Clinico-Radiologic

Conference
Lavadia | Lazatin | Leachon | Lee, Sh | Lee, St | Leonor
General Data

17 years, 9 months
Male
Roman Catholic
Quiapo, Manila
Informants: Sister & Mother
Reliability: Good
Admitted: August 31, 2018
2
Chief Complaint:
Difficulty of breathing

3
 History of Present Illness
● Admitted at USTH-PD due to left
6 months pneumothorax, initially presenting with
PTA sudden difficulty of breathing
● Underwent CTT insertion and VATS, left

1 day PTA ● Sudden difficulty of breathing accompanied

by occasional cough and discomfort upon
lying down flat
● No fever or colds
4
 History of Present Illness
● One episode of vomiting clear fluids after
Few hours waking up
PTA ● CXR done showed:
○ area of lucency with no lung markings on
the right lung area
○ visceral pleural line
○ air-fluid level at the right lower hemithorax
○ hyperinflation was noted
● A> Pneumohydrothorax
● Patient was advised admission
5
 Review of Systems
General: No weight loss, weight gain, decreased activity, and decreased appetite
Cutaneous: No rash, no jaundice, pigmentation, pallor, cyanosis
HEENT: No lacrimation, blurring of vision, nasoaural discharge, epistaxis, toothache,
sore throat
Cardiovascular: no chest pain, palpitations, edema
Gastrointestinal: no abdominal pain, nausea/vomiting, constipation, diarrhea
Neurologic: no loss of consciousness, convulsions, sleep problems, behavioral
changes, weakness
Extremities: No joint swelling, limitation of movements, stiffness
6
 HEADS/S/FIRST
Home Shares room with two cousins at boarding house in Quiapo, and is comfortable with his privacy
because there are dividers in their room. At Romblon during vacations.

Education Grade 12 SHS student at UST Health Allied Track. Aims to talk up Medicine. Does well at his own
assessment of his academics. No extracurricular activities.

Abuse No experience of bullying, and receives no physical or psychological abuse from his family

Drug Use Does not smoke, drink alcohol. Denies illicit drug use alone or with peers

Sexuality Heterosexual, male. Never had sexual contact

Safety Does not use helmet while riding the bike but otherwise stays at home after going to school.

7
 HEADS/S/FIRST
Family/Friends Lives at boarding house with his 2 cousins, has a good and close relationship with his family and
friends

Image Insecurities about his weight. Wisher to be larger and not be too skinny. Otherwise, comfortable
with other aspects with his body

Recreation Good sleep, does not exercise. Likes to read fictional books and medical literature for his own
amusement and is also fond of watching Youtube and browsing the net.

Spirituality Catholic but does no go to church every Sunday, but, comfortable about his own spirituality.

Threats Does not engage in self-harm and does no think of inflicting harm to other people.

8
 24 Hour Food Recall
Food Calories

Breakfast 2 spoons of corned beef + ½ egg + 1 glass milk + ½ fish + 1 cup 192 + 45 + 126 + 100 +
rice 205 = 595kcal

Lunch Sinabawang isda + 1 cup rice 150 + 205 = 352 kcal

Snack(s) Biscuit 212kcal

Dinner 1 cup rice + ½ fish 205 + 100 = 305 kcal

Total 1,630

RENI: 2,300 % Deficiency: 30%

Takes multivitamins Caregiver: Mother

9
 Past Medical History

Previous illness and hospitalizations:

◉ Dengue (August 2018)

No previous accident, blood transfusion, allergies,

current medications

10
 Immunization
Vaccine Date/Place Vaccine Date/Place

BCG 11/06/2000 Hib 1,2,3 01/2001, 02/2001,

03/2001

Hepatitis B 1,2,3 11/06/2000 Hib Booster 11/2004

DTP/DTaP 1,2,3 01/2001, 02/2001, OPV 1,2,3 01/2001, 02/2001,

03/2001 03/2001

DTP Booster 11/2004 OPV Booster 11/2004

Measles 08/2001 Varicella 1,2 11/2001

MMR 1,2 11/2001 Hepatitis A 1,2 05/2001

Td 11/2008 11
 Family Profile
Educational
Member Age Occupation Health Status
Attainment

