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Case history: Patient first reported to the hospital on May 15, 2013, with complaint of severe right shoulder pain and at some times breathlessness.

Case history: Patient first reported to the hospital on May 15, 2013, with complaint of severe right shoulder pain and at some times breathlessness. Clinical examination could not reveal much apart from pain complaint. An X-ray was ordered and revealed nothing abnormal. Patient was treated as an outpatient.

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Figure 1

On June 5, 2013, the patient reported back to the hospital in critical clinical condition, severe breathlessness. The patient also had a fever. Immediately patient was commenced on oxygen therapy. An X-ray was taken and radiograph revealed gas below the diaphragm. However the clinician on duty did not notice the gas. And patient was treated for pneumonia and asthmatic attack.

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Figure 2: An AP CXR showing gas below both diaphragms

On the third day we looked at the radiograph and noticed gas below the diaphragm. This gave us suspicion of perforation. To convince the clinical department that it was perforation, an erect anteroposterior view of the chest was retaken including a supplementary view left lateral decubitus.

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Figure 3: An AP view of the Chest radiograph (see gas below the right diaphragm

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Figure 4: Left lateral decubitus view revealing fine line suggestive of fluid level

Radiographers also complimented the radiographic findings with ultrasonongraphy. The second imaging modality revealed free peritoneal fluid which had an increased echogenicity and suggestive of pus or leaked gastrointestinal contents. Following radiographic and ultrasound findings and discussion with medical ward clinician, patient was referred to surgical department for surgical intervention.

Surgery revealed a lot of pus in the peritoneum. The surgeon aspirated three liters of pus. Patient was put on gentamycin and metronindazole.

After surgery patient showed no improvement; the abdomen started distending and there was high fever. This necessitated surgeon to order pus culture and sensitivity. It isolated culprit organism as streptococcus pyogenes which was resistant to gentamycin and sensitive to ampicillin, amoxicilline and chloraphenicol. Patient was then put on ampicillin and improved greatly.

Nelson Nkosi, Zone Radiography Supervisor
Zone Health Support Office, Mzuzu, Malawi

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