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Discussion in 'Spot Diagnosis' started by Stefan Misaca, Apr 9, 2013.

  1. Stefan Misaca

    Stefan Misaca Famous Member

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    What do you think about this ?

    [​IMG]

    I dont know if I did right or not that I posted this ex here .. but this is my rx, and a doctor said that I have a normal cord and normal lungs, I'm only a 3rd year medical student and I'm not sure that I read it right(in my oppinion seems to be a normally cord and lungs ), but I wanna know if its something wrong with the diaphragm or that spot into the left (stomach air bubble - if this is normally looks like)
     

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    Last edited: Apr 9, 2013

  2. Carmen

    Carmen Active member

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    Maybe is pneumothorax
     

  3. soha azab

    soha azab Famous Member

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    emphysema
     

  4. madhubhashini

    madhubhashini Famous Member

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    bilateral tension pneumothorax
     

  5. neo_star

    neo_star Moderator

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    provisional diagnosis - agree with Madhu ( b/l tension pneumothorax ) >?>?..
     

  6. apparat

    apparat Well-Known Member

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    I'm sorry I think it would be massive disservice and grave mistake to attempt to read an xray based on the resolution of that picture

    it could be a copd picture with narrowed mediastinum +/- (unconvincing) diaphragm flattening
    it could (very unlikely imo) be bilateral ptx
    it could also be a very normal cxr, with the vascular markings being unnoticeable because of the poor resolution picture
     

  7. Stefan Misaca

    Stefan Misaca Famous Member

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    neo_star I'm not smoking and I drink ocasionally like 1 cocktail / month ... and I dont have sympton right now. I made that rx only cuz I cough 3 days . But it happened last month. Now I'm ok :) So, its tricky because of the resolution ??
     

  8. Walkov

    Walkov Famous Member

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    emphysema
     

  9. kangourou

    kangourou Famous Member

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    Stefan misaca, I must agree with apparat on this one.

    The x-ray itself maybe of good quality, but we cannot visualise the necessary details from this picture to even begin to make a diagnosis. The only reason the differential diagnosis of bilateral pneumothorax came about was because both lung field look completely black... i.e. we see only air and no vascular markings. This is obviously not the case as the symptom you describe is a cough that resolved on its own after 3 days.

    I strongly urge you not to seek differential diagnosis for your own ailments on this forum. This is used for educational purposes only, and it would be highly unprofessional, not to mention impossible, for any doctor to give you a diagnosis based on information given here.

    Having said that, I sincerely hope you are feeling better now, and if you are having any concerns about this chest x-ray i suggest you go back and discuss this with the doctor where they can view the original x-ray.
     

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  10. neo_star

    neo_star Moderator

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    Thanks Dr. Kangourou 4 putting things in the right perspective (Y)

    Dear Dr. Apparat, i guess u know dat v ( myself and Dr. Madhubhashini ) wer not serious wen v gave the diagnosis of Ptx. Sarcasm and a little bit of fun is good 4 health. Stefan Miaca is my friend and that was just a little something bet'n the 2 of us ( he does pull my legs every once in a while & i gave him one back ) (-:

    Do u think wid dat kind of b/l Ptx, he wud have been in our midst. P:

    I totally agree with the points dat u gave 4 a COPD xray, though (Y)
     

    Last edited: Apr 10, 2013
  11. Stefan Misaca

    Stefan Misaca Famous Member

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    Ok, thx alot for all of you :) and neo :p I just wanted to hear your oppinion just cuz you have many explications ?:p Nothing bad...all respect for you mate.
    I still have 1 more question .. if its possible a b/l ptx should I be bad or some symptoms ?
     

  12. neo_star

    neo_star Moderator

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    I am preparing a detailed response...will b up in a couple of hours and it shud ans all ur question on CXR (-:
     

  13. Stefan Misaca

    Stefan Misaca Famous Member

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    Thanks !
     

  14. neo_star

    neo_star Moderator

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    Dear Stefan,

    I won't comment on ur X-ray for precisely the reasons mentioned by Dr. Apparat and Dr. Kangourou but will take this opportunity to teach u and some of our junior members on the basic steps in PA CXR intepretation.


    2 things b4 v can even dream of commenting about the pathology i.e whether it is well centralised and well exposed.

    How do u know if the Xray is well centralised ?

    Medial clavicular ends will be equidistant from the spine

    Significance -

    1) if CXR is not well centralised then we cannot comment about - medistinal shift, cardiomegaly, narrow mediastinum
    Why ? ....to understand this - get a torch, a bottle of XXX rum ( or any brand u prefer ) and keep it a foot away from a wall. Now switch off the light and shine the torch on the bottle from different angles and c how the shadow changes. Alternatively u can point the torch straight at the bottle and ask ur gf to slightly tilt the orientation of the bottle & c the shadow change....i hope u got the point - the xray source is akin to the torch and XXX rum is akin to mediastinum.

    Now if u hav understood, pls keep the bottle back...ur gf can stay with u 4 the rest of the show ( if she is > 18 )

    2) comparitive radiolucency of the lung fields....if the x ray beam is not well centralised then one lung will receive more than it's fair share and will appear darker than it should.


    [​IMG]


    #############################################################

    Now coming to exposure ( it's ok, ur gf can stay P: )

    How do u judge adequate exposure ?

    Ans - only 4 thoracic spines should be seen. The rest r covered by heart shadow. If overexposed more vertebrae r seen and the heart appears more translucent.


