01-02-2012 to 29-02-2012

Case 1
R. F. M C S; 83 years; male,
Clinical Details: Old IWMI Breathlessness x 2 years; aggravated since few months X ray: Tracheal compression by goitre - ? R/c

Haemorrhage. Requisition for CECT Chest & Neck

Tracheal deviation to left.

Minimal widening of superior mediastinum.

Multiple areas of central bronchiectases in bilateral lower lobes.

Rest of the lung were normal.

Enlarged thyroid , heterogenous lesions with central areas of hypodensity, scattered macrocalcifications, retrosternal extension & Mass effect.

Mass effect:Compression & lateral displacement of trachea & esophagus to the left. Compression of pre vertebral space. Lateral displacement of the left carotid space. Compression with proximal dilatation of right internal jugular vein. Fat planes with adjacent structures: mantained.

 FINAL DIAGNOSIS
Multinodular goitre with retrosternal extension of the

right side. Multiple areas of central bronchiectases in bilateral lower lobes. FOLLOW UP Patient not willing for surgery in view of comorbidities. Suggested 3 monthly review by treating physician.

Case 2
Mrs. A V, 61 years, Female
Clinical details: k/c/o Ca Left Breast Infiltrating duct carcinoma, Bloom Richardson grade II. Post mastectomy, post chemotherapy & radiotherapy x 5 years back. Presenting complaint:

Right shoulder pain x 1 month.

Mass over anterior aspect of chest.

Widening of superior mediastinum. Discontinuity of the head of humerus on the right side.

Multiple well defined rounded soft tissue density lesion in lingular segment & basal segment of right lower lobe.

Pleural thickening in left apical region.

Lytic destructive & expansile lesion of sterum in its entire extent. Adjacent soft tissue extension into the anterior mediastinum & into the intramuscular & subcutaneous plain of anterior chest wall in the midline & right parasagittal location. Soft tissue show lobulated apprarance & heterogenous post contrast enhancement, probably representing central necrosis.

Pretracheal & Preaortic lymphnodes with necrosis

# humerus

Left post mastectomy

splenunculi

Adrenal Liver : Normal

 FINAL DIAGNOSIS
Local recurrence of disease with lung , bone & nodal

metastases. Pathological fracture of right humeral head. LOST FOLLOW UP Patient has not reported back to treating doctor at Caritas Hospital, KTM, till date.

Case 3
Mr. P, 30 yr, male.
H/o RTA. FAST: Free fluid with internal echoes

- ? Hemoperitoneum. Left sided pleural effusion. Requisition: CT Brain & CT abdomen.

SDH & SAH & Pneumocephalus

Extensive facial # with hemosinus

Parasymphyseal # of mandible.

Grade 3 laceration of liver. Peri hepatic, subhepatic, perisplenic & pelvic fluid. Compressed IVC - 2 to shock. No PE.

 FINAL DIAGNOSIS
Extraaxial haemorrhage, pneumocephalus with extensive

facial # & hemosinus. Parasymphyseal # of mandible. Grade 3 laceration of liver. Moderate hemoperitoneum. FOLLOW UP Burr hole drainage of SDH. Maxillo mandibular fixation with interdental wiring & ORIF of maxilla. Conservative management for liver trauma. Patient doing well, tide over critical stage, discharged.

Case 4
Mrs.PD, 51yrs old, Female. Clinical details: B/L pedal edema 3 episodes of syncopal attack. JVP CCF. ECHO RV Dysfunction, PAH. CDS Leg B/L Posterior tibial vein thrombosis. X ray: PE Right.

? Pulmonary embolism.

Requistion CECT Pulmonary Angio

Wedge shaped opacity in right lower zone.

Pulmonary arteries up to segmental branches show intraluminal non enhancing areas. Crescent like appearance. Doughnut sign + wedge shaped opacity showing contrast enhancement.

Wedges shape soft tissue opacities B/L basal lobes

Passive collapse medial basal segt.

Bands Aorta : PA >1:1

 FINAL DIAGNOSIS

Chronic Thrombo Embolism; however, Few segmental pulmonary arteries show central non enhancing

areas with peripheral contrast pooling right lower lobe, possibility of an acute thrombotic episode cannot be completely excluded. FOLLOW UP Was put on iv heparin. Deferred admission to CCU, thus thrombolysis with streptokinase could not be done. D-dimer not sent, due to poor economic status of patient. Condition improved, discharged & returned to hometown.

