Case of the Week #1
|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.
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.