22 “Must See”

Diagnostic Images for

Medical Students

William Herring, M.D. © 2004

 AMSER’s “Shortlist”
 AMSER is the national Alliance of Medical
Student Educators in Radiology
 Their National Curriculum for Medical
Students, developed by Kitt Shaffer, MD and
Petra Lewis, MD, contains a “Diagnostic
Shortlist” of “must see" images “all students
should recognize”
 This is a limited list of diagnoses that
AMSER believes all students should be able
to recognize, regardless of their planned
specialty
Diagnosis
1
Can you tell why this patient is short of breath?
Tension pneumothorax
Tension pneumothorax
Pneumothorax
Pneumothorax
 Pneumomediastinum
(Mediastinal Emphysema)
 Rare in adults (except in ICU patients) and most
common in newborns
 ETIOLOGIES
Spontaneous – most common mechanism in kids and adults

 Pathophysiology involves increased intralveolar pressure such as

from cough or vomiting which ruptures alveolus, air tracks back
along blood vessels to mediastinum
 Accompanying pneumothorax common in neonates
 When air builds up in mediastinum and can’t pass into the neck
(especially in kids) this produces mediastinal air block which can
reduce flow of blood in great vessels
 In adults, the air in mediastinum usually progresses into the neck
and the subcutaneous tissue

Traumatic – 2° closed chest trauma

Same mechanism as spontaneous
 Rupture of the esophagus – Boerhavve's
Syndrome
 May occur with vomiting, labor, severe asthmatic
attacks and strenuous exercise (each of these can
produce pneumomediastinum without rupturing the
esophagus)
 LEFT, POSTEROLATERAL WALL, DISTAL 8 CM

 X-ray – combination of pneumomediastinum and left pleural

effusion is very suggestive; continuous diaphragm sign
 Symptoms – infants – none.
 Adults – chest pain (retrosternal) radiating down both arms
aggravated by respiration and swallowing; Hamman’s
sign – crunching sound heard over the apex of the heart with
cardiac cycle