diagnostic studies and surgical evaluation are warranted.
In this particular case, review of the patient’s imaging history showed he had a chest radiograph two years ago, at which time these findings were present. This favors substernal goiter as the diagnosis. Multinodular goiter was later confirmed with a thyroid ultrasound, and referral to general surgery was made.
ANSWER
The radiograph shows some evidence of hyperinflated lungs, consistent with COPD. There is a small right effusion evident.
Of note is a superior mediastinal mass, which is causing right-sided and anterior displacement of the intrathoracic trachea. The differential includes possible adenopathy related to a carcinoma or a substernal goiter. Further diagnostic studies and surgical evaluation are warranted.
In this particular case, review of the patient’s imaging history showed he had a chest radiograph two years ago, at which time these findings were present. This favors substernal goiter as the diagnosis. Multinodular goiter was later confirmed with a thyroid ultrasound, and referral to general surgery was made.
ANSWER
The radiograph shows some evidence of hyperinflated lungs, consistent with COPD. There is a small right effusion evident.
Of note is a superior mediastinal mass, which is causing right-sided and anterior displacement of the intrathoracic trachea. The differential includes possible adenopathy related to a carcinoma or a substernal goiter. Further diagnostic studies and surgical evaluation are warranted.
In this particular case, review of the patient’s imaging history showed he had a chest radiograph two years ago, at which time these findings were present. This favors substernal goiter as the diagnosis. Multinodular goiter was later confirmed with a thyroid ultrasound, and referral to general surgery was made.
A 60-year-old man presents for evaluation of fever, cough, and back pain. His symptoms have been intermittent but have worsened over the past month or so. He has had no treatment prior to today’s visit. His medical history is significant for hypertension, COPD, and chronic renal insufficiency. He denies any history of tobacco use. On physical exam, you see an older man in no obvious distress. His vital signs are stable. He is afe-brile, with a blood pressure of 150/90 mm Hg, a heart rate of 66 beats/min, and a respiratory rate of 18 breaths/min. His O2 saturation is 98% on room air. His neck is supple, with no evidence of ade-nopathy. Lung sounds are slightly decreased bilaterally, with a few crackles heard. The rest of his physical exam, overall, is normal. You order preliminary lab work as well as a chest radiograph (shown). What is your impression?
Hand Slammed in Door
ANSWER
The radiograph shows a comminuted fracture of the proximal fifth phalanx. Soft tissue swelling is noted as well. The patient’s hand was splinted, and arrangements for outpatient orthopedic follow-up were made.
ANSWER
The radiograph shows a comminuted fracture of the proximal fifth phalanx. Soft tissue swelling is noted as well. The patient’s hand was splinted, and arrangements for outpatient orthopedic follow-up were made.
ANSWER
The radiograph shows a comminuted fracture of the proximal fifth phalanx. Soft tissue swelling is noted as well. The patient’s hand was splinted, and arrangements for outpatient orthopedic follow-up were made.
A 48-year-old woman presents to the urgent care center with complaints of right hand pain second-ary to an injury she sustained earlier in the day. Her hand was accidentally caught in a metal door as it was being shut by someone else. The door struck her in the middorsal aspect of her hand. She is now complaining of pain and swelling. She is healthy except for mild but well-controlled hypertension. Her vital signs are normal. Examina-tion of her right hand shows mild to moderate soft tissue swelling and some early bruising. There is extreme tenderness over the fourth and fifth metacarpal bones. Good capillary refill time is noted, and sensation is intact. She is able to flex her fingers somewhat, although this is limited by the swelling. Radiograph of the right hand is obtained. What is your impression?
Unresponsive Woman Extricated From Car
ANSWER
The radiograph shows a right acetabular fracture that is mildly displaced. In addition, the right hip and femoral head are dislocated. Orthopedic consultation was made to reduce the hip and evaluate the fracture.
ANSWER
The radiograph shows a right acetabular fracture that is mildly displaced. In addition, the right hip and femoral head are dislocated. Orthopedic consultation was made to reduce the hip and evaluate the fracture.
ANSWER
The radiograph shows a right acetabular fracture that is mildly displaced. In addition, the right hip and femoral head are dislocated. Orthopedic consultation was made to reduce the hip and evaluate the fracture.
