Internal Medicine Weekly X-RAY Challenge
Send us your answers by clicking the link below the image. On Friday, we will post the first correct answers by all-comers, residents, and students. Other answers of particular interest will also be posted as well as brief comments on the radiographic findings and the clinical problem.
Week 14-Clinical Description
46 year old male admitted for dyspnea and hypoxemia. The patient has a long history of multiple sclerosis. He has a chronic tracheostomy for recurring respiratory muscle failure.
The radiographic finding is opacity of the left hemithorax. Note that the right heart border is not seen indicating shift of the mediastinum to the left or toward the lesion. This pretty much rules out either pleural effusion or consolidation as the cause. The important clinical point of this film is that one should not attempt a thoracentesis in a case like this.
This film strongly suggests endobronchial obstruction of the left mainstem bronchus. The presence of small amounts of air suggest the obstruction is at or near the bifurcation into left upper lobe and left lower lobe. Possible etiologies include tumor, foreign body and mucous plug. The clinical history is most consistent with mucous plug. Mucous plugs are common complications of neuromuscular compromise of ventilatory capacity.
A bronchoscope was passed through the tracheostomy. A mucous plug was visualized originating from the left lower lobe bronchus extending proximal to the bifurcation of the left mainstem bronchus. The plug was suctioned away. The lower film was taken shortly after the procedure and demonstrates re-expansion of the left lung.
Ahmed Salahudeen, MS4, was the first correct answer. Musab Nusrat was the first correct answer from our Internal Medicine house staff. Nureddin Almaddah extended his winning streak with another correct answer. Robert DeMurro, PA student Midland Class of 2013, was our first correct answer from TTUHSC outside of Lubbock.
This will be the last Challenge for the time being. There are technical difficulties that must be worked out before CXR Challenge can resume. If you wish to be notified when CXR Challenge resumes, subscribe to the mailing list. .
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