Case Conference

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Case Conference

• ??? 0961026

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Case 1

• Age 15 year and 3 months old
• Gender male
• Body weight 55kg ( 50th percentile)
• Body height 174cm ( 90th percentile)

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Chief complaint

• Left chest pain for 2 days and dyspnea since this
  morning.

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Present illness-1

• The patient had left chest pain when respiration
  was noted in 5 months ago, visited to our TPER.

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Present illness-2

• The EKG revealed normal sinus rhythm and VPC, and
  CXR revealed no significant abnormality.
• The atypical chest pain rule out myofacial pain
  was diagnosed and acetaminophen was prescribed.
  The condition was persisted for 35 days and
  subsided gradually.
• This time, the patient had mild cough, rhinorrhea
  for 2 days, and left chest pain when inspiration
  and mild fever ( 37.8C) was developed since the
  morning.
• The chest pain was not radiate to the left hand.
• Mild dyspnea and general weakness was also noted.
  
• There was no trauma, no palpation nor chest wall
  retraction.

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Physical examination

• Vital sign (ER) BP129/58 mmHg, BT37.8?, PR
  103 /min, RR 21/min, Sat 98
• General appearance fair
• Conscious alert
• Skin No ecchymosis, no petechiae
• HEENT no icteric sclera
• Neck supple, no jugular vein engorgement

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Physical examination

• Chest decreased breathing sound, Lt.
  
• No retraction
• Heart Regular heart beat, no murmur
• Abdominal soft, flat, no distension, no
  tenderness, normal active bowel sound, no
  hepatosplenomegaly
• Extremities freely movable, no edema

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1cm

• ER

A
24
B
9
Admission Lab Data
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Hospital course

• Chest tapping 475cc
• No apparent improvement ? operation on 5th day.
• No apical bullae was detected easily, mechanical
  scratching was done on the parietal pleura. A
  Fr.16 chest tube was inserted through one of the
  trocar wounds.
• Chest tube removed on 6th day.
• Final diagnosis
• Spontaneous pneumothorax s/p left video-assisted
  thoracoscopic (VATS) pleurodesis