Mystery Quiz

Mystery Quiz

November 9, 2017
Mystery Quiz

Vivian Hayashi MD, Robert Smith MD

The patient is a 72 year old man who presented with an incidentally noted right mid-lung density on a chest radiograph.  The patient was asymptomatic at the time and was begun on empiric treatment with moxifloxacin, then a course of amoxicillin-clavulanate for a presumed pneumonia (Image 1), without substantive improvement.  A chest CT scan was subsequently obtained (Image 2).  Further history was noteworthy for absence of hemoptysis, night sweats, fever, breathlessness, sputum production and weight loss. He did recall …

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Mystery Quiz-The Answer

November 28, 2016
Mystery Quiz-The Answer

Before you read the answer, please review the original Mystery Quiz posted 11/18/16.

Vivian Hayashi MD, Robert Smith MD

The answer to the mystery quiz is aspiration pneumonia.  The CXR (Image 1) shows a total opacification of the right hemithorax.  Importantly, the tracheal air column is deviated to the side of the opacification.  This indicates loss of volume of the right lung due to endobronchial obstruction from aspiration (e.g. gastric contents), endobronchial tumor or foreign body.  Although one might consider pleural effusion, chylothorax and empyema …

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Mystery Quiz

November 18, 2016
Mystery Quiz

Vivian Hayashi MD, Robert Smith MD

The patient is an 86 year old man who presented with weakness, lethargy and falls.  His history was noteworthy for an episode of empyema nine years earlier that was managed with tube thoracostomy followed by decortication.  Seven years prior to this admission, upper endoscopy revealed Barrett’s esophagus and adenocarcinoma of the distal esophagus.  An esophagectomy and gastric pull-up was performed.  The patient had intermittent episodes of aspiration over the subsequent years.  Prior to the current admission, the patient complained …

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Mystery Quiz

October 28, 2016
Mystery Quiz

Vivian Hayashi MD, Robert Smith MD

The patient is an 86 year old man who presented with weakness, lethargy and falls.  His history was noteworthy for an episode of empyema nine years earlier that was managed with tube thoracostomy followed by decortication.  Seven years prior to this admission, upper endoscopy revealed Barrett’s esophagus and adenocarcinoma of the distal esophagus.  An esophagectomy and gastric pull-up was performed.  The patient had intermittent episodes of aspiration over the subsequent years.  Prior to the current admission, the patient complained …

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Mystery Quiz-The Answer

June 19, 2015
Mystery Quiz-The Answer

Vivian Hayashi MD, Robert Smith MD

The answer to the mystery quiz is methicillin-resistant S. aureus (MRSA) pneumonia. The initial CXR (image 4) showed increased density in the area of the left hilum, hinting at a process in the superior segment of the left lower lobe. The next CXR (image 5) showed an airspace process in the left lower lobe that had rapidly evolved over 2 days. An interstitial process can be seen, as well, along with airspace disease (image 5, arrow). In addition, there …

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Mystery Quiz

June 18, 2015
Mystery Quiz

Vivian Hayashi MD, Robert Smith MD

The patient is a 46 year old female who presented to the emergency room with breathlessness, productive cough, subjective fever, and myalgia for one week. Her history was notable for mild persistent asthma treated with tiotropium, mometasone, formoterol, and albuterol as needed. The patient was homeless and lived in a shelter. She was poorly compliant with her medications. In the ER, the patient had a pulse rate of 102 bpm, was afebrile with normal blood pressure, and had diffuse …

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Mystery Quiz-The Answer

December 17, 2014
Mystery Quiz-The Answer

Vivian Hayashi MD, Robert Smith MD

The answer to the mystery quiz is pleural effusions, specifically, bilateral subpulmonic effusions. The chest radiograph shows a number of findings: (1) the apparent diaphragm shadow is in fact fluid sandwiched between the undersurface of the lung and the actual diaphragm (Image 2a, arrow); (2) the density of this shadow is homogenously white (Image 2a, asterisk) and differs from a normal diaphragm which has a graded density (Image 2b, triangle) due to superimposed air that progressively decreases towards the …

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Mystery Quiz

December 2, 2014
Mystery Quiz

Vivian Hayashi MD, Robert Smith MD

The patient is an 82 year old man with frequent breathlessness. The patient had been admitted several times in the past two years for congestive heart failure. Two years earlier, the patient suffered an NSTEMI. A diagnostic cardiac catheterization revealed triple vessel coronary disease. A decision to perform CABG vs coronary stenting was delayed pending an evaluation of iron-deficiency anemia associated with a positive test for fecal occult blood. A recent echocardiogram showed normal left ventricular function but diastolic …

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