Mystery case file: Mahangin

1. Mystery case file:Mahangin Jesus Martin Generoso, Jr. February 18, 2011

2. General information • MPB 33M • Roman Catholic • Married • Filipino • Employee • Taytay, Rizal • Good reliability

3. Chief complaint • Chest pain

4. History of the Present Illness • 8 hours prior to admission • After back stretching, patient noted a sharp pain, 9-10/10, “kumikirot”, at the upper right portion of the back, increasing in intensity when inhaling • Difficulty of breathing  shortness of breath • Pressure compressing the right chest forward from behind

5. History of the Present Illness • Consult was done • With decreased intensity of pain to 6/10, pain relieved by rest • Advised to go to the hospital for a chest x-ray, probable air in the chest • Hence, patient went to TMC • (-) trauma, (-) fever, (-) loss of consciousness, (-) headache, (-) blurring of vision, (-) dysphagia, (-) orthopnea, (-) paroxysmal nocturnal dyspnea, (-) cough and colds, (-) hemoptysis, (-) calf pain

6. Past Medical History • (+) hypertension – highest BP at 160/110, usual BP at 120/80, maintained with amplodipine (Norvasc) 5 mg OD • (+) Asthma – since childhood, last attack was >20 years ago. Trigger unrecalled. No maintenance medications • (-) DM, (-) TB, (-) CA, (-) stroke, (-) pnuemothorax, (-) lung disease, (-) allergies, (-) blood dyscrasia • (+) appendectomy 14 years ago

7. Family History • (+) hypertension – father’s side • (+) asthma – siblings • (-) DM, (-) TB, (-) CA, (-) heart problems, (-) allergies, (-) pneumothorax, (-) lung disease

8. Personal and Social History • Regular office employee • Desk job, with no strenuous activity • Married, with 1 daughter • 6-7 pack year smoker • Occasional alcoholic beverage drinker • No diet restrictions. Fond of meat, fish, vegetables, soda. Not fond of coffee. • No exercise regimen • No exposure to hazardous chemicals

9. Review of systems • Cutaneous: no rashes, sores, itching • HEENT: no gum bleeding, no nose bleeding, no coryza, no conjunctivitis • Gastrointestinal: No vomiting, no change in bowel habits, no hematemesis, no hematochezia • Genitourinary: urine is clear and yellow, no burning sensation, no discharge, no dysuria, no nocturia • Muskuloskeletal: no swelling of joints, stiffness, limitation of motion, limping, cyanosis • Hematopoietic: no easy bruisability • Neurologic: no loss of sensation

10. Physical examination Vital signs General survey Awake oriented Coherent Cooperative Not in cardiorespiratory distress • BP 120/ 70 • HR 76 • RR 22 • Temp: 37.1 • 87 kg • 170 cm • BMI 30 • Pain 5/10

11. Physical examination: • Skin • Good turgor, not jaundiced, not cyanotic • HEENT: • no exophthalmos, no ptosis, no eye discharge, pink palpebral conjunctivae, anicteric sclerae, no nasal/aural discharge, no lymphadenopathies, no tonsillopharyngeal congestion, no alar flaring • No neck vein engorgement, trachea was midline, no neck masses

12. Physical examination Chest and Pulmonary Cardiac Adynamic precordium S1 and S2 are distinct normal rate, regular rhythm, no murmur Apex beat at 5th ICS LMCL • Symmetric chest expansion • Resonant lung fields • No rales, no rhonchi, no wheezes • Decreased breath sounds at right upper lung field • Decreased vocal fremitus right upper lung field

13. Physical examination Abdomen Extremities Pulses full and equal No calf tenderness Extremities warm to touch • Flabby • Normoactive bowel sounds • No tenderness, no organomegaly

14. Salient Features History Physical examination Slightly tachypneic, afebrile With decreased breath sounds and vocal fremitus at right upper lung field • Sudden onset of DOB, chest and back pain • No history of trauma/infection • With pertinent negatives

15. Primary impression spontaneous pneumothorax, right, r/o pulmonary embolism, r/o pleural effusion

16. Differential diagnoses Asthma in exacerbation, pulmonary embolism, chf, pleural effusion

17. Pulmonary Embolism Rule in Rule out No calf pain/tenderness No cough, No hemoptysis **trachea midline • Sudden onset • DOB and chest discomfort • Pleuritic chest pain • Tachypneic • With unilateral decreased breath sounds and decreased vocal fremitus

18. Pleural Effusion Rule in Rule out Sudden onset No apparent cause No signs of infection No signs of heart illnesses • DOB and chest discomfort, with pleuritic chest pain • Tachypneic • Decreased breath sounds • Decreased vocal fremitus

19. Asthma Rule in Rule out No apparent trigger present Pleuritic chest pain Decreased breath sound only at one side No wheezes Decreased vocal fremitus • Sudden DOB and chest discomfort • With history of asthma • Tachypneic • Decreased breath sounds

