Case Study #1

Elsevier Clinical Solutions Case Study

9/20/2016

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Source: USMLE Premium ©CCS Cases, Crush Step 3 CCS

Case Introduction

A 62-year-old Latino man is brought to the emergency department for severe chest pain and respiratory distress. He is in acute distress and holding the right side of his chest.

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Source: USMLE Premium ©CCS Cases, Crush Step 3 CCS

Initial Vital Signs

• Initial Vital Signs- Pulse: 124 beats/min, Weak- Respiratory rate: 32/min- Blood pressure, systolic: 105 mm Hg-  Blood pressure, diastolic: 62 mm Hg

• Initial History- The patient was at home resting when he developed severe,

sudden right-sided chest pain with marked acute respiratory distress. He rates the pain as 9 on a 10-point scale. The pain increases with respiration. His wife states he has a history of emphysema but has been generally healthy over the past few years

- All other history is unobtainable

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Source: USMLE Premium ©CCS Cases, Crush Step 3 CCS

Initial Management• Orders

- Blood pressure monitor- Cardiac Monitor- Pulse Oximtry

• Exam- General- Chest- Heart

•  Initial Results- Pulse Oximetry: Oxygen Saturation 91% (nl = 94-110)- Results (Pertinent Findings)

o General: Well Developed, appears in respiratory distress; moaning and holding the right side of his chest.

o Chest: Chest wall normal. Breath sounds absent on the right with hyperresonance to percussion. Breath sounds normal on the left.

o Tachycardia; Heart sounds faint. No murmurs. Bilateral central and peripheral pulses weak. No jugular venous distention.

What is the suspected diagnosis?

Check back tomorrow for an additional slide containing the answer

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Source: USMLE Premium ©CCS Cases, Crush Step 3 CCS

Answer: Keys to Diagnosis

• To practice this case, go to USMLE Case #1 in the CCS Primum ® software. Although these patients can present spontaneously, they can also present after trauma to the chest. Symptoms include sudden, severe chest pain; dyspnea; sweating; anxiety; and fatigue. Vital signs show hypotension, tachycardia, and tachypnea.

• Examination shows decreased breath sounds and hyperresonance over the affected side, tracheal deviation to the opposite side, weak peripheral pulses, and faint heart sounds

• The diagnosis should be made on the physical exam results. Although the diagnosis can be confirmed with FAST ultrasound or portable chest X-ray, treatment should not be delayed for these studies

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