T.S. is a 22 y/o male with no past medical history presents with chest pain and shortness of breath for the last 2 hours.

History Elements:

Onset: 2 hours

Location: right sided chest pain

Duration: constant, worse when he takes a deep breath in.

Characterization: Pain is sharp, pleuritic

Alleviation: Patient took no medication

Radiation: Radiates to the back and right shoulder

Severity: 7/10

Pertinent positives: Patient has developed a slight cough, SOB, tightness in the chest, cold sweats.

Pertinent negatives: Denies contact with anyone who has been sick, denies dizziness, fever, nausea, vomiting, hematemesis, tachycardia.

No past medical history

No family history of cardiac conditions

Social history: 2 pack year history smoker, does not drink alcohol.

Sexual activity:  Sexually active with one female partner, uses condoms

Vital Signs

BP: 124/60

HR: 88 beats per minute regular

RR: 18 breaths per minute slightly labored
O2: 95% on room air

Height: 5’10”

Weight: 165 lbs

BMI: 23.7

Physical Exam:

General: A/O x3, appears to be in great discomfort, with hand clutching right side of chest.

Head: Normocepalic, atraumatic, nonicteric

Skin: warm, no rashes or lesions noted

HEENT: No changes in vision or hearing.

Heart: Normal heart sounds, S1 and S2. No murmurs or gallops noted. Regular rate and rhythm.

Lungs:  Diminished breath sounds over the right side and hyperresonance heard over the right side. Normal AP:Lat diameter. Nontender to palpation.

Lab:

Troponin levels: 0.2 ng/mL

D-dimer level: 0.30

CBC:

RBC – 4.5

Hgb- 13.4

Hct- 39

WBC – 4.8

PLT-  273

Differential diagnosis:

1. Spontaneous pneumothorax: chest pain, shortness of breath, slight cough, cold sweats
2. MI : chest pain, SOB, cold sweats
3. PE: Chest pain, slight cough, SOB
4. Pneumonia: Chest pain, slight cough, SOB, cold sweats
5. Stable angina : chest pain, SOB

Imaging:

CXR: A linear shadow of visceral pleura with lack of lung markings peripheral to the shadow is observed on the right lung.

ECG: Normal ECG.

US: Multiple bright A-lines noted  over the right lung field

DX: Spontaneous Pneumothorax

Treatment

1. Observation for 6 hours with O2
2. Repeat CXR after 6 hours
   1. If resolved discharged with education on the risk of recurrence
3. If pneumothorax  resolves then patient should follow up outpatient in 2-4 weeks for a repeat CXR
4. If pneumothorax fails to improve or worsens, then plan for pleural air removal via needle aspiration or chest tube thoracostomy.

https://www-uptodate-com.york.ezproxy.cuny.edu/contents/treatment-of-primary-spontaneous-pneumothorax-in-adults?search=treatment%20of%20spontaneous%20pneumothorax&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H1550645151

https://www.saem.org/about-saem/academies-interest-groups-affiliates2/cdem/for-students/online-education/m4-curriculum/group-m4-respiratory/pneumothorax

https://www-uptodate-com.york.ezproxy.cuny.edu/contents/clinical-presentation-and-diagnosis-of-pneumothorax?search=spontaneous%20pneumothorax%20&source=search_result&selectedTitle=5~150&usage_type=default&display_rank=5#H3610837211