What happened, in summary

A 74-year-old woman with moderate chronic obstructive pulmonary disease had biopsy-confirmed, moderately differentiated adenocarcinoma in the left upper lung lobe. The tumor measured 1.9 cm, and she underwent robotic left upper lobectomy with lymph-node dissection. Her immediate postoperative course was reassuring: pain was controlled, no air leak was noted, the chest tube was removed, and she went home on postoperative day 1. On postoperative day 2, however, she returned to the emergency department with altered mental status. She was hemodynamically stable, but hemoglobin had fallen from 11.8 to 10 g/dL. Head CT was negative, venous blood gas did not suggest hypercapnia, and chest CT showed a loculated left pleural effusion consistent with hemothorax plus multiple left-sided rib fractures. The rib fractures were not present during surgery and were thought to have occurred after discharge, possibly from a fall or other trauma. On postoperative day 3, ultrasound-guided chest-tube placement drained 250 cc of fluid, but imaging improved only minimally. A repeat CT scan showed persistent hemothorax and a possible mucus plug. Bronchoscopy on day 6 removed the left-sided mucus plug, yet the hemothorax persisted. With consent, the team administered intrapleural tPA and DNase, first at half dose and then at full dose the next day. Fluid drainage improved, respiratory discomfort eased, the lung fully re-expanded, and the effusion nearly resolved. She was discharged to rehabilitation, and follow-up showed no recurrent hemothorax, infection, bleeding, or fibrothorax. Her course ended with completed surgery for early lung adenocarcinoma and successful treatment of a serious postoperative hemothorax during early recovery.