A 43 year old woman presents to the emergency department with a one week history of feeling unwell with dyspnoea, effort intolerance and productive cough. She has recently completed a week’s course of penicillin based antibiotic with no improvement. She also complains of left sided chest pain.
She is a current smoker and uses intravenous recreational drugs intermittently, with last usage one week ago.
Examination reveals a BP 120/70mmHg, heart rate 98 bpm, and respiratory rate of 24/min. She is pyrexial to 37.8 °C. She has bibasal coarse inspiratory crackles with decreased air entry on the bases, a raised JVP and 6cm non-tender hepatomegaly.
Her chest X-ray is shown (click to enlarge) and an ECG shows a sinus tachycardia with small ventricular complexes and partial RBBB.
ABG on 12L O2 (FiO2 0.35):
pH=7.43 (7.37-7.43)
pO2=66mmHg (81-111)
pCO2=33.2mmHg (33-43)
Base excess=-1.7
HCO3 21.9mmpl/L
- What does the chest x-ray show?
- What is your approach to this case in the acute medical ward (include any investigations you may want)?
- What would be your preliminary management plan?