CD QUIZ 1: Twelve More Great Cases

Next

Unknowns

Introduction: Here are 12 unknown cases. They are presented in the same manner as
quizzes in the text, with questions to guide you. When plain films and CT scans are
presented, make the plain film observations before turning to the CT scans. Use a piece of
paper to write your answers before clicking on
The next quiz, Quiz 2, will give you only a brief history.
In some cases, additional images will be shown when you click on:

Exit

Previous

Next

This is an AP portable x-ray from the ICU.

A.

1) The lung density is [symmetrical/asymmetrical].

2) The [left lung is too radiodense/right lung is too radiolucent].
This asymmetry could be due to:

Image A

lung consolidation

diffuse atelectasis

layered pleural effusion

all of the above

3) The nasogastric tube tip is in the

is in the
right main bronchus .

stomach

4) The best explanation for the dense left lung is

to right main bronchus intubation
.

Click

. The endotracheal tube

left lung atelectasis due

for an additional image (B).

Exit

Previous

Next

This is a 56-year-old woman with hemoptysis.

A.

B.

Figure A

C.

Figure B

Figure C

1) Figure A is a Scout view from a CT scan. You know or can tell that the patient is [supine/erect/decubitus].
2) The principal finding is a
this mass? central cavity

mass

in the [right upper lobe/right middle lobe/right lower lobe]. Is there anything unusual about

3) Figure B is a chest CT at [lung/bone] windows. The CT confirms the mass and also an air
fluid level within the cavity.
The air fluid level was not seen on the Scout view. Why not? The beam is not parallel to the fluid level on the Scout view .
4) On the CT, the interface with the lung is [well defined/ill defined]. This suggests we are dealing with a [cavitary pneumonia/an
intrapleural collection/cavitation within a tumor].
5) Figure C was taken 10 minutes later, at mediastinal windows. What do you think is happening to the patient at this moment?
percutaneous needle biopsy (histology = lung cancer) .

Exit

Previous

Next

This is a routine chest x-ray (A, B) on a middle-aged man. There are two abnormalities, one at each end of the density scale.

A.

B.

Image A

Image B

1) The high density abnormalities on the right are [in the axilla exclusively/in the lung exclusively/probably in both].
These metallic densities are due to
Buckshot
.
2) Dont let satisfaction of search stop you there. There is another significant abnormality, of low density, on this radiograph. It is
a
hiatal hernia behind the heart
.

Click here

for additional images (C & D).

Exit

Previous

Next

This is a 70-year-old woman with shortness of breath.

A.

B.

Image A

Image B

1) Image A is [axial/sagittal/coronal].
2) Image B is

sagittal

. They are displayed at [lung/mediastinal/bone] windows.

3) Density marked with the * is

diaphragm (liver)

4) The pattern is one of [interstitial thickening/alveolar consolidation/bronchiectasis].

5) The interstitium is [sharp/indistinct] and is also [distorted/not distorted].
6) This process appears to be [

acute

chronic

].

Exit

Previous

Next

This is an older man with chronic nonproductive cough. He comes to the emergency room because of increasing shortness
of breath over the past six hours. This is an AP Supine image.

A.

Image A

1) The 5th right posterior rib is marked. The diaphragm is at approximately the level of the posterior [9th/10th/11th/12th] rib. The
diaphragm is normally at the level of the [8-9th/9-10th/10-11th/11-12th] posterior rib.
2) The markings in the left upper lobe are [increased/normal/decreased]. Answers 1&2 should lead you to the diagnosis of
emphysema, COPD
.
3) What explains the acute shortness of breath? right pneumothorax
How did you make that diagnosis? see pleural line, air in the pleural space (crowded markings)

Click here

for an additional image (B).

Exit

Previous

Next

This is a 26-year-old man with pressure in his chest.

A.

B.

Image A

Image B

1) Image A shows that the right paratracheal stripe is (visible/not visible). The aortic knob is [large/small/not visible]. The right
lung [contacts/does not contact] the right tracheal wall.
2) The left hemidiaphragm is elevated .
3) On Image B, there is blunting of the
probably on the left.

left

costophrenic angle, indicating a

pleural effusion . The fissures are also thick,

4) The large mass seen on the PA film is also seen on the lateral film (Image B) in the
Click here

retrosternal space

for additional images (C & D).

(Continued)
Exit

Previous

Next

This is a 26-year-old man with pressure in his chest. (Continued)

A.

B.

Image A

Image B

5) This mass must be in the (choose one or more):

a. anterior mediastinum Why?
in retrosternal space
b. middle mediastinum Why?
adjacent to trachea and aorta affects phrenic nerve (elevated diaphragm)
c. posterior mediastinum Why?
not posterior mediastinum
6) The most likely cause of a mass in the anterior and middle mediastinum in a 26 year old man is [thymoma/thyroid
enlargement/thoracic aortic aneurysm/terrible lymphoma].

Click here

for additional images (C & D).

Exit

Previous

Next

This is an 18-year-old with chronic cough.

A.

B.

Image A

C.

Image B

Image C

1) On Images A and B, the lung volumes are large . What criteria did you use?
The diaphragms are low. The retrosternal space is increased. The AP diameter is increased .
2) In most patients with emphysema, the markings in the upper lobes are [normal/increased/decreased]. In this patient, the
markings are [normal/increased/decreased].
3) On Image C, the tubular structures in the upper lobe represent

bronchiectasi

4) This axial CT (Image D) shows that many of the bronchi are [normal/dilated/narrowed]. The walls of the bronchi are
[normal/thicker/thinner] than usual.
5) The best diagnosis for this young lady, who has been sick since childhood, is
Click here

cystic fibrosis .

for an additional image D.

