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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.

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Presentation on theme: "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."— Presentation transcript:

1 Case 2

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 5 th LICS  Flat abdomen, NABS, (-) mass (-) tenderness 34/F Chief Complaint: epigastric pain  (+) vague abdominal pain  (-) change in BM  Persistence consult Physical Examination History of present illness

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

4

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 vs Small Bowel  Large bowel  Peripheral  Haustral pattern does not fully traverse the colon  Small bowel  Central  Valvulae conniventes

10 SFA correlation normalpatient

11 CXR correlation normalpatient

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  “Catamenial pneumothorax”  Marfan’s syndrome  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 normalpatient

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

20 THANK YOU!


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