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This is a 50-year-old gentleman

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who presented to the ED with shortness of breath, and AP and lateral views

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of the chest radiographs were requested and were obtained.

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And so, looking at the x-ray, we noticed that there are, you know,

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relatively low lung volumes and there's a little bit of maybe some atelectatic

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changes here at the right base with blunting of the costophrenic angle.

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The lungs themselves look otherwise okay.

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No large effusion on the left.

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We don't see a large effusion. Don't see a pneumothorax.

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When we look at the mediastinum, the width is a little prominent,

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but I think some of this is just secondary to low lung volumes.

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You can still make out the aortic contour, the cardiac contour.

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We take a look at the bones, just make sure that we are looking at everything.

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And the soft tissues,

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you can kind of see that there is some gas here in, most likely, colon.

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And you see some overlying monitoring wires.

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So taking a look at the lateral view,

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again, you don't see both the costophrenic angles, particularly the one on right.

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Really clearly, there is this band of opacity here.

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And I think, initially, we were kind of attributing that to atelectasis,

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associated with what is likely a pleural effusion.

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But I think at the last minute we said,

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'Hey, well, what's going on with this patient?'

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This is a patient with shortness of breath.

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Other things that could have this appearance

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that can fool you also include things like aspiration or probable consolidation

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and pneumonia, that you also want to at least consider.

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Some of your differential might expand,

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depending on what information is given to you from the clinical team.

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But we also saw down the pipeline that they were giving this patient a CT.

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So while we were able to differ it out, we said,

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'Hey, we're going to look at the CT really shortly and all this will make sense.'

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But I think it is helpful to know what

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other things the radiograph may be included and where you may want

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to actually include some degree of expanded differential.

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So, as I mentioned, the patient was also getting a CT.

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So here is the scout view.

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And again, great opportunity to look at the lay of the land.

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Again, see low lung volumes.

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The right effusion is not as pronounced on the scout as we saw before.

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But what we do see now is some blunting on the left.

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And so certainly, given the time

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difference, it's not unusual to see minor changes like that.

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But we'll take a look at the axial images and try to pull this all together.

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So, taking a look from the top. Again, kind of going through,

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you can see that there is some scattered lymph nodes here in the AP window.

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I'm just taking a look here at the aorta.

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Kind of running that through because I

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like to do that first, get that out of the way.

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So we don't have a lot of contrast in the aorta, but we can tell that it's

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normal caliber. In terms of what we can see,

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I don't see anything that looks, or is suspicious for dissection.

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Don't see any intimal flaps.

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I don't see any intramural hematoma.

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Looking down at the root, again, you can see the coronary arteries.

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The left ventricle caliber related to the right ventricle looks normal.

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So again, I kind of take the opportunity

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as I'm scrolling back to take a look at the left-sided pulmonary arterial tree.

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I'm looking for any major filling defects

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and I'm not seeing anything on the left side.

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Coming back down now on the right and scrolling through,

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looks like there's a little bit of a filling defect right here.

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Just to kind of note.

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Although when I look at that, that's really on the pulmonary vein side.

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So we're going to kind of leave that alone for right now.

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That may just be mixing artifact.

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But here in the right lower lobe, in the pulmonary artery here,

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we do have a filling defect that straddles a branch point.

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And so there is a small pulmonary embolism there in addition to the right pleural

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effusion that we initially saw on the radiograph.

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So we're going to have put this all together.

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And again, when we see pulmonary emboli,

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we want to ask ourselves, is there any evidence of heart strain?

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Do we want to take a look at the lungs

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and see if there's any evidence of pulmonary infarct?

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So as we switch over to, or as we look in the soft tissue windows,

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we do see that there's airspace opacification in the right lower lobe.

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It does look peripheral.

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It does look wet shaped.

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We'll take a look at this in the lung windows, but we can kind of satisfy

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ourselves here that we do see a small effusion. And perhaps that band that we

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were saying, could have been atelectasis or could have been aspiration.

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The one thing that we didn't really consider, because we weren't thinking about

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pulmonary embolism, is also pulmonary infarct.

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So that's one more thing to add to the list

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as you're thinking about things that could be also going on.

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We'll take a look at the lung windows,

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looking at the midline trachea and the branching bronchi, and those look normal.

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Again, when you get down to the lung base,

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there is some atelectasis here, but more importantly and more

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interestingly is the wedge-shaped peripheral pacification here,

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right in the area that was fed by the area where there was a pulmonary embolism.

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And so, I would really put this airspace

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consolidation would include, at the top of my differential, pulmonary infarct.

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But certainly other things like aspiration

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and pneumonia would also be included in the proper clinical context.

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Taking a look at other areas,

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this may be a little bit of atelectasis, although it's not quite dependent enough,

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but just kind of comes in and out really easily.

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Don't see any nodules, don't see any pneumothorax.

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We'll take a look at the soft tissues and the bones and make sure that there's

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not anything that looks aggressive or worrisome.

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You do see there's some degenerative

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changes of the thoracic spine, which in a patient of this age is not unusual.

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Then let's take a look at the soft tissues.

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All right, so this is a case that we

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started with a concern around a small pleural effusion.

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The patient did have shortness of breath.

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We did see on the lateral view and kind

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of wonder whether or not we're looking at some degree of atelectasis or

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whether or not it could have been pneumonia.

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Although on the CT, we did identify a pulmonary embolism

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in the right lower lobe and in that same area, wet-shaped airspace consolidation,

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which is certainly compatible with a pulmonary infarct.

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Because we did see pulmonary emboli,

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we did want to make sure that we didn't see any evidence of heart strain.

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So the PA was normal in caliber.

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We looked at the caliber between the right ventricle and the left ventricle.

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We looked at the interventricular septum

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to make sure that it wasn't a flattening or any bowing.

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There wasn't any reflexive contrast into the intrahepatic IVC.

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And I think we're fairly certain that we didn't see some of those latter signs.

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We did see an evidence of pulmonary infarcts.

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So this is a patient who had multiple things.

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This is an examination that has multiple findings, which, again,

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you don't want to get caught in the satisfaction of search.

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So while we did see a small, right pleural effusion,

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we were able to better characterize the opacification because we found

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a pulmonary embolism, but we're also able to give some

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of the pertinent positives and pertinent negatives for that finding as well.

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So, again, teaching points here are, you know,

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the radiographs and the CT opportunities to kind of correlate what you're finding.

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Keep your differential sufficiently broad if you don't know what's going on and if

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you've got concern, CT can be very helpful for further characterization,

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and you may find additional findings that you weren't expecting

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if you look for them and you really go through your routine search every single

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time. If you look for it, you will find it.

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If you're not looking for it, it's very likely that you won't.

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So this is a case with multiple findings.

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Keep your search pattern established and do it every single time.