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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:
- What does the case image show?
- What should you do next?
- Want a 1-minute consult/tutorial on this case?
- Want to know what happened with this patient?
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ANSWERS:
- What does the case image show? The image shows a large PTX with onset of mediastinal shift (radiographic tension PTX).
- What should you do next? Emergent chest tube thoracostomy
- Want a 1-minute consult/tutorial on this case? See yellow area from sample page below.
- 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:
- Always check for tracheal deviation when there are unilateral diminished breath sounds
- Never start with suction on the water seal if the lung may have been down for more than 2-days.