A small child has had an upper respiratory infection for a few days. He went to his PCP and was told he had a viral infection. On the way out, his mother noticed he had a handful of rocks in his hand and one was in his mouth.
She took them away, but on the drive home noticed that he was having more trouble breathing than he had been having over the past few days.
On arrival he is in no distress. He has some upper airway wheezing but lung sounds are otherwise clear bilaterally. X-rays show:
Thoughts?
Not so fast, former Mr. President Obama.
Don’t get distracted by the abdominal film. The official read is “air distended stomach”. The chest x-ray was initially read as “perihilar interstitial infiltrate”. Since I had the benefit of having the patient in front of me and knew what I was looking for, I pulled up the films myself and immediately arranged transfer to the nearest children’s hospital. Then I called the radiologist and asked him to take another look. The report was amended with: “hyperdense filling defect and hyperexpanded right lung suspicious for foreign body”. He underwent a bronchoscopy and had foreign body removed.
Learning points:
If you’re concerned about something and the radiologist’s findings don’t line up, review the films yourself. It’s unreasonable to expect to look at all of your own films, but in these cases where there’s a discrepancy between what you highly suspect and what is being reported, do take a look.
Don’t get distracted. I showed these images to a few colleagues and everyone was stuck trying to interpret the abdominal part of the films.
The ideal study for evaluating possible foreign body aspiration is lateral decubitus films. When the affected side is down, it should appear under-inflated.
For more reading on this and for other cool stuff, check out The Ultimate Emergency Medicine Guide!
