Standing up for the practicing physician
Send them to the ER!
I think it is aortic aneurysm or mediastinal mass. It also shows hyperaeration which reflect chronic lung disease and possible smoking history which increase the risk of aneurysm or lung cancer. I also concern about right lower lobe patchy infiltrate, blunting of left costophrenic angle and haziness in right upper lung field close to mediastinum. I'm amazed to see "an asymptomatic patient" was hooked with telemetry and got portable CXR rather than regular PA and lateral which would yield much more information.More history and physical exam, previous CXR and obtaining CXR PA and lateral should help.
Is that the apex of the heart sticking up to the left? It looks like the cardiac shadow is sideways. I don't read xrays but is the diaphragm in the right place? Is "something" pushing the heart up and to the left?
Do a needle biopsy in the office.
It's not every day you see a descending aortic aneurism that exceeds 8 cm in diameter (confirmed by CT).Needless to say, we didn't do an atrial flutter ablation until the aneurism was addressed and no office-based needle biopsy was performed.:)
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