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Key Image

Contrast enhanced CT of the abdomen and pelvis at the level of the lung bases.

Key Findings

Partial visualization of the lung bases demonstrates a large right pleural effusion (blue arrow) with an air fluid level (red arrow). Pneumothorax (white arrow) confirmed on lung windows (shown below)

Lung Windows

Lung W/L image of the same slice as above. Note the absence of vessels and lung parenchyma in the right pneumothorax, compared to the normal left lung.

PA Radiographs

PA radiograph of the chest in the same patient, acquired soon after the CT abdomen. Note the moderate sized pneumothorax in the right apex. There is an air-fluid level in the right hemi-thorax at the level of the right hilum. Near total obscuration of the right heart and right hemi-diaphragm. No findings to suggest tension.

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Diagnosis

Hydropneumothorax

Discussion

This patient presented with abdominal pain and nausea. The patient did not have any respiratory difficulty over her baseline, according to the medical records. The pain may have been referred from the large pleural effusion.

This case represents the incidental findings that you are sure to encounter while on call. Sometimes findings that are not expected are more significant than the presenting problems. This patient likely has chronic lung disease and has recurring pleural effusions. Effusions this large require thoracentesis. Given the pneumothorax, a chest tube is also indicated.

References / Resources

Additional Information:

1. Dahnert*: 443-447
2. Primer*: 41, 49-50

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