Subjective
Date of visit
Reason for visit (initial evaluation for pneumothorax, follow-up for chest tube placement)
History of present illness:
Sudden onset of sharp, pleuritic chest pain (worsened with inspiration or cough)
Dyspnea (shortness of breath) – may be mild or severe
Non-productive cough (may be present)
History of pneumothorax (if applicable)
Symptoms of underlying lung disease (if present)
Past medical history (relevant conditions):
Chronic obstructive pulmonary disease (COPD) – most common risk factor for spontaneous pneumothorax
Asthma
Smoking history (increases risk of pneumothorax)
Previous lung trauma or surgery
Recent travel history (flying at high altitude can increase risk)
Medications (current medications)
Allergies
Objective
Vital signs (temperature, heart rate, respiratory rate, oxygen saturation) – tachypnea (rapid breathing) and hypoxia (low oxygen) may be present in larger pneumothoraces
Physical exam:
General (signs of respiratory distress)
Chest exam:
Inspection (asymmetry of chest wall movement, use of accessory muscles)
Palpation (decreased tactile fremitus on the affected side)
Percussion (hyperresonance on the affected side)
Auscultation (diminished breath sounds on the affected side)
Neck veins (distention may suggest tension pneumothorax – a life-threatening condition)
Assessment
Pneumothorax (confirmed by chest X-ray):
Size of pneumothorax (small, medium, large)
Tension pneumothorax (ruled out based on clinical presentation and chest X-ray)
Underlying cause of pneumothorax (spontaneous, secondary to lung disease, traumatic)
Plan
Imaging:
Chest X-ray (initial and follow-up to assess size and response to treatment)
Treatment (based on size, symptoms, and underlying cause):
Observation (for small, stable pneumothoraxes)
Needle aspiration (removal of air with a needle)
Chest tube placement (insertion of a tube into the pleural space to drain air)
Surgical intervention (for large pneumothoraxes, recurrent pneumothorax)
Supplemental oxygen therapy as needed
Education
Explain pneumothorax, potential causes, and the planned treatment approach.
Importance of smoking cessation (if applicable)
Signs and symptoms of pneumothorax recurrence to watch for and report promptly.
Follow-up
Schedule for follow-up appointments:
Monitor response to treatment (clinical improvement, chest X-ray)
Repeat chest X-ray to assess resolution of pneumothorax
Consider referral to a pulmonologist for complex cases or recurrent pneumothorax
Disclaimer: This information is for educational purposes only and should not be interpreted as medical advice. Please consult with a qualified healthcare professional for diagnosis and treatment of pneumothorax.