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Diaphragmatic rupture
78%
36/46
Perforated viscus
2%
1/46
Pulmonary contusion
7%
3/46
Spontaneous pneumothorax
Tension pneumothorax
9%
4/46
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This patient is presenting with shoulder pain, vomiting, shortness of breath, and a radiograph demonstrating bowel in the chest after a motor vehicle accident, which suggests a diaphragmatic rupture.Diaphragmatic rupture typically occurs after trauma. Bowel in the chest will be seen on chest radiography. Shoulder pain is due to referred pain secondary to irritation of the phrenic nerve (C3, 4, and 5). Patients will also have decreased respiratory function given the compression of the lungs by the bowel. Patients should promptly be made nil per os, given a nasogastric tube, and sent to the operating room for surgical correction. Surgical repair consists of closure of the defect and relocation of the bowel to the abdomen.Adamthwaite reviews the evidence regarding the diagnosis and treatment of diaphragmatic hernias. He discusses how it is commonly diagnosed with imaging. He recommends surgical repair using an abdominal approach.Figure/Illustration A is a chest radiograph demonstrating the bowel in the chest cavity on the patient's left (red circle). This suggests a diagnosis of diaphragmatic rupture.Incorrect Answers:Answer 2: Perforated viscus presents after trauma with free air under the diaphragm on radiography. Treatment is with emergent surgical laparotomy.Answer 3: Pulmonary contusion presents with diffuse opacification of the lung several hours after blunt chest trauma, shortness of breath, and O2 desaturation. Treatment is with respiratory support.Answer 4: Spontaneous pneumothorax presents with a radiolucent area on the chest radiograph typically secondary to rupture of an emphysematous bleb. Treatment is supportive for small lesions (without symptoms and with stable vitals) and decompression of larger lesions.Answer 5: Tension pneumothorax occurs due to penetrating chest wall injury with an absence of pulmonary markings on chest radiography. Signs of tension include hemodynamic instability, tracheal deviation, and jugular venous distension.Bullet Summary:Diaphragmatic rupture presents with nausea, vomiting, shortness of breath, shoulder pain, and bowel in the chest on radiography.
4.7
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