Case 2. 5 hrs PTC VS BP 120/90 HR 88 RR 24 T 38.2°C Symmetrical chest expansion, hyperresonant on percussion left, absent breath sounds left Apex.

STEPHANIE M. GO

Case 2

5 hrs PTC

VS BP 120/90 HR 88 RR 24 T 38.2°C Symmetrical chest expansion, hyperresonant on

percussion left, absent breath sounds left Apex beat parasternal 5th LICS Flat abdomen, NABS, (-) mass (-) tenderness

34/FChief Complaint: epigastric pain

(+) vague abdominal pain

(-) change in BM Persistence

consult

PhysicalExamination

History of present illness

Patient’s Radiographs

Scout film of the abdomen Chest X-Ray

On interpretation, plain film of the chest was requested by the radiologist

SCOUT FILM OF THE ABDOMEN

Information from a plain scout film:

Presence of calcifications Abnormal gas collection Abnormal size of the liver and spleen Ascites Abnormal gas pattern Abscesses Foreign bodies

Normal Scout Film of the Abdomen

What to examine?

Gas pattern Extraluminal air Soft tissue masses Calcifications

Normal Gas Pattern

Large vs Small Bowel

Large bowel Peripheral Haustral pattern does

not fully traverse the colon

Small bowel Central Valvulae conniventes

SFA correlation

normal patient

CXR correlation

normal patient

PNEUMOTHORAX

Presence of air in the pleural space Anatomy

Visceral pleura is adherent to lung surface

There is no air in the pleural space normally

The introduction of air into the pleural space separates the visceral from the parietal pleura

PNEUMOTHORAX

Pathophysiology Either from disruption of visceral

pleura trauma to parietal pleura

Clinical findings Acute onset of:

Pleuritic chest pain Dyspnea (in 80-90%) Cough Back or shoulder pain

PNEUMOTHORAX

Etiologies: Penetrating trauma Blunt trauma Iatrogenic Spontaneous pneumothorax Other causes of a pneumothorax

Neonatal disease Malignancy Pulmonary infections Complication of pulmonary fibrosis Asthma or emphysema “Catamenial pneumothorax” Marfan’s syndrome Ehlers-Danlos syndrome Pulmonary infarction Lymphangiomyomatosis and tuberous sclerosis

PNEUMOTHORAX

TYPES: Closed pneumothorax = intact thoracic cage Open pneumothorax = "sucking" chest wound Tension pneumothorax

Accumulation of air within pleural space due to free ingress and limited egress of air

Pathophysiology: Intrapleural pressure exceeds atmospheric pressure in lung

during expiration (check-valve mechanism) Frequency

In 3-5% of patients with spontaneous pneumothorax Higher in barotrauma (mechanical ventilation)

Simple pneumothorax –no shift of the heart or mediastinal structures

Imaging findings in PNEUMOTHORAX visceral pleural white line

Very thin white line that differs from a skin fold by its thickness

Absence of lung markings distal or peripheral to the visceral pleural white line

Displacement of mediastinum and/or anterior junction line

Deep sulcus sign On frontal view, larger

lateral costodiaphragmatic recess than on opposite side

Diaphragm may be inverted on side with deep sulcus

Supine position

PNEUMOTHORAX

NORMAL Pneumothorax, R

CXR correlation

normal patient

PNEUMOTHORAX

Pitfalls in diagnosis: Skin fold

Thicker than the thin visceral pleural white line Air trapped between chest wall and arm

Will be seen as a lucency rather than a visceral pleural white line

Edge of scapula Follow contour of scapula to make sure it does not

project over chest Overlying sheets

Usually will extend beyond the confines of the lung Hair braids

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