Download Radiology assignment for Clerkship

Radiology assignment for Clerkship
RADIOLOGY CASE REPORT
Patient ID: OH # 34029470 Date of Study: 25 November 2008
Type of Study: __X-ray of the Chest.
1. Clinical Indication:
ID: 83 y/o male, with known CAD, COPD and HSRD on dialysis.
Presents to ER with a several day hx of increasing dyspnea. No orthopnea, no chest pain. No
cough/sputum/fever. Requested: chest X-ray to R/O pulmonary edema and ECG to R/O cardiac
causes.
2. Picture:
2. Describe the radiological findings:
Chest PA:
Adequate exposure, as bony structures are well visualized. No body abnormalities noted.
Trachea is midline.
The lungs fields are somewhat hazy, with a ground-glass appearance. Lung volumes are normal.
The hilar region is enlarged, with ill-defined vessels. Mild-moderate peribronchial cuffing can be
seen. Both the right and left heart borders are obscured by the increased vascular markings. The
right and left costophrenic angles are blunted and obscured. A few Kerley-B lines extend inwards
from the pleural surface. This accumulation of fluid in the perihilar space is symmetric, and
increased at the lung bases.
The heart may be slightly enlarged in size. Gastric air bubble visible. No free air noted under the
diaphragm.
Central line is in place.
Diagnosis: pulmonary edema.
3. Provide possible differential diagnosis(es):
Cardiogenic causes:
 L-sided heart failure / LV dysfunction (secondary to CHF or cardiomyopathy),
 Atrial outflow obstruction s/a mitral stenosis
 aortic or mitral valve regurgitation resulting in fluid overload
 acute exacerbation of preexisting cardiac disease due to
o Acute MI or ischemia
o Patient noncompliance with dietary restrictions (eg, dietary salt restrictions)
o Patient noncompliance with medications (eg, diuretics)
o Severe anemia
o Sepsis
o Thyrotoxicosis
o Myocarditis
o Myocardial toxins (eg, alcohol, cocaine, chemotherapeutic agents)
o elevated ++ systemic BP
 acute aortic insufficiency (endocarditis, aortic dissection)
 constrictive pericarditis or pericardial tamponade
 dysrhythmias s/a new-onset rapid atrial fibrillation or ventricular tachycardia
Non-cardiogenic causes:
 Lungs:
o ARDS
o Pneumonia or other lung infections
o Inhalation or smoke or other toxins
 renal failure w fluid overload
 iatrogenic fluid overload
4. What would you recommend next for this patient?
This patient could benefit from the following…
- dialysis or treatment with a diuretic
- an ECG to R/O cardiac causes
5. Is the use of this test/procedure appropriate?
_Yes. A chest x-ray is appropriate to confirm one’s clinical suspicion of pulmonary edema on
clinical exam.
6. Is(are) there any alternate test(s)?
If the patient is stable, a CT-scan could be done to further assess the lungs
In addition, an ECG should be done to rule out cardiac causes of pulmonary edema
If these tests do not reveal the reasons for pulmonary edema, a pulmonary artery catheterization
could be done to assess the pulmonary wedge pressure.
7. How would you explain to the patient about the possible risks and benefits of this test?
Some risks and benefits of CT-scan:
CT-scan will all for better visualization of the air spaces within the lungs, to allow for better
resolution of the area and better recognition of nodular and reticular patterns. It provides images
free of superimposition of structures. It is much more sensitive and specific for identification and
localization of disease than a conventional chest X-ray.
CT-scan increases one’s exposure to radiation at a dose much higher than that of a conventional
X-ray. While an X-ray machine can be portable and used to assess unstable patients, a patient
must be relatively stable to have a CT- scanning/evaluation done.
8. What is the cost of this test?
The cost of a CT-scan ranges from $300-2000 by online searches. I am unsure of the cost of an
X-ray vs that of a CT-scan to the TOH.