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Summary 19 years old Indian gentleman presented with shortness of breath, with sudden chest pain ±sharp stabbing pain, pleuritic in nature at the right chest. It associated with non-productive cough, and malaise.
Introduction a. Background of the study Pneumothorax is the presence of air in the pleural cavity with associated lung collapse. It is classified into spontaneous (occurring without an obvious preceding event), traumatic (direct or indirect), and iatrogenic. Spontaneous is the commonest condition in general medicine and is sub-classified as: (i) primary spontaneous pneumothorax (PSP) occurring in the absence of obvious lung disease and (ii) secondary spontaneous pneumothorax (SSP) was complicating a pre-existing lung disease.  Primary spontaneous pneumothorax occurs in patients without underlying pulmonary disease, classically in tall, thin young men in their teens and 20s. It is thought to be due to spontaneous rupture of subpleural apical blebs or bullae that result from smoking or that are inherited. It generally occurs at rest, although some cases occur with activities involving reaching or stretching. Primary spontaneous pneumothorax also occurs during diving and high-altitude flying because of unequally transmitted pressure changes in the lung.  Although some view primary spontaneous pneumothorax as more of a nuisance than a major health threat, deaths have been reported. Secondary spontaneous pneumothoraces can be life threatening, depending on the severity of the underlying disease and the size of the pneumothorax. Compared with similar patients without pneumothorax, agematched patients with COPD have a 3.5-fold increase in relative mortality when a spontaneous pneumothorax occurs. Mortality percentages in patients with COPD and spontaneous pneumothorax vary from 1-17% b. Rationale and significance of choosing the case The researcher decided to choose this because of he wanted to understand more of the nature of this disease and its clinical presentations. Pneumothorax can be a medical emergencies ±tension pneumothorax, and it can occurs spontaneously especially among the age of 18 to 40 years old and it is occurring more in men than women 6:1 for primary and 3:1 for secondary pneumothorax. Therefore, there is a need for further understanding of pneumothorax through a case study in Malaysia. This is also an opportunity for the researcher to study about spontaneous pneumothorax in joint hyperflexibility syndrome such as Marfan¶s syndrome and Ehlers-Danlos syndrome patient ±if it is prove to be.
History of Admission a. Patients biography Name initials Age Sex Religion Civil status Race Occupation Admission Clerking : : : : : : : : : MR. RB 19 y/o Male Hindu Single Indian IT sales assistance 21/12/2009 21/12/2009
b. Chief complaint Patient presented with chest pain accompanied with shortness of breath on emergency admission at HKL. He was then transferred to IPR for further management. History of presenting illness As mentioned, patient was presented with shortness of breath associated with sudden chest pain on the right chest. The characteristic were acute, sharp, and stabbing in nature. It worsened at attempt on inhaling, and movement of the right chest. He also experienced pleuritic pain. Patient claimed that he used to experience the same pain, but this is the worst. It was associated with shortness of breath on regular activity, cough, and malaise. Patient claimed that he had lost of weight from 60kg to 43kg prior to admission. Prior to admission, patient claimed that he was riding motorcycle with thin linings covering his body, and has the habit of bathing at late night. He had history of similar pain before. The first episode of pain started a few weeks before the admission, after came back from work at late night. The pain was similar in characteristic but then dissolved after a day ±he not experiencing any shortness of breath at then. During that eventful day, he was playing soccer with his friend in the evening. He experienced some trauma to the chest while playing soccer but there was no pain or injury suspected. He then continued to play soccer and jogging. After the game he went for bath and had a cold drink, settling down watching television. Suddenly, he experienced the second episode of chest pain and worst, he had shortness of breath and difficulty to breath. The pain got worse that he cannot even walk by himself ±carried by his father and had to be taken to the hospital.
