Case 2

 

HPI:  62 y/o female c/o abd pain from being constipated x 2d. Her last BM was 2d ago. She reports some nausea w/ decreased appetite, but denies V/D, fever, dysuria. She’s currently undergoing XRT for metastatic lung CA to the brain.

 

 

PMH:  as above, s/p RUL lobectomy for lung CA

 

Meds:  Vicodin, Colace, FeSO4, Prednisone, Cytotec

 

PE:       Vs  T 97.5,  P 87,  R 20,  BP 107/66, 93% sat on RA

Gen:  non toxic appearing

HEENT:  no scleral icterus, mucous membranes moist

Neck:  supple, no JVD

CV:  RRR

Resp:  slightly decreased on right ULF, otherwise clear, no W/C

Abd:  soft, mild subjective tenderness diffusely, hypoactive BS, no peritoneal signs, Guaiac trace positive stools w/out impaction

 

 

ED Course:  Pt’s labs, including CBC, Comp Chem, UA, EKG & CKs were all essentially normal.  The AAS are as followed.

 

 

 

 

What’s your diagnosis?

 

Click here for answer.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Answer:  perforated viscous w/ free air under left hemidiaphragm.

 

 

 

Note the difference between free air (on the left) and a stomach bubble (on the right) which typically has an air-fluid level & does not enhance the border of the diaphragm.

 

           

 

You can also order decubitus films to look for free air.

 

 

 

Discussion

 

I chose this case for two reasons.

 

 

First, to demonstrate free air which most of you picked out – damn good job! Remember that, to optimize your chance of picking up free air on a CXR, the pt should be sitting upright for at least 20 minutes. Thus, if you’re going to order an AAS, put the pt up if he/she can tolerate it. Also notice that our AAS did not automatically come with a decubitus film. If you’re not sure whether it’s free air or the stomach bubble, get some decub films.

 

 

Secondly, consider getting AAS in elderly patients presenting with abdominal pain. We don’t usually get an AAS unless we suspect perforation or obstruction, both of which should be easily evident through the history or physical. (Yes, AAS can also demonstrate lower lobe pneumonias or mass such as kidney stones.) The AAS is otherwise a very low yield test in a typical patient with abd pain. However, the one exception to order AAS as a routine test is with elderly patients. The elderly classically have a less reliable exam, and can be on several medications with anticholinergic properties that can slow the bowels and lead to dilated non-obstructive process such as Ogilvie’s syndrome. This pt did not have any reliable signs that she perforated an ulcer, likely from being on chronic steroids. She went to the OR, and was still recuperating when last checked.