Father 61 HS Carpenter Gout

Mother 54 HS Housewife Healthy

Brother 36 College Safety Officer Healthy

Sister 34 College Sanitary Officer Healthy

Brother 32 Technical None Healthy

Sister 30 College Teacher Healthy

Sister 28 College Accountant Healthy

Sister 26 College Lending company Healthy

Brother 15 Elementary Student Healthy

12
 Family History
Cardiovascular: (-) HTN Allergies: (-) No known allergies Cancer: (-)

Endocrine: (+) DM - Maternal Renal: (-) Renal diseases Seizures: (-)

Uncle and brother

Respiratory: (-) Asthma, (-) PTB Blood: (-) Blood dyscrasia

13
 Socioeconomic & Environmental History

◉ Lives in the 3rd floor of a boarding house in Quiapo,

Manila with cousins
◉ Water supply: Mineral water
◉ Has personal restroom
◉ Garbage is collected everyday, not segregated
◉ No pets
◉ Exposed to secondhand and thirdhand smoke
◉ House is not near a factory, near the main road

14
Physical Exam

15
General Survey: conscious, coherent, not in cardiorespiratory distress, well hydrated,
wasted, ambulatory
Vital Signs: BP 90/60 mmHg, CR 113 bpm, RR 26 cpm, T 37.0 C, SpO2 98% at room air
Anthropometrics: Weight 42 kg, Height 164cm, (z score below -1), BMI 15.6 (z score -2)
Skin: no cyanosis, warm to touch, good skin turgor, (+) 4 cm longitudinal scar located at the
L 5th ICS MAL
Head: evenly distributed fine hair, no nits and lice
Eyes: pink palpebral conjunctiva, anicteric sclera, pupils 2-3 mm ERTL, full intact EOM, (-)
opacities, (+) ROR
Ear: normally set ears, (-) ear discharge, (-) tragal tenderness AU, non-hyperemic EAC
AU, intact TM AU
Nose: nasal septum midline, (-) nasal discharge, (-) alar flaring, (-) congested/inflamed
turbinates
Mouth & throat: moist, pink buccal mucosa, (-) gum bleeding, non-hyperemic posterior
pharyngeal wall, non-hyperemic tonsils, (-) exudates
16
Neck: (-) cervical lymphadenopathies, thyroid gland not enlarged, trachea not deviated
Chest/Lung: (-) retractions, symmetric chest expansion, hyperresonant on right lung field,
decreased tactile and vocal fremiti, decreased breath sounds on the right, (-) adventitious
lung sounds.
Heart: adynamic precordium, apex beat at 5th LICS MCL, (-) heaves, thrills, lifts, (-)
murmurs
Abdomen: flat, (-) visible pulsations, normoactive bowel sounds, tympanitic at all
quadrants, soft, non-tender
Extremities: warm, no gross deformities, no joint swelling, pulses full and equal

17
Neurologic Examination
Cerebral: conscious, coherent, oriented to person, time, place
GCS: 15 (E4V5M6)
Cranial Nerves:
CN 1 - no anosmia
CN II - 2-3mm ERTL
CN III, IV, VI - EOMs intact
CN V - facial sensation intact, can clench teeth
CN VII - no facial asymmetry, can raise eyebrows, resists eye opening, smile, puff
cheeks, frown
CN VIII - gross hearing intact
CN IX, X - uvula midline, GAG reflex not assessed
CN XI - can turn head side to side, raise shoulders against resistance
CN XIII - tongue protrusion midline, no atrophy
Motor: no atrophy, no limitation in active and passive movement
Cerebellar: (-) tremors, (-) clumsiness, (-) ataxia, (-) atonia
Sensory: no sensory deficit
Reflexes: 2+ on all extremities
Meningeal: (-) nuchal rigidity, (-) Brudzinski, (-) Kernig
18
Salient Features
SUBJECTIVE OBJECTIVE
◉ Conscious, coherent, not in cardiorespiratory
◉ 17 year 9 month old, Male
distress, well hydrated, wasted, ambulatory
◉ CC: Difficulty breathing
◉ Previous history of ◉ BP 90/60 mmHg, CR 113 bpm, RR 26 cpm,
pneumothorax - L sided S/P T 37.0 C, SpO2 98% at room air
CTT insertion & VATS ◉ Trachea deviated to the left
◉ Hyperresonant on right lung field
(2/2018) ◉ Decreased tactile and vocal fremiti right
◉ Sudden difficulty of ◉ Decreased breath sounds on the right
breathing, occasional CXR (08/31/18)
cough, discomfort upon ○ area of lucency with no lung markings
lying down flat on the right lung area
◉ (-) fever, (-) asthma, (+) ○ visceral pleural line
vomiting ○ air-fluid level at the right lower
hemithorax
○ hyperinflation was noted
19
Approach to Diagnosis
Look for a sign, symptom or laboratory finding
pointing to a definite organ or system

