Saturday, August 23, 2008

Fascinoma / Incidentaloma

An 'incidentaloma' is doctor-speak for a diagnosis made while looking for or 'ruling out' something else. In this case a young gentleman hopped up on oxycontin, marijuana, and alcohol got shivved in the gut. I can't imagine why... he was nothing but nice to us.

I took this chest Xray to rule out free-air under the right hemidiaphragm which would have made a trip to the OR necessary. Using other means we made sure that this fine citizen had suffered nothing but a flesh wound.

This chest film demonstrates a very rare diagnosis, and rather than have all the other doctors tell you what it is I will tell you that it is dextrocardia. His heart is on the wrong side of his chest (just like in the prologue to SCRUBS but that film on the show is merely placed backwards on the light box).

Usually this is an error made by the XR tech who labels 'left' and 'right' mistakenly, but this is truly dextrocardia as the stomach bubble is where it should be... under the left hemidiaphragm. Also, the tech repeated the film because she thought she had mislabelled it the first time.

This is the second time I've seen this and it was of no clinical consequence either time. Whether folks with dextrocardia have a predisposition to being douchebag wastes of carbon is open for debate. It of course goes without saying that this young gentleman did not have a job, money, or insurance.


  1. Dude, it's shank, it's a verb. You know: to shank.

    Please tell me you've seen the comcast commercial.

  2. I've seen one guy with dextrocardia along w/ situs inversus (known prior to my involvement in his care doing a nuc stress test on him).
    Wanted to play around with his EKG leads and get L as well as R sided precordial leads and then wanted to switch the RA and LA leads - mostly to educate myself and for teaching purposes.
    He was a bit of a douchebag and would not let me do the different tracings. BTW, he was not a contributing member of society. So anecdotally, 2 for 2.


  3. So is it like a regular heart, just on the right side, or is everything reversed like a mirror image? I thought I had found a dextrocardia once while doing a physical, even ordered an X-ray, but the heart was in its normal spot. I always thought that just showed how worthless the Physical Exam is, but maybe the tech just labled the film wrong.

  4. The two I've found it was on EKG, when the computer read-out stated 'leads reversed'

  5. I wish I'd seen a case like this.. :(

    I also saw a case of situs inversus with dextrocardia in a 6 year old girl, with UNBELIEVABLE clubbing.. which was probably the only thing I could appreciate since we had just entered the wards (2nd year of our course). She was a perfectly cooperative child.. which was really sad, since her last few days were being used up by her parents as an investment; she was a paid 'exam case'. Sad. So I guess the statistic doesn't hold..

  6. So what happens to the rest of the vasculature anatomy in case of an isolated dextrocardia? I mean, what happens to the arch of aorta and its branches, for example?

  7. This comment has been removed by the author.

  8. And I'm sure you meant INCIDENTALOMA.. an incidental finding.

    Or maybe you just saw a puddy tat.. :P

    * Had to delete my previous post cause of formatting errors. *

  9. His hearts not in the right place in more ways than one..

    Next time he's smoking crack he'll be bragging to everyone about his heart, no doubt.

  10. I have run into patients like this in the prehospital environment. We did a 12 lead on a chest pain patient and it was all fucked up. I looked my EMT partner and was like, "Hey, let's try putting the patches on correctly in the future." EMT was like, "Look at them yourself prick."

    Indeed, they were on correctly. Man's wife, seeing this interaction, pipes up about 1 minute late, "Oh, you boys need to know that Mr. Mumbles has his heart backwords."

    So Mumbles got both a right and left sided 12 lead.

    I don't know whether this man was a waste or not. He semed to have an affinity for pooping himself and eating vienna sausages from the can.

  11. No Job, Money, or Insurance, but I bet he's got Tatoos. He needs one that says "Cut Here" on the right side of his chest when he comes in for the inevitable ER thoracotomy.

  12. abacus,

    thank you.


    you are correct. tattoo positive. many. would have put a pic of the stab wound up but for hipaa. still had all his teeth though, so he's got that goin' for him... which is nice.

  13. amy,
    one may use 'shank' but one may also say 'shivved' according to the urban slang dictionary.

  14. I'm just teasing. Seriously though, I was just quoting the Comcast commercial. I take it you haven't seen it? I tried to find it on youtube, but alas, no success.

  15. i think this was dr peel's son and his dextrocardia mirrors her levocrania.

  16. He has all of teeth pretty amazing, a few more years on the crack pipe they'll be gone or will have to come out for his pending valve surgery.

  17. " It of course goes without saying that this young gentleman did not have a job, money, or insurance."

    ahh but he has something you dont have ... Dextrocardia!

    Oz never did give nothing to the tin man that he didn't already have.

  18. Nice Ikeane! We seriously have some genius commenters here.

  19. I was the grateful recipient of an 'incidentaloma' last year. (Not as exotic as the dextrocardia.) A chest x-ray for simple lung check revealed a suspicious shadow in my chest, which turned out to be a large substernal mass. There had been no symptoms, but I'm sure thankful for that fortuitous x-ray. Isn't that how the doctors discovered the recurrence of cancer in Elizabeth Edwards?