Exit

Previous

Next

This is a middle-aged woman with a cough and fever for three days.

A.

B.

Image A

Image B

1) On Images A & B, there is a 3-cm area of consolidation in the

left lower

lobe.

2) There is an additional finding on the lateral radiograph. There is blunting of one costophrenic angle. The fluid is against the
[small ribs (A)/big ribs (B)]. The small ribs are on the [
left/right
]. Therefore, this is a [left/right] effusion.
3) The history and X-ray findings support a diagnosis of

Click here

pneumonia

for additional images (C & D).

Exit

Previous

Next

This is a middle-aged man with shortness of breath. Here is a series of CT images that you will be asked to scroll through.

Scroll through the images given below, then attempt the questions.

Image 1

Image 2

Image 3

Image 4

Image 5

Image 6

Image 7

Image 8

(Continued)
Exit

Previous

Next

This is a middle-aged man with shortness of breath. Here is a series of CT images that you will be asked to scroll through.
(Continued)

Scroll through the images given below, then attempt the questions.

Image 9

Image 10

Image 13

Image 14

Image 11

Image 15

Image 12

Image 16

(Continued)
Exit

Previous

Next

This is a middle-aged man with shortness of breath. Here is a series of CT images that you will be asked to scroll through.
(Continued)

Scroll through the images given below, then attempt the questions.

Image 17

Image 21

Image 18

Image 22

Image 19

Image 23

Image 20

Image 24

(Continued)
Exit

Previous

Next

This is a middle-aged man with shortness of breath. Here is a series of CT images that you will be asked to scroll through.
(Continued)

Scroll through the images given below, then attempt the questions.

Image 25

Image 29

Image 26

Image 30

Image 27

Image 31

Image 28

Image 32

(Continued)
Exit

Previous

Next

This is a middle-aged man with shortness of breath. Here is a series of CT images that you will be asked to scroll through.
(Continued)

Scroll through the images given below, then attempt the questions.

Image 33

Image 37

Image 34

Image 38

Image 35

Image 39

Image 36

Image 40

(Continued)
Exit

Previous

Next

This is a middle-aged man with shortness of breath. Here is a series of CT images that you will be asked to scroll through.
(Continued)

Scroll through the images given below, then attempt the questions.

Image 41

Image 45

Image 42

Image 46

Image 43

Image 47

Image 44

Image 48

(Continued)
Exit

Previous

Next

This is a middle-aged man with shortness of breath. Here is a series of CT images that you will be asked to scroll through.
(Continued)

Scroll through the images given below, then attempt the questions.

Image 49

Image 53

Image 50

Image 54

Image 51

Image 55

Image 52

Image 56

(Continued)
Exit

Previous

Next

This is a middle-aged man with shortness of breath. Here is a series of CT images that you will be asked to scroll through.
(Continued)

Scroll through the images given below, then attempt the questions.

Image 57

Image 61

Image 58

Image 62

Image 59

Image 63

Image 60

Image 64

(Continued)
Exit

Previous

Next

This is a middle-aged man with shortness of breath. Here is a series of CT images that you will be asked to scroll through.
(Continued)

1) This is displayed in [bone/mediastinal/lung] windows.

2) This was done [with/without] intravenous contrast.
3) Mediastinal windows are used to evaluate for (Select one or more):
a. bone metastasis
b. for bronchiectasis
c. lymphadenopathy

d. vascular lesions
e. cardiac abnormalities
f . cavitation

4) Scroll through the images and determine why the patient was short of breath
large bilateral pulmonary emboli, most severe in the left main pulmonary artery
and in the artery to the right middle and right lower lobe (truncus inferior)

Click here

for additional images Y & Z, after you answer all the questions.

Exit

Previous

10

Next

This is a 58-year-old male with a cough and weight loss. Lets do something different! Lets start off with the CTs, make
the observations, and mentally reconstruct the chest x-ray.

A.

B.

Image A

C.

Image B

Image C

1) A and B are cross-sectional images at the level of the [aortic arch/carina/left ventricle]. The major abnormality is a [nodule/mass].
2) Medial to the lesion is another soft-tissue density, which probably
represents [a mediastinal mass/a big pulmonary artery/hilar nodes].
3) The lesion sits [anterior/posterior] to the major fissure. Therefore, it is in the

left upper

lobe.

(Continued)
Exit

Previous

10

Next

This is a 58-year-old male with a cough and weight loss. Lets do something different! Lets start off with the CTs, make
the observations, and mentally reconstruct the chest x-ray. (Continued)

A.

B.

Image A

4) Image C is a coned-down view of the right upper lobe. It shows

emphysema

C.

Image B

bulla

Image C

. Therefore, the patient has what chronic disease?

5) What is your most likely diagnosis? Not surprisingly, this is a left upper lobe cancer with hilar adenopathy in a smoker
Now visualize the chest PA and lateral in your mind or sketch it on your paper.

Click here

to see the real thing (D & E).

Exit

Previous

11

Next

This is a young man with mild shortness of breath for several months.

A.

B.

Image A

Image B

1) In Image A, the hilar structures are [large/normal/small]. The most frequent cause of bilateral large hila is [big pulmonary
arteries/adenopathy/idiopathic].
2) In Image B, the lungs show [cysts/nodules/fibrosis and distortion].
3) The best diagnosis would be [sarcoidosis/lymphoma/miliary TB].

Exit

Previous

12

This is an older man with right chest pain.

A.

B.

Image A

Image B

1) Images A and B show an obvious mass on the right. It appears to be in the [RUL/RML/RLL/cant tell].
2) How does Image C help define the origin?

There is an expansile lesion of rib

3) The best diagnosis is [multiple myeloma/lung cancer/pneumonia].

Click here

for an additional image C.

Exit