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Mon Mar 16 19:56:01 GMT 2009

I thought you would enjoy this one. A elderly male patient presented the
night before I reviewed him with severe left arm pain. The pain does not
sound cardiac and has no associated features. He has no throat discomfort or
difficulty swallowing. He is presently resident in a rehabilitation facility
awaiting surgery for a pseudocyst following pancreatitis secondary to a
gallstone once he is fit enough. 20 years ago he had a severe bout of
pneumonia after a viral URTI and he has residual lung scarring and has been
under review by a chest physician since. He has a normal ECG(EKG). Apart
from mild evidence of continuing hepatic inflammation his blood results are
normal - in particular his amylase is not elevated.

On the ward round he appears fit and ready to go home. His pain has lysed.
His overnight chest Xray is appended. What does it show and what do you do
now?

Best Wishes,

Rowley. 

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