Pneumomediastinum diagnosed from a remote tele-ICU center?


Background: The propagation of remote “telemedicine” has allowed intensivists (and other medical professions) to expand their ability to provide critical care medicine services to intensive care units (ICUs). The physical exam is a pertinent skill that all providers learn early in their medical careers. Key components of the physical exam can help a clinician narrow the differential diagnosis. Even with modern monitoring devices and high-powered imaging, it is hard to replicate the physical exam on a critical care patient from a tele-medicine center.

Case presentation: An experienced intensivist working in a telemedicine (Tele-ICU) center reviewed the daily chest radiograph on a patient with a complex prolonged ICU course. The radiograph was immediately recognized as being concerning for an acute case of pneumomediastinum in a patient with recent tracheostomy manipulation. However, the intensivist was unable to corroborate his suspicions with a good physical exam as the differential diagnosis list was explored.

Conclusions: Acute pneumomediastinum is a severe disease process arising from numerous etiologies that can be life threatening. This disease process can often times be diagnosed from plain chest radiography alone. However remote telemedicine patient care should never supersede a direct bedside physical exam. Every good clinician knows that the fundamental physical exam truly is fundamental.

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