Review of system system Cardiovascular Endocrine Gastrointestinal Genitourinary Hematopoietic Musculoskeletal Neurologic Respiratory Skin, hair, nails finding no significant findings such as palpitation, lower limb edema, orthopnea, syncope, dizziness, etc. No significant findings such as moon features, exophthalmos, tremor, acrommegaly, etc. No significant findings such as diarrhea, constipation, altered bowel movement, etc. No significant findings such as dysuria, oliguria, hematouria, incontinence, nocturia, etc. No significant findings such as pallor, jaundice or bleeding tendency, etc. No significant findings such as myalgia, arthargia or arthrit is, etc. No significant findings such as recurrent headaches, fits, blurring of vision or drowsiness, etc. As stated No significant findings. The skin color is normal according to his race; with hair growth distribution is normal. Nail is normal, no clubbing, koilonychia, leukonychia, etc. Normal head size, shape and symmetry; no skull enlargement, bossing, etc. no significant findings of the neck such as webbing, goiter, etc.
Head and neck
Comprehensive health history a. Past medical/ surgical history Patient had 2 history of hospital admission. The first admission was due to pneumothorax in this year. He was treated as an out-patient. The second admission was in HUKM due to dengue fever 2008. He was admitted for a week. He had no other significant medical history, no hypertension or diabetes mellitus. Plus, he completed the immunization according to MoH immunization program, and additional immunization for hepatitis as previous job requirement.
b. Social history Patient is currently working as an IT sales assistance at Petaling Jaya ±he ride motorcycle everyday from Balakong to Petaling Jaya. He also plays for local soccer league at Cheras and part-time as professional Indian dancer. He currently stays with his family in Balakong. He claimed that he does not smoke and not sexually active. However, he does drinks alcohol occasionally. c. Family history Patient had a brother passed away due to respiratory disorder in 2007 at the age of 19. However, the cause of death is identified simply as due to respiratory infection. Other than that, he claimed to have no family history of diabetes mellitus, hypertension, ischemic heart disease, and malignancy. d. Allergy and medication history Patient claimed had no known allergy to food or medication yet.
Examination and assessment a. General Patient appearance matches his description of age and race; he was a young gentleman age of 19 years old with a fair brown skin of Indian. His mental status was normal whereas he was alert, conscious ±place and time oriented, and comfortable. He was breathing normally and able to talk comfortably. He was well nourished and well hydrated. He appeared to be slender moderate build and fit; with height of 173cm and weight of 43kg. His body mass index is 14.38kg/m2 ±underweight. His posture was normal and there was no abnormal gait pattern when he walks. On inspection of the hands, there was no clubbing, peripheral cyanosis or nicotine stain. There was no swelling and tenderness of the wrist. There was also no wasting of the small muscle of the hand and flapping tremor. The hand was warm and dry. The radial pulse were palpable, beats per minute, it is regular rhythm and good volume. There was no radio-radial delay or radio-femoral delay and there was also no collapsing pulse.
Examination of the eyes showed, there was no sign of Horner¶s syndrome such as partial ptosis, constricted pupil and loss of sweating. There was no jaundice noted on the sclera and the conjunctiva was not pale. The tongue was moist means her hydration status is fair, there was no central cyanosis and the oral hygiene was good. His vital signs as recorded; Blood pressure Heart rate Respiratory rate Temperature : : : : 110/70 mmHg 82 beat per minute 20 breaths per minute 37°C
Impression: patient is not appearing cachexic; he is fit but he does appear slender and tall. He claimed that he had lost weight from 60kg to 43kg -13 kg lost after first episode of his chest pain. b. Cardiovascular assessment Inspection JVP demonstrated; no elevation, no chest deformities, no visible pulsation except at the fifth left intercostals space at mid clavicular line ±apex pulsation, no dilated vein noted. Apex beat palpable at fifth left intercostals space at or medial to mid clavicular line. No loss cardiac dullness, palpable thrills or parasternal heaves. No pulsation at aortic and pulmonic areas, no pulsation at tricuspid area. Full pulsation at apical area. Pulsation at epigastric area. Dullness along the cardiac border Auscultation Full and rapid pulsation. 82 bpm BP: 110/70 mmHg The sounds on aortic and pulmonic areas; lub sound on apex and dub sounds on tricuspid area. 1st and 2nd heart sounds were audible without presence of murmur. All peripheral pulses were present.
