A 57-year-old male smoker attends the ED complaining of 24-hours of sudden onset pleuritic chest pain. He is only coughing a small amount of white sputum (normal for him) and denies a fever. Percussion of the chest is equal bilaterally and on auscultation you identify no wheeze or crepitations. You cannot elicit any chest wall tenderness and the ECG is normal.
His observations are BP 150/90, pulse 90 and regular, O2 sats. 93% on room air, temperature 36.9 degrees Celsius, and respiratory rate (RR) 22. There is no clinical suggestion of a DVT. You request a D-Dimer, a chest radiograph and perform blood gases on room air.
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The results are as follows:
|D-Dimer and Blood Gasses
|D-Dimer – not elevated
True or false: A pneumothorax can be seen on the chest radiograph.
Which of the following investigations is the most likely to identify the presence of an occult pneumothorax?
The CT thorax demonstrates a small pneumothorax. According to the BTS guidelines, what is the treatment for this 57-year-old gentleman, who denies breathlessness?
You offer to admit the gentleman for observation and fixed concentration oxygen. He refuses to come in because the pain is mild, he doesn’t feel breathless and nothing will be done other than giving extra oxygen.
Explain to the patient how giving extra oxygen may help.
He is not convinced by your interpretation of Henry’s Law and he is concerned that he will not be allowed to smoke on the ward and leaves against medical advice.
You write to the GP, recommending referral of the patient to a respiratory physician and before he leaves you ensure that the patient is given verbal and written advice.
The patient returns by ambulance the following day complaining of increasing breathlessness. His oxygen saturations are 90% on 35% oxygen and his respiratory rate is 24. You perform an AP chest radiograph in the resuscitation room. This is shown below.
True or False: The radiograph shows a large pneumothorax.
The pneumothorax is highlighted in yellow in the radiograph shown on the right.
According to the BTS guidelines what is the treatment for this 57-year-old gentleman, who is breathless?