Correct!
1. Assess for left-sided thoracotomy scar
The simplest and easiest approach to exclude one of the main causes for the appearance of extensive left-sided thoracic volume loss previously listed is to ascertain whether or not the patient has undergone left thoracotomy. This could be accomplished through the performance of a thorough and careful history, but occasionally patients do not provide accurate historical data, even for procedures as major, and presumably as memorable, as a thoracotomy. However, a thoracotomy would leave a visible left chest scar; absence of such is good evidence that previous surgical resection is not the etiology for the patient’s left-sided volume loss. Thoracic CT and thoracic MRA could both assess for the various etiologies that may be responsible for the extensive left lung volume loss, but both are premature at this point- if the patient has a thoracotomy scar on the left, then he has undergone previous left pneumonectomy and is simply currently seeking medical attention for a right lower lobe bronchopneumonia, and advanced cross sectional imaging is not needed. Similarly, bronchoscopy is not yet required at this point, and probably would not be indicated unless cross sectional imaging were obtained and did not provide information that clarifies the patient’s situation. Repeat chest radiography is unlikely to be beneficial because the chest radiographic findings are very unlikely to be artefactual.
The patient was questioned and examined and he denied any previous surgeries, not was a thoracotomy scar seen.
Which of the following now represents the next most appropriate step for the evaluation of this patient? (Click on the correct answer to proceed to the sixth of nine pages)