Author: Reuben Cooper / Editor: Jason M Kendall / Reviewer: Phil Delbridge / Codes:  IC2, IP1, OncC2, ResC8, RP2, RP5, RP6, SLO1, SLO2, SLO3, SLO6, SLO7Published: 24/12/2020

A 67-year-old man presents via ambulance with shortness of breath and fever. He has recently completed his first 2 week chemotherapy course for auricular Squamous Cell Carcinoma (SCC), administered via a PICC line.

He reports a 24 hour history of non-productive cough with fever. Also, he has experienced increasing shortness of breath over the past 2 weeks following insertion of the PICC line. This has significantly worsened in the last 24 hours. He is pain free.

Past medical history includes left-sided auricular SCC, which has been surgically resected with adjuvant radiotherapy. He lives at home with his wife and is normally independent. Over the last 2 days however, he has been confined to bed.

On examination, he is cachexic with marked surgical emphysema covering the medial aspect of the right arm, right side of the thorax and extending over the back. The surgical emphysema is notably worse around the PICC line insertion site in the right antecubital fossa, over the right clavicle and over the right pectoralis major. There are no associated skin colour changes overlying the course of the PICC line.

Further examination findings:

  • A – patent, no tracheal deviation
  • B – RR 24, Sp02 92% on air (98% on 4 litres via face mask), left basal bronchial breathing with left apical reduced breath sounds. His left base is dull to percussion and the apex is hyperresonant. The right side of the chest has global “crunching” added sounds, quiet but audible breath sounds with no reduction in expansion.
  • C – P 130, CRT 3 seconds, BP 144/57, HS normal
  • D – GCS 15/15
  • E – Abdomen soft and non-tender. Temp = 38.4 degrees
  • BM 6.7mmol/l.