0:01

As a companion case to the benefit of CT

0:05

and looking at radiography,

0:08

this is a patient, 66-year-old female, presenting to the ED with complaints

0:14

of weight loss, chest pain, and shortness of breath.

0:19

And so as we go through in our systematic approach, through the left lung here,

0:23

we notice that there's a rounded focal opacity here.

0:27

And there's a little bit of loss of the left

0:29

hemidiaphragm, with maybe some blunting of the costophrenic angle.

0:32

So this could be atelectasis, maybe a small pleural effusion.

0:35

But really, our attention is drawn to this nodular opacity here.

0:40

And there's a question of prominence here along the left mediastinum

0:43

and the AP window is actually quite full of soft tissue.

0:48

The airway we can see pretty nicely, and it's midline.

0:52

The right lung looks predominantly clear.

0:55

There's a nodular opacity right here, but it's a similar nodular opacity right here.

1:00

And these are likely just nipple shadows.

1:02

If we do the edge enhancement, we'll see again that there's this nodular

1:06

opacity with some fullness of the left hilum.

1:11

You can see pretty nicely, again, that the nodular opacities at the lung

1:14

bases are really just corresponding to nipple shadows.

1:17

The hemidiaphragm here on the left is seen a little bit better.

1:20

So not as concerned that there might be a large effusion there,

1:24

but perhaps it was just some atelectasis that we're seeing.

1:27

So, again, given the history of cough and fever, and chest pain,

1:31

shortness of breath, initially we thought, hey, this could certainly be pneumonia,

1:36

but there are other things to be concerned about.

1:38

This is a 66-year-old woman,

1:40

you know, is oncology something that we should be concerned about.

1:43

So, we did recommend at least consideration

1:46

for CT, and they did provide or did obtain a CT.

1:50

And so we can take a look and see what CT shows.

1:53

And again, if we look at the scout view

1:56

on the CT, it's a little bit hard to see the opacity that's sitting right here.

2:00

But we see really nicely on the coronal

2:03

view that opacity that we saw on the radiograph.

2:06

And what we see more clearly now is that it's a pretty dense consolidation

2:10

with a rim of ground glass opacity that's surrounding it.

2:13

But as we scroll through, you know, we see some other atelectasis and then

2:19

perhaps some other areas that are also involved.

2:22

So let's take a look at the axial images

2:24

where I think we'll get a better lay of the land.

2:31

All right, so there's some pleural

2:33

and parenchymal scarring, which in a 66-year-old patient is not unusual.

2:38

But we do have this ground glass

2:40

and consolidative opacity here at the right apex.

2:47

We've got similar areas that are coming into view here on the left side.

2:52

And we see that dense consolidation, which is primarily what we're seeing

2:55

on the radiograph, but you're seeing it much more pronounced.

3:02

And we suspected some stuff at the left base, and it looks like that's more going

3:06

to be atelectatic changes, which you see bilaterally.

3:11

And there is likely a small left pleural effusion that's here.

3:15

So, sometimes you're right, sometimes you're almost right.

3:19

The CT is helpful for putting it all together.

3:22

Now, the one thing I'll do is we come back through and look at on the soft tissue

3:27

windows, is all of this soft tissue that's coming into view here in a subcarinal

3:32

and the perihilar area, that's seen on both sides of the midline.

3:38

And for me, given the history of weight loss and this cough, and the appearance

3:42

of this consolidation, I became much more concerned that this was a malignancy.

3:47

And again, if you're looking at all the nodes here in the AP window,

3:51

this is a little bit more than I would expect and a little bit more than we saw

3:54

in the last case, where we did see a few reactive lymph nodes.

3:57

These are huge lymph node conglomerates that are on both sides of the midline.

4:02

And as it turns out, after this patient was really continued

4:05

to be worked up, this was a patient with a bronchogenic cancer.

4:09

So, sometimes pneumonia can masquerade as many things, cancer can masquerade as many

4:15

things, and you want to keep in mind your patient population.

4:18

So this was an elderly patient.

4:20

There wasn't an initial history, given that she was a long-term smoker,

4:25

but certainly that isn't...

4:26

them giving you the history of smoking does not preclude the fact

4:29

that there is a history of smoking or that there could be malignancy.

4:33

So, again, when you're seeing big, bulky,

4:35

extensive lymph nodes like this, mass like consolidation, consider malignancy.

4:41

So this is a case on radiograph, we thought it was pneumonia.

4:47

The CT provided a lot more information in terms of the extent of the disease

4:52

and some of the factors that were associated with it, that really helped make

4:56

us or push us into a direction of a much more accurate diagnosis of malignancy.

5:02

So CT, again, can be a helpful tool in problem solving in the ED.

5:07

I think it's very much dependent

5:08

on understanding when to appropriately use it.

5:12

And a lot of that is a lot easier when you can actually understand what's going on

5:15

with the patients and confer with your referring clinicians.