Clinical Vignette XVII

• Which of the following is the most likely diagnosis?

A 20-year-old male is evaluated in the Medtigo Medical Center Emergency Department for a 2-day history of shortness of breath and left-sided chest pain. The patient reports the symptoms began suddenly while swimming and free diving with some friends at the lake. He describes the left-sided chest pain as being sharp when it first started but has since become a steady ache which is worse with breathing especially when taking deep breaths. He also reports the shortness of breath began suddenlyat the same time as the left-sided chest pain and has not changed in quality since. He reports no history of associated trauma, recent respiratory illnesses, or similar symptoms. He has no notable medical history and currently takes no medications. He consumes alcohol socially, smokes a few cigarettes when he gets really stressed since starting his new job about one year ago, and does not use illicit drugs. He has no family history of chronic obstructive pulmonary disease, connective tissue diseases, or other inheritable lung diseases to the best of his knowledge.

On physical examination, temperature is 98.4°F (36.9°C), blood pressure is 133/82 mm Hg, pulse rate is 105 beats/min, respiration rate is 23/min, and oxygen saturation is 97% breathing ambient air. Height is 6’4” (193 cm), bodyweight is 170 lbs (77.1 kg), and body mass index is 20.7 kg/m². The patient appears to be in no acute distress and is able to speak in full sentences. Cardiac exam reveals tachycardia and a normal S1 and S2. Pulmonary exam reveals mildly diminished breath sounds on the left side as well as mild resonance on percussion. The remainder of the physical exam is unremarkable.

• The patient appears to be in no acute distress with vital signs indicating no hemodynamic instability or respiratory compromise. With a working diagnosis of a primary spontaneous pneumothorax of the left lung, which of the following is the most appropriate next step in management?

• Close inspection of the patient’s chest radiographs allow the visualization of a thin, visceral pleural line (< 1 mm in width) which is found to be displaced from the chest wall on the upright PA chest radiograph thereby confirming the diagnosis of a primary spontaneous pneumothorax of the left lung. In addition, the measured distance between the visible visceral pleural and the chest wall at the level of the hilum is < 1.5 cm which is further evidence confirming the presence of a small spontaneous pneumothorax of the patient’s left lung. Which of the following is the most appropriate next step in management of this patient medical condition?

Given the patient’s sudden change in clinical status and the new chest radiographic imaging study, which of the following is the most appropriate next step in management of this patient?

Approximately six hours later, the patient is transported to the Emergency Department’s Radiology Wing for repeat chest radiographic imaging studies. While being prepped for the radiographic imaging studies by the radiology technician, the patient suddenly develops severe shortness of breath with concomitant sharp left-sided chest pain. The radiology technician decides to proceed quickly with the imaging studies and immediately transports the patient back to his bed in the Emergency Department’s Observation Unit.

On physical examination, the patient appears to be in acute distress and is unable to complete full sentences, blood pressure is 117/74 mm Hg, pulse rate is 135, respiration rate is 34/min, and oxygen saturation is 88% breathing ambient air. Cardiopulmonary exam reveals absent breath sounds in some areas of the left lung field. Telemetry shows no acute ST-segment or T-wave abnormalities. The newly completed chest radiographic imaging study is viewed on the PACS computerized network.

• After successful treatment of the patient’s primary spontaneous pneumothorax with spontaneous conversion to a tension pneumothorax, the patient is about to be discharged from the hospital. Which of the following would not be included in this patient’s list of post-discharge recommendations?