Impression: no remarkable findings
c. Respiratory assessment Inspection Anterior; breathing normally. No chest deformit ies. There was also no dilated vein. The chest was slightly deviated to the right from the chest symmetry during respiration ±not asymmetrical. No accessory muscle used while breathing. Posterior; spine is vertically aligned, the shape and symmetry of chest are normal. Anterior; the skin is intact, equal warmth on both side. No masses noted. Trachea slightly deviated to the left. Posterior; no masses or tenderness; equal warmth on each side. reduced tactile vocal fremitus at right lung *asymmetry chest expansion noted. Increase hyper resonance dullness at right side; upper zone to slightly middle zone. Other; cardiac dullness and liver dullness at fifth intercostals space. Significant hyperresonance noted. Anterior; diminished breath sound at right lung. Decrease air entry at upper zone. Whispering pectoriloquy demonstrated; the right side presented with low and distanced vocal resonance.
Impression: physical findings consist of diminished tactile fremitus, hyper resonance to percussion, and decreased breath sounds on the right lung. Shortness of breath is caused by collapsing of the lung due to change in pleural space pressure. Air occupying the empty pleural space of the lung resulted the findings ±classical finding for pneumothoraces. d. Abdominal assessment Inspection No distension noted, move symmetry with respiration. Umbilical centrally located and inverted. No previous scar, localized swelling, distended vein, or pulsation noted. Soft, non tender. No organomegaly; liver, spleen are normal. No other masses noted. Kidneys are not ballotable. Upper border of the liver was at right fifth intercostals space, with liver span of 12cm. spleen percussion was not demonstrated. No shifting dullness or fluid thrills. Bowel sound present and normal
Impression: unremarkable findings
e. Musculoskeletal examination Generally, muscle size and side comparison appears normal. Muscle tone and strength also appears normal. However, patient is noticed to have long limbs and flexible joints. Impression: he was tall and slender, with long limbs, and hyper-flexible joints. He was noted to have hyper extensive skin as well. ±the findings are common in Marfan¶s syndrome as well as Ehlers Danlos syndrome. f. Nervous examination Patient was alert and conscious. No slurred speech or abnormal behaviour. He is well oriented to time, place and person. No cerebellar signs present ±nystagmus, past-pointing. Gait was stable Impression: unremarkable findings
Summary 19 years old Indian gentleman presented with sudden chest pain with sharp stabbing pain, pleuritic in nature at the right chest. It associated with shortness of breath, non-productive cough, and malaise. He also had loss of weight of 13kg. Provisional diagnosis Primary spontaneous pneumothorax Patient presented classical symptoms of spontaneous pneumothorax which is sudden chest pain, shortness of breath, cough, and malaise. Primary spontaneous pneumothorax occurs typically in patients who are between 18 and 40 years old. Based on examination, the evidences found are consistent with clinical presentation of pneumothorax; diminished tactile fremitus, hyper resonance to percussion, and decreased breath sounds. There are no medical illnesses or trauma that can contribute to pneumothorax to be found from the patient¶s history.
diagnosis Myocardial infarction
Positive relevant Shortness of breath, sudden chest pain ±sharp, stabbing pain in nature.
Negative relevant No cardiac disease, no history or symptom suggestive of M.I; patient is young, fit, no family history of hypertension No hemoptysis. No back pain. No wheezing, no fever. Do not explain loss of weight, No fever and night sweats. No shifting dullness.
Chest pain, cough, shortness of breath. Shortness of breath, chest pain, cough, Dullness to percussion, decrease tactile fremitus, diminished breath sounds, egophony, etc.
Reason to support Pneumothorax classical appearance is the presence of radiolucent air and the absence of lung markings between the shrunken lung and the parietal pleura Ultrasonography has been shown to have high sensitivity (95%), specificity (100%), and diagnostic effectiveness (98%) for pneumothorax. It is useful for detecting small collections not seen on plain films and the extent of the air collection can be estimated by tracking the presence of the µsliding lung sign¶ over the chest wall. To look for haemoglobin, white blood cell and platelet levels. To rule out other possibilities whether it is infection or other causes.
