Perhaps the most obvious finding is that there is mild cardiomegaly, Careful review of the lung parenchyma suggests pulmonary vasculature may also be slightly prominent. These are unusual finding for a patient aged 20. This might suggest cardiac or renal impairment.Consideration of renal impairment should prompt evaluation of osseous structures, to determine whether there is mild osseous sclerosis that might indicate renal osteodystrophy. There is questionable mild sclerosis present, however, more specifically evaluation of the lower thoracic/upper lumbar spine demonstrates that there is multilevel mild central endplate depression. This finding, often referred to as H-shaped vertebral bodies is relatively characteristic findings of sickle cell disease due to microvascular end plate infarction.
In turn identification of this finding should on search for further findings that would corroborate the diagnosis of sickle cell disease. One might consider evaluating the gallbladder for gallstones. In this patient surgical clips are present, consistent with a cholecystectomy, again unusual in a patient of this age, unless the patient has sickle cell disease, confirming our diagnosis.
Further considerations may include evaluation of the left upper quadrant to identify a very small or densely calcified spleen, not clearly visible in this case. Further review of the osseous structures should extend to evaluate whether there are sclerotic changes of the humeral head which may reflect early avascular necrosis, again not present in this case.
The cardiac features may relate to a variety of causes, including left heart failure due to myocarditis/cardiomyopathy, including ischaemic changes or relate to right cardiac impairment. Right cardiac impairment may be secondary to recurrent pulmonary parenchymal infection/scarring, acute or chronic thromboembolic disease or microvascular peripheral pulmonary arterial disease.
There is an interesting case because it highlights that although a repeatable systematic approach to the evaluation of chest radiographs, other radiographs or cross-sectional imaging has its value, it should be as an adjunct to directed evaluation of focal areas based on the principle that when a finding is present, consider and look for what may have caused that finding and consider also what that finding may lead onto. Considering films in this way greatly increases your diagnostic interpretation quality.