Answer: B
This patient gave a history of good past health on presentation. Because of the chest X-ray finding of a left straight heart border, upper lobe venous diversion and prominent pulmonary trunk, echocardiogram was done and confirmed the presence of moderate mitral stenosis, with also some mitral regurgitation and tricupid regurgitation. Overall picture is compatible with chronic rheumatic heart disease. On further questioning, she is having occassional palpitation on exertion and had been told to have some form of rheumatic heart disease more than 20 years ago, but without subsequent follow-up.
Chest x-ray of mitral stenosis usually shows straightening of the left cardiac border due to a dilated LA appendage, and widening of the carina. Lateral chest x-ray will show the dilated LA displacing the esophagus posteriorly in barium esophagogram. The main pulmonary artery (trunk) may be prominent; the descending right pulmonary artery diameter is ≥ 16 mm if pulmonary hypertension is significant. The upper lobe pulmonary veins may be dilated. A double shadow of an enlarged LA may be seen along the right cardiac border. Horizontal lines in the lower posterior lung fields (Kerley B lines) indicate interstitial edema associated with high LA pressure.
In pulmonary embolism, one-fourth of patients had normal chest radiographs. Common abnormalities were cardiomegaly (27 percent), pleural effusion (23 percent), elevated ipsilateral hemidiaphragm (20 percent), pulmonary artery enlargement (also called Fleishner’s sign, 19 percent), atelectasis (18 percent), and infiltrates (17 percent). Other special signs are Hampton’s hump (wedge shaped lung infarct), Westermark’s sign (a focus of oligemia due to vasoconstriction distal to a pulmonary embolus), Fleishner’s lines (when the area of focal atelectasis is viewed on end). Sensitivity and specificity is variable, and the CXR has to be interpreted in light of the clinical condition. CXR of this patient is not typical of pulmonary embolism.
Routine bronchoscopy is not indicated in straightforward community-acquired pneumonia, and also will not even alter outcome in ventilator-associated pneumonia. However, bronchoscopy may be considered if there is lung collapse or suspicion of atypical pathogens the cannot be diagnosed by some other less invasive means.