20. CHF Rule in Rule out Sudden onset No known heart problems No failure symptoms Not tachycardic No edema No crackles • DOB, chest discomfort • Tachypneic • Decreased breath sounds

21. Course in the ER • Triaged to Emergent area • ECG normal • Chest x-ray • Lucent area devoid of lung markings with visible pleural lines is seen in right hemithorax. • 30% pneumothorax • Impression: pneumothorax, right

25. Course in the ER • No atelectasis, no fluid, no cardiomegaly • Ruled out pulmonary embolism, ruled out pleural effusion • For stat closed tube thoracotomy (OR)

29. Course in the Wards • After CTT insertion • Good fluctuation, positive for bubbling • Succeeding days after CTT insertion • Subjective • comfortable, no difficulty in breathing, no chest pain • With pain at operative site • Objective • Dry dressing • stable vital signs, afebrile • **Still with decreased breath sounds at right

30. Course in the Wards • Succeeding days after CTT insertion • Assessment: pneumothorax, right, s/p closed tube thoracostomy • Plan • Encouraged deep breathing exercises • CT scan done • Minimal pneumothorax, right. Amount too small to quantify • With bleb at the right lung apex • May go home, with subsequent advice

35. Discussion pneumothorax

36. Pneumothorax • accumulation of air within the pleural space • compresses lung tissue and reduces pulmonary compliance, ventilatory volumes, and diffusing capacity

37. Pneumothorax • Primary spontaneous pneumothorax • Typically in tall, thin males who are between 25 and 40 years of age • Without known cause OR evidence of diffuse pulmonary disease OR from subpleural blebs • occur almost exclusively in smokers

38. Pneumothorax • Secondary spontaneous pneumothorax • Peak after age 55 • result of an underlying pulmonary process • Most are due to chronic obstructive pulmonary disease • Air enters the pleural space via distended, damaged, or compromised alveoli • More life-threatening in patients with lung disease since they have less pulmonary reserve

39. Pneumothorax • Tension pneumothorax • Emergency! • air enters the pleural space repeatedly and is unable to escape, positive pressure develops  compression/collapse of the entire lung, shifting of the mediastinum and heart away from the pneumothorax, and severe respiratory compromise with hemodynamic collapse

40. Pneumothorax • Tension pneumothorax • Emergency! • air enters the pleural space repeatedly and is unable to escape, positive pressure develops  compression/collapse of the entire lung, shifting of the mediastinum and heart away from the pneumothorax, and severe respiratory compromise with hemodynamic collapse

41. Pneumothorax • Traumatic pneumothorax • results from penetrating or nonpenetrating chest injuries

43. Primary Spontaneous Pneumothorax • Most common presentation: chest pain • often sharp and pleuritic • 2nd most common presentation: dyspnea

44. Pneumothorax • History and PE • Acute onset of chest pain - Severe and/or stabbing pain, radiating to ipsilateral shoulder and increasing with inspiration (pleuritic) • Sudden shortness of breath • Tachypnea • Tachycardia (most common finding) - If faster than 135 beats per minute (bpm), tension pneumothorax is likely

45. Pneumothorax • History and PE • Diminished chest excursion and hyperresonance on percussion of the affected side • Decreased breath sounds • Hypotension (often with tension pneumothorax) • Asymmetric lung expansion - Mediastinal and tracheal shift to the contralateral side with a large tension pneumothorax • Decreased tactile fremitus

46. Pneumothorax pathophysiology • Primary spontaneous pneumothorax (PSP) • PSP is associated with the presence of apical pleural blebs (“emphysematous-like changes or ELCs”) lying under the visceral pleura • thought to be related to increased shear forces in the apex • Hypothesis: lung inflammation and oxidative stress • Current smokers • ELCs result from degradation of lung tissue due to imbalances of enzymes and antioxidants released by innate immune cells

47. Pneumothorax pathophysiology • smoking associated with increased risk of spontaneous pneumothorax • smoking associated with increased risk of first spontaneous pneumothorax in dose-response relationship (overall relative risk 8.8 in women and 22.3 in men, p < 0.001) • Chest 1987 Dec;92(6):1009

48. Pneumothorax • Confirmed by chest x-ray • Displacement of the visceral pleura from the parietal pleura by air in the pleural space • hyperlucent with absent pulmonary markings • An end-expiratory chest radiograph appears to increase the size of the pneumothorax because of reduction in lung volume during forced expiration

49. Pneumothorax • Chest CT for patients with bullous disease • The routine use of CT in patients with spontaneous primary pneumothorax is not warranted because the confirmation of apical blebs does not change treatment recommendations

50. Pneumothorax treatment • Smoking sessation • For first episode • Small pneumothoraces (<20%) that are stable  monitored if the patient has few symptoms. Chest radiograph to assess stability within 24 to 48 hours. An uncomplicated pneumothorax reabsorbs at a rate of about 1% per day • Intervention: progression, delayed pulmonary expansion, development of symptoms