Watch out! The ET tube is malpositioned into the right mainstem bronchus. This emergency required us to call the ER doctors because removal and repositioning of the ET tube is warranted.
Observation
Clinical History: s/p cardiac arrest.
Technique: DX chest, portable 1 view
ET tube with its tip in the right mainstem bronchus. Suggest retraction by about 5 cm. There is marked cardiomegaly. Opacities are noted bilaterally more on the suprahilar and perihilar regions with air-bronchograms. Followup with PA and lateral chest radiograph is recommended.
Impression
APPARENT MALPOSITION OF ET TUBE, AS DESCRIBED. SUGGEST RETRACTION BY ABOUT 5 CM. MARKED CARDIOMEGALY. FINDINGS IN THE LUNGS POSSIBLY DUE TO PULMONARY EDEMA OR PNEUMONIA. RECOMMEND FOLLOW-UP.
For best results, don’t miss the opportunity to be with your loved one on Valentine’s Day this Sunday. Also, Presidents’ Day is the following day so why not make it a long weekend? 24/7 Radiology is here around the clock to help cover your after-hours, vacation and holiday reading needs. Just let us know how we can help and we will be here for you.
If you are not currently a 24/7 Radiology customer, contact us at 1-888-RADS-247 and we will show you how easy it is to receive the benefits and great service that 24/7 Radiology provides.
Textbook case of Emphysematous pyelonephritis, which is incredibly rare these days given the super strong antibiotics available…
Observation
Clinical history: Rule out PE, chills, elevated D-dimer
Technique: CT scan of the chest and bilateral lower extremity venogram with intravenous contrast
No CT features of pulmonary embolism in the central pulmonary arteries. However, evaluation of the peripheral subsegmental vessels is limited by a suboptimal bolus of contrast and small peripheral emboli cannot be entirely excluded. The pulmonary arteries are prominent, suggesting an element of possible pulmonary arterial hypertension. Calcified granulomas are noted in the lungs bilaterally. No pleural effusion or pneumothorax is seen. No pericardial effusion is seen. Mild cardiomegaly is noted. Calcified right hilar lymph nodes are noted. The aorta is unremarkable without aneurysm or dissection. Degenerative changes of the spine are noted. The left kidney is severely enlarged with severe hydronephrosis and significant cortical thinning. There are air fluid levels within the left kidney, suggestive of emphysematous pyelonephritis. There is an approximately 9 cm diameter abscess off the upper pole of the left kidney centered on approximately image 163 which at its lower aspect on image number 165 appears to necessitate through the renal capsule and extend through left lateral abdominal wall possibly involving the lateral extra peritoneal abdominal wall musculature. There is a second large abscess which appears to extend from a left medial inferior renal calyx to involve the psoas muscle. This also has associated gas within it consistent with a large abscess necessitating from the kidney to the psoas muscle. A few small bowel loops are prominent, likely representing ileus. Bilateral lower extremity veins are well opacified. No filling defect is noted to suggest deep vein thrombosis.
Impression
Chest CT impression: No Ct features of pulmonary embolism in the central pulmonary arteries. However, evaluation of the peripheral subsegmental vessels is limited by suboptimal bolus of contrast as well as breathing motion artifact and small peripheral emboli cannot be excluded. Correlate clinically. Consider further evaluation with nuclear medicine ventilation perfusion scan.
Abdominal CT report: severe emphysematous pyelonephritis with two large abscess is one which necessitates to the lateral abdominal wall likely extending into the extra peritoneal deep muscle layer. A second appears to necessitate from the lower medial renal calyx to involve the psoas muscle. Follow up recommended. No CT features of deep vein thrombosis.
This case shows laterally dislocated 2nd through 5th metatarsal bones relative to the tarsals and suggests a Lisfranc dislocation, named after Jacques Lisfranc, who, as a field surgeon in Napoleon’s army, described an innovative technique to amputate the forefoot of soldiers as a means to treat frostbite. Of the two basic types, our patient appears to have the Homolateral type, wherein all the metatarsals are dislocated to one side.
Clinical History: Pain, swelling, ankle and foot fractures
Technique: DX left foot (3 views)
Compared with prior study dated February 2, 2010 (21:03)
The presence of cast material obscures subtle bony detail, limiting the study. At least three well corticated osseous structures posterior to the talus are again seen, unchanged. Partly imaged fractures of the medial and lateral malleolus show no significant interval change and are described in detail in the accompanying ankle films. The mineralization of the visualized bony structures is well maintained. Soft tissue swelling around the ankle joint is again seen and appears unchanged. Compared to the pre-reduction film, a lateral displacement of the second through fifth metatarsals and possibly also of the first metatarsal in relation to the tarsal bones, is now more apparent.
Impression
INTERVAL PLACEMENT OF CAST. LATERAL DISPLACEMENT OF THE SECOND THROUGH FIFTH METATARSALS IN RELATION TO THE TARSAL BONES, AND PROBABLY OF THE FIRST METATARSAL IS NOW MORE APPARENT, SUGGESTIVE OF A LISFRANC DISLOCATION. FURTHER EVALUATION WITH MRI MAY BE OF BENEFIT. OTHERWISE STABLE STUDY OF THE LEFT FOOT.
Holiday coverage is one of our specialties, and let’s be honest: Super Bowl Sunday is a holiday. Do your rads want to take off this Sunday to catch the big game? Let us know and we’ll get you set up!
Today’s case is a rare condition where there is transposition of a loop of large intestine (usually transverse colon/hepatic flexure of the colon) in between the right diaphragm and the liver, as seen in on plain abdominal X-ray or chest X-ray. It is said that this seen in only about 0.1-1.0% of chest x-rays.
Observation
Clinical History: Pre-op
Technique: DX chest 2 views
The cardiomediastinal silhouette appears to be within normal limits. The lungs are hyperexpanded with flatteing of the hemidiaphragms. No acute focal infiltrate or consolidation is seen. There is presence of an air-filled bowel loop, between the liver and right hemidiaphragm, which is usually of no clinical significance.
Impression
CLEAR CHEST. CONSIDER COPD. OTHER FINDINGS AS NOTED ABOVE.
With the new year, many hospitals and radiology groups are reviewing their JCAHO requirements checklist. One of the more burdensome requirements is peer review. When your operation is already running at full capacity, and you already feel maxed out just doing normal case load, the notion of peer reviewing 5-10 cases per radiologist per month can be quite daunting.
If your group would like a quick external peer review, let us know!
Some observant readers have noticed that capitalization varies between the reports featured in “Case of the Day” and posted in the “Sample Reports” on our website. Are we inconsistent? Do different radiologists write reports using different styles?
The answer is: no, we are actually very consistent! We consistently produce reports how our customers want them. If a customer requests reports to be written in ALL CAPS, we will do it. If a customer requests reports to be written in normal capitalization, we will do it. Our process ensures that you get reports formatted exactly to your preference.
Furthermore, we are sensitive to the fact that certain ER docs and certain radiologists really hate certain phrases. Do you cringe every time you see “limited study” or “fecal materials”? Don’t worry, we can ensure that those words never appear on your reports. Instead, we’ll use medically equivalent terms that will best satisfy your preferences.
