STEPHANIE M. GO

1. Case 2 STEPHANIE M. GO

2. 34/F • Chief Complaint: epigastric pain • (+) vague abdominal pain • (-) change in BM • Persistence History of present illness • 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 consult Physical Examination

3. Patient’s Radiographs Scout film of the abdomen Chest X-Ray • On interpretation, plain film of the chest was requested by the radiologist

4. Scout film of the Abdomen

5. 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

6. Normal Scout Film of the Abdomen

7. What to examine? • Gas pattern • Extraluminal air • Soft tissue masses • Calcifications

8. Normal Gas Pattern

9. Large vsSmall Bowel • Large bowel • Peripheral • Haustral pattern does not fully traverse the colon • Small bowel • Central • Valvulaeconniventes

10. SFA correlation normal patient

11. CXR correlation normal patient

12. 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

13. 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

14. 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 • “Catamenialpneumothorax” • Marfan’ssyndrome • Ehlers-Danlos syndrome • Pulmonary infarction • Lymphangiomyomatosis and tuberous sclerosis

15. 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

16. 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

17. PNEUMOTHORAX NORMAL Pneumothorax, R

18. CXR correlation normal patient

19. 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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