20
 History and Physical examination
Difficulty breathing, cough, orthopnea, decreased
breath sounds and fremiti, tracheal deviation

Respiratory Cardiac

Pneumothorax Atelectasis Pleural Effusion

21
Differential Diagnosis

22
Classic Physical Findings in some common pulmonary and cardiac disorders

Differential Diagnosis Inspection Palpation Percussion Auscultation

Pneumothorax Asymmetrical Decreased tactile Hyper-resonant Decreased breath

chest expansion fremiti sounds, decreased
Contralateral vocal fremiti
tracheal deviation

Atelectasis Asymmetrical Decreased tactile Dull Decreased breath

chest expansion fremiti sounds, decreased
Ipsilateral tracheal vocal fremiti
deviation

Pleural Effusion Asymmetrical Decreased tactile Dull Decreased breath

chest expansion fremiti sounds, decreased
Contralateral vocal fremiti
tracheal deviation
23
 Primary Spontaneous Tension Pleural
Salient Features Pneumohydrothorax Pneumothorax Effusion

17 year 9 month old, Male Rupture of subpleural bleb Hx of Mechanical History of

Wt 42 kg, Height 164cm, (z score below -1), BMI 15.6 Smoker Ventilation or coronary artery
(z score-2) Young pre-adolescent males resuscitation or disease
Previous history of pneumothorax - L sided S/P CTT
insertion & VATS (2/2018)
Tall and thin body habitus Trauma Dyspnea
Sudden difficulty of breathing occasional cough Sudden onset of dyspnea Hypotension Cough
Discomfort upon lying down flat, (-) fever, (-) asthma, Pleuritic chest pain Tachycardia Low grade fever
(+) vomiting Asymmetrical chest expansion Tachypnea Orthopnea
CXR done showed: Contralateral tracheal deviation Mediastinal shift Asymmetrical
○ area of lucency with no lung markings Hyper-resonance on affected Sudden onset of chest expansion
on the right lung area side dyspnea Decreased tactile
○ visceral pleural line
○ air-fluid level at the right lower
Decreased tactile and vocal Pleuritic chest pain and vocal fremiti
hemithorax fremiti Contralateral Dull on
○ hyperinflation was noted Decreased breath sounds tracheal deviation percussion
Conscious, coherent, not in cardiorespiratory distress Hyper-resonance on Decreased Breath
BP 90/60 mmHg, CR 113 bpm, RR 23 cpm, T 37.0 C, affected side sounds
SPO2 98% Decreased tactile
Trachea deviated to the left and vocal fremiti
Hyperresonant on right lung field
Decreased tactile and vocal fremiti right
Decreased breath
Decreased breath sounds on the right sounds

