|
December 2007
By Phillips Perera, MD, RMDS, and Diku Mandavia, MD, FACEP, FRCPC
|
|
|
Presentation:
A 50-year-old woman presents to your emergency department with increasing dyspnea. It is brought on by minimal exertion and has steadily worsened over the last few days. Today, she is unable to lie flat without a feeling of suffocation. Her medical history is significant for lung cancer that is being treated with chemotherapy.
The patient’s vital signs are: heart rate, 116; blood pressure, 100/70; temperature, 99°F; respirations, 28; and oxygen saturation, 88% on room air. She is in obvious respiratory distress, and on examination decreased breath sounds are noted in the left hemithorax. While starting oxygen administration via face mask, you order a portable chest radiograph.
WHAT IS YOUR DIAGNOSIS? |
| |
| |
 |
|
Diagnosis and discussion:
The chest radiograph demonstrates opacity of the left hemithorax. The differential diag-nosis in this case includes atelectasis from a compressive mass and a large pleural effusion. On further inspection of the film, it is evident that the trachea is shifted away from the involved hemithorax, suggesting a space-occupying lesion like a pleural effusion.
To better evaluate the patient, you bring the ultrasound machine to the bedside and examine her with a 3 MHz probe. Starting in the standard left upper quadrant FAST (focused assessment with sonography for trauma) position, you angle the probe up toward the chest cavity. A large anechoic (black) area above the left diaphragm representing pleural fluid is apparent (see image).
Since the patient is extremely short of breath and hypoxic from the pleural effusion, emergent thoracentesis is necessary to ease her discomfort. With the patient in the sitting-forward position, you use ultrasound guidance to determine the optimal placement of the thoracentesis needle. Nearly 700 ml of serosanguineous fluid drains from the left pleural cavity without complications. Following the procedure, the patient feels much better. Her pulse oximetry reading improves to 95%, and she is able to lie flat without dyspnea. She is subsequently admitted to the hospital and undergoes a pleurodesis procedure. |
|
Dr. Perera is an assistant clinical professor of emergency medicine at Columbia University College of Physicians and Surgeons and Weill Cornell Medical College and director of emergency ultrasound at New York Presbyterian Hospital in New York City. Dr. Mandavia is a clinical associate professor of emergency medicine and director of emergency ultrasound at Los Angeles County-USC Medical Center and an attending staff physician at Cedars-Sinai Medical Center in Los Angeles.
Emerg Med 39(12):55-6, 2007
|
|
