Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with sudden onset of sharp, pleuritic chest pain localized to the [Right/Left] hemithorax, associated with acute dyspnea. No history of preceding trauma, mechanical ventilation, or underlying chronic lung disease. Symptoms occurred at [rest/exertion]. Denies fever, hemoptysis, or syncope.
Clinical Examination Findings
Vitals: [T, HR, BP, RR, SpO2]. General: Patient appears [distressed/comfortable] at rest. Respiratory: Diminished or absent breath sounds on the [affected] side. Hyper-resonance to percussion on the [affected] side. Trachea midline. No signs of tension physiology (stable BP, no JVD). Cardiovascular: Tachycardia present; heart sounds regular.
Treatment Protocol
Management plan: Supplemental oxygen administered. If small (<2cm): Observation with serial CXR. If large (>2cm) or symptomatic: Needle aspiration or small-bore chest tube (pigtail catheter) insertion. Analgesia provided. Repeat CXR post-intervention to confirm lung re-expansion. Admission to [Observation Unit/Pulmonary Service] for monitoring.