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Pulmonary Fibrosis

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History of Present Illness:

A 72-year-old female with a history of pulmonary fibrosis presents to the ED for 3 days of gradually worsening painless SOB.  She denies any fever or other complaints

Vital Signs & Physical Exam:

Vital signs are normal except for a pulse of 125, RR of 38, Sat of 93 and BP of 200/120.  Physical exam is otherwise normal except for Velcro rales on the left and diminished breath sounds on the right.

Initial Differential Diagnosis:

  • Pneumonia
  • Pleural effusion
  • Pneumothorax

Initial Diagnostic Testing:

  • Imaging: see CXR below

QUESTIONS:

  1. What does the case image show?  
  2. What should you do next?  
  3. Want a 1-minute consult/tutorial on this case? 
  4. Want to know what happened with this patient?

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ANSWERS:

  1. What does the case image show?  The image shows a large PTX with onset of mediastinal shift (radiographic tension PTX).
  2. What should you do next?  Emergent chest tube thoracostomy
  3. Want a 1-minute consult/tutorial on this case?  See yellow area from sample page below.
  4. Want to know what happened with this patient?  See case conclusion below tutorial page.

1-Minute EM Consult on the topic for this case from the Emergency Department Quick Reference Guide

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CASE CONCLUSION: Chest tube successfully re-expanded lung.  Suction was avoided to minimize risk of re-expansion pulmonary edema.  The patient was admitted and did well.

CASE LESSONS:

  1. Always check for tracheal deviation when there are unilateral diminished breath sounds
  2. Never start with suction on the water seal if the lung may have been down for more than 2-days.
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