Clinical examination of the chest revealed a linear bruise mark on the front of the chest, this was

the initial, direct injury as a result of the car crash since it was a head on collision. This blunt force
led to a fracture of the lower part of the sternum. The sternum, displaced because of the fracture,
caused tenderness in the lower half of the sternal area. A portable X-Ray of the chest confirmed
this fracture.
The fracture & displacement of the sternum most likely resulted in fracture of lower ribs, as these
are connected to the sternum by the intercostal cartilages. This caused multiple bruises on lateral
aspect of the right chest and caused tenderness where the broken ribs pierced the overlying flesh.
Fractured ribs penetrated the right lung, which led to puncture of the lungs. This led to air escaping
from the lung and filling the pleural cavity, between the lung and chest wall. This buildup of air put
pressure on the lung, preventing it from expanding normally, resulting in decreased expansion of
the right chest during breathing and ultimately to the collapse of the lung, that is, Tension
Pneumothorax. This escaped air caused the presence of a subcutaneous crepitus on the right
side of the chest as air gets into tissues under the skin. The fractured ribs along with the punctured
lungs caused severe pain in right side of the chest and prevented the patient from breathing
normally, resulting in rapid, shallow breathing of 30 breaths per minute. The collapsed lung also
resulted in absence of lung markings in the X-Ray, lung markings normally extend to the very
edge of the thoracic cavity. Presence of thin white line on right side of the chest in the X-Ray was
because of buildup of fluid in the interstitium of the lung.
(ALTERNATE SCENARIO) This lung collapse however is most likely not a pneumothorax (which is a
complete collapse of the lung). The absence of breath sounds only in the lower half of the right chest
suggest an incomplete or partial lung collapse, also known as atelectasis.

The fact that the lateral aspect of the right chest wall sucked in which each breathe means that
the patient had flailed chest. The flail segment moves in the opposite direction to the rest of the
chest wall because of the ambient pressure in comparison to the pressure inside the lungs.
Since the heart sounds were normal, it means there was no cardiac tamponade. However, the
hypotension (95/50), sweatiness, paleness and especially the low volume pulse of 120 per
minute- suggest massive internal bleeding. (Hemorrhagic shock)
Doctor on duty ordered for a procedure in emergency as tension pneumothorax is a life
threatening condition as the buildup of air causes a positive pressure, which can displace
mediastinal structures, put pressure on the heart and damage it, resulting in compromise of the
cardiopulmonary function.

References:
https://www.medscape.com/answers/424547-67555/what-is-tension-pneumothorax
https://www.mayoclinic.org/diseases-conditions/low-blood-pressure/symptoms-
causes/syc-20355465
http://education.rad.msu.edu/Resources/IM_Tutor/pages/steps/step8.htm
https://medlineplus.gov/ency/article/000087.htm
https://www.summitmedicalgroup.com/library/adult_health/aha_collapsed_lung__injury_
related/
https://medlineplus.gov/ency/article/007535.htm
https://www.medicalnewstoday.com/articles/318682#Treatment
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3665058/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6625325/
https://www.biofeedback-tech.com/articles/2016/3/24/the-blood-volume-pulse-
biofeedback-basics