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Feb case 2
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RE: Feb case 2 - February 24, 2008 12:22:18 AM
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Sebastian Asselbergs
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From: Barrie, Canada
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How/why did he fall? How are the breath sounds? And how are the bowels and bowelsounds...
For starters...
(Thanks Wags - for these)
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Mundi vult decipi
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RE: Feb case 2 - February 24, 2008 9:52:37 AM
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Sebastian Asselbergs
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From: Barrie, Canada
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nope....
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RE: Feb case 2 - February 24, 2008 2:59:47 PM
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kamryn
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In addition to the above:
1. did the pain come on immediately following the fall?
2. any current SOB or difficulty breathing?
3. is there a lateral view of the t-spine?
4. past medical history and current meds?
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RE: Feb case 2 - February 24, 2008 7:25:53 PM
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bonez
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There appears to be significant air below the diaphram. additionally the cardiac shadow appears deviated to the right along with the trachea. I assume that he percusses like a drum and has difficulty to lay and breathe.
Did he break a rib falling which has accounted for the air distortation esp below the diaphram? There is a significant amount of air in the bowel too.
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RE: Feb case 2 - February 24, 2008 10:32:15 PM
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Dr.Wagner
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Difficulty breathing; pain with each breath.
Very little injury or pain at the time of the fall.
Abdomen is soft, non distended, but painful to palpate.
Breath sounds are equal bilat
abdominal sounds are overactive.
Past medical history is 1. Depression, 2. Hypertension, 3. NIDDM, 4. Reflux
Meds: Zoloft, diovan, atenolol, glucophage, pepcid, alprazolam, ibuprofen, vicodin
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RE: Feb case 2 - February 24, 2008 11:43:20 PM
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jlharris
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From: Nebraska
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The above chest xray doesn't seem to fit with the rest of the clinical presentation as well as the other xrays provided. It seems to be a tension pnuemo especially what appears to be a chest tube in the upper left chest and no free air below the diaphram as seen on the abdominal films.
With this amount of free air under the diaphram, I hope the pt has been sent to the OR to repair what is most likely a small bowel (or other hollow viscus) injury. It is common to see this with chance fx's of the Tx and Lx spine. With his scenario of back pain and recent fall, this would be first (with xray) on my DDX.
Also, if pt has been taking a large amount of NSAID's (or hx of ulcer disease) this could lead to a ulcer perforation of the bowel.
One could also see a psuedo obstruction d/t narcotics which, left untreated, could proceed to perforation of the right colon.
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My PT Blog
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RE: Feb case 2 - February 25, 2008 1:49:57 PM
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Dr.Wagner
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From: Indianapolis
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HAHAHA!
Yes, I have put together multiple films and accidentally included one with a chest tube.
This patient had a ulcer (GERD history) and developed a perforation with NSAID usage.
Sometimes when I do not have the films myself, I put them together (hence the Medscape images).
Perforation of peptic or duodenal ulcers are acute surgical conditions which have rates of mortality that increase with time from onset.
The fall was incidental.
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Dr. Wagner DO
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RE: Feb case 2 - February 25, 2008 3:47:13 PM
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jma
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That was definitely a good case. Long term NSAIDS do their damage in the long run. Unfortunate.
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RE: Feb case 2 - February 25, 2008 7:31:09 PM
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jlharris
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BTW, I have to admit that I cheated in my answer. My wife is a general surgeon and she pointed out the chest tube and Chance fx (which until that point I'd never heard of). I did come up with the perforated bowel d/t NSAIDS myself (where else would free air come from). Thanks Doc.
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Jason L. Harris, PT, DPT
My PT Blog
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