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Chest X-ray Showed Mild Calcification Aorta And ECG Says Sinus Rhythm With Occasional PVC. Suggest

Posted on Wed, 11 Dec 2013

Question: For Dr. I have a question for my mom. We just went for a physical check for her. She is 74 years old and quite healthy and active otherwise. the doc said everything was normal but he heard some crackling sound on her lungs while check up so he sent for xray to check it. here is what the x-ray report said INDICATION: Bibasilar crackles COMPARISON: None TECHNIQUE: XR CHEST 2 VIEWS PA LATERAL Impression: IMPRESSION: Cardiomediastinal silhouette normal. Mild calcification aorta. Heart size normal. Minimal small nodular densities lung apices to exclude minimal fibronodular change. Lungs otherwise clear. Minimal blunting far posterior costophrenic angle bilaterally cannot exclude small pleural effusion. If patient has previous or outside films these may be useful for comparison. -------------------------------------------- She has very occasionally complained of shortness of breath like from last so many years. Doc did the ECg today too. Which was almost normal and just said sinus rhythm with occasional PVC . The Pulmonologist What do you think. Otherwise she seems quite ok as I said. Please advise.heard dry fine crackles. She never smoked or drank. Also, Her breast exams have been normal so far. Many thanks

Answered by Dr. Gyanshankar Mishra (20 hours later)

Brief Answer: Further evaluation required Detailed Answer: Hi, Thanks for posting the query on XXXXXXX After going through the query, I would like to comment the following: 1. If bibasilar crackles are present further evaluation is required considering her complaint of exertional breathlessness. 2. Is she hypertensive? Does she have leg swelling? Does she look pale? Any swelling in the neck (nodes)? Is she currently on any medications? Any significant past medical history? Any previous history of prolonged cough even in the childhood? 3. Further evaluation in the form of 2D echo, Pulmonary function test and HRCT scan Thorax may be required. 4. Possibilities include early heart failure, early intertitial lung disease, or other non infective causes which need to be ruled out. 5. You need to get a detailed clinical evaluation done by a Pulmonologist. I hope I have answered your query. I will be glad to answer follow up queries if any. Please accept my answer if you have no follow up queries. Regards Dr. Gyanshankar Mishra MBBS MD DNB Consultant Pulmonologist

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Gyanshankar Mishra (8 minutes later)

I have a question -What do you make out of the xray though. Does it look normal to you? Here are my further questions please.. 1. If bibasilar crackles are present further evaluation is required considering her complaint of exertional breathlessness. Are Bibasiliar crackles always mean Intertial lung disease or heart failure? Are there any non serious causes. 2. Is she hypertensive? Does she have leg swelling? Does she look pale? Any swelling in the neck (nodes)? Is she currently on any medications? Any significant past medical history? Any previous history of prolonged cough even in the childhood? She has never had prolonged cough. No leg Swelling. No neck nodes. No medications. No hypertension. No diabities .. Nothing of that sort. 3. Further evaluation in the form of 2D echo, Pulmonary function test and HRCT scan Thorax may be required. 4. Possibilities include early heart failure, early intertitial lung disease, or other non infective causes which need to be ruled out. Can there be less serious causes as well? What do you mean by non infective causes. If xray is not showing anything, is it still necessary to do any more of these tests. 5. You need to get a detailed clinical evaluation done by a Pulmonologist.

Answered by Dr. Gyanshankar Mishra (8 hours later)

Brief Answer: If crackles are present, evaluate them. Detailed Answer: Hi, Thanks for the follow up. After going through your follow up query, I would like to comment the following: 1. What do you make out of the xray though. Does it look normal to you? Ans: I can comment on the Xray report since the fim is not available. Presence of nodular opacities in the lung apices could be due to active infection and if there is possibility of fibronodular densities then those can be due to old healed infections of the lungs. In any case nodular opacities need to be evaluated by HRCT thorax or follow up Xrays at regular intervals. 2. Are Bibasiliar crackles always mean Intertial lung disease or heart failure? Are there any non serious causes? Ans: First get her evaluated for bibasilar crackles by a Pulmonologist and confirm their presence. If present they can be due to Interstitial lung diseases, pulmonary edema of cardiac or non cardiac origin but pulmonary edema is picked up on Xray. So ILD is a possibility. Other causes could be Bilateral lower zone pneumonitis but again it appears on Xray. So considering her profile, either the crackles are present and she needs to be evaluated or theay are absent and in such a scenario further evaluation may6 be avoided. Pulmonary function test, ecg and HRCT scan thorax are useful. 3.Can there be less serious causes as well? What do you mean by non infective causes. If xray is not showing anything, is it still necessary to do any more of these tests. Ans: Xray can miss ILD in early stages. Other causes may include rarely cancers in early stage or some benign conditions like fibronodular opacities secondary to old healed infections. 4. If xray is not showing anything, is it still necessary to do any more of these tests? Ans: If crackles are present, even with a normal evaluation further evaluation is required. 5. The first priority is to get the patient clinically evaluated by a Pulmonologist. I hope I have answered your query. I will be glad to answer follow up queries if any. Please accept my answer if you have no follow up queries. Regards Dr. Gyanshankar Mishra MBBS MD DNB Consultant Pulmonologist

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Gyanshankar Mishra (16 hours later)

Doc one last question- what does this mean in the xray- Minimal blunting far posterior costophrenic angle bilaterally cannot exclude small pleural effusion. Can there be other causes of blunting too? IS it not pulmonary edema? Thanks

Answered by Dr. Gyanshankar Mishra (2 hours later)

Brief Answer: Minimal blunting can be pleural effusion. Detailed Answer: Hi, The minimal blunting of posterior Costophrenic angle could be due to small pleural effusion / pleural thickening. It does not look like pulmonary edema since the rest of the chest does not have any findings of pulmonary edema nor does the clinical profile (symptoms) support it. USG scan thorax or CT scan thorax (better investigation, where rest of lung parenchyma can also be studies) should be done to confirm it. I hope I have answered your query. I will be glad to answer follow up queries if any. Please accept my answer if you have no follow up queries. Regards Dr. Gyanshankar Mishra MBBS MD DNB Consultant Pulmonologist

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Gyanshankar Mishra (1 hour later)

I know plueral effusion can be due to many causes, including CHF, but her heart exam,ECG was normal just showing occasional PVCs.can small plueral effusion cause crackles. And the effusion could be just benign and not of any significance but still causing crackles. I know the bottom is to evaluate it further but trying to understand all the possibilities. Also, the shortness of breath is very rare in her case and that is not when she exercises.. Is ILD the only possibility? Can it not be something less significant than that?

Answered by Dr. Gyanshankar Mishra (1 hour later)

Brief Answer: Early ILD and pleuritis are possible Detailed Answer: Hi, Thanks for the follow up. 1. Crackles are present in early pleural effusion i.e. pleuritis (pleural rub) or if there is associated pleural fibrosis. If crackles are present then early ILD is also possible. Remember there are more than 100 causes of ILD. Early ILD is also missed on chest Xray. Early stages of consolidation could also lead to crackles. Considering her clinicoradiological profile ILD is a possibility in her. 2. But the first point is to confirm the crackles and for that she needs to be evaluated by a Pulmonologist. I hope I have answered your query. I will be glad to answer follow up queries if any. Please accept my answer if you have no follow up queries. Regards Dr. Gyanshankar Mishra MBBS MD DNB Consultant Pulmonologist

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar