Thu7October1249PM 6

A 35-year-old asthmatic has been admitted to the MAU with a 24 hour history of worsening wheeze.

You are called urgently as he has become acutely short of breath despite three sets of salbutamol nebulisers. The patient is now hypotensive and desaturating. There is reduced air entry with a resonant percussion note in the left lung field with a trachea deviated to the right.

What is the most likely diagnosis?

(Please select 1 option)

Pneumonia

Panic attack

Tension pneumothorax Correct

Pulmonary embolism

Simple pneumothorax

Explanation

This patient has clinical signs of an evolving pneumothorax.

Though classically a tension pneumothorax is thought to present with a deviated trachea away from the side of the pathology and hyper-resonance, in reality these are very late signs.

A simple pneumothorax is possible, however in light of the hypotension, the patient must be treated urgently as tension pneumothorax with urgent needle decompression.

In the acutely unwell patient there is no role for chest imaging prior to needle decompression. This involves a large bore needle in the second intercostal space in the mid-clavicular line followed by a chest drain.

A background of pneumonia is often the precipitant for exacerbations of asthma.

Severe worsening chest sepsis can present with desaturation and hypotension (systemic inflammatory response syndrome [SIRS] criteria evolving into severe sepsis) however a clinical picture of acute respiratory distress syndrome (ARDS) often predominates with 'wet lung fields'.

Similarly massive pulmonary embolism (PE) can of course present with desaturation and hypotension, however in this clinical picture there are no other obvious risk factors.

Though acute exacerbations of asthma can induce high levels of anxiety in many patients, the diagnosis of panic attacks must always be purely one of exclusion.

Answer Statistics

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Times answered: 288