An unidentified female is brought in as a trauma code. She was apparently in a motor vehicle crash, the specific details of which are unclear. Emergency medical personnel describe extensive damage to her vehicle, which resulted in a pro-longed extrication time. Due to unresponsiveness at the scene, she was intubated in the field. The patient is probably in her late 30s to early 40s. She has two large-bore IV lines with normal saline infusing at a wide-open rate. Blood pressure is 90/60 mm Hg and heart rate, 140 beats/min. She has several superficial lacerations on her head, her pupils are fixed and dilated, and there is minimal withdrawal to pain in her extremities. No other trauma is im-mediately evident. Portable radiographs of her chest and pelvis are obtained prior to sending her for CT. Pelvis radiograph is shown. What is your impression?
Knee Pain After Falling Off Ladder
ANSWER
The radiograph shows a lucency within the lateral tibial plateau and tibial metaphysis, consistent with a fracture. It is mildly depressed and slightly comminuted.
Fluid collection is also evident on the lateral view, likely reflecting a lipohemarthrosis. The patient was placed in a knee immobilizer and made non–weight-bearing. She was instructed to follow up with an orthopedist when she returned home (as she was visiting from out of town).
ANSWER
The radiograph shows a lucency within the lateral tibial plateau and tibial metaphysis, consistent with a fracture. It is mildly depressed and slightly comminuted.
Fluid collection is also evident on the lateral view, likely reflecting a lipohemarthrosis. The patient was placed in a knee immobilizer and made non–weight-bearing. She was instructed to follow up with an orthopedist when she returned home (as she was visiting from out of town).
ANSWER
The radiograph shows a lucency within the lateral tibial plateau and tibial metaphysis, consistent with a fracture. It is mildly depressed and slightly comminuted.
Fluid collection is also evident on the lateral view, likely reflecting a lipohemarthrosis. The patient was placed in a knee immobilizer and made non–weight-bearing. She was instructed to follow up with an orthopedist when she returned home (as she was visiting from out of town).
A 25-year-old woman presents for evaluation of left knee pain secondary to a fall. She states she was descending a ladder when she missed a step while still several feet above the ground. She landed on her left foot, awkwardly twisting her leg. She now has swelling and pain in her knee and difficulty bearing weight on that leg. Her medical history is unremarkable. Examination reveals a moderate amount of swelling that limits her ability to flex her left knee. She has diffuse tenderness throughout the knee. Because of the swelling and the patient’s severe discomfort, instability tests are not performed. She has good distal pulses and sensation. Radiographs of the knee are obtained. What is your impression?
Chest Wall and Knee Pain Following Motor Vehicle Collision
ANSWER
The radiograph demonstrates lateral dislocation of the patella, with no evidence of an acute fracture of any surrounding bones. The patella was easily reduced in the emergency department, and the patient was placed in a knee immobilizer. Orthopedic consultation was obtained.
ANSWER
The radiograph demonstrates lateral dislocation of the patella, with no evidence of an acute fracture of any surrounding bones. The patella was easily reduced in the emergency department, and the patient was placed in a knee immobilizer. Orthopedic consultation was obtained.
ANSWER
The radiograph demonstrates lateral dislocation of the patella, with no evidence of an acute fracture of any surrounding bones. The patella was easily reduced in the emergency department, and the patient was placed in a knee immobilizer. Orthopedic consultation was obtained.
A 20-year-old man presents following a motor vehicle collision in which the car he was driving was broadsided by another vehicle. His air bag deployed, and the patient is now complaining of right-sided chest wall pain and right knee pain. His medical history is unremarkable. In a primary survey, the patient appears stable, with normal vital signs. Inspection of his right knee shows some deformity of the joint, with mild swelling and moderate tenderness. The patient is unable to perform flexion with his right knee. Good distal pulses are present, and sensation is intact. Radiograph of the right knee is obtained. What is your impression?
Is Chest Pain Related to Prior Fracture?
ANSWER
The radiograph demonstrates evidence of previous surgery on the sternum. There also is evidence of scarring or discoid atelectasis along the left mid lung.
Of note, though, is a soft tissue mass (about 5 to 6 cm) within the left pulmonary apex. This lesion could represent a rounded infiltrate, an atypical infection such as a mycetoma, or possibly a pulmonary neoplasm.
Since the patient was stable, he was placed on antibiotics with instructions to follow up with his primary care provider for further work-up on the mass. The patient did follow up; the lesion persisted and subsequent biopsy confirmed carcinoma.
ANSWER
The radiograph demonstrates evidence of previous surgery on the sternum. There also is evidence of scarring or discoid atelectasis along the left mid lung.
Of note, though, is a soft tissue mass (about 5 to 6 cm) within the left pulmonary apex. This lesion could represent a rounded infiltrate, an atypical infection such as a mycetoma, or possibly a pulmonary neoplasm.
Since the patient was stable, he was placed on antibiotics with instructions to follow up with his primary care provider for further work-up on the mass. The patient did follow up; the lesion persisted and subsequent biopsy confirmed carcinoma.
ANSWER
The radiograph demonstrates evidence of previous surgery on the sternum. There also is evidence of scarring or discoid atelectasis along the left mid lung.
Of note, though, is a soft tissue mass (about 5 to 6 cm) within the left pulmonary apex. This lesion could represent a rounded infiltrate, an atypical infection such as a mycetoma, or possibly a pulmonary neoplasm.
Since the patient was stable, he was placed on antibiotics with instructions to follow up with his primary care provider for further work-up on the mass. The patient did follow up; the lesion persisted and subsequent biopsy confirmed carcinoma.
A 61-year-old man presents to your urgent care center for evaluation of “chest pain” he has been experiencing for almost four weeks. He denies any injury or trauma. He describes the pain as “sharp” and “stabbing” and says occasionally it is associated with breathing, localized primarily to the left side. There is no radiation of the pain. He denies fever, nausea, weight loss, night sweats, and hemoptysis. He has smoked a half-pack of cigarettes daily for more than 40 years. His medical history is otherwise unremarkable, except that he was told he had “high blood pressure” and he had his sternum repaired several years ago, following fracture in an accident. Vital signs are as follows: temperature, 36.4°C; blood pressure, 174/100 mm Hg; ventricular rate, 88 beats/min; respiratory rate, 20 breaths/min; and O2 saturation, 100% on room air. He appears to be in no obvious distress. Lung sounds are normal, as is the rest of the physical examination. You obtain a chest radiograph. What is your impression?
Man with Consistent Headaches
ANSWER
The image shows obvious mass effect throughout the left hemisphere. On close examination, there is evidence of an isodense subdural collection within the left frontoparietal region. This is causing a left-to-right shift of almost 11 mm.
This finding is most likely a subacute subdural hematoma, probably seven to 14 days old. Further questioning reveals that the patient had fallen in the shower approximately two weeks prior and hit his head. The patient was admitted for observation and subsequently underwent a craniotomy for evacuation of the subdural hematoma.
ANSWER
The image shows obvious mass effect throughout the left hemisphere. On close examination, there is evidence of an isodense subdural collection within the left frontoparietal region. This is causing a left-to-right shift of almost 11 mm.
This finding is most likely a subacute subdural hematoma, probably seven to 14 days old. Further questioning reveals that the patient had fallen in the shower approximately two weeks prior and hit his head. The patient was admitted for observation and subsequently underwent a craniotomy for evacuation of the subdural hematoma.
ANSWER
The image shows obvious mass effect throughout the left hemisphere. On close examination, there is evidence of an isodense subdural collection within the left frontoparietal region. This is causing a left-to-right shift of almost 11 mm.
This finding is most likely a subacute subdural hematoma, probably seven to 14 days old. Further questioning reveals that the patient had fallen in the shower approximately two weeks prior and hit his head. The patient was admitted for observation and subsequently underwent a craniotomy for evacuation of the subdural hematoma.
You are called to the emergency department (ED) in reference to a patient who was sent there by radiology with a reported “brain mass” noted on imaging. During further investigation in the ED, the patient, who is in his 50s, stated that he has had headaches for the past several weeks; he consulted his primary care provider, who ordered outpatient MRI of the brain—the test that ultimately led to his arrival in the ED. Since the MRI results were not immediately available for review, the ED staff obtained noncontrast CT of the head. The ED provider notes that it “looks like there is something there causing significant mass effect and shift.” When you arrive to see the patient, you note that he is awake, alert, and oriented times three. His Glasgow Coma Scale score is 15, and his vitals signs are normal. He states he has a mild headache, rating it a 3 out of 10 on a pain scale. His only other complaint is mild right-sided weakness, which he has noticed in the past week or so. Clinically, the strength in his right upper and lower extremities is good. His medical history is significant for prostate cancer and hypertension. A single cut from the CT of his head is shown. What is your impression?
Wrist Pain After a Fall
ANSWER
The radiograph shows some osteopenia and significant vascular calcifications. Of note, there is a fracture of the styloid process of the radius, extending slightly to the joint space. The patient was placed in a splint and orthopedic referral was obtained.
ANSWER
The radiograph shows some osteopenia and significant vascular calcifications. Of note, there is a fracture of the styloid process of the radius, extending slightly to the joint space. The patient was placed in a splint and orthopedic referral was obtained.
