#004 Curveball Case Study - Swiss cheese CXR

67M admitted with SOB

Frailty

ETOH excess

Lives alone

4L O2 requirement to meet target saturations of >94%. Haemodynamically stable, Hb 120

credit: Dr Khalil Secker

After CXR, a consensus is reached of diagnosis of pleural effusion by ED doctor, clerking medical SHO, post-take medical consultant AND consultant radiologist reporting on the CXR

Rib fractures at the right lower aspect of the chest not initially noticed on CXR by anyone. Patient didn’t mention his previous fall.

Massive haemothorax and rib fractures only discovered after CT CAP which had been ordered for ?malignant cause of pleural effusion

Patient was subsequently transferred to ICU for chest drain insertion and drainage of massive haemothorax (defined as >1.5L of blood or >third of a patients’ intravascular blood volume).

Learning points:

• Be aware that a massive haemothorax can be caused by relatively minor trauma, especially in frail patients with a history of falls and alcohol misuse/impaired coagulation.

• This is a good example of ‘search satisfying bias’, which involves the clinician stopping the search for additional diagnoses after the anticipated diagnosis has been made. Another textbook example would be ordering a CXR for a patient with SOB, correctly diagnosing a lobar pneumonia but missing their clavicular fracture or shoulder dislocation.