Muhamad Na'im B Ab Razak (jacknaim) is a fresh graduate Muslim Doctor from Universiti Sains Malaysia and waiting for the enrollment into the housemanship program. Ambitious in pursuing master program in emergency and traumatology medicine and loves to spent his free time joining humanitarian missions, writing and speaks as an amateur public speaker in motivation and comparative religion. [HOME]

Answer and discussion for Sudden Onset SOB with pleuritic chest pain


1) X Ray findings

- Seperation of pleural line of the left lung

- Left lung is collapsed

-No vessel shadow on left side

-Mediastinal shift but diaphragm is not flattened (trachea is deviated to the right)


2) Diagnosis

Tension pneumothorax secondary to Pulmonary Tuberculosis.


3) Management for this patient

A) Give oxygen 100% via high flow mask. Prepare for intubation if patient got worsen.

B) Maintain the circulation as tension pneumothorax can reduce cardiac output (consider fluid resus)

C) Emergency Needle thoracotomy with large bore needle while waiting for chest tube

D) Insert chest tube

E) Search for any other injury

F) Post chest tube X-ray

G) Admit patient to ward for observation; patient's respiratory rate, heart rate, blood pressure,

O2 pulse oximetry, skin color, and other signs/symptoms.

H) Monitor ABG

I) Blood investigation; FBC, Blood C&S,

I) Antibiotic prophylaxis amoxacillin 500 mg tds for 5-7 days

J) surgical intervention of lung fails to re-expend after chest tube insertion, history of two or more previous pneumothorax at the same side and any occurance of bilateral pneumothorax.


Discussion


Pneumothorax occur due to accumulation of air in the pleural space which could either be to alveolar rupture, injury to visceral pleura or injury to parietal pleural.


It can be due to lot of thing. Basically, we classify pneumothorax into traumatic or spontaneus.


Traumatic pneumothorax could either be due to penetrating chest wound (gun shot, stab, flial chest etc), Iatrogenic or chest compression.


Spontaneous pneumothorax is the most common cause. this classification is sub divided intp primary (most common causes-with no known underlying aetiology) or secondary (COPD, Asthma, Congenital cyst and bullae, pleural malignancy, rheumatoid lung disease, bacterial pneumonia, TB, Whooping cough, cyctic fibrosis, Histiocytosis X, Tuberous sclerosis, Marfan's syndrome, sarcoidosis, oesophageal rupture, Pneumocyctic carinii pneumonia)


Pneumothorax can be further classify into four type based on extension of the problem; small, medium, large and tension pneumothorax


Small pneumothorax; small rim of air, best seen on expiratory CXR, <20%>


Medium pneumothorax; definite 20-50% of radiographic value.


Large pneumothorax; obvious >50% radiographic volume, some shift of trachea and mediastinum.

Tension pneumothorax; lung grossly deflated, marked deviation of trachea and mediatinum.


The usual presenting complaint is sudden onset unilateral pleuritic chest pain or progressively increasing breathlessness.


If pneumothorax enlarges; increase in breathless, pallor and tachycardia


Signs that can be elicited from chest examination are; hyperresonance on percussion over affected area, decrease breathe sound, displaced apex beat and subcutaneous emphysema.


In tension pneumothorax, there will be trachea deviation, cyanosis and JVP


CXR is beneficial in detecting pneumothorax. If tension pneumothorax is excluded and patient is stable, repeating the CXR may confirm the diagnosis.


Reference:

1) Peter Armstrong, Martin Wastle & Andrea Rockall, Diagnostic Imaging, 5th edition, Blackwell Publishing, 2004

2) Parveen Kumar & Michael Clark, Clinical Medicine 6th edition, Elsevier Saunders, 2005.

3) Hua-Huat soo, Lee-Gong Lau& Peng-Hong Chew, Sarawak Handbook of Medical Emergencies 2nd edition, C.E. Publishing, Sarawak, 2005.


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