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Shortness of breath and diffuse chest pain
  1. S Singh,
  2. A A Lone,
  3. B A Khan,
  4. A K Khan,
  5. M M Wani
  1. Department of Accident and Emergency, Sher-i-Kashmir Institute of Medical Sciences, Soura, Srinagar, India
  1. Dr Surjit Singh, Nishat Medicate Sonwar, B B Cantt, Srinagar 190 004, J&K State, India

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A 60 year old man presented to the emergency medicine department of Sher-i-Kashmir Institute of Medical Sciences, Srinagar with a one day history of shortness of breath and diffuse chest pain aggravated by breathing. He had no history of trauma, fever, altered sensorium, syncope, cough, haemoptysis, weakness, or oliguria. He had a three month history of generalised aches and pains and easy fatigability for which he had received non-steroidal anti-inflammatory drugs and was not evaluated.

Clinical examination revealed moderate pallor, tachycardia, tachypnoea, a depressed anterior chest wall with sharp indentations around the mid-clavicular line on both sides, paradoxical motion of the anterior chest wall, and diffuse bone tenderness. There was no cyanosis, oedema, lymphadenopathy, or organomegaly, and cardiovascular and neurological variables were normal.

Preliminary investigations revealed a haemoglobin concentration of 80 g/l, a normocytic normochromic peripheral smear, total leucocytic count 5.5 × 109/l, and platelet count 200 × 109/l. Erythrocyte sedimentation rate was 65 mm/hour (Wintrobe's), serum urea nitrogen 26.5 mmol/l, creatinine 194.5 μmol/l, calcium 2.9 mmol/l with a normal blood glucose, electrolytes (sodium, potassium), liver profile, alkaline phosphatase, and routine urine examination. Chest radiography revealed double fractures in the 4th, 5th, 6th, and 7th ribs and osteoporosis. Arterial blood gas analysis showed a pH of 7.45, carbon dioxide tension 4.67 kPa, oxygen tension 9.33 kPa, and bicarbonate 19 mmol/l with a saturation of 90%. Further evaluation of the patient revealed presence of Bence Jones protein in the urine (Kappa), presence of M band (quality not determined) on serum and urine electrophoresis, and serum immunoglobulin concentrations of IgG 36 g/l (normal 8–15 g/l), IgA 1.3 g/l (0.9–3.2 g/l), and IgM 0.8 g/l (0.45–1.5 g/l). A skeletal survey revealed multiple lytic lesions in the skull, diffuse osteoporosis, and compression fracture at T4, T5, L4, and L5 vertebrae. Bone marrow examination revealed 35% plasmacytosis.

Questions

(1)
What is the diagnosis?
(2)
What is the primary disease?
(3)
What are the causes of flail chest?
(4)
What are the treatment options?

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