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A 25 year old man presented with a two week history of malaise. Following a sore throat he had developed dyspnoea, a productive cough, anorexia, and vomiting. Two days before admission he had haemoptysis and left sided pleuritic pain with shoulder discomfort. On examination he had a pyrexia (38°C), mild cervical lymphadenopathy, and right sided chest crepitations. His chest radiograph showed pneumonia (see fig 1) and on electrocardiography there was T wave inversion in lead 3. Arterial blood gas analysis showed hypoxia (oxygen tension 7.19 kPa). He was given oxygen, rehydrated, and treated with co-amoxiclav and erythromycin. The next day he developed severe left sided pleuritic pain and further treatment was added. On day 3 he had an episode of syncope but the electrocardiogram and observations remained stable. His haemoglobin level had dropped from 158 g/l to 86 g/l.
Chest radiograph.
By day 4 he had a tachycardia (140 beats/min) and developed generalised abdominal pain. At this stage clinical examination of the abdomen was normal. An urgent abdominal computed tomogram was done (see fig 2). His haemoglobin dropped further to 62 g/l. The surgeons were immediately informed of his condition and he underwent emergency surgery. He made a gradual uncomplicated postoperative recovery.
Abdominal computed tomogram.
QUESTIONS
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Given his history of haemoptysis and subsequent severe pleuritic pain, what further diagnosis would you consider and how would you treat this?
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What condition was diagnosed from his computed tomogram and what further management was indicated?
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What did the laboratory find on reviewing this patient's blood film?
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What follow up testing did they perform and what diagnosis was made?
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What is the significance of his shoulder discomfort?
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