Author: Ammar M Salem / Editor: Jason M Kendall / Reviewer: Michael Perry / Codes: A2, R2 / Published: 27/03/2021
A 67-year-old man is brought into the Emergency Department with a history of fainting on the way to the bathroom in the morning. He collapsed and felt dizzy. He had right sided lower chest pain (tight and not pleuritic).
He had a past history of a laparotomy for a perforated appendix with peritonitis 3 weeks before this ED presentation. He completed a course of oral antibiotics after hospital discharge. He is not on regular medication.
On examination he is pale, sweaty and peripherally shut down. His observations are as follows: P = 75 (irregular), BP = 98/77, SaO2 = 100% on 15 litres O2, RR = 24, Temperature = 35.7 degrees centigrade. His JVP is elevated. On chest auscultation he has good bilateral air entry with no added sounds.
His laparotomy wound has a small open area with granulation tissue and slight oozing. His abdomen is soft with mild right upper quadrant discomfort on palpation. There is no guarding. He has bilateral leg oedema.
His ECG shows atrial fibrillation with a ventricular rate of 86 per minute and anterior T wave inversion.
His arterial blood gas analysis on 15litres O2 is: pH = 7.50, pCO2 = 3.39kPa, pO2 = 22.52kPa, HCO3 = 22.4mmol/l, BE -2.5, lactate = 2.76mmol/l.
Plasma glucose = 12.6mmol/l.
His CXR is shown below (the elevated right hemidiaphragm is similar on a previous CXR):
