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Endgames Picture Quiz

A 64 year old woman with headache and breathlessness

BMJ 2012; 344 doi: (Published 15 May 2012) Cite this as: BMJ 2012;344:e3158
  1. Robert Lord, core medical trainee,
  2. William Flight, clinical fellow ,
  3. Alan Sweeney, core medical trainee ,
  4. Nauman Chaudhry, consultant respiratory medicine
  1. 1University Hospital of South Manchester, Manchester M23 9LT, UK
  1. Correspondence to: R Lord roblord{at}

A 60 year old woman presented to the chest clinic with four years of worsening dyspnoea. On waking she felt unrefreshed and had a headache. She felt sleepy throughout the day. Her medical history included kyphoscoliosis, spina bifida, hypertension, and osteoporosis. The drugs she was taking included amiloride, furosemide, nitrazepam, and calcium-vitamin D supplements. She was born in the United Kingdom, was a lifelong non-smoker, and a retired teacher. She owned no pets and reported no exposure to asbestos.

On physical examination, her respiratory rate was 28 breaths/min and oxygen saturation was 86% on ambient air. Temperature and haemodynamics were normal. General inspection showed marked kyphosis and rapid shallow breathing. She had a global reduction in breath sounds but no crackles, wheeze, or rub. The rest of the examination was unremarkable, with no evidence of right heart failure.

Blood tests showed a raised haemoglobin of 157 g/L (reference range 115-165), but other haematological, biochemical, and inflammatory markers were normal. Arterial blood sampling on ambient air showed pH 7.36, arterial carbon dioxide tension 9.14 kPa, arterial oxygen tension 6.4 kPa, base excess 7.8, and bicarbonate 33 mmol/L. Her body mass index was within the normal range. Figure 1 shows the chest radiograph.


  • 1 What is the primary abnormality on the chest radiograph?

  • 2 Why would this abnormality cause her symptoms?

  • 3 What investigations would you perform to evaluate the underlying disorder?

  • 4 How should she be managed?


1 What is the primary abnormality on the chest radiograph?

Short answer

The primary abnormality of the chest radiograph is severe kyphoscoliosis with profoundly reduced lung volumes.

Long answer

This radiograph shows kyphoscoliosis with predominantly left lateral mediastinal displacement. Lung volumes are profoundly reduced, and this is more marked on the left. The left hemidiaphragm is raised with the gastric bubble …

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