A 70-year-old man comes to the emergency department due to severe right-sided chest pain and shortness of breath after a fall. While doing yard work, the patient fell off of a ladder, striking his back on several large stones. Immediately afterward, he felt sharp pain over his posterior chest and had trouble catching his breath. Blood pressure is 120/80 mm Hg, pulse is 88/min, and respirations are 24/min. Chest x-ray is shown in the exhibit. Physical examination of the right side of the chest would most likely reveal which of the following?

Question

A 70-year-old man comes to the emergency department due to severe right-sided chest pain and shortness of breath after a fall.  While doing yard work, the patient fell off of a ladder, striking his back on several large stones.  Immediately afterward, he felt sharp pain over his posterior chest and had trouble catching his breath.  Blood pressure is 120/80 mm Hg, pulse is 88/min, and respirations are 24/min.  Chest x-ray is shown in the exhibit.  Physical examination of the right side of the chest would most likely reveal which of the following?

Quizplus · Accepted Answer

11ec160b_3b43_7256_9249_b57dc7034bf3_MD0001_00 This patient experienced sudden-onset shortness of breath and chest pain following chest trauma; chest x-ray shows several rib fractures and a collapsed right lung, findings consistent with traumatic pneumothorax. Traumatic pneumothorax can result from puncture of either the chest wall (eg, penetrating chest trauma) or the lung (eg, by fractured ribs), allowing air to enter the pleural space. The communication pathway causes intrapleural pressure to equalize with atmospheric pressure (ie, loss of intrapleural negative pressure), which prevents lung expansion during inspiration and leads to breathing difficulty. Because air in the pleural space insulates sounds and vibrations originating in the airways, physical examination reveals decreased breath sounds and decreased tactile fremitus on the affected side. In addition, the relatively low density of air compared to normal lung tissue causes hyperresonance to percussion. Disruption of the skin or parietal pleura during the initial injury often allows air to enter the subcutaneous tissues of the chest wall, which is detected as subcutaneous crepitus (ie, crackling during palpation). (Choice A) Bronchophony is a phenomenon in which spoken words (eg, "ninety-nine," "toy boat") are heard more loudly and clearly when auscultated over an area of alveolar consolidation (eg, lobar pneumonia) compared to normal lung. It results from increased sound transmission due to increased tissue density. (Choice B) Dullness to percussion over the chest is expected with conditions that cause increased density (eg, hemothorax, pleural effusion, alveolar consolidation) compared to normal lung tissue. (Choice C) The increased thoracic pressure with pneumothorax flattens the resting position of the diaphragm and restricts its movement with respiration. Therefore, diaphragmatic excursion (the distance the diaphragm moves between expiration and inspiration) is decreased. (Choices D and F) Prolonged expiration and wheezing are expected with bronchoconstriction, usually in the setting of obstructive lung disease (eg, asthma, chronic obstructive pulmonary disease). Bronchoconstriction is not expected with pneumothorax. Educational objective: Traumatic pneumothorax can involve puncture of either the chest wall (eg, penetrating chest trauma) or the lung (eg, by fractured ribs), allowing air to enter the pleural space. Patients usually experience chest pain and difficulty breathing. Crepitus, caused by air in the subcutaneous tissues of the chest wall, is often present on physical examination. __________ References: Principles of diagnosis and management of traumatic pneumothorax. (http://www.ncbi.nlm.nih.gov/pubmed/19561940)

A 70-Year-Old Man Comes to the Emergency Department Due to Severe