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You are currently working with a patient you have have been seeing post TKR in a rehab facility (ECF). He has been progressing well and you will be able to discharge him soon. During a rehab session he complains of middle back pain in addition to his post operative pain. You find out that he did fall this morning while attempting to transfer from his bed to a chair. His pain is deep in the back and "aching" it is non radiating. He tells you it is bad enough to vomit. You are able to order an xray.
Here are the films. Would you like any additional information?
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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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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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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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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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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 Moderator of Medical Complexity Forum
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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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