24
 Expected
Primary Spontaneous Expected Chest
Salient Features Pneumohydrothorax X-ray finding
Chest
Ultrasound

17 year 9 month old, Male Rupture of subpleural bleb visible visceral pleural Absent lung
Wt 42 kg, Height 164cm, (z score below -1), BMI 15.6 Smoker edge is seen as a very sliding (-) comet
(z score-2) thin, sharp white line
Young pre-adolescent males tail
Previous history of pneumothorax - L sided S/P CTT
insertion & VATS (2/2018)
Tall and thin body habitus no lung markings are
Sudden difficulty of breathing occasional cough Sudden onset of dyspnea seen peripheral to this Lung point sign -
Discomfort upon lying down flat, (-) fever, (-) asthma, Pleuritic chest pain line junction between
(+) vomiting Asymmetrical chest expansion lung sliding and
peripheral space is
CXR done showed: Contralateral tracheal deviation absent sliding
radiolucent compared to
○ area of lucency with no lung markings Hyper-resonance on affected (100% specific)
the adjacent lung
on the right lung area side lung may completely
○ visceral pleural line collapse On M mode -
○ air-fluid level at the right lower
Decreased tactile and vocal
fremiti barcode
hemithorax mediastinum should not
○ hyperinflation was noted Decreased breath sounds sign/stratosphere
shift away from the
Conscious, coherent, not in cardiorespiratory distress pneumothorax unless a
sign
BP 90/60 mmHg, CR 113 bpm, RR 23 cpm, T 37.0 C, tension pneumothorax is
SPO2 98% present
Trachea deviated to the left
Hyperresonant on right lung field subcutaneous
Decreased tactile and vocal fremiti right emphysema and
Decreased breath sounds on the right pneumomediastinum
may also be present

(+) air fluid level 25

Salient Features Pleural Effusion Expected Chest
Expected
Chest
X-ray finding
Ultrasound

17 year 9 month old, Male History of coronary artery blunting of the Quad sign -
Wt 42 kg, Height 164cm, (z score below -1), BMI 15.6 disease costophrenic angle
(z score-2) usual
Dyspnea
Previous history of pneumothorax - L sided S/P CTT blunting of the boundaries
insertion & VATS (2/2018)
Cough cardiophrenic angle
Low grade fever fluid within the
defining a
Sudden difficulty of breathing occasional cough
Discomfort upon lying down flat, (-) fever, (-) asthma, Orthopnea horizontal or oblique pleural effusion
(+) vomiting Asymmetrical chest expansion fissures
CXR done showed: Decreased tactile and vocal Sinusoid sign -
meniscus, on frontal
○ area of lucency with no lung markings fremiti
on the right lung area
films seen laterally and inspiratory
Dull on percussion gently sloping medially
○ visceral pleural line (note: if a
decrease in the
○ air-fluid level at the right lower
Decreased Breath sounds
hydropneumothorax is depth of the
hemithorax present, no such
○ hyperinflation was noted effusion,
meniscus will be visible)
Conscious, coherent, not in cardiorespiratory distress classically
BP 90/60 mmHg, CR 113 bpm, RR 23 cpm, T 37.0 C, with large volume demonstrated
SPO2 98% effusions, mediastinal
Trachea deviated to the left shift occurs away from
in M-mode
Hyperresonant on right lung field the effusion
Decreased tactile and vocal fremiti right
Decreased breath sounds on the right

26
 Initial Assessment
Primary Spontaneous Pneumohydrothorax, Right

27
Course in the Ward

28
Upon Admission at the ER (August 31, 2018)
Clinical Features Laboratory Management

● Conscious, coherent, not in ● CBC with platelet ● O2 via face mask at 10

distress, hydrated, tall and count LPM
lanky, ambulatory ● Chest X-Ray (PA) ● IVF: D5NSS 1 L to run at
● BP: 90/60, HR: 113, RR: 26 20-21 gtts/min (100%)
● T: 36.4°C, O2 Sat: 98%, room ● Ampicillin-sulbactam (94.8
air mkday)
● No retractions, no lagging ● Refer to:
● (+) 4cm Scar at left 5th ICS ○ Pediatrics-
MAL Pulmonology
● Symmetrical chest expansion ○ TCVS
● Decreased tactile fremiti, Right ● Emergency CTT insertion
from T6 down
● Hyperresonant, Right
● Decreased breath sounds,
Right
● No crackles, no wheezes
29
Chest X-Ray | 08/31/2018 30
CBC
08/31/2018

