Respiratory Medicine in Dundee
Case of the Week #1
 Can you explain the CXR findings? | A 51 year old man attends the A&E department having fallen 20 feet from a ladder whilst clearing out his gutters. He complains of right sided chest pain, worse on inspiration. He is a smoker, with hpypertension controlled with “a couple of pills”. He has no allergies. He has oxygen saturations of 95 % on room air, a respiratory rate of 20, heart rate of 110, and a blood pressure of 140/85 On examination he has diffuse tenderness around the right lateral chest. There is dullness to percussion over the right lateral chest. Breath sounds are reduced over the same area. The CXR is shown. |
Discussion points:
1. Why is he tachycardic?
He is in pain. Pain is an often overlooked cause of tachycardia. Remember, when faced with an unexplained tachycardia, to think of pain, PE, and occult infection.
2. What does the CXR show?
There is right sided consolidation. The pattern of consolidation is more likely to be pulmonary contusion, rather than infection; the history is more compatible with pulmonary contusion.
3. How many rib fractures does he have?
Trick question. It’s not possible to quantify rib fractures on a CXR. If they are visible, they are there, but the CXR is not sensitive – rib fractures are easily missed. In your A&E posts, you will see patients wanting a CXR to see if they have rib fractures; a CXR is only indicated if you feel a pneumothorax is likely.
4. How long will it take for the problem to resolve?
The pulmonary contusion is likely to resolve radiologically within a couple of weeks, but any rib fractures will take at least 6 weeks to heal fully.
5. How much oxygen should you put him on?
He doesn’t need to be on any oxygen! His saturations are normal on air.
Hi,
I was just wondering about the rib fractures in this case. Are there any? I know you said you can’t see them, but how would you check for them instead? CT? Would it be worth checking for them? Is there a risk of further damage if there were fractures and they were just left?
Also (I could be making this up!) but is there a pneumothorax seen on the lateral edge of the left lung? There is a thin white line and I’m not sure what it could be if it isn’t a pneumothorax and I don’t know if this would be relevant with this patient’s right sided lung injury (unless he was very unlucky)
Sorry for all the questions!
Cheers!
Caitlin.
Please ignore the above comment, is the thin white line the scapula?
Sorry! I should have waited to figure it out first!
Sorry! Please ignore the above comment, is the thin white line the scapula?
I should have waited to figure it out first!
(Also, is there something wrong with the right clavicle at the Sternoclavicular joint?)
Rob fractures. Essentially a clinical diagnosis. We don’t do CTs to look for the fractures, as it doesn’t make any difference to the outcome – they heal by themselves, and we can’t put the thorax in a stookie.
Yes, that’s the clavicle.
The sternoclavicular joint is normal, the CXR is just a bit squinty.
Thanks!
And sorry about the “technical difficulties”, I didn’t mean to post 3 posts!!