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.
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.
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.
