1. Case 2
STEPHANIE M. GO

2. 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

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

10. SFA correlation
normal
patient

11. CXR correlation
normal
patient

12. 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

13. 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

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
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

20. THANK YOU! 