38 CLINICAL FOCUS
38 CLINICAL FOCUS
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Case Report
| THE | RESPIRATORY ISSUE
A potential workplace peril
When a man presents with chest pain , tests point to an unexpected diagnosis thought to be linked to occupational exposure years earlier .
Dr Lucy Heyworth Sydney-based resident medical officer .
SAM is a 38-year-old office manager who presents to ED with a one-hour history of left-sided sharp pleuritic chest pain . He denies shortness of breath , cough , palpitations or other cardiac symptoms . Systems review is otherwise unremarkable .
Sam has a past medical history of depression , childhood asthma and provoked DVT following a trimalleolar fracture and open reduction internal fixation three years ago . He takes no regular medications , is an ex-smoker with a five pack-year history and infrequently drinks alcohol . Sam has no significant family history and lives at home with his wife and two children .
Initial assessment
Sam appears healthy and comfortable with no increased work of breathing . His vital signs are within normal limits . Heart sounds are dual with no murmurs and auscultation of the chest is clear . Pain is not reproducible on palpation .
Pathology shows FBC , EUC , calcium , magnesium and phosphate are normal and serial troponins negative . D-dimer is slightly elevated at 0.52μcg / mL ( normal < 0.5 ).
ECG shows normal sinus rhythm , with no dynamic changes on serial ECGs .
Chest X-ray demonstrates normal cardiomediastinal borders , no pleural effusion or pneumothorax and no focus of consolidation . Multiple small , rounded opacities ranging from 2 to 8mm are distributed in the upper zones .
History revisited
On reflection , Sam has had mild shortness of breath on exertion over the past six months , which he had attributed to being out of shape . He reports before he took his current job managing a masonry business , he worked as a stonemason for seven years from age 18 to 25 . This work involved cutting stone with angle grinders and polishing
stone with machinery . He wore a non-fitted dust mask and did not undertake any workplace screening at the time .
Progress
Sam ’ s pleuritic chest pain spontaneously resolves in the department and he is eager to get home . He reluctantly undergoes a CT pulmonary angiogram before discharge , in light of the positive D-dimer . This does not demonstrate pulmonary embolism but
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