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Evaluation of Epigastric Pain and Pneumothorax Diagnosis in a Patient

A case study on a patient, Stephanie M., presenting with epigastric pain and vague abdominal symptoms. Clinical examination showed abnormal findings including hyperresonance on percussion on the left side, absent breath sounds, and elevated temperature. Imaging results revealed calcifications, abnormal gas collections, and signs of pneumothorax. The case explores the importance of thorough physical and radiographic examinations in diagnosing pneumothorax, differentiating types, and understanding potential etiologies and pathophysiology.

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Evaluation of Epigastric Pain and Pneumothorax Diagnosis in a Patient

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  1. Case 2 STEPHANIE M. GO

  2. 34/F • Chief Complaint: epigastric pain • (+) vague abdominal pain • (-) change in BM • Persistence History of present illness • 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 5th LICS • Flat abdomen, NABS, (-) mass (-) tenderness consult Physical Examination

  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 vsSmall Bowel • Large bowel • Peripheral • Haustral pattern does not fully traverse the colon • Small bowel • Central • Valvulaeconniventes

  10. SFA correlation normal patient

  11. CXR correlation normal patient

  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 • “Catamenialpneumothorax” • Marfan’ssyndrome • 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! 

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