2. General Data
Name: M.A
Age/Gender: 20/ M
Birthday: January 17, 2002
Occupation: Student
Address: Antipolo City
Chief Complaint
Difficulty of Breathing
5. HISTORY OF PRESENT ILLNESS
2 days PTA, Patient had sudden difficulty of
breathing, associated with non-productive
cough and chest pain radiating to his left
side body. No other symptoms noted such
as fever. No consult nor medications taken.
6. HISTORY OF PRESENT ILLNESS
1 day PTA, still with difficulty of breathing,
patient sought consult at a private clinic in
antipolo and was prescribed with muscle
relaxant and pain medications which
provided no relief of symptoms.
7. HISTORY OF PRESENT ILLNESS
Few hours PTA, still with the above
symptoms, patient sought consult at a
private hospital. Chest X-ray revealed
massive pneumothorax, Left. Patient was
advised to transfer to tertiary hospital.
hence , thus admission.
8. PAST MEDICAL HISTORY
Patient completed PTB treatment for 6
months in 2018, has no Hypertension, no
diabetes mellitus. No previous
hospitalization or surgery.
10. PERSONAL/SOCIAL HISTORY
Patient is a 1st year college student. Was an
occasional smoker 1 stick per month
since grade 6, occasional alcoholic drinker
with 1 bottle per session, Denies illicit
drug use. And fully vaccinated with 2 doses
of pfizer.
12. VITAL SIGNS:
BP: 110/80
HR: 89
Temp: 36.6
O2 sat: 96%
RR: 22
GENERAL: Awake, Conversant
SKIN: no cyanosis, no pallor, no rash
HEENT: Anicteric sclerae, pink palpebral conjunctiva, pupil reactive to light, no nasoaural
discharge, moist and pinkish lips, no palpable cervical lymphadenopathy.
CHEST AND LUNGS: symmetrical chest expansion, Decreased breath sounds at L
HEART: Adynamic precordium, normal rate, regular rhythm
ABDOMEN: Flat non tender abdomen
EXTREMITIES: no edema, no joint swelling, full and equal pulses
13. SALIENT FEATURES
Subjective Objective
● RR: 22
● Afebrile
● O2 sat 96%
● BP: 110/80, PR 89
● Decreased breath sounds at L
● Sudden onset Difficulty of Breathing
● Non-productive cough
● Chest pain radiating to the left
● Prescribe with muscle relaxant and
pain medications with no relief of
symptoms
● Hx of ptb (2018)
● occasional smoker 1 stick per
month since grade 6
15. Differentials Rule in Rule out
Primary Spontaneous
Pneumothorax
(+) sudden onset shortness
of breath
Non productive cough
Chest pain
Cannot be ruled out
Secondary spontaneous
pneumothorax
(+) sudden onset shortness
of breath
Non productive cough
Chest pain
(+) history of PTB
Cannot be ruled out
16. Differentials Rule in Rule out
Community acquired
pneumonia
(+) Cough
(+) dyspnea
(-) fever
(-) productive cough
Pleural effusion (+) non productive Cough
(+) dyspnea
(+) chest pain
No history of lung infection,
malignancy,heart failure,or
cirrhosis
COVID-19 (+) Cough
(+) Dyspnea
(-) fever
Need rt pcr to rule out
Cardiac cause (MI) (+) Chest pain radiating to
the left
(+) Dyspnea
Patient is young
(-) Hypertension
(-) Diabetes
Need 12 L ecg
17. CBC, BUN, crea,
PT,PTT, Na, K, AST,
ALT
CXR, CT Scan
with contrast
12L ECG RT PCR
DIAGNOTICS
21. Subjective Objective Assessment Plan
(+) shortness
of breath
(+) Non
productive
cough
(-)Fever
BP: 110/80
HR: 89
Temp: 36.6
o2 sat: 96%
RR: 22
Awake, conscious
Anicteric sclerae, pink palpebral conjunctiva
Decreased breath sounds at L
Adynamic precordium, normal rate, regular
rhythm
Flat non tender abdomen
no edema
CXR: Massive Left sided pneumothorax, with
mild mass effect, lung volume disposition of
60-70%
Pneumothorax left IVF: PNSS 1L x 60
cc/hr
DX:
- CXR portable
- CBC,
- BUN, Crea,
PT,PTT, Na,
K, AST, ALT,
- 12 L ECG,
- RT PCR
For referral to
surgery for ctt
insertion
Emergency Room 4-6-22
22. Admission day. 4-7-22
Subjective Objective Assessment Plan
(-) DOB
(-) cough
(-)Fever
(+) pain on CTT
site
BP: 110/70 mmHg HR: 75 T: 36.6 o2 sat: 97% RR: 20
HT: 167 cm, WT- 50 Kg
(-) desaturation episodes
(+) CTT left
Awake, conscious
Anicteric sclerae, pink palpebral conjunctiva, no
nasoaural discharge, no palpable cervical
lymphadenopathy.
