CASE NUMBER ONE
1) –Anterio-posterior [AP] chest radiograph shows multiple cystic lesions in
the middle and lower zones of the left hemi-thorax with ill-defined left hemidiaphragm. There is mediastinal shift toward the right. These lesions are
bowel loops inside the left hemi-thorax. The film is over exposed (overpenetration).
2) - The diagnosis is Left Sided Congenital Diaphragmatic Hernia (CDH). This
is called bockdalic CDH. CDH is usually in the left side (90 %). The defect is
found in the posterio-lateral aspect of the diaphragm. CDH is associated with
lungs hypoplasia in the same side and to a lesser extent in the opposite side.
This may be complicated by pulmonary hypertension and severe hypoxemia.
3 ) - The treatment of CDH is immediate endo-tracheal incubation if it is
diagnosed in-utero or if it is highly suspected after birth (with following
symptoms and; respiratory distress (RD), cyanosis, asymmetrical chest
movement, bowel sounds heard in the chest and scaphoid abdomen ). After
intubation, the patients is put on mechanical ventilator and the pulmonary
hypertension [PH] is controlled and hypoxemia is reversed. PH and severe
hypoxemia may require inhaled Nitric Oxide [iNO], High frequency Oscillatory
Ventilation [HFOV] and Exogenous Surfactant administration through
endotracheal tube [ETT]. After the stabilization of the arterial blood gases
[ABGs], the patient is taken to suture the defect. If the defect is large, a mesh
device may be used. The most important differential diagnosis is Cystic
Adenomatoid Malformation [CAM].
CASE NUMBER TOW
1) - AP chest film showing that the naso-gastric tube (NGT) is inside the left
hemi-thorax. There is an ill-defined line separating the upper and middle
zones of left lung.
2) - The diagnosis was ruptured left hemi-diaphragm possibly secondary to
the trauma to the abdomen.
3) - During surgery, there was a ruptured diaphragm and intestines, spleen
and stomach were found in the left chest. There was evidence of left sided
CDH which facilitated the rupture.
CASE NUMBR THREE
1) - There is a homogeneous opacification of both lungs with white -out lungs
field (grounds glass appearance) and air bronchogram bilaterally.
2) - The diagnosis is Acute Respiratory Distress Syndrome (ARDS).
3) - The most common causes of ARDS are;
A- Bacterial or viral pneumonia.
B- Sepsis.
C- Major trauma.
D- Major surgery.
E- Massive aspiration pneumonitis.
F- Severe poisoning and intoxication.
G- Severe envenomation (snake bite and scorpion sting).
H- Severe and prolonged hypoxia.
I- Massive blood transfusions.
CASE NUMBER FOUR
1) - The abdominal X-ray shows a hyper-lucent shadow separating the liver
from the abdominal wall. This represents free air in the abdomen
(pneumoperitoneum) which results from intestinal perforation.
2) - The cause of perforation is early and rapid feeding after cardiac arrest.
Intestinal ischemia after cardiac arrest needs time to resolve.
3) - This complication can be prevented by delaying the feed till 7 days elapse
from the arrest and upgrading the feed gradually.
CASE NUMBER FIVE
1) - This X-ray is a lateral view of the legs showing severe osteopenia and
spiral fracture in the middle of the tibia. There are signs of rickets in
the metaphyses such as cupping in both knee and ankle joint.
2 ) - The cause is Osteopenia Of Prematuriy [OOP] found in premature
babies. It is similar to rickets. The causes are; calcium, phosphorus and
Vitamin D deficiencies. The fracture can occur with mild twisting of the legs
during attempt to insert an intra-venous access. The treatment is
supplementation with Calcium, Phosphorus and Vitamin D.
CASE NUMBER SEX
1) - There is symmetrical, bilateral, hyper-dense (whitish), rounded lesions,
approximately 1.5 × 1.5 cm in diameter located in the basal ganglion regions.
2 ) - The diagnosis is intra-cranial calcification.
4) - The corrected calcium level is = Measured serum Ca level + (40 measured serum albumin level) x 0.owe.
40 is the usual normal albumin level. So the corrected Ca level is 1.45 + (40 19) × 0.022 = 1.45 + (21 x 0.022) = 1.45 + 0.46 = 1.91 mmol/L.
3 ) - The cause is high dose of Vitamin D (One Alpha Calcidol ) which was
used to control hypocalcemia. The hypocalcemia is secondary hypo parathyroidism which is a part of Middle East Syndrome
(Sanjad SaqqatiSyndrome).
C ASE NUMBER SIX
1) - AP chest film which shows complete opacification of the whole right lung
with shifted mediastinum and trachea to the left side.
2) - This indicates pleural effusion (PE).
