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NBME 19 Answers

nbme19/Block 3/Question#17 (10.1 difficulty score)
45 yo patient, chronic alcohol dependence, ...
Chest radiograph labeled 'D'πŸ”,πŸ“Ί
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 +6 
submitted by cassdawg(1172),

I love this question because we are all obviously trained radiologists...

In reality, rather than identifying every X-ray given and trying to match it to the question stem, the best way to approach this question is to identify what his most likely issue(s) and match to the general characteristic of an X-ray, going to the X-rays looking for these characteristics.

He is an alcoholic with foul smelling (ding anaerobic) sputum. Because he is an alcoholic he is at risk for aspiration pneumonia and anaerobic pulmonary abscesses from aspiration (which is why they mentioned the bouts of blacking out). So what are the characteristics of these diseases? Aspiration pneumonia is a lobar pneumonia which would present with lobar infiltration (see here for example). Pulmonary abscess would present with cavitation and an air-fluid line (see here for example with air fluid level pointed out and here for cavitation/abscess pointed again).

Thinking of this now approach the X-rays looking for specific findings. One has the air fluid level and cavitation, so that is the answer (it is an abscess). None of the others have lobar infiltrate and are either more diffuse or hilar so they should be ruled out.

an_improved_me  The even more frustrating part of this question is that they don't show an abscess in a more dependent region of the lung! +