Decreased breath sounds at L
Adynamic precordium, normal rate, regular rhythm, no
murmur
Symmetrical chest expansion, no retractions, decreased
breath sounds L
Flat non tender abdomen
no edema, full and equal pulses
CXR: Massive Left sided pneumothorax, lung volume
disposition of 60-70%
CXR post CTT- 30-40 %
RT-PCR negative
CBC- PLT-365, Hgb- 16, Hct- 48, wbc- 8.2
BUN:2.54, crea- 105.33
AST 18, ALT 14, NA 143.7, K 4.64
Primary
spontaneous
Pneumothorax left,
s/p CTT left
(4/7/22)
IVF: PNSS 1L x 80 cc/hr
DAT diet
VS q4, MOnitor I and O
DX:
- Sputum Gs/CS
- Sputum GeneXpert
- For chest CT scan with
contrast
Medications
1. Ceftriaxone mg IV OD- D/C the
same day
2. Azithromycin 500 mg OD- D/C
the same day
3. Paracetamol 300 mg IV q4 for
temp >37.8
4. Salbutamol MDI 2 puffs every 8
hrs
5. Tramadol 50 mg TIV q8 as
needed for breakthrough pain
For daily incentive spirometry
Advise deep breathing exercises
Maintain on o2 support via FM at 10 lpm
23. 1st hospital day 4-8-22
Subjective Objective Assessment Plan
(-) DOB
(-) Non productive
cough
(-)Fever
(+) pain on CTT site
BP: 110/80 mmHg HR: 74 T: 36.4 o2 sat: 98% RR: 20
I: 2800 - O: 1200= +1600, CTT-0
(-) desaturation episodes
(+) CTT left
Awake, conscious
Anicteric sclerae, pink palpebral conjunctiva, no
nasoaural discharge, no palpable cervical
lymphadenopathy.
Adynamic precordium, normal rate, regular rhythm, no
murmur
Symmetrical chest expansion, no retractions,
decreased breath sounds L
Flat non tender abdomen
no edema, full and equal pulses
Sputum GSCS
- Pus <25, epithelial cells >25
- Predominant organism- Gram + cocci in
chain
- Others Gram (-) bacilli, gram (+) cocci in
chains
Primary
spontaneous
Pneumothorax
left, 30-40% s/p
CTT left (4/7/22)
IVF: shift to heplock
DAT with SAP
VS q4, MOnitor I and O
DX:
- Still For chest CT scan with
contrast
- For Procalcitonin stat
- Repeat CXR today
Medications
1. Paracetamol 300 mg IV q4 for
temp >37.8
2. Salbutamol MDI 2 puffs every 8
hrs
3. Tramadol 50 mg TIV q8 RTC
4. NAC 600 mg ODHS
For daily incentive spirometry
Advise deep breathing exercises
WOF: DOB, DEsaturation, Fever, Chest
pain
24. 2nd hospital day 4-9-22
Subjective Objective Assessment Plan
(-) DOB
(-) Non
productive
cough
(-)Fever
(-) weight loss,
(-) night sweats
(+) pain on
CTT site
(+) poor
appetite
(+) no bowel
movement for
3 days
Previous
history of PTB
2018, treated
No exposure to
TB patient
BP: 110/70 mmHg, HR: 82 bpm, RR: 20, T: 36.3C, O2 sat 98%. I- 1400,
O-1000 = +400
(-) desaturation episodes
(+) CTT left
Awake, conscious, not in cardiorespiratory distress
Anicteric sclerae, pink palpebral conjunctiva, no nasoaural discharge, no
palpable cervical lymphadenopathy.
