What is the appropriate workup for a 79-year-old female with chronic obstructive pulmonary disease (COPD), osteoporosis, prior rib fractures, and prior pneumothorax presenting with severe back pain and bilateral rib pain?

From the Guidelines

The appropriate workup for a 79-year-old female with COPD, osteoporosis, prior rib fractures, and pneumothorax presenting with severe back pain and bilateral rib pain should begin with a thorough history and physical examination, followed by imaging studies. Initial imaging should include chest and thoracic spine X-rays to evaluate for acute rib fractures, vertebral compression fractures, and pneumothorax, as recommended by the American College of Radiology 1. Given her history of osteoporosis, a DEXA scan should be ordered if not performed within the past 1-2 years to assess current bone mineral density. Laboratory tests should include:

• Complete blood count
• Comprehensive metabolic panel
• Calcium, phosphorus, vitamin D levels
• Inflammatory markers like ESR and CRP to rule out infection or malignancy. If X-rays are inconclusive but clinical suspicion remains high, a chest and thoracic spine CT scan would provide more detailed evaluation of bone integrity and potential lung pathology, as suggested by the increased sensitivity of CT for detecting rib fractures 1. Pain management should be initiated with acetaminophen 650-1000mg every 6 hours and possibly a short course of an NSAID like ibuprofen 400-600mg three times daily if not contraindicated. Opioids should be used cautiously due to respiratory depression concerns in COPD, as highlighted by the 2018 GOLD report 1. This comprehensive approach is necessary because her symptoms could represent various conditions including new osteoporotic fractures, COPD exacerbation with musculoskeletal strain, recurrent pneumothorax, or even malignancy given her age and risk factors. The management of COPD should be based on exacerbation risk and symptoms, rather than solely on pulmonary function, as recommended by the Global Initiative for Chronic Obstructive Lung Disease report 1.

From the Research

Workup for Severe Back Pain and Bilateral Rib Pain

The patient's symptoms of severe back pain and bilateral rib pain, combined with a history of COPD, osteoporosis, prior rib fractures, and prior pneumothorax, require a thorough workup to determine the underlying cause. The following steps should be considered:

• Imaging studies: A chest X-ray or computed tomography (CT) scan is essential for diagnosing pneumothorax, as stated in 2. Additionally, a CT scan can help identify other potential causes of back and rib pain, such as fractures or osteoporotic changes.
• Ultrasonography: This modality has been shown to be highly sensitive and specific for detecting pneumothorax, with a sensitivity of 90.9% and specificity of 98.2% 3. It can be used as a rapid bedside test to rule out pneumothorax.
• Abdominal CT scan: This scan can help identify occult thoracic injuries, including pneumothoraces, hemothoraces, pulmonary contusions, and rib fractures, as noted in 4.
• Bone density assessment: Given the patient's history of osteoporosis, assessing bone density using dual-energy X-ray absorptiometry (DXA) or measuring bone attenuation on routine chest CT may be useful in evaluating the risk of fractures, as discussed in 5.
• Clinical evaluation: A thorough clinical evaluation, including a physical examination and medical history, is crucial in determining the underlying cause of the patient's symptoms. The patient's concern about possibly having another pneumothorax should be addressed, and her symptoms of occasional cough, intermittent shortness of breath, and mild chest tightness should be evaluated in the context of her COPD and prior pneumothorax.

Diagnostic Considerations

When interpreting the results of the workup, the following should be considered:

• Pneumothorax: The patient's symptoms and history suggest a possible pneumothorax, which requires immediate attention and treatment, as emphasized in 2.
• Fractures: The patient's history of osteoporosis and prior rib fractures increases her risk of fractures, which should be evaluated using imaging studies and clinical assessment.
• COPD exacerbation: The patient's symptoms of cough, shortness of breath, and chest tightness may indicate a COPD exacerbation, which should be evaluated and treated accordingly.