Dr. Muhammad Shoyab
Radiodiagnosis
The following is an actual conversation between an iCliniq user and a doctor that has been reviewed and published as a Premium Q&A.
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Patient's Query
Hi doctor,
Could you provide a second radiology opinion? This is for a patient with right-sided rib fractures (4th and 5th) who exhibits the following symptoms. The patient complained of pain in the right side of the chest and shoulder. She has right arm fatiguability, right-sided retrosternal chest pain, and pain when taking a breath. She also experiences pseudo-angina-like symptoms with intermittent or intractable hiccups. And also has right-sided dyspnea, dysphagia, or odynophagia (symptoms exacerbated by exercise). All these symptoms first appeared three years ago.
Hello,
Welcome to icliniq.com.
I understand your concern. I have reviewed the reports (attachment removed to protect the patient's identity). The source of the various issues the patient has been experiencing lies somewhere other than the chest. In particular, the rib fractures are old and healed, and there is no evidence of focal pleural reaction or thickening, which could explain the chest pain on inspiration. And there is a breast nodule on the left side, which could be benign but is unlikely to be related to the symptoms. Therefore, considering the constellation of her symptoms, the injury or pathology is in the cervical spine or spinal cord. This could be due to the fact that the nerves that supply the right arm (in which you have got weakness and numbness) originate from the cervical cord, the nerves that control breathing (phrenic nerve) originates in the cervical cord, the vagus nerve and its branches associated with swallowing and hiccups traverse the neck and throat. After consulting her physician, I suggest she take a new cervical spine MRI (magnetic resonance imaging). A follow-up is to be done with an MRI (magnetic resonance imaging) of the cervical spine.
Thank you.
Patient's Query
Hello doctor,
First and foremost, I would like to thank you very much for your response and insight into this case. It is very much appreciated. I have taken your recommendations into consideration and have shared your opinion with my treating physician who has investigated further. It appears that your presumptive diagnosis is correct and that the injury or pathology involved is from the cervical spine and or cervical spinal cord. The whole body diffusion-weighted imaging MRI (WB-DWI or MRI) performed two years back demonstrated pathology of the cervical spine, specifically, minimal central disc osteophyte complex at C2 to C-3 and C3 to C-4. If it is not too late, I would like to share the imaging studies from the WB MRI performed and get your feedback on the cervical spine findings. Note that this was not a dedicated cervical spine study, so I do not know how much pathology in that area will be shown. Also note that in light of your previous comments, some sections of the history and physical examination (H and P) (specifically sections 8 to 11) have been updated to reflect your recommendations. If it is not too much to ask, could you also provide me with your comments on the updated sections 9, 10, and 11 of the H and P to let me know if your medical judgment aligns with what is written? I have attached the updated sections of the Hand P to this message, as well as the MRI report and imaging studies. Note, that page four of the report pertains to the spine.
Hello,
Welcome back to icliniq.com
I am extremely sorry for the delayed reply, quite due to some familial engagements and then my own illness. So I have gone through your doctor's notes and the whole body magnetic resonance imaging (MRI) images and reports (attachment removed to protect the patient's identity). It is appreciable that the doctor has given you a detailed outline of the upcoming plan. From the whole body MRI, I find that the cervical spine and cord do not have many significant changes that could be correlated with your history. As such, you no longer need to do MRI culture and sensitivity (C/S), since I have seen the required portion from the whole body MRI. Better, you can perform an MRI brachial plexus (right), because the brachial plexus is not seen on the whole body or cervical MRI. For the rest of the H and P, I consider those points appropriate and you can follow them accordingly. I hope this information will help, and once again apologize for the undesired delay. Follow-up to be done with MRI of brachial plexus (right).
Thank you.
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Radiodiagnosis
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