History of Present Illness:

A man in his early-40’s with a history of bradycardia presents to the hospital with sudden onset pleuritic chest pain on the left side

Vital Signs & Physical Exam:

Vital signs are normal except for a pulse in the 40s.  Physical exam is otherwise normal except for pain with range of motion and decreased range of motion

Initial Diagnostic Testing: see EKG and CXR below

 

What is the most likely diagnosis?

  • A) PE
  • B) Pericarditis
  • C) Pneumothorax
  • D) Aortic dissection

SCROLL DOWN FOR ANSWERS & 1-MINUTE CONSULT

<<<<<<<<<<<<<<<<<<<<< ADVERTISEMENT & SPACER >>>>>>>>>>>>>>>>>>>>>

****************************************************************************

THE EMERGENCY MEDICINE POCKETBOOK TRIFECTA

Emergency Medicine 1-Minute Consult, 5th edition

A-to-Z EM Pharmacopoeia & Antibiotic Guide, 5th edition

8-in-1 Emergency Department Quick Reference, 5th edition 

******************************************************************************

Check Out Our Weekly EM Case Challenges

We’re no longer emailing these but instead are posting on Facebook (ERpocketbooks.com) & Twitter (@EM1MinuteGuru) each Wednesday

***************************************************************************

<<<<<<<<<<<<<<<<<<<<<<<<< END SPACER >>>>>>>>>>>>>>>>>>>>>>>>>

 

ANSWER: What is the most likely diagnosis?

  • A) PE
  • B) Pericarditis
  • C) Pneumothorax – CORRECT – XR shows a left basilar PTX.  Always look at image yourself when worried about PTX
  • D) Aortic dissection – can’t rule out with CXR but it looks very normal.  Always look at image yourself when worried about AD

 

OUTCOME: PTX stable on repeat x-ray.  CT surg consulted.  Sent home with f/u.  H/o prior PTX with pleurodesis

PNEUMOTHORAX: (See TRAUMA chapter for traumatic)

Clinical:         Pleuritic chest pain >DOE >SOB at rest >hypoxia >hypotension

Causes:       Primary: no known lung disease and age <50y.  Usually a 20-40y/o svelte smoker.

Secondary: trauma, COPD, cystic fibrosis, PCP, TB, CA, endometriosis (catamenial)

Catamenia: w/in 72h before/after start of menses; often right-sided w/ pleural lesions

Testing:         Sensitivities: XR: 80% (must look for it carefully, supine CXR much worse), CT:100%

Size:             Small (<15%): <1cm lateral & <3cm at apex. Large (>15%): >1cm lateral & >3cm apex

EKG:            If left-sided may show low voltages in lateral and precordial leads

Treatment:    Varies depending on cause, size, duration and if recurrent

If PTX >2d old, re-expand w/o suction to prevent Re-Expansion Pulmonary Edema

   Primary:       Small: <3cm from inner rib to apex: O2 x 6h, home w/ 24 & 48h f/u if no ­ after 6h obs

Large: Aspirate àshut valve, 4h CXR: if nl remove cath & CXR in 2h, if +PTX then Heimlich

If >2.5L aspirated, air leak likely so chest tube and admit to ICU

ACI:           Stop smoking, 24 & 48h f/u: reabsorb about 1%/day, no air travel or ascent to altitude

Recurrent: if second episode needs to see surgeon for possible pleurodesis or stapling

Secondary: If age >50 likely secondary.  Chest tube (because usually have air leak) & admit to ICU

Refractory: stapling, abrasion or pleurodesis to prevent recurrences