Case 5
Mrs.S, 70 yrs old, female.
Clinical details: k/c/o Carcinoma breast 1987. Chest wall recurrence 2005. U/L Pleural effusion , pleural tap : twice ve, empirically started on AKT. Now; On AKT, r/c PE.

Right side pleural effusion. Collapse of middle lobe & Passive collapse of lower lobe. Mediastinal shift to left

Subsegmental collapse of lingula.

Pericardial thickenin g with calcification

Pleural calcification

Lytic area in body of sternum.

Cholelithiasis Bilateral extrarenal pelvis

 FINAL DIAGNOSIS
Moderate PE Right right middle lobe collapse, passive

collapse of right lower lobe, mediastinal shift to left & sub segmental collapse of lingula. B/L pleural calcification & lytic lesion with sclerotic margin of sternum post RT & Post op change. FOLLOW UP Pleural tap: ve for malignant cells. During hospital stay, developed hypotension. TB PCR : -ve. Referred to amrita for pleural biopsy: lost follow up.

Case 6
Mrs.K A, 70 year, female.
Clinical details: Anaemia & weight loss o/e: NAD USG: Multiple hypodense lesions of liver s/o liver

metastases. Requisition for CECT Abdomen: r/o disseminated malignancy.

Enlarged heterogenous liver , multiple peripherally enhancing lesions.

Peripherally enhancing lesion in head & tail of pancreas.

Moderate ascites

Loss of fat plane with spleen & stomach

Thickened enhancing GB wall

? Pulmonary nodule

Lytic lesion in L3 vertebra

 FINAL DIAGNOSIS
Hepatic metastases with probable metastases in bone

& lung. Lesion in Pancreas of gall bladder may represent primary lesion. FOLLOW UP CT guided biopsy from liver: Moderately differentiated metastases from adenocarcinoma. Took 2 cycles of chemotherapy. Expired on 06.03.12.

Case 7
Mr. G T K, 62 year, male
Clinical details: k/c/o restrictive lung disease, COPD, Polycythaemia,

Sarcoidosis. h/o significant weight loss & loss of appetite P/A: hard liver USG: 17 cms liver, multiple focal lesions -? Metastases / ?multifocal multicentric hepatoma

hepatomegal y

Multiple well defined hypodense nodules

Peritoneal nodules

Adrenal lesion

Apical & paraseptal emphysematous changes. Multiple confluent & discrete soft tissue density nodules left lower lobe. Aslo, bilateral pleural thickening. Confluent nodules showed enhancement.

 FINAL DIAGNOSIS
Peripheral bronchogenic carcinoma with rest of the

lesions as distant metastases. All lesions may be considered as metastases with an unknown primary. FOLLOW UP CT guided biopsy from lung lesion: SMALL CELL CARCINOMA. Patient chose to take palliative care at local hospital.

Case 8
Mr. C M M, 75 years, male.
Clinical details: k/c/o COPD, chronic smoker.

o/e B/L Rhonci, + Crepitation.

X ray: Right lobulated mass in upper zone,

? Soft tissue lesion in the left lower zone. Provisional :? Malignancy/ ?consolidation.

Air space opacity in the apico posterior segment of left patchy upper lobe - ? Consolidative change.

Multilobulated heterogenous moderately enhancing soft tissue lesion , anterior segment, upper lobe. Destruction of sternal surface of 5th & 6th ribs & lateral surface body & manubrium of sternum. Architectur al distortion of both lungs

 FINAL DIAGNOSIS
Peripheral bronchogenic carcinoma with local spread

and bone metastasis. FOLLOW UP CT guided biopsy report: Squamous cell Carcinoma.

Case 9
Dr.T D H, 42 year, Male.
Clinical Details: h/o on and off fever & excessive lethargy. 1 episode of hemoptysis. Chest x ray: Cavitatory lesion in right mid zone.

Well defined immobile air filled cavity with enhancing wall (4mm), RLL apical segt.

Few discrete bronchiectases.

Non enhancing fluid within, ?clot/secretn.

 FINAL DIAGNOSIS
Right lower lobe apical segment cavity with - ? Clot/? Secretions: Features suggestive of infective

process tuberculosis with cavity. - In view of negative TB- PCR, other possibility of cavitating pneumonia may also be considered. - Bronchiectases & centrilobular emphysema. - FOLLOW UP - Patient started on AKT, condition remains status quo.