Chapter I-9

A 24-year-old man presented to the ED with unilateral chest pain that began about six hours earlier.

The pain was initially “sharp” in quality and began abruptly. The pain had been persistent since it began and was now dull and aching. It was worse with deep inspiration. There was no associated shortness of breath, diaphoresis, nausea, cough, fever, or chills. The pain was not relieved by ibuprofen.

The patient had no risk factors for coronary artery disease aside from a history of smoking one pack of cigarettes per day for the past six years. He denied using cocaine or other drugs.

On examination, he was a healthy appearing young man in no apparent distress.

• Vital signs—blood pressure 120/80 mm/Hg, pulse 84 beats/ min, respirations 18 breaths/min, temperature 99.°F rectal, SO2 97% on room air

Lungs—equal bilateral breath sounds without wheeze or râles; there was no chest wall tenderness

Heart—regular rhythm without murmur, rub, or gallop.

Abdomen—soft and nontender

• What does his chest radiograph show (Figure 1)?

###### Figure 1

Chest radiography is often not a helpful test in the evaluation of patients with chest pain; however, when pneumonia, malignancy, thoracic aortic aneurysm, or pneumothorax is suspected, radiography can be diagnostic. An upright chest radiograph can confirm or exclude a pneumothorax in nearly all patients, although in some cases, the findings can be subtle and must be specifically sought when examining the chest radiograph.

A spontaneous pneumothorax (not due to trauma or iatrogenic) can be either primary or secondary, i.e., associated with an underlying pulmonary disorder. Such disorders include chronic obstructive pulmonary disease (COPD), cysts or cavities due to necrotizing pneumonia (staphylococcus aureus), malignancies, tuberculosis, or pneumocystis pneumonia, and interstitial lung diseases such as sarcoidosis, collagen vascular diseases, pneumoconiosis, or idiopathic pulmonary fibrosis.

Primary spontaneous pneumothorax occurs in patients without underlying lung disease. It is most common in young adults, predominantly males in their third or fourth decades, who almost invariably have histories of cigarette smoking. There is rupture of an apical bleb (air-containing cyst within the visceral pleura) or subpleural bulla (enlarged airspace due to degeneration of alveoli). The precipitating event may be increased intrathoracic pressure due to physical exertion, although most cases occur at rest.

### Clinical Manifestations

Chest pain is the primary symptom, occurring in 90% of cases. It is usually of abrupt onset, “sharp” in quality, localized to one side of the thorax, and worse with deep inspiration (pleuritic). The chest pain may become “dull and aching” over the subsequent 1–2 days. Dyspnea is present in 80% of patients, although it may abate over time. Severe dyspnea is uncommon and, when present, is often a sign of a tension ...

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