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Internal Medicine

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45-year-old male presents to the urgent care clinic with a 2-hour history of central chest pain that began at rest with associated shortness of breath. In addition, he has had a mild dry cough and rhinorrhea for a few days but no fever. He has not had any nausea, dizziness, or diaphoresis, and the chest pain does not radiate. He took a low-dose aspirin at home at the insistence of his partner but states that it did not affect the pain. He has no past medical history, takes no medications, consumes 4–6 alcoholic drinks per night, and does not smoke. He has a sedentary job in customer service and walks his dog twice a day. He lives at home with his partner and toddler, who also has a mild cough and runny nose.

On examination the patient has a temperature of 37.0°C (98.6°F), a blood pressure of 150/100 mm Hg, a heart rate of 118 beats/min, a respiratory rate of 14/min, and an oxygen saturation of 98% on room air. The patient is well appearing, and an HEENT examination reveals no jugular vein distention. A cardiovascular examination reveals tachycardia without murmur. There is no chest wall tenderness to palpation. The lung examination reveals decreased breath sounds on the right compared with the left, and there are no crackles or wheezes. There is no lower extremity edema.

A chest radiograph and an EKG are shown below. Laboratory studies including D-dimer and troponin levels, a CBC, and a comprehensive metabolic panel have been ordered and the results are pending.

Which one of the following would be the most appropriate next step in management?

A) Initiation of antibiotics

B) Initiation of heparin infusion

C) Chest tube placement

D) Cardiac catheterization


Mazen Kherallah
T S
H S
N G

ANSWER: C

This patient's chest radiograph is consistent with a large right pneumothorax and complete lung collapse. In addition, there is a leftward mediastinal shift that raises the concern for a tension pneumothorax. The most appropriate next step in management would be placement of a chest tube.

The chest radiograph is notöconsistent with pneumonia, so antibiotics would not be appropriate.

While a pulmonary embolus and non-ST-elevation myocardial infarction could have a similar presentation, the abnormal chest radiograph points to the most likely diagnosis, and a heparin infusion would not be indicated. Cardiac catheterization is not the most appropriate next step in the management of a

pneumothorax because the focus should be on stabilizing the lung condition and ensuring proper healing before considering invasive procedures.

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