A 64-year-old white man presented with a complaint of
worsening dyspnea on exertion and new left pleural effusion 28 days
after suffering traumatic fracture of three left ribs (Fig 1
). He had previously been admitted to the hospital 10 days earlier for
unstable angina and treated initially with aspirin andβ
-adrenergic blockade. Coronary angiography had revealed
significant one-vessel disease in the circumflex artery. He received
treatment with coronary angioplasty and coronary stent placement.
During the catheterization, he received unfractionated heparin as an IV
bolus of 8,000 U followed by an IV infusion of 1,000 U/h for 2 h.
A chest radiograph obtained 1 day after the stent procedure on the day
of discharge revealed mild left lung atelectasis caused by fractures of
the seventh to ninth ribs (Fig 2
). The rib fractures had occurred 28 days before the admission with
hemothorax as a result of an accidental fall onto the wooden arm of a
couch. Rib pain, which worsened on deep inspiration, had slowly
improved. His discharge medications after stenting included
ticlopidine, 250 mg bid, and aspirin, 325 mg/d. Dyspnea on exertion now
was occurring at < 50 feet of level walking compared with a baseline
of 2 blocks. Cough and sputum production had also slightly increased.
He denied recurrent anginal chest pain or any other chest pain or
pressure. Additional medical history included left ventricular systolic
dysfunction with an ejection fraction of 35%, a remote myocardial
infarction, moderate COPD, hypertension, and remote tobacco use. Review
of systems was otherwise noncontributory to include a negative history
for alcohol use, tuberculosis, or positive purified protein derivative
test. There was no history of additional traumatic injury.