Pneumothorax in the exam
Getting a film with a pneumothorax in the exam is one of the many exam set-pieces that can be prepared for.
It is unlikely that they will give you a simple pneumothorax - so, it is worth while considering the likely causes and whether it is under tension. Miss it at your peril (both in real life and in the exam - it's either P45 time or time you get your coat and leave).
The film goes up and after a couple of seconds pause, you need to start talking:
There is increased lucency of the left hemi-thorax with a pneumothorax and evidence of mediastinal shift indicating tension.
I would check the time that the film was taken and whether subsequent films had been performed to see if a drain had been sited. If this is a recently taken film I would check to see if the patient was still in the department. If they were, I would find them, assess them and consider decompression of the pneumothorax with a venflon in the 2nd intercostal space, mid-clavicular line. If they were no longer in the department I would contact the clinical team looking after them urgently to communicate my findings.
There are background features to suggest COPD - hyperexpansion on the right (which is difficult to accurately assess given the tension pneumothroax), coarse bronchovascular markings and reduced subcutaneous tissue suggesting chronic disease.
- as soon as you have seen a tension pneumothorax, you need to say so and say what you'd do - if the patient is still in the department, go and find them (or send your willing registrar)
- if there is a pneumothorax under tension and there is a chest drain in situ, don't assume all is well - there are some tricky films with a chest tube that has been clamped (in the corner of the film) and a pneumothorax that has subsequently developed tension
- think of some causes of pneumothorax - is there evidence of COPD or trauma?