Question

A 23 yo health scuba driver with no medications begins to have retrosternal chest pain 4 hours after her ascent to the surface. She has never had any problems related to diving before. She was well within her prescribed dive times and followed appropriate guidelines in her ascent. On exam, she appears anxious and has palpable swelling in her neck. A crunching sound is heard over the precordium during the cardiac exam. What is the most likely diagnosis? A. Commotio cordis B. Pneumomediastinum C. Pulmonary barotrauma D. Pulmonary embolus

Answer 1

The most likely diagnosis is B. Pneumomediastinum.

Step-by-step explanation:

Pneumomediastinum is a condition characterized by the presence of air in the mediastinum, the space in the chest between the lungs. In the given scenario, the patient experienced retrosternal chest pain and palpable swelling in the neck, which are consistent with the clinical manifestations of pneumomediastinum. The crunching sound heard over the precordium during the cardiac exam, known as Hamman's sign, is a classic finding associated with pneumomediastinum. This occurs due to the movement of air in the mediastinum during the cardiac cycle.

The patient's symptoms likely resulted from barotrauma during scuba diving. Barotrauma occurs when there is a pressure difference between the inside and outside of the body, leading to the release of air into the mediastinum. The ascent during scuba diving may have caused expansion of trapped air in the lungs, leading to alveolar rupture and subsequent migration of air into the mediastinum. This can explain the chest pain and the palpable swelling in the neck. It's crucial to consider pneumomediastinum in individuals experiencing chest pain after diving, as prompt recognition is essential for appropriate management and preventing complications.

In conclusion, the patient's symptoms, physical findings, and the context of scuba diving suggest that pneumomediastinum is the most likely diagnosis. Awareness of this condition is vital for healthcare professionals involved in the care of individuals engaged in activities with pressure changes, such as diving.

Answer 2

The most likely diagnosis in this scenario is B. Pneumomediastinum.

Step-by-step explanation:

Pneumomediastinum involves the presence of air in the mediastinum, the space in the middle of the chest between the lungs. In this case, the retrosternal chest pain, palpable neck swelling, and the presence of a crunching sound (Hamman's sign) over the precordium during the cardiac exam strongly suggest pneumomediastinum.

It commonly occurs due to barotrauma during scuba diving, where changes in pressure can lead to the rupture of alveoli, allowing air to leak into the mediastinum. The physical exam findings align with the classic signs of pneumomediastinum and can be further confirmed by imaging studies like a chest X-ray or CT scan.

Pulmonary barotrauma, another possible consideration, may lead to pneumomediastinum. However, the characteristic findings of retrosternal chest pain, palpable neck swelling, and Hamman's sign during the cardiac exam favor pneumomediastinum as the primary diagnosis in this case. Differential diagnoses such as commotio cordis (a sudden impact to the chest causing fatal arrhythmias), pulmonary embolus (blood clot in the lung arteries), or other cardiac issues are less likely given the presented symptoms and examination findings.

The key to the diagnosis lies in recognizing the distinct clinical signs associated with pneumomediastinum after scuba diving, differentiating it from other conditions, and confirming it through appropriate imaging studies for definitive confirmation and treatment guidance.