Clinical Case 009: Thor-racic Trauma
This is one of the freakiest cases I have ever seen, and it all happened exactly as below I swear. Apologies for the apalling pun in the title, but it is so rare that I get the chance to combine Nordic mythology with trauma blogging – just had to do it…
Fit, healthy 25 yo labourer is dropped off to ED by workmates after a day toiling in a trench. He states he felt something hit him in the chest whilst working with a pick and sledge hammer on some rocks. He didn’t bother to look at the time, but now 3 hours later he noticed a bit of blood on his thick, flannel shirt, hence the trip to ED – “do I need stitches?”
So I did my usual thing – send in the Med Student to check it out. He comes back with the following history: fit guy aside from a spontaneous pneumothorax 3 years ago. Well, normal obs, complaining of mild pleuritic left chest pain “a bit like the pneumothorax”. He as a small skin lac… 5 mm wide just over the pect major. Chest exam all normal.
To examine: the wound was small, explored with a bit of local, it didn’t seem to be more than a cm deep, no track. I wanted to sew it up and send the chap home, but my very astute, super-keen M.Student wanted to call the poor Radiographer in from her dinner to do a CXR in order to exclude a repeat PTX. So I said:
“Fine, if you write the form and explain it to the cranky Xray staff then you can do a CXR.” So we got one…
And what did it show? I was thinking – I’ll teach this student to stop wasting money and irradiating patients when it comes back normal…
The CXR was done and 5 minutes later the Radiographer came running around looking a bit worried….click here to see why FYI there was no pneumothorax on the full view.
Umm yeah, is that where I think it is? And what is it?? Maybe a lateral CXR will show us some more…
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About The Author
Casey Parker
I am a GP working in Broome, NW of Western Australia. I work as a hospital DMO (District Med Officer) doing Emergency, Anaesthestics, some Obstetrics and a lot of miscellaneous primary care. Also on the web as @broomedocs | + Casey Parker | Contact
love your work- keep it up
cheers from exmouth via margaret river
Good pick Casey,just remember its always in the history.
Great Case Casey. Chest trauma can cause isolated tachycardia in the treating staff and flight doctors.
“He states he felt something hit him in the chest whilst working with a pick and sledge hammer on some rocks”
As soon as I read that, I knew exactly what you’d (hopefully!) find. The only thing I got wrong was that I was expecting it to be a stone chip or splinter (& possibly not as visible on an X-ray), rather than a chip from the sledgehammer. This sort of injury is common in workplaces where metal is being machined or otherwise banged on. It’s more than a little scary to me that nobody picked up on it immediately.
Yep, it is always in the history – as Dr Jameson has said above.
90% of diagnoses are in the history they say. The story, the context and the clinical picture are required to diagnose most diseases.
Gotta say, even with the story, the end-result in this case was a bit extreme. I would expect a subcut FB at worst!
The real lesson here – be cautious. In the remote parts of Australia, th epatient doesn’t have the luxury of a second opinion or going to the bnext hospital – so you gotta get it right up front!
C