Thought the CXR was backwards!!

[NontradICUdoc]

But the patient really have DextroCardia!! Her heart was on the right side of the chest, confirmed by CT!!!

Will probably never see it again.

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[J-Rad]

I hope the next question someone asked after suspecting dextrocardia was: which side are the guts on.

For curiosity's sake (if you're inclined): age range, why coming to the doctor (or ER), and why CT when there is a non-irradiating study that could have given the answer?

 

[NontradICUdoc]

I hope the next question someone asked after suspecting dextrocardia was: which side are the guts on.

For curiosity's sake (if you're inclined): age range, why coming to the doctor (or ER), and why CT when there is a non-irradiating study that could have given the answer?

The patient went to the ER for chest pain that would not subside. She knew she had the condition but she stunned the x-ray techs and the rest of the people at the ED with the film.

The chest pain was caused by hyperventilation due to an anxiety attack. So the dextracardia was not an incidental finding. Although, it was pretty wild listening to the heart sounds on the right side of the chest and setting up the leads on the right to look at the LV.

 

[J-Rad]

Come on man, you're holding out Where were the guts? Obviously you know a lot more about the case than me, but that question, depending on the rest of the history could be critical...Pleeeeaze

 

[Jamers]

But the patient really have DextroCardia!! Her heart was on the right side of the chest, confirmed by CT!!!

Will probably never see it again.

haah I read this and I thought "he must be talking about the early episodes of Scrubs where the x-ray is backwards in the beginning of every episode" but its still cool none-the-less though.

 

[NontradICUdoc]

Come on man, you're holding out Where were the guts? Obviously you know a lot more about the case than me, but that question, depending on the rest of the history could be critical...Pleeeeaze

I am in my fm rotation and the patient said she has situs inversus so I am assuming she is totally backwards. I only saw the cxr but it would have been cool to see the rest of her.

 

[engineeredout]

 

[J-Rad]

Where was the stomach bubble? That will tell you on both the CXR (most catch a little bit of the bubble) and likely the CT.

 

[metalmd06]

Did the patient have Kartagener Syndrome?

 

[NontradICUdoc]

Did the patient have Kartagener Syndrome?

Nope

 

[NontradICUdoc]

Where was the stomach bubble? That will tell you on both the CXR (most catch a little bit of the bubble) and likely the CT.

stupid me. I did not look. I was amazed at what I was seeing that I forgot to look for the gastric bubble.

 

[J-Rad]

This is a very cool case given the CC. And to be given the Dx of hyperventilation as the underlying cause of the CC...requires a very detailed Hx. This is an extreme case of "diagnosis of exclusion".

Your homework assignment, if you choose to accept, is to figure out why this is so cool. (Hint: your google search should also include the words "situs solitus" and "inversus").

If the ED has a PACS system, can you snag an anonymized pic of the CXR? And how about an EKG?

 

[J-Rad]

PS

A few life (in medicine) hints:

1. Don't always trust what the radiologist reports. They may not comment or even see if you didn't know to ask.
2. Never assume that a patient knows exactly what they have or what the significance of it is.
3. Never assume that a patient that might need to be followed for their whole lives for a particular condition actually is following up as recommended.

I'll get to why these points might be relevant later...

 

[J-Rad]

Well since no one else is game...

There's a ton of dextrocardia CXRs on google image search; this is just one.

So what if her heart looked like the one on the right?

 

[WestcoastMedicine]

Do a Pediatric Cardiac ICU rotation, you will see it atleast once a week

 

[J-Rad]

Do a Pediatric Cardiac ICU rotation, you will see it atleast once a week

Indeed (and try echoing a dextrocardia, single something ventricle, Fontan...loads 'o fun). That's what interesting about the case as presented. Definitely not the expected milieu to just bump into it. So the DDx for her (presumably an adult) presenting complaint becomes interesting. If she has situs solitus there is a 90% chance she has congenital heart disease of some type. If she has situs inversus (without PCD [Kartagener's]) there is still a 10% chance of some type of CHD. Not all of these would be cyanotic or associated with pulmonary overcirculation (in this patient's case clearly not the former and likely not the latter) but some with some definite ties to the C/C if present in this patient.