Adynamic precordium, normal rate, regular rhythm, no murmur
Symmetrical chest expansion, no retractions, decreased breath sounds(left
lower)
Chest -ray (April 8, 2022)
● Lung volume displacement 15-25 %. Almost complete
resolution in the previously seen reexpansion edema in the
left lower lung.
Chest CT Scan with contrast
● Pneumothorax - Left lung
● PTB Superior segment of left lower lobe
● Pulmonary blebs formations, apicoposterior segment of the
left lower lobe and superior segment of left lower lobe.
● Segmental atelectasis and low fibrosis, superior portion of
the lateral basal segment of left lower lobe.
● Minimal pleural effusion bilaterally
Procalcitonin <0.05.
Primary
spontaneous
Pneumothorax
left, 30-40% s/p
CTT left (4/7/22)
2. PTB
Presumptive
IVF Maintain heplock
DAT with SAP
VS q4, MOnitor I and O
Medications
1. Paracetamol 300 mg IV
q4 for temp >37.8
2. Salbutamol MDI 2 puffs
every 8 hrs
3. Tramadol 50 mg TIV q8
RTC
4. NAC 600 mg ODHS
5. T/S Lactulose 30 cc
ODHS
For daily incentive spirometry
Advise deep breathing exercises
Maintain oxygen support via
facemask at 10 lpm
WOF: DOB, Desaturation, Fever,
Chest pain
25. 3rd hospital day 4-10-2022
Subjective Objective Assessment Plan
(-) DOB
(-) Non productive
cough
(-)Fever
(-). Night sweats
(+) poor appetite
(+) pain on CTT site
Previous history of
PTB 2018, treated
No exposure to TB
patient
BP: 100/80 mmHg, HR: 79 bpm, RR: 20, T: 36.4C,
O2 sat 98%.
(+) CTT
Primary spontaneous
Pneumothorax left,
30-40% s/p CTT left
(4/7/22)
IVF Maintain heplock
DAT with SAP
VS q4, MOnitor I and O
Clamp CTT ( 12 pm)
DX: Repeat CXR 24 hrs post
clamping
Continue previous medications
1. Paracetamol 300 mg IV q4 for
temp >37.8
2. Salbutamol MDI 2 puffs every 8
hrs
3. Tramadol 50 mg TIV q8 RTC
4. NAC 600 mg ODHS
5. Lactulose 30 cc ODHS
Continue daily incentive spirometry
Continue deep breathing exercises
Maintain on Moderate high backrest
Maintain oxygen support via facemask
at 10 lpm
WOF: DOB, Desaturation, Fever, Chest
pain
26. 4th hospital day 4-11-2022
Subjective Objective Assessment Plan
(-) DOB
(-) Non productive
cough
(-)Fever
(-). Night sweats
(+) poor appetite
(+) pain on CTT site
BP: 100/60 mmHg, HR: 62 bpm, RR: 20, T:
36C, O2 sat 98%
I- 950, O- 900 = 50
CTT- Clamped.