31
Day 1 (September 1, 2018)
Clinical Features Laboratory Management

● Comfortable, not in ● Repeat Chest X-ray ● Day 1 of Ampicillin

distress Sulbactam
● BP: 110-125/70-85, HR: ● Maintain O2
51-76, RR: 17 - 25, T: supplementation via
36.5 - 37°C, SpO2 100% face mask at 10 lpm
at 10 LPM via facemask ● Refer to
● No retractions Anesthesiology
● Decreased breath
sounds, right
● Decreased tactile and
vocal fremiti, right
● No wheezes, No
crackles

32
Chest X-Ray
09/01/2018

33
Day 2 (September 2, 2018)
Clinical Features Laboratory Requests Management

● No respiratory ● Na, K ● Day 2 of Ampicillin

distress, chest pain, ● PT, aPTT Sulbactam
comfortable ● 12L ECG ● Encourage incentive
● RR: 18-20, HR: 55-60 spirometry
● O2 sat: 97-100% ● Preop risk assessment:
● Decreased breath PS3 severe
sounds, no wheeze disturbances that
crackles, right interfere with daily
● Decreased vocal and ordinary activity
tactile fremiti, right ● Refer to pediatric
● Abdomen flat, soft, cardiology
nontender
● Good pulses

34
 Ancillaries | 09/02/2018
Coagulation Studies Blood Chemistry

Result Reference Range Result Reference Range

PT 13.7 sec 10.3 - 14.1 Sodium 136 136 - 145 mmol/L

Normal Control 11.9 sec Potassium 4.46 3.5 - 5.1 mmol/L
Prothrombin Ratio 1.1

INR 1.2 0.8 - 1.3

aPTT 42.2 sec 27 - 45 secs

Normal Control 33.2 sec

35
 Ancillaries | 09/02/2018
Electrocardiogram

Rhythm Sinus Bradycardia

Atrial Rate

Ventricular Rate 50 - 60/min

PR 0.16 sec

QRS 0.04 sec

QTA 0.40 sec

QTC

Mean Frontal Praxis

QRS Axis +90° 36

 Day 3 September 3, 2018

● Operation done: Video-Assisted Thorascopic Surgery,

Bullectomy , Right apical segment

● Gross description of the specimen:

Multiple bullae on apical segment of right upper lobe

● Post-operative diagnosis: Primary Spontaneous Pneumothorax,

right probably secondary to ruptured bullae

38
Chest X-Ray |
09/03/2018

39
Day 4 (September 4, 2018)
Clinical Features Management

● Asymptomatic, comfortable ● Day 4 of Ampicillin Sulbactam

● BP: 110/70 ● Patient was advised incentive
● HR: 70-90 spirometry
● RR: 17-22
● No murmurs
● No post-operative complications
noted

40
Day 5 (September 5, 2018)
Clinical Features Management

● Day 2 post-op with no subjective ● Day 5 of Ampicillin Sulbactam

complaints ● O2 supplementation discontinued
● BP: 100-110/60-80
● Shift paracetamol/IV to paracetamol
● HR: 45-63 (w/ resting bradycardia 45-59)
● RR: 18 500mg/tab 1 tab q6 for pain
● SpO2: 100%
● No retractions - Ampicillin Sulbactam shifted to Co-
● Good air entry amoxiclav 1g/62.5mg, 1 tablet every 12
● Improved breath sounds, right hours
● No wheeze
● No crackles
● No crepitus

41
Discussion

45
 PNEUMOTHORAX HYDROTHORAX

Accumulation of Transudate that

extrapulmonary air accumulates in the
within the chest, pleural cavity
most commonly ● Hemothorax: major
from leakage of air chest injuries
● Pyothorax: chest
from within the lung infections
● Chylothorax: rupture
of the thoracic duct

