A mistaken case of tension pneumothorax

The patient was an otherwise usually fit and well 25-year-old man who presented to A&E department in extremis. The initial working diagnosis was a tension pneumothorax, and he was subsequently treated with needle thoracocentesis causing a release of air. A chest radiograph was taken, after which a chest drain was inserted. Bilious fluid was drained from the chest drain. The patient was taken for an emergency CT, which demonstrated a Bochdalek diaphragmatic hernia, with the spleen and bowel found to be causing a near total left lung collapse. He was taken to the theatre to return the bowel to the correct anatomical position, in addition to undergoing a sleeve gastrectomy, and diaphragmatic defect repair. The patient has had a complex and protracted recovery in the intensive therapy unit (ITU) with complications including wound dehiscence, gastrectomy leak requiring additional surgical repair, fluid overload and bilateral pleural empyema.