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A 52-year-old male presented to the emergency department with four weeks of shortness of breath and right sided chest pain. His symptoms had gradually progressed in severity and were worse with exertion. These symptoms started several days after he fell against a counter and struck his right chest wall. He initially had a “small gash and black and blue mark” on his right lateral chest wall but these resolved over the course of the month. He denied similar symptoms in the past or recurrent injury dating from the initial insult.

The patient’s past medical history was significant for hypertension, uncontrolled due to medication non-compliance. He denied any drug allergies and had a long smoking history. The patient did not recall any chronic medical diseases in his family.

On examination, the patient had a low-grade fever of 37.9 C orally. He was mildly hypertensive, 160/95, and had a heart rate of 111. His respiratory rate was 26 and his oxygen saturation was normal on room air. The patient appeared tachypneic with no accessory muscle use and his trachea was mid-line. He had clear breath sounds on the left, but had absent breath sounds on the right chest in all lung segments. The patient had a regular tachycardia on auscultation, with normal S1 and S2, no murmurs, and no muffled sounds. There was no JVD. His chest wall was non-tender throughout palpation without any crepitance. The remainder of his examination was unremarkable.

A PA and lateral chest x-ray was immediately obtained (see images). What is your suspected diagnosis?

  1. Hemothorax
  2. Empyema
  3. Intraparenchymal lung abscess
  4. Unilateral diaphragm perforation

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