3) - After inserting chest tube, pus was coming out. This means that the PE is
an Empyema.
4) - The cause of this empyema is most likely a Bacterial Pneumonia.
5) - The age of the patient is 10 years which means that the most likely
organism is Streptococcus Pneumonae.
CASE NUMER SEVEN
1) - AP plain X-ray of both hands and wrests.
2) - There are severe osteopenia, rarefaction of bone and wide wrests joints.
3) - Signs of rickets (cupping, fraying and flaring) are evident at the ends of
the radius and ulna.
CASE NUMBER EIGHT
1) - AP chest film which shows opacification of the middle and lower zones of
the left lung. The upper border of the opacity is concave.
2) - This indicates pleural effusion (PE).
3) - After inserting chest tube, pus was coming out. This means that the PE is
an Empyema.
4) - The cause of this empyema is most likely a Bacterial Pneumonia.
5) - The age of the patient is an 8 years which means that the most likely
organism is Streptococcus Pneumonae.
CASE NUMBER NINE
1) - AP chest film showing moderately increased heart size. Heart diameter to
trans-thoracic diameter ratio is 78 %. This is a cardiomegally.
2) - The cause is Congestive Heart Failure [CHF] secondary to viral
myocarditis.
CASE NUMBER TEN
1) - AP chest film of the chest which shows a left sided pneumothorax and
chest tube in place.
2) - There is a thin wall spherical cyst measuring 3 X 4 cm in the upper zoon
of the right lung. This is called Pneumatocele.
3) - Pneumatocel can ruptured and leads to Pneumothorax.
4) - Both Pneumatocele and Pneumothorax are complication of Bacterial
Pneumonia caused by Stalhylococcus Aureus, Streptococcus Pneumonae
and Gram Negative Rods such as KleibsellaPneumonae.
CASE NUMBER ELEVEN
1) - AP chest film showing the following; 1)- Laterally located Bilateralb
Opacities in both lungs indicating resolving ARDS, 2)- Bilateral hyper-lucent
shadows in the Superior Mediastinum which resemble Butter Fly Wings
indicating Bilateral Pneumomediastinum, 3)- Rim of air encirciling the heart
and indicates Pneumopericardium.
2) - Both of them May be complication of ARDS or secondary the high
pressure used during Mechanical Ventilation.
CASE NUMBER TWELF
There is hyper-lucent area involving the majority of the right hemi-thorax
which is devoid of lung tissues. This is separated from the heart with a very
well demarcated opacity. The hyper-lucent area is a pneumothorax and the
well demarcated opacity is the severly compressed right lung from the
pneumothorax.
- The diagnosis is a Right Sided Tension Pneumothorax.
- This is a killer if not drained immediately.
- The physical examination of the chest will not show the typical signs seen in
adult, however, limitation of movement and plugging of the right hemithorax,
displaced heart sounds more laterally and absent air entry over the right side
can be found.
- The Bed Side Test which can be used for the diagnosis is the
Transilluminationof both hemi-thorax using a strong beam of light. The area of
the transillumination over the side of the pneumothorax is far larger and wider
than the normal side.
- The treatment must be immediate withought waiting for chest X-ray
confirmation. The collected air is evacuted by a butterfly needle connected to
a 3 stop-cock connector which is attached to a 20 or 50 ml syringe. The
needle is inserted perpindicularly in the 2d inter-costal space (ICS) at the midclavicular line untill a gush of air is seen. The air is then aspirated by the
syring then pushed to the outside. More than 2 aspirations may be needed.
You may aspirate 200 ml in severe cases.
- The needle evacuation is followed by chest tube insertion.
- It is known for bronchiolitis to be complicated by pneumothorax because of
air-trapping and hyper-inflation of the lung secondary to inadequate deflation
from bronchioles narrowing by inflammation, edema and bronchospasm.
CASE NUMBER THIRTEEN
1) - The CBC and differential counts show severe leucocytosis and
neutrophelia. The platelets count is high. Both the ESR and the CRP are
markedly high. All of the above including high platelets are called Acute
Phase Reactant and found during severe infection such as Pyelonephritis.
2) - The radiological test shown is called Micturating Cysto-urethrogram
(MCUG) or voiding cysto-urethrogram (VCUG).
- There is reflux of the dye up to the collecting system with cupping of calysis
and tortiusity of the ureter in the right side (Vesico-uretric Reflux [VUR] grade
V)). The left ureter is less severely affected.
- The patient is slightly hypertensive which means there is residual damage
from recurrent UTI.
For that reason, she needs further investigation such as Renal U/S looking for
hydronephrosis and assessing the echogenisity of the kidneys, DTPA for
functional assessment of renal function and DMSA to look for renal scar from
previous UTIs.