Correct!
1. Perform enhanced chest CT
The previous frontal chest radiograph from 7 years earlier is of good quality and shows no abnormality; the abnormal chest radiographic findings are new since that prior study.
Although the patient does complain of some arm pain, there are no features that suggest either risk factors or clinical features suggestive of acute pulmonary embolism. Enhanced chest CT is a good choice for the next step in this patient’s evaluation, but that study should be performed with appropriate timing for the evaluation of the right-sided chest mass, and a CT pulmonary angiogram typically employs contrast infection timing optimized for pulmonary arterial enhancement, which results in suboptimal assessment of other aspects of chest anatomy, such as the mediastinum and pericardial and pleural surfaces; therefore, CT pulmonary angiography technique should not be performed. Repeat chest radiography would be an appropriate choice for low-risk lesions in an imaging-clinical concordant situation, such a focal chest radiographic finding suggesting pneumonia in a patient with cough and fever. In such circumstances, repeat chest radiography to assure resolution of the chest radiographic finding is appropriate. Cardiac MRI would not be an appropriate examination for this patient as that examination restricts evaluation to the immediate area surrounding the heart, and would therefore not include the right apical opacity in the field of view. Chest MRI could prove useful for this patient, but typically is performed after chest CT assessment has been conducted and found to be indeterminate. Similarly, 18FDG-PET scan may be of value for this patient’s evaluation, but is premature at this point and is typically employed in the context of previous chest CT assessment.
The patient underwent enhanced chest CT (Figure 5).
Figure 5. Axial enhanced chest CT displayed in soft tissue (A-E) and lung (F-I) windows. Right: Video of chest CT in soft tissue windows.
Which of the following represents an appropriate interpretation for this examination? (Click on the correct answer to be directed to the sixth of 12 pages)