Here is the same CXR from last time.
Here’s some further information about the case:
Pt is a 52 y/o man with a history of smoking, atrial fibrillation, and HTN that presents to the ED today with a 2-3 day history of fatigue, weakness, fever, generalized body pains, drenching night sweats, increased urinary frequency, L ear discomfort, throat discomfort and blurry vision in the morning. The symptoms came on suddenly and have been constant since the beginning of the episode. The fatigue and weakness cause the patient to want to “drop into a hole” and sleep. His nightly sleep patterns have been disrupted by his night sweats and his increased urinary frequency. The night sweats are drenching and he often wakes up in the middle of the night with his shirt completely soaked. Around 8-9 AM in the morning he reports being cold and getting chills. He also has some lower sternal chest pain that occurs mostly with deep breathing. The pain does not radiate. The pt has a 30-35 year history of smoking cigarettes and drinking 15-20 alcoholic drinks/week. The pt stopped smoking yesterday with the intent to quit.
The pt has no change in appetite or weight, no new masses or lumps anywhere on his body and no syncope or LOC. The pt denies any history of similar symptoms. The pt denies any family history of these symptoms. The pt denies any sick contacts. The pt’s wife does not have similar symptoms. The patient has no N/V or history of recent travel. The pt was routinely tested for tuberculosis 2 years ago as part of an employment physical and the test was negative.
Vitals: BP 142/106 | Pulse 105 | Temp(Src) 100.6 °F (38.1 °C) (Oral) | Wt 228 lb (103.42 kg) | BMI 31.36 kg/m2 | SpO2 99%
General appearance – alert, well appearing, and in no distress; slightly pale
Eyes – PERRLA, EOMI
Ears – bilateral TM’s and external ear canals normal
Mouth – mucous membranes moist, pharynx normal without lesions
Neck – supple, no significant adenopathy
Lymphatics – no palpable lymphadenopathy, no hepatosplenomegaly
Chest – clear to auscultation, no wheezes, rales or rhonchi, symmetric air entry
Heart – normal rate, regular rhythm, normal S1, S2, no murmurs, rubs, clicks or gallops, no pericardial rub on auscultation with patient leaning forward
Abdomen – mild suprapubic ttp without rebound/guarding
Neurological – alert, oriented, normal speech, no focal findings or movement disorder noted, CN 2-12 grossly intact
Skin – normal coloration and turgor, no rashes, no suspicious skin lesions noted
With all of that in mind, let’s take a look at the x-ray again. The last post went through the ABCDE methodology to review the image and the A through D aspect was pretty well outlined there. The airway is patent, there is no obstruction and it lines up with the cervical spinous processes. The bones have no step-offs or other evidence of fractures and there are 10 ribs visible. The cardiac silhouette is not enlarged (in other words, not more than twice the width of the chest cavity) and the AP window sits between the aortic arch and pulmonary artery. The diaphragm has normal contour and the costo-vertebral angle is sharp.
The E is where things get interesting. One of the ways I like to do it is to try and look for asymmetry in the lung fields. And I think I see something!
The blue circle seems like a focal area of consolidation (either liquid or solid). That same “opacity” is not present on the corresponding place on the L lung field. I think its important to note that this finding has a large differential diagnosis attached to it, even if you put the finding on the x-ray in context with the case presentation. Most of the diagnoses on the list would be infectious, like TB or pneumonia, but other possibilities include lung cancer, edema, hemorrhage and systemic inflammatory conditions like sarcoidosis.
The radiologist read that image as most likely a case of lobar pneumonia. There was some hedging by the radiologist on the read because the lateral film was taken from L to R, therefore the opacity in the R lung field was very hard to see (that’s why I didn’t include a lateral view as well, but we can save that particular x-ray type for another post). In general, you want to get two views on any pathology on x-ray because it’s important to try and construct a 3D image in your head about where the pathology is located.
In any case, his patient presented with fever, cough, loss of energy, chills and body aches, with all of those symptoms having an acute onset. This makes an infectious process more likely (I say “more likely” because as everyone in medicine learns at some point or another, it is very dangerous to talk and think in absolutes). He was treated empirically with antibiotics for pneumonia.
Hopefully this example helps you to have a system in place when you look at any chest x-ray. If you have any questions, feel free to drop them in the comments and I’ll do my best to answer them. Also, if you have any requests for certain types of images you would like to see for the next post, also let me know in the comments. Until next time!
Author: Jaymin Patel