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Case Study: Stiff neck

CC: "Stiff neck "

HPI:
38 year old female presents18 hours status post colonoscopy with removal of two polyps at the hepatic flexure complaining of stiff neck and difficulty breathing. Patient reports gradual onset of submandibular swelling, stiff neck and difficulty breathing since procedure. Patient believes she is having an allergic reaction to the anesthetic agent. Patient denies any other symptoms.

VS: afebrile, P120, RR24, BP 130/80, SaO2 99% room air

PE:
GEN: mild distress
HEENT: no photophobia, submandibular swelling
NECK: no meningismus, subcutaneous emphysema
LUNGS: clear to auscultation, no wheezes, rales or rhonchi
COR: tachy regular rhythm, no murmurs, rubs or gallops
ABD: soft, nondistended, nontender, normal active bowel sounds, no
guarding or rebound.

	QUESTIONS: 1. Where is there air? 2. Where is the perforation? RESULTS/DISCUSSION:
View large image

ANSWERS/DISCUSSION:

1. This patient has air under the diaphragm, pneumomediastinum, pneumopericardium (notice where the air stops at the pericardial reflection), and subcutaneous emphysema in the soft tissues of the neck.

2. This patient has a retroperitoneal perforation at the hepatic flexure. The psosas muscle and right kidney are outlined by air. This combined with the clinical history indicate a retroperitoneal perforation. Retroperitoneal perforations can dissect up into the thorax whereas peritoneal perforations do not.

• This patient requires an urgent surgical consult.

Case courtesy of Susan O'Malley, M.D.