    [​IMG]


    #############################################################

    the next section will be on a schema 4 systematically looking at a CXR. U can take a "Beer Break" now, but do come back.
     

  15. neo_star

    neo_star Moderator

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    Now coming to looking at the Xray systematically

    Intro - the humble, unassuming X ray is actually an ex. of information overload and if u try to look at it as a whole, u could be overwhelmed and miss out on a lot of stuff.

    So u hav to look sequentially at diff structures. A very common order of looking at things is:

    1) lung fields ( and here again, it's better to divide the lungs into 3 zones, namely upper ( above ant end of 2nd rib ) middle ( bet'n ant ends of 2nd & 4th ribs ) and lower ( below d ant. end of 4th rib ) and compare the corresponding lung fields on both sides. The lung fields should be equally radioluscent on both sides at same levels.
    In the upper zone, look 4 any cavitary lesions ( usually from tb in developing countries ) or parenchymal opacities.
    In the mid zone, u have to look at the hila in addition to the parenchyma. ( Note the rt. hilar vessels r slightly lower than the left ).
    In the lower zone - focus on the cardiophrenic and costo phrenic angles. They r sharply defined in the absence of a pathology. Any blunting / opacity - would mean fluid in the pleural space. Also the rt. diaphragm should be .5 - 1.5 cm higher than the lt. diaphragm and both should be smoothly curved.

    Clinical pearl - a) if u can see the ribs thru the pleural effusion, then it's more likely 2 b a transudate ( ex. congestive heart failure, nephrotic syndrome etc. ) and if not then an exudate ( ex. pus, blood, chylous fluid, ). In pyothorax, the viseral pleura will show some opacity / thickening in some cases ( due to calcfication ).

    [​IMG]


    b) if the diaphragm on either side is a little higher than usual and is not smoothly curved esp. the medial 1/2 being slightly horizontal, then think of a subpulmonic effusion....something i guess i missed out here - http://forum.facmedicine.com/spot-diagnosis/15588-chest-xray-pathological-findings.html#post42586



    2) trace the trachea ( if possible all d way 2 d carina ) - look for any deviation in it's course which cud be becos of fibrosis pulling it towards the side of the lesion or a mass lesion, pneumothorax etc. pushing it towards the opp side.

    [​IMG]


    3) cardiac silhouette & Cardio-thoracic ratio

    rt. border ( from above to blo ) - svc and rt. atrium
    lt. border ( from above to blo ) - aorta, pulmonary conus, lt. atrium & lt. ventricle

    [​IMG]


    Cardio-thoracic ratio : not very reliable ( 4 protean reasons ) but this is how u do it.....draw a vertical line thru the center of the spine , then draw lines "a" & "b" perpendicular to this line...to the maximum widths of the lt. and rt. heart borders. Add "a" & "b". Now measure the max. transverse diam of the chest ( it's the line joining the inner borders of the ribs at the widest portion of the chest ) and call it "c".

    a+b =/< c/2

    [​IMG]


    4) study the bones and soft tissues - CXR examination won't be complete without studying the bones and soft tissue ( an aspect often ignored by non-radio guys & gals ).

    ribs ( 4 crowding, spreading & bony lesions ), clavicle, scapula and shoulder joints
    soft tissue - 4 surgical emphysema, cold abscess etc.


    Just 4 u Stefan !!!
     

  16. neo_star

    neo_star Moderator

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    Now since we r childhood buddies, i am going to break protocol ( just once ) and allay ur fears about ur Xray (-:

    The main reason u never had a tension pneumo... is becos, wid such massive b/l tension pneumo...i wud have been speaking about u in the "past tense".

    Spots on pneumothorax, have been posted here, take a look at them

    1) http://forum.facmedicine.com/spot-diagnosis/15464-spot-diagnosis.html#post42208

    2) http://forum.facmedicine.com/spot-diagnosis/12751-chest-xray.html

    read further, only if u have visited the above pages.....u will notice that in a partial pneumothorax, there is a white line (representing the visceral pleura ) demarcating the border between the collapsed lung and air in the pleural cavity and in a completely collapsed lung, u can see the collapsed lung as a bunched up opacity at the hilum. None of that is seen in ur Xray.


    So what really is wrong with ur Xray ?

    Ans) it's over-exposed, i.e to say to many Xrays and so they went past everything ( notice how the ribs and cardiac shadow r also almost transparent ) and the details of the spine is almost discernible all the way to the diaphragm ( usually hidden by the cardiac shadow ).

    yes the mediastinum looks a little narrow, but the cardiothoracic ratio is the least reliable thing on a PA CXR. Centralisation is one issue, but in ur case it seems ok...so it cud well be a normal variation, wherein ur medisinum is a bit more AP in orientation ( than usual ). If u have asthma or chronic bronchitis, then may be, u will get some narrowed mediastinum from the hyperinflated lungs....but then again as Apparat mentioned...ur diapragm looks nice and dome shaped ( like a baby's a$$ ).....So don't worry
    (Y)

    a nice place to learn some cool radiology is - learningradiology.com
     

    Last edited: Apr 12, 2013
  17. Stefan Misaca

    Stefan Misaca Famous Member

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    Well, I have to learn so many things from you :) Thanks alot Neo !
     

  18. neo_star

    neo_star Moderator

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    Always a pleasure and honor, to share knowledge with fellow colleagues (Y)
     

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