Symmetric chest expansion, no retractions,
decreased breath sound on left lower. Lobe
Sputum gram stain
● Gram positive cocci in pairs
● Epithelial cells>25
Sputum culture
● No isolated pathogen
*CTT unclamped
● CTT: 0
● (+) fluctuations
● (-) bubbling
Primary spontaneous
Pneumothorax left,
30-40% s/p CTT left
(4/7/22)
IVF Maintain heplock
DAT with SAP
VS q4, MOnitor I and O
DX:
Repeat CXR 24 hrs post clamping (12 pm)
Therapeutics
1. Paracetamol 300 mg IV q4 for temp
>37.8
2. Salbutamol MDI 2 puffs every 8 hrs
3. Tramadol 50 mg TIV q8 PRN for pain
4. NAC 600 mg ODHS
5. Lactulose 39cc ODHS
Non pharmacologic
● Unclamped CTT -4:50 pm
● For daily incentive spirometry
● Advise deep breathing exercises
● Maintain oxygen support via facemask
at 10 lpm
● Monitor vital signs every 4 hours
● WOF: DOB, Desaturation, Fever, Chest
pain
27. 5th hospital day 4-12-2022 (9:50AM)
Subjective Objective Assessment Plan
(-) DOB
(-) Non productive
cough
(-) desat
(-) fever
(-) chest pains
(+) pain on CTT site
BP: 110/60 mmHg, HR: 67 bpm, RR: 20, T: 36.0C, O2 sat
98%. I- 600, O-1000 = -400
Awake, conscious, not in cardiorespiratory distress
Symmetrical chest expansion, no retractions, decreased
breath sounds upper lobe
Chest X-ray
● Post 24 hrs clamping
● 5-10% volume displacement
1. Primary
spontaneous
Pneumothorax
left, 5-10% s/p
CTT left (4/7/22)
2. PTB- clinically
diagnosed
IVF Maintain heplock
DAT with SAP
VS q4, MOnitor I and O
Medications
1. Paracetamol 300 mg IV q4 for
temp >37.8
2. Salbutamol MDI 2 puffs every 8
hrs
3. Tramadol 50 mg TIV q8 RTC
4. NAC 600 mg ODHS
5. T/s HRZE 3 tabs OD
For daily incentive spirometry
Advise deep breathing exercises
WOF: DOB, Desaturation, Fever, Chest
pain
Discontinue O2 support
28. 6th hospital day 4-13-2022
Subjective Objective Assessment Plan
(-) DOB
(-) Desaturation
(-) Fever
(-) Cough
BP: 110/60 mmHg, HR: 72 bpm, RR: 20,
T: 36.5C, O2 sat 97%. I- 800, O-1000 =
-200 CTT= 0
Awake, conscious, not in
cardiorespiratory distress
Symmetrical chest expansion, no
retractions, decreased breath sounds
upper lobe
Chest X-ray
● Post 24 hrs clamping
● 5-10% volume displacement
I. Primary spontaneous
Pneumothorax left,
5-10%
A. s/p CTT left
(4/7/22)
B. S/P CTT
removal
(4/13/22)
II. Pulmonary
tuberculosis-
Clinically diagnosed
IVF to heplock
VS q4, monitor I&O
DAT
Dx:
Repeat CXR prior to CTT Removal
Medications
1. HRZE 3 tabs OD
2. Paracetamol 300 mg IV q4 for temp
>37.8
3. Salbutamol MDI 2 puffs every 8 hrs
4. Tramadol 50 mg TIV q8 RTC
5. NAC 600 mg ODHS
For daily incentive spirometry
Advise deep breathing exercises
CTT removed- 4:05 pm
● Maintain occlusive dressing for 2
weeks, then may regular Change of
dressing
WOF: Desaturation, Tachycardia, Difficulty of
breathing.
29. 7th hospital day 4-14-2022
Subjective Objective Assessment Plan
(+) pain on CTT site
No other complaints
T:36.3
PR 60
RR 20
BP 100/60
Awake, ambulatory
With occlusive drainage on left chest
I. Secondary spontaneous
pneumothorax left
II. PTB clinically diagnosed
Patient may go home today
Take home medications:
● Salbutamol MDI 2 puffs every 8
hrs
● Tramadol 50 mg PRN for pain
For Follow-up on april 26/2022 at IM
OPD
Patient is advised to continue
anti-TB medications
Patient is Discharged
30. Pneumothorax
● Presence of gas in the pleural space
● Types
○ Spontaneous pneumothorax
■ Primary
■ Secondary
○ Traumatic pneumothorax
○ Tension pneumothorax
Jameson, J. L., Kasper, D. L., Longo, D., Fauci, A. S., Hauser, S. L., Loscalzo, J. 2018. Harrison’s Principle of Internal Medicine. 20th edition.
