WIDI - C20) Post-operative dyspnea

C20) Post-operative dyspnea

Review the Learning Outcomes, Hx, PE and Labs, and begin the module with your Provisional Diagnosis. Keep hitting "Next" to move through the module.

Learning Outcomes

Articulate your relationship with the consulting diagnostic radiologists in the evaluation of a patient with hypoxia.
Review the DDx considerations in a patient with hypoxia.
Identify the spectrum of imaging findings in appropriate modalities for evaluating a patient with hypoxia.

History

A 65-year-old female undergoes a laparotomy and sigmoid resection for a perforated diverticulitis. The patient reports uncontrolled post-surgical pain and subjective dyspnea eight hours post-operatively.

Physical Exam

BP: 117/65, HR 99, RR 21, Temp 36.4, O2 saturation 88%. General: Patient is morbidly obese. Appears comfortable. Pulmonary: Decreased breath sounds at lung bases. Shallow breaths.

Labs

WBC: 12,000 (nl 4,500 to 11,000 x 10^9/L)

Provisional Diagnosis

Select the Dx you believe is most appropriate

Pneumothorax

Pneumonia

Atelectasis

Deep venous thrombosis with pulmonary embolism

The patient’s post-operative hypoxia is most likely secondary to atelectasis considering uncontrolled pain leading to shallow breaths and decreased breath sounds at the lung bases. The elevated white blood cell count most likely represents reactive leukocytosis following surgery.

Well done. You were correct

Potential Acuity

What is your assessment of the likely acuity for this patient?

Emergent (immediate plan required)

Urgent (plan required within 4 hours)

Routine

Well done. You were correct

This patient should be evaluated to prevent respiratory decompensation.

First Imaging Study

What is the first imaging study you will order?

Chest X-ray

Chest CT

V/Q scan

A chest X-ray is a good initial test to evaluate respiratory issues.

View ACR Appropriateness Criteria

Well done. You were correct

Pertinent Imaging Observations

Click on the links below to view images from the study, and assess these key findings as best you can.

Chest x-ray

What best describes the findings on the Chest X-ray?

Linear densities

Lobar collapse

Airspace opacifications

All of the above

View Report

Watch our video

View the full study if you'd like to take a look yourself.

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Second Imaging Study

What is the next imaging study you will order?

Chest CT

None

The diagnosis is made with chest x-ray.

Well done. You were correct

What is your Diagnosis now that you have seen the imaging results?

Subsegmental atelectasis

Linear atelectasis

Round atelectasis

Both A and B

Both A and C

This patient has post-operative linear atelectasis, which is a form of subsegmental atelectasis.

Current Acuity

Initially, you selected and we suggested acuity.

Has your concern for this patient changed?

Emergent (immediate plan required)

Urgent (plan required within 4 hours)

Routine

Although their condition is not immediately life threatening, this patient requires management.

Assessment and Plan

Please provide your assessment and plan for this patient

This is a 65-year-old female with post-operative subsegmental atelectasis. She will require an incentive spirometer with education and frequent encouragement on its use. She should also be on a multi-modal pain regimen to ensure adequate pain control to permit adequate respiration.

Lessons Learned:
- Subsegmental atelectasis often is more likely to occur in obese patients with poor post-operative pain control who do not use incentive spirometry.
- By definition, subsegmental atelectasis includes all atelectasis forms that do not involve an entire bronchopulmonary segment. This patient has linear atelectasis, which is a form of subsegmental atelectasis.

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