ANSWER
The radiograph shows some osteopenia and significant vascular calcifications. Of note, there is a fracture of the styloid process of the radius, extending slightly to the joint space. The patient was placed in a splint and orthopedic referral was obtained.
A 90-year-old man is brought to your facility for evaluation after a fall. The patient states he was out in his yard, near his garden, when he “just passed out.” He landed in an ant bed and was eventually found by a neighbor, who brought him for evaluation. The patient says he has felt weak for the past several days. He has no other constitutional complaints. He is also experiencing bilateral wrist pain, he presumes as a result of receiving multiple ant bites. His medical history is significant for diabetes. His vital signs are normal. Inspection of both wrists demonstrates mild to moderate circumferential swelling with several raised, reddened bumps. Both wrists are tender; range of motion does cause some tenderness. Sensation is intact, and good capillary refill time is noted. While waiting for lab results, you obtain a radiograph of the left wrist (shown). What is your impression?
Elderly Woman with Shoulder Pain
ANSWER
The radiograph demonstrates significant osteopenia. In addition, there is a slightly impacted subcapital fracture of the humeral neck.
Orthopedics was consulted, and the patient was to be treated with nonoperative management. She was given a swathe for immobilization and comfort.
ANSWER
The radiograph demonstrates significant osteopenia. In addition, there is a slightly impacted subcapital fracture of the humeral neck.
Orthopedics was consulted, and the patient was to be treated with nonoperative management. She was given a swathe for immobilization and comfort.
ANSWER
The radiograph demonstrates significant osteopenia. In addition, there is a slightly impacted subcapital fracture of the humeral neck.
Orthopedics was consulted, and the patient was to be treated with nonoperative management. She was given a swathe for immobilization and comfort.
A 90-year-old woman is transferred to your facility from an outside hospital for evaluation of an intracranial hemorrhage secondary to a fall. The patient normally resides in a nursing home and has dementia. She was reportedly ambulating with her walker when she tripped and fell forward. In addition to dementia, her medical history is significant for sick sinus syndrome, for which she has a pacemaker. She also has hypertension and degenerative joint disease. Examination reveals an elderly female who is alert but very confused. Her vital signs are normal. She has moderate swelling and bruising on the left side of her forehead and left orbit. Her pupils react well. As you examine her, you note her unwillingness to use or move her left arm. When you inquire, she states, “It hurts.” Close examination of the left upper extremity shows no obvious deformity or swelling. She does have some tenderness over the left shoulder. You order a radiograph of the left shoulder (shown). What is your impression?
Elderly Man Failed To Mention Hip Pain After Fall
ANSWER
The radiograph demonstrates diffuse bony demineralization, as well as generalized degenerative changes. No obvious fracture or dislocation of the hip joint is seen.
Of note, though, are air lucencies within the area of the scrotum. This most likely represents a bowel finding and is strongly suggestive of an inguinal hernia. No acute intervention is warranted for this incidental finding; outpatient follow-up with general surgery was arranged.
ANSWER
The radiograph demonstrates diffuse bony demineralization, as well as generalized degenerative changes. No obvious fracture or dislocation of the hip joint is seen.
Of note, though, are air lucencies within the area of the scrotum. This most likely represents a bowel finding and is strongly suggestive of an inguinal hernia. No acute intervention is warranted for this incidental finding; outpatient follow-up with general surgery was arranged.
ANSWER
The radiograph demonstrates diffuse bony demineralization, as well as generalized degenerative changes. No obvious fracture or dislocation of the hip joint is seen.
Of note, though, are air lucencies within the area of the scrotum. This most likely represents a bowel finding and is strongly suggestive of an inguinal hernia. No acute intervention is warranted for this incidental finding; outpatient follow-up with general surgery was arranged.
An 87-year-old man is admitted to the hospital with a traumatic subarachnoid hemorrhage secondary to a fall down some steps. He is taking warfarin for atrial fibrillation; because his INR is elevated, he is placed in the ICU for close observation and warfarin reversal. His medical history is otherwise unremarkable, except for mild hypertension. During rounds, he complains of severe hip pain, possibly related to the fall. He admits that he “probably didn’t mention this” while he was in the emergency department. Physical examination demonstrates moderate tenderness and bruising in the left hip. No obvious leg shortening is noted. There is pain in the left hip with abduction and adduction, as well as with internal and external rotation. Good distal pulses are noted, as well as good color and sensation. His vital signs are normal. You order a portable pelvis radiograph (shown). What is your impression?
