Question

A 42-year-old Caucasian female, Ms. R., presents to the emergency room 4 days after being knocked down by a wave at the beach. When she was knocked down, she did not lose consciousness. However, she did develop some back pain as well as some dyspnea on exertion. These symptoms did not worsen over the past 4 days nor did they improve. For this reason, she presented to the emergency room.

Upon further discussion with the patient, we learn that Ms. R. had a pneumothorax in 2008 when she had a very severe pneumonia. Her past medical history consists of hypertension, allergy-related asthma, and recurrent rightsided pneumothoraces. In terms of her medication, she takes hyzaar/hydrochlorothiazide. She is allergic to ACE inhibitors that cause facial numbness.

Her social history consists of no alcohol or illicit drug use. She did smoke a pack of cigarettes a day from the age of 17 to age of 32; therefore, she smoked for 15 years. She has the following vital signs: temperature of 99.4°F, heart rate of 110, respiratory rate of 30 breaths/min, blood pressure of 164/84 mm Hg, height of 168 cm, weight of 88.7 kg, and pulse oximetry of 88% on room air. Her physical examination findings are benign with the exception of her respiratory examination. She has some increased work of breathing. Her breath sounds are clear upon auscultation on the left lung fields. On the right lung fields, her breath sounds are clear in the right lower and middle lobes and somewhat diminished in her right upper lobe. She also complains of pleuritic pain with deep inspiration.

A posteroanterior (PA) and lateral chest x-ray was performed that revealed no pulmonary infiltrates but did show slight white-out in the right upper lung field on the PA view. In the lateral view, the x-ray film showed an air level in the upper lung field.

What additional diagnostic tests would be useful?

Answer 1

Pneumothorax occurs as a result of the presence of air within the pleural space. Its one of the most common forms of the thoracic disease mainly seen in smokers. It can be spontaneous, traumatic, or iatrogenic.

Diagnostic measures used

Chest radiography:

It can be used as the first diagnostic method performed to assess pneumothorax. It is the simple, inexpensive, rapid, and noninvasive method but it is much less sensitive than chest computed tomography (CT) scanning in detecting a small pneumothorax. If possible, compare the radiograph with previous films.

CT scan:

High-resolution thin-slice CT is found to have a greater capacity to find blebs and bullae than routine CT. CT can identify the visceral pleural line easily.

Ultrasound :

It is used in detection of pneumothorax in both adults and children

Bronchoscopy:

It helps in direct visualization of endobronchial obstruction and thereby identify the reason for Pneumothorax.

Lung function test:

To find out the lung capacities and volumes.

Blood tests: To rule out infection in case of pleuritic pain

ECG / EKG: To rule out cardiac involvement

ABGs: to find out CO2 and O2 concentration, and to find out the extent of the cardiopulmonary compromise.