A 75-Year-Old Man With Dyspnea and Chest Pain

Giovanni Volpicelli, MD


November 30, 2016

Physical Examination and Workup

Figure 1

Figure 2

Upon physical examination, the patient has significantly abnormal vital signs, including a heart rate of 140 beats/min (sinus rhythm), a respiratory rate of 40 breaths/min, a blood pressure of 170/100 mm Hg, and a pulse oximetry reading showing an oxygen saturation of 60% while breathing room air. He appears agitated, uncomfortable, and in respiratory distress. His airway is patent, and he speaks single words at a time. His breathing is labored, and peripheral cyanosis is appreciated.

The patient has no breath sounds in the left hemithorax, but normal air movement is noted in the right hemithorax. In addition, no murmurs or friction rubs are appreciated. The left hemithorax is tympanic to percussion, and there is no tenderness to palpation. No tracheal deviation is noted.

The patient is immediately placed on supplemental oxygen, and he maintains an SPO2 of approximately 90%. While chest radiography is urgently performed, preparations are made for emergency tube thoracostomy placement. The radiograph (Figure 1) reveals a left-sided tension pneumothorax.

An emergency left-sided tube thoracostomy is inserted under local anesthesia in the left fourth intercostal space at the midaxillary line. A large rush of air is appreciated. After the pneumothorax is drained, the clinical picture rapidly improves. At this point, the patient becomes much less dyspneic, with a respiratory rate of 22 breaths/min, a blood pressure of 124/63 mm Hg, a heart rate of 90 beats/min (normal sinus rhythm), and 92% SPO2 via face mask.

Approximately 10 minutes later, the patient experiences dramatic worsening of his condition, including significant shortness of breath. The respiratory rate rises to 32 breaths/min, and the SPO2 drops to 80% despite administration of oxygen via a nonrebreather mask. The blood pressure is maintained at 120/74 mm Hg, with a heart rate of 118 beats/min (sinus rhythm). Crackles are now heard over the left lung, most prominently at the base.

Blood gas analysis reveals a pH level of 7.30, a PCO2 of 35.4 mm Hg, a PO2 of 52.8 mm Hg, and a bicarbonate level of 17.2 mEq/L, with a base excess of -7.9 mEq/L. As the patient is prepared for a new chest radiograph (Figure 2), empirical treatment is initiated with medications.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.