Case Presentation: The boy with Chest Pain : Case Presentation: The boy with Chest Pain Ward 12, LRI, Balmoral Building
Background : PC: Chest pain
HPC:
2 days history of sudden onset, right-sided chest pain since 15/8/10
Pain was present all the time
No particular trigger, was just sitting down when pain first came
Pain was described as sharp, with gurgling noise. Rated pain as 4/10. Background
Slide 3: Aggr. Factor: Movement
Relieving factor: None
Associated with mild SOB.
No coughing episodes, sputum production, wheezes, fever, prior infection
Never had symptoms before.
Went for holidays for 2 weeks, when returned on 1/9, went to see GP and had a chest X-Ray
Slide 4: PMH:
Inguinal hernia (Operation-10 months old)
caused him feeding problem
Bell’s Palsy
Age 1 year old & recur at 14 years old
Birth history: Normal pregnancy and delivery
DH
None.
Allergic to erythromycin. (diarrhoea)
Slide 5: FH
Nothing of significance
Immunisation hx
Up-to-date with vaccinations.
Developmental hx
After operation at 10 months old, never been able to catch up with feeding(weight always lower than centile).
Height always been normal.
Normal milestones.
Slide 6: Social history
Lives with Mom, Dad, and elder sister in a detached house.
All family members tall stature.
No one in family smokes.
Doing well at school, except PE (least enjoyed subject)
Systems Review
No problem with bowel, bladder, abdomen and others.
Examination Findings on Admission : General inspection:
Tall, very thin stature.
Alert
Inspection:
Fingers: No significant findings.
RR: 20bpm
Pulse: 80bpm
Not cyanosed, no signs of anaemia
JVP not raised
High arched palate.
No scars on chest. Pectus carinatum present. Examination Findings on Admission
Slide 8: Palpation
Central trachea. No lymphadenopathy.
Apex beat is not displaced.
Reduced chest expansion on the right side.
Percussion
Hyperresonant on right side.
Auscultation
Reduced air entry on right side. No crepitations/wheezes.
Differential Diagnosis : Spontaneous Pneumothorax associated with ?Marfan Syndrome
Musculoskeletal pain
Pneumonia
Pulmonary Embolism
Asthma Differential Diagnosis
Investigation : Chest X-Ray
Arterial Blood Gas Investigation Management ABC
Oxygen 100% high-flow
Chest drain
Analgesia
Plan of investigation for Marfan Syndrome : Urine homocysteinuria
Genetic screen for Marfan syndrome
Echocardiographymonitor aortic root width and heart valve
Ophthalmology review Plan of investigation for Marfan Syndrome
Pneumothorax : Pneumothorax defined as air in the pleural space.
Classifications:-
Traumatic
Spontaneous pneumothorax
Aetiology : Aetiology Primary – healthy no lung disease
Secondary – lung disease
Asthma
COPD
CTD (eg: Marfan’s syndrome, Ehlers-Danlos syndrome),
Trauma
Smoking causes an increased risk of a spontaneous pneumothorax:
Thin, tall man
Clinical features : Clinical features sudden onset of pleuritic chest pain accompanied by pallor, tachycardia and sweating
reduced chest expansion on the affected side
hyper-resonant percussion note - if large pneumothorax
reduced or absent breath sounds at the affected site
sticky clicking sound, heard in time with the heart beat - in a left sided pneumothorax
Investigations : Investigations Chest radiograph:
Inspiratory & expiratory PA view
Size of pneumothorax
In these
new guidelines the size of a pneumothorax is divided
into “small” or “large” depending on the presence of
a visible rim of <2 cm or >2 cm between the lung
margin and the chest wall.
Arterial blood gases
Management : Management ABC
High flow O2 (10l)
Simple aspiration & re-xray to check for resolution - is recommended as first line treatment for all primary pneumothoraces requiring intervention.
Chest drain – large pneumothorax (>2cm)
Analgesia for pleuritic pain
Complications chest drain : Complications chest drain Bleeding
Infection in the pleural space (empyema)
Damage to adjacent structures (e.g long thoracic nerve – wing scapula, lympathic damage, chylothorax)
Abdominal and thoracic injury lung, stomach, spleen, liver, heart and great vessels, and are potentially fatal
Surgical emphysema
SURGERY : Surgery is required for
Air leak persisting for more than 10 days
Failure of lung re-expansion
Recurrent spontaneous pneumothorax
Surgical options include
Partial pleurectomy
Operative abrasion of pleural lining
Resection of pulmonary bullae
Poor-risk patients may benefit from chemical pleurodesis with tetracycline SURGERY
Prognosis : Prognosis Reabsorption of air and re-expansion of lung will occur over 3-12 weeks unless bronchopleural fistula or tension pneumothorax develop
Respiratory failure if respiratory function is poor
Recurrence rate of 10-15% within 1 year for spontaneous pneumothoraces
Marfan Syndrome : Marfan Syndrome An inherited connective tissue disorder with characteristic skeletal, dermatological, cardiac, aortic, ocular and dural malformations.
Autosomal dominant.
Symptoms:
Can be asymptomatic. Ptts are disproportionately tall and thin with unusually long arms and legs compared to their trunk (dolichostenomelia)
Long 'spidery' fingers and toes (arachnodactyly).
Slide 22: Signs
Skin – striae
Heart and blood vessels - thoracic aortic dilatation/rupture/dissection, aortic regurgitation, mitral valve prolapse, mitral regurgitation, abdominal aortic aneurysm, cardiac dysrhtyhmia
Eyes –lens dislocation, closed angle glaucoma, high myopia
Joints – hypermobility, arthralgia, instability
Skeleton – pectus excavatum or carinatum deformities, misshapen chest, kyphoscoliosis
Arachnodactyly
Facial characteristics - maxillary/mandibular retrognathia, long face and high, arched palate are important and relatively discriminating signs of the condition
Pleural rupture causing pneumothorax
Reference : Reference M Henry. British Thoracic Society guidelines for the management of spontaneous pneumothorax; Thorax 2003;58:ii39-ii52 doi:10.1136/thorax.58.suppl_2.ii39
O’Hara VS. Spontaneous pneumothorax. Milit Med 1978;143:32–5.[III]
10 Jansveld CA, Dijkman JH. Primary spontaneous pneumothorax and smoking. BMJ 1975;4:559–60. [IIa]
Baumann M H, Strange C. Treatment of spontaneous pneumothorax. Chest 1997; 112: 789-804.
Patient.co.uk –Marfan’s syndrome