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A 55 year old man suffered severe car accident and brought to the ER. He was disoriented and tachypnic and had sever tenderness upon palpation of the left hemithorax. Initial skeletal survey showed fracture right femur and elevated left hemidiaphragm. There was diminished breath sounds on the left side and the saturation was 83% on room air. What could be the cause of this patient's diminished breath sounds?

A- Diaphragmatic rupture
B- Pulomary fat embolism
C- Tension pneumothorax
D- Pleural effusion
E- Tracheal/bronchus rupture
 

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It should be diaphragmatic rupture indeed. Notice that the question stem underlines that the problem has to do with the LEFT hemithorax. The left hemidiaphragm is more vulnerable to rupture following a rapid increase of intra-abdominal pressure (the hemidiaphragm bursts like an overinflated balloon, a scenario compatible with this trauma case). On the contrary, the right hemidiaphragm is "protected" from this "ballooning" by the liver. Diminished breath sounds on the left just come to complete the picture of constraint of the left lung.
 

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It should be diaphragmatic rupture indeed. Notice that the question stem underlines that the problem has to do with the LEFT hemithorax. The left hemidiaphragm is more vulnerable to rupture following a rapid increase of intra-abdominal pressure (the hemidiaphragm bursts like an overinflated balloon, a scenario compatible with this trauma case). On the contrary, the right hemidiaphragm is "protected" from this "ballooning" by the liver. Diminished breath sounds on the left just come to complete the picture of constraint of the left lung.
i absolutely agree with u
 

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RE: Why not fat embolism

Why not fat embolism!
It's not fat embolism because although the patient is presented with fracture femur (most common cause of fat embolism) and hypoxemia and depressed consciousness all of which are typical features of fat embolism, there should be a specific mention of neck/axilla petichae otherwise nobody can ever say this is fat embolism.
Moreover, the chest x ray clearly pointing to traumatic diaphragm rupture.
 
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