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