Case 2 STEPHANIE M. GO

Chief Complaint: epigastric pain (+) vague abdominal pain (-) change in BM Persistence History of present illness 5 hrs PTC consult Physical Examination 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

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 Anatomy Presence of air in the pleural space 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 Clinical findings 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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