Nelson Textbook of Pediatrics 20th ed. Vol. 2 ch. 411; pg. 2135 46
 Primary spontaneous Secondary spontaneous
pneumothorax pneumothorax
◉ Occurs without trauma or ◉ A complication of an
underlying lung disease underlying lung disorder but
◉ Males who are tall, thin without trauma
◉ Subpleural blebs
Trauma Catamennial pneumothorax
◉ External chest or abdominal
blunt or penetrating trauma ● Related to menstruation
can tear a bronchus or
abdominal viscus, with
leakage of air into the pleural
space
◉ Iatrogenic

Nelson Textbook of Pediatrics 20th ed. Vol. 2 ch. 411 47

PATHOGENESIS

Nelson Textbook of Pediatrics 20th ed. Vol. 2 ch. 41148

 MANIFESTATION

◉ Onset: usually abrupt

◉ Dyspnea, pain, and cyanosis.
◉ Amphoric breathing or, when fluid is present
in the pleural cavity, of gurgling sounds
synchronous with respirations

Nelson Textbook of Pediatrics 20th ed. Vol. 2 ch. 41149

 DIAGNOSIS

◉ Clinical
◉ Radiographic examination
(expiratory view)
◉ Ultrasound
◉ Chest CT scan

Nelson Textbook of Pediatrics 20th ed. Vol. 2 ch. 50

Treatment

51
 Small (<5%)

◉ Normal child may resolve without specific

treatment(usually within 1 wk)
◉ Administering 100% oxygen may hasten
resolution
◉ Analgesic treatment

Nelson Textbook of Pediatrics 20th ed. Vol. 2 ch. 411

Tintinalli’s Emergency Medicine 8th ed. Ch 68
52
Recurrent/Secondary/Under Tension/>5% Collapse

◉ Chest tube drainage is necessary

Nelson Textbook of Pediatrics 20th ed. Vol. 2 ch. 411

Tintinalli’s Emergency Medicine 8th ed. Ch 68 53
Closed Thoracotomy

54
Tension pneumothorax

◉ Needle aspiration/tube thoracostomy

Nelson Textbook of Pediatrics 20th ed. Vol. 2 ch. 41155

Chemical pleurodesis

◉ Talc
◉ Doxycycline
◉ Iodopovidone

Nelson Textbook of Pediatrics 20th ed. Vol. 2 ch. 41156

Open Thoracotomy/VATS

57
 PROGNOSIS

◉ Without a surgical treatment, after 1st ep (16-58%), 2nd (60%),3rd (80%)

◉ Biggest proportion of recurrences (>60%) were observed within 2 years
after the initial attack, with a reported risk (from 6% to 18%) of a
pneumothorax in the contralateral lung
◉ Children vs. adult (50%vs 30%)
◉ Blebs/bullae (48%) vs none (20%)
◉ VATS (13%) vs chest drain (42%)

58
Furia S, Breda C. Primary spontaneous pneumothorax in children and adolescents: a systematic review. Pediatric Med
2019;2:12. doi: 10.21037/pm.2019.04.01
Journal

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60
Outcomes

◉ Primary
○ Ipsilateral recurrent spontaneous pneumothorax
verified by chest radiography
◉ Secondary
○ Complications
○ Length of Hospitalization

61

Criteria
Inclusion
◉ Patients in Western
Denmark
◉ Admitted with their 1st
episode of PSP verified by
chest radiography within a
7 year period
◉ Otherwise healthy
◉ 18 - 40 years old
Exclusion
◉ Minors (< 18 years old)
◉ > 40 years of age
◉ Previous pneumothorax
◉ Secondary spontaneous
pneumothorax
◉ Pregnancy
◉ Breastfeeding
◉ Previous chest surgery
◉ Known contraindications for
general anesthesia
◉ Patients presenting with a
small and asymptomatic
pneumothorax
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68
69
 Conclusion

◉ VATS was an effective treatment to prevent ipsilateral recurrence in

patients with the 1st presentation of PSP
◉ Large bullae as an independent predictor for recurrence
◉ Recommendation: all patients admitted with their 1st incident of
PSP should undergo HRCT and if this reveals major dystrophic
lesions > 2 cm, preventive surgery should be the standard of care

70
Thank You

71