31. Process
Leakage of air into pleural
space through blebs on
visceral pleura, with
resulting partial or complete
collapse of the lung
Timing
Sudden onset Pleuritic pain, cough
Setting
Spontaneous pneumothorax
Often a previously
healthy young adult
Associated
sx
Physical findings
Percussion: Hyperresonant or tympanitic over the pleural
air
Trachea shifted to opposite side if so much air
Breath sounds- decreased to absent over pleural air
Adventitious sounds- none, except a possible pleural rub
Tactile fremitus- Decreased to absent over the pleural air
Bickley, Lynn S.Bates' guide to physical examination and history taking. Philadelphia :Lippincott Williams & Wilkins,
32. ● Occurs in the absence of
underlying lung disease
● Usually due to rupture of
apical pleural
blebs, small cystic spaces
that lie within or
immediately under the
visceral pleura
● Almost exclusively in
smokers
● Suggests subclinical
disease
● 50% will have recurrence
Primary
Pneumothorax
Secondary
Pneumothorax
● Occurs in presence of
underlying lung disease
● Most are from COPD (but
have been reported in all
lung disease)
A. SPONTANEOUS PNEUMOTHORAX
Jameson, J. L., Kasper, D. L., Longo, D., Fauci, A. S., Hauser, S. L., Loscalzo, J. 2018. Harrison’s Principle of Internal Medicine. 20th edition.
33. B. Traumatic Pneumothorax
● Results from penetrating or non-penetrating chest injuries,
can also be iatrogenic
C. Tension Pneumothorax
● Pressure in the pleural space is positive throughout the respiratory
cycle
● Occurs during mechanical ventilation or resuscitative efforts
● Strongly suggested by difficulty ventilation during resuscitation
or high peak inspiratory pressures during mechanical ventilation
MEDICAL EMERGENCY !!!
● Death from inadequate cardiac output
● Death from hypoxemia
Jameson, J. L., Kasper, D. L., Longo, D., Fauci, A. S., Hauser, S. L., Loscalzo, J. 2018. Harrison’s Principle of Internal Medicine. 20th edition.
35. Primary
pneumothorax
TREATMENT: simple aspiration
● If failure of aspiration or recurrent:
○ Thoracoscopy with stapling of
blebs
○ Pleural abrasion (~100%
success)
Secondary
Pneumothorax
● Tube thoracostomy or
thoracoscopy
● Thoracotomy with stapling of blebs
and pleural abrasion
● Pleurodesis by intrapleural
injection of a sclerosing agent such
as doxycycline (if not a surgical
candidate or refuses surgery)
Management
Jameson, J. L., Kasper, D. L., Longo, D., Fauci, A. S., Hauser, S. L., Loscalzo, J. 2018. Harrison’s Principle of Internal Medicine. 20th edition.
36. Traumatic PTX Tension PTX
TREATMENT: tube thoracostomy
● If hemopneumothorax:
○ One tube at superior part to
evacuate air
○ One tube at the inferior part to
drain blood
● Insert large bore needle into the
pleural space at the 2nd anterior
intercostal space
● Diagnosis is confirmed when large
amount of gas escapes
● Leave the needle in place until
thoracostomy tube is inserted
Management
Jameson, J. L., Kasper, D. L., Longo, D., Fauci, A. S., Hauser, S. L., Loscalzo, J. 2018. Harrison’s Principle of Internal Medicine. 20th edition.
37. References
Jameson, J. L., Kasper, D. L., Longo, D., Fauci, A. S., Hauser, S. L., Loscalzo, J. 2018. Harrison’s Principle of
Internal Medicine. 20th edition.
Bickley, Lynn S.Bates' guide to physical examination and history taking. Philadelphia :Lippincott Williams &
Wilkins,
