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WWWTP #24 Answer…

July 1, 2015

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Trauma patient came in to the ED:

CXR 1

What’s Wrong With This Picture?

The patient’s chest tube is not inserted far enough.  It is also a bit high residing between ribs 3-4.

Chest tubes have a side port and a distal port for suctioning fluids, air from the pleural space.  There is a radiopaque line seen on the tube that is interrupted at the side port (see magnified image).  In this case the radiograph shows that the side port is subcutaneous and not inserted all the way into the pleural space.  The chest tube needs to be replaced!

Author:  Russell Jones, MD

Image Contributor:  David Barnes, MD

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What’s Wrong With This Picture #24 (WWWTP?)

June 26, 2015

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Trauma patient came in to the ED:

CXR 1

What’s Wrong With This Picture?

Author:  Russell Jones, MD

Image Contributor:  David Barnes, MD

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WWWTP #23 (What’s Wrong With This Picture?) Answer

March 12, 2015

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Patient presented with cough, fevers.  This Chest Xray was obtained:

WWWTP 21 1

One finding on this Xray is very concerning.  The Xray showed free air under the diaphragm.

A further diagnostic study was obtained (CT abdomen/pelvis):

WWWTP 21 2 WWWTP 21 3

Turns out this patient has pneumatosis cystoides intestinalis.  He has a history of this disorder and has had a prior laparoscopy showing multiple cystic structures in the intestinal walls.

Findings on imaging:

1.  Chest Xray:  Concern for free air underneath the diaphragm.  He also has a tracheostomy, pacemaker, scoliosis, and a right lower lung infiltrate.

2.  CT abdomen/pelvis:  The coronal imaging shows multiple cystic structures full of free air in the cecal area.  The cross-sectional imaging above shows a large amount of pneumoperitoneum.

Luckily this patient has a history of pneumatosis cystoides intestinalis.  He has had multiple abdominal CT’s showing similar findings.  Clinically he had no abdominal tenderness.  Keep this rare diagnosis in mind for the patient presenting with free air in the abdomen!  Information about pneumatosis cystoides intestinalis:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3235639/

Author:  Russell Jones, MD

Image Contributor:  Mary Bing, MD

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WWWTP #23 (What’s Wrong With This Picture?)

March 5, 2015

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Patient presented with cough, fevers.  This Chest Xray was obtained:

WWWTP 21 1

One finding on this Xray is very concerning.  What is it?

A further diagnostic study was obtained (CT abdomen/pelvis):

WWWTP 21 2 WWWTP 21 3

What’s Wrong With This Picture?

Answer to follow.

Author:  Russell Jones, MD

Image Contributor:  Mary Bing, MD

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WWWTP #22 (What’s Wrong With This Picture?) Answer…

February 3, 2015

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Patient presented short of breath.  Here is his chest xray:

WWWTP #22 PA WWWTP #22 LA

What’s wrong with this picture?

The findings are very subtle.  This patient has multiple lucencies in the bony structures including ribs, clavicles, scapula, and visualized proximal humerus:

WWWTP 22 edited

This patient turned out to have leukemia.  His shortness of breath was actually symptomatic anemia and he had a severe leukocytosis with a WBC nearing 180 K/MM3.

Remember to approach all imaging with a systematic approach so you don’t miss subtle findings like this!

Author:  Russell Jones, MD

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WWWTP #22 (What’s Wrong With This Picture?)

January 27, 2015

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Patient presented short of breath.  Here is his chest xray:

WWWTP #22 PA WWWTP #22 LA

What’s wrong with this picture?

Answer to follow.

Author:  Russell Jones, MD

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WWWTP #21… Answer

October 28, 2014

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This is an interesting X-ray of a newborn with respiratory distress:

WWWTP 21

WWWTP 20

 

The upper Chest X-ray has an endotracheal tube near the carina (probably should be pulled back a bit).  It also has cardiomegally with vascular congestion.  The line coming up from below is an umbilical venous catheter in the inferior vena cava.

The “baby gram” below shows the same.  This image gives a better view of the umbilical line.

An umbilical venous catheter should traverse as this one does.  It comes straight up from the umbilicus to just above the diaphragm near the right atrium and inferior vena cava junction.  If the catheter does not go straight up and veers to the left side of the patient, it may have erroneously entered the hepatic vasculature.  This can result in hepatic complications.

The patient ended up having a double outlet right ventricle (both the aorta and main pulmonary artery are attached to the right ventricle) which is one of many anatomic heart abnormalities that can lead to congestive heart failure.  There was also a patent ductus arteriosus and a large ventral septal defect (VSD) that allowed for mixing of deoxygenated and oxygenated blood.  Without the large VSD the patient would not have been able to survive.

Author:  Russell Jones, MD

 

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What’s Wrong With This Picture #21 (WWWTP?)

October 21, 2014

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This is an interesting X-ray of a newborn with respiratory distress:

WWWTP 21

WWWTP 21

 

What are the findings in this picture?

Answer to follow.

Author:  Russell Jones, MD

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WWWTP #18 Answer

September 11, 2014

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This is a classic knee film in an elderly lady who fell.  What is the finding and diagnosis?

lipohemarthrosis-1 edits

Just anterior to the distal femur there is an example of lipohemarthrosis.  Note the horizontal line seen in the suprapatellar pouch (blue arrow).  This occurs when fat and blood have been released into the joint space and creates an interface (fats don’t mix with mostly water-based blood).  The fat has been released from an occult fracture, most commonly a tibial plateau or distal femur fracture.  If you can’t see the fracture it may be a good idea to obtain further imaging (CT or MRI) or refer the patient to an orthopedic surgeon.

Author:  Russell Jones, MD

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WWWTP #18 (What’s Wrong With This Picture?)

September 8, 2014

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This is a classic knee film in an elderly lady who fell.  What is the finding and diagnosis?

WWWTP #18

Answer to follow.

Author:  Russell Jones, MD

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