Monday, September 30, 2013

Case review 4: Bronchiectasis


A 34 year old man presented with chronic cough with yellowish greenish sputum. A chest x-ray was done and sent to NR Medical Imaging for reporting. What do you think?
X-ray findings
His chest x-ray showed multiple ring lesions scattered over both lung fields especially at the bases. These are consistent with bronchiectasis. Some air fluid levels are seen indicating super-added infection.
Bronchiectasis is a condition in which the lungs' airways are abnormally stretched and widened.This stretching and widening is caused by mucus blockage. More and more mucus builds up in the airways, allowing bacteria to grow. This leads to infection.
Bronchiectasis can develop at any age. It begins most often in childhood, but symptoms may not appear until much later. Bronchiectasis can occur as part of a birth defect or as a result of injury or other diseases, like tuberculosis, pneumonia and influenza. It also can be caused by a blockage in your airways due to a growth or something you inhaled as a child such as a piece of a toy or peanut.
Bronchiectasis cannot be cured. But with proper treatment most people with bronchiectasis can live a normal life.

Monday, September 23, 2013

Case review 3: Bronchial carcinoma


A 41 year old man had a routine chest x-ray done as part of his medical check up.  
Look at the x-ray above. There is an opacity in the right upper zone overlying the right 6th posterior rib. Is this a lung nodule or callus formation from an old fractured rib?

Not sure? Look at the magnified image below:

X-ray findings

The nodule doesn't exactly overlie the 6th rib. Thus, it is unlikely to be bone callus.
The nodule has inhomogenous density and irregular margin. 
Bronchial carcinoma is a strong possibility.

Further management
The next course of action would be to do CT chest and bronchoscopy. 

Thursday, September 19, 2013

Case review 2: Right Lower Lobe Collapse


A 31 year old lady presented to her GP (Klinik Chung) with a 1 month history of chronic cough. A chest radiograph was done.

X-ray findings

The x-ray showed a homogenous triangular opacity at the right lower zone with well-defined upper border.
The right heart border can be seen through the shadow but the right hemi-diaphragm and costo-phrenic angle are obliterated.
The findings are consistent with a right lower lobe collapse.

Other features to look for are elevated hemi-diaphragm and depressed right hilum. The radiologic features are summarised in this diagram: 

The causes for this kind of lung collapse may be divided into: 
  1. Luminal: causes include aspirated foreign material or mucous plugging. 
  2. Mural: cause is usually due to bronchogenic carcinoma. 
  3. Extrinsic: cause may be due to compression by adjacent mass.
Further management

The next course of action would be to do bronchoscopy. 

Wednesday, September 18, 2013

Case review 1: Solitary Pulmonary Nodule in chest x-ray

 PA chest x-ray 
PA chest x-ray (enlarged image) shows a homogeneous well defined nodule


A 34 year old man works in Oil & gas industry came for routine medical check up. He denied any symptoms but smokes 1 packet a day.

X-ray findings

Chest x-ray was done & showed a 1.5cm nodule in the left mid zone peripherally (yellow arrow). The nodule has well defined margin and is homogenous in density.
No associated calcification, hilar lymphadenopathy or pleural effusion. 
No bony changes such as rib metastases. 

Impression: The findings are consistent with a solitary pulmonary nodule. 

*Important notes: Nodule is defined as a lesion smaller than 3 cm. Meanwhile, mass is a lesion larger than 3cm.

Differential diagnosis of Solitary pulmonary nodule includes:
-bronchial carcinoma

Further management

Depending on clinical presentation, the nodule most commonly represents a benign tumour such as a granuloma or hamartoma. 
However, around 20% of cases it represents a malignant cancer, especially in older adults and smokers.
Thus, further radiological studies such as CT chest & lung biopsy will be very helpful to exclude the possibility of cancer.

Wednesday, September 11, 2013

Avulsion fracture of knee

A 22 year old woman came complaint of pain on the left knee for 1 week. 
She was actually fell down and knee hit the road surface. 
Patient have difficulty in walking & taking the staircase. 


Routine AP & Lateral knee x-ray was done. 
The x-ray showed possibility of avulsion fracture of anterior cruciate ligament. 
The anterior cruciate ligament tearing cause small fragment of bone to break. In this case it involves the bone in the intercondylar notch. 
It is evidence by 2 bony pieces - one large (11mm) and one small (2mm) - seen in the intercondylar notch (red circle).

Tuesday, September 10, 2013

Trauma Case 1: Fracture midshaft of Radius Ulna

 Left radius ulna x-ray (AP view)
Left radius ulna x-ray (Lateral view)

Trauma case 1:

A 20 year old man came with pain on the left forearm. 
Patient fell while walking down the staircase & the forearm hit the edge of staircase.
Can you name the type of fracture involved?


Fractures mid shaft of both radius and ulna.
The bone fracture displaced medially and posteriorly.
There is comminuted fracture shown by fragmented segment of the ulna.

Monday, September 9, 2013

Granuloma in Chest X-ray

 PA chest x-ray 
Right lateral chest x-ray

A foreign worker came for medical check up and a PA view was done.
There is a 3mm nodule at the right lower zone below the level of the diaphragm.
Do you think that is a granuloma or an end on vessel?


Both end on vessel and granuloma looks alike. However, granuloma at lower zones are uncommon.

Subsequently, a right lateral view was done and the nodule may be seen posterior to the diaphragmatic shadow.
This confirmed that the nodule is a granuloma and not an end on vessel.

Thursday, September 5, 2013

Wednesday, September 4, 2013

Quick Quiz 1


39 year old lady presented with pain in the left loin.
A KUB x-ray was done.

What are 2 most important findings?
What would you do next?


Important findings
1. Left Staghorn calculus
2. Surgical clips after cholecystectomy 

Suggestion for further diagnosis: Ultrasound of abdomen
1.     To confirm no gallbladder
2.    To confirm staghorn calculus
3.    To look for hydronephrosis
4.    To look for signs of renal damage