Full blood count
Chest X-ray findings There is presence of radiolucent air at the right lung with clear margin of 3 cm between the pleura and the right lung. Impression: The diagnosis of pneumothorax is established by demonstrating the outer margin of the visceral pleura (and lung), known as the pleural line, separated from the parietal pleura (and chest wall) by a lucent gas space devoid of pulmonary vessels. 
Full blood count Blood Count WCC RBC Hb HCT MCV MCH MCHC Platelet Neutrophil Result 9.0 5.21 14.3 42.3 81.2 27.4 33.8 242 Interpretation Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal range 4.5-13.5 4.0-5.4 11.5-14.5 37.0-45.0 76.0-92.0 24.0-30.0 28.0-33.0 150-400 40.0-75.0 2.9-7.9 20.0-45.0 1.8-4.0 2.0-10.0 0.2-0.8 0.0-5.0 0.04-0.44 0.0-2.0 0.0-0.2 x 109 /L x 1012 /L g/dL Ratio fL Pg g/dL 109 /L % 109/L % 109/L % 109/L % 109/L % 109/L
49.7 3.5 Lymphocyte 38.9 1.9 8.6 Monocyte 0.7 1.1 Eosinophil 0.0 1.7 Basophil 0.0 Impression: no remarkable findings
Final diagnosis Primary spontaneous pneumothorax 1) Based on history, Mr RB presented with sudden chest pain, shortness of breath, cough, and malaise. These are classical symptoms for pneumothorax. From the history also, we found out that this gentleman do not have any medical or surgical history that may resulting a secondary pneumothorax. It occurs when the patient was resting. 2) On physical assessment, there are additional evidences that support the diagnosis; diminished tactile fremitus, hyper resonance to percussion, and decreased breath sounds. There are no other findings such as wheezing, ronchi, crepitations, etc. 3) Investigation done, chest X-ray shows that there is a presence of radiolucent air at the right lung with clear margin of 3 cm between the pleura and the right lung. Full blood count was done to rule out any other condition ±the result was unremarkable. Based on the findings, we can conclude that the patient¶s disease was primary spontaneous pneumothorax.
Principal management 1) 2) 3) 4) 5) 6) 7) 8) Admission for respiratory ward Oxygen therapy if necessary Encourage oral fluids and intake Encourage ambulation Monitor vital signs Catheter aspiration Observation at ward Follow up X-ray
Clinical course and progression
Mr. A was referred for further management of pneumothorax ±he was undergone chest X-ray at emergency department during HKL admission. The initial margin was about 3~4 cm of air between parietal pleura and the lung ±needle aspiration will not be adequate. Chest tube insertion was done at 21/12/2009. Patient currently still experiencing pleuritic pain, and cough. The shortness of breath still not yet resolved ±need nebulizer from time to time, especially at long conversation. 2-3 days after the chest tube insertion, patient was able to breathe normally ±doctor ordered for screening of air X-ray done. It revealed that the air between spaces have been decrease to 1~2 cm. Mr. A are now more comfortable and well ambulated. The doctor plan includes changing the chest tube apparatus by daily inspection ±the procedure however caused complication to the patient later. He complained that the chest tube was not properly inserted and introduced more air compare to previous tube placement. The claimed was justified by the X-ray that shows slight increase of 1~2.5 cm from previous X-ray. 7th day of the admission, the X-ray revealed that the air inside the pleuritic space was reduced less than 2 cm and he was then planned for removal of chest tube. Mr. A¶s condition was good and he is comfortable. He still has slight shortness of breath when exerting his activity but it is well tolerated.
