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Study: Stiff neck
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.
P120, RR24, BP 130/80, SaO2 99% room air
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
guarding or rebound.
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
Case courtesy of Susan O'Malley, M.D.