Discussion Primary spontaneous pneumothorax occurs when air collects in the pleural space without preceding trauma in a healthy individual, and without obvious underlying lung disease. It typically occurs in patients between 18 and 40 years of age, whereas a secondary pneumothorax usually occurs in older patients with lung diseases such as chronic obstructive pulmonary disease, cystic fibrosis, pyogenic infections, pulmonary fibrosis and cancer. The incidence of primary spontaneous pneumothorax is estimated to be approximately 7.4-18 per 100 000 per year for men and approximately 1.2-6 per 100 000 per year for women.
This patient was suspected for spontaneous pneumothorax because of his chief symptom associated with sudden chest pain of stabbing and pleuritic in nature. From there, the investigation goes on as to confirm the assumption. Other respiratory diseases do presented with chest pain but it is not sudden in nature, and usually accompanied by symptoms of infection such as fever ±high or low grade depending on the causative agent. The other differential diagnosis that would gave out sudden chest pain as the criteria is myocardial infarction ±ruled out because it is not pleuritic in nature, not to mention the age of patient is 19 years old; is unlikely to have cardiovascular disorder.
Patient history revealed that his brother was passed away due to respiratory disorder at the same age of the patient which in a way gave a puzzling idea for his diagnosis. According to Hsienchang et al, over 10% of patients with primary spontaneous pneumothorax report a positive family history of the disease . Therefore, it might be possible that patient condition was a family inherited disorder ±similar to Marfan¶s syndrome or Ehlers Danlos syndrome; both are at high risk of primary spontaneous pneumothorax. Other than that, the patient history shows no evidence of diseases that might cause secondary pneumothorax.
The diagnosis of primary spontaneous pneumothorax was confirmed by erect chest X-ray ± presence of radiolucent air at the right lung with clear margin between the pleura and the right lung. In stable patients, the diagnosis is suspected in patients with dyspnoea or pleuritic chest pain and is confirmed with upright inspiratory chest x-ray. Radiolucent air and the absence of lung markings juxtaposed between a shrunken lobe or lung and the parietal pleura are diagnostic of pneumothorax. Tracheal deviation and mediastinal shift occur with large pneumothoraces.
Goal of the treatment is to resuscitate patient in distress ±especially patient with symptoms of hypoxemia and recorrect the pleural space pressure by withdrawing the air inside the space. Patients should receive supplemental O2 until chest x-ray results are available, because O2 accelerates pleural reabsorption of air. Treatment then depends on the type, size, and effects of pneumothorax. Primary spontaneous pneumothorax that is < 20% and that does not cause respiratory or cardiac symptoms can be safely observed without treatment if follow-up chest x-rays obtained at about 6 and 48 h show no progression. Larger or symptomatic primary spontaneous pneumothoraces should be evacuated by catheter aspiration. Tube thoracostomy is an alternative.
However, the treatment is not without complication. There are three main problems encountered which are; air leaks, failure of the lung to expand, and reexpansion pulmonary edema.
1) Air leaks are usually due to the primary defect²ie, continued leakage of air from the lung into the pleural space²but can be due to air leaking around the chest tube insertion site if the site is not properly sutured and sealed. Air leaks are more common in secondary than in primary spontaneous pneumothorax. Most resolve spontaneously in < 1 week.
2) Failure of the lung to re-expand is usually due to a persistent air leak, an endobronchial obstruction, a trapped lung, or a malpositioned chest tube. Thoracoscopy or thoracotomy should be considered if an air leak or an incompletely expanded lung persists beyond 1 week.
3) Re-expansion pulmonary edema occurs when the lung is rapidly expanded, as occurs when a chest tube is connected to negative pressure after having been collapsed for > 2 days. Treatment is supportive, with O2, diuretics, and cardiopulmonary support as needed.
Conclusion Primary spontaneous pneumothorax can occur without any preceding trauma in a healthy individual, and without obvious underlying lung disease ±typically occurs in patients between 18 and 40 years of age. Diagnostic test for pneumothoraces in general is imaging ±either chest X-ray, chest ultrascan, CT-scan, etc. The goal of treatment is to resuscitate the patient by withdrawing the air inside the chest itself and to avoid complication.
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