Mini-CEX

Marwan Al-Shaik Hussain

212528277

H/o
Mr. X a 28 year-old male, working as tractor operator. Single and lives in Al-Ahsa.
Patient complaint from left sided chest pain and shortness of
onset since 3 days.

breath pf sudden

Ex- 2 years smoker, he smoked 40 cigarettes per day for 8 years.

Present History:
Patient started complain 1 hour prior to admission from severe left sided
stabbing chest pain mainly in the left axilla and radiating to the left shoulder.
Pain increase with breathing, coughing and holding breath.

Con
Associated with shortness of breath and dry cough.
No history of: fever, expectoration, hemoptysis or chest wheeze.

DD

Pneumothorax
PE
Angina
Aortic Dissection

Past Medical
History

Family History

No past history of
similar condition
No history of surgery
No history of chronic
diseases

No family history of
similar problem

MEDICATIONS
No history of
medication

Vitals
Weight. 68 kg
Height. 178cm
RR. 16 breath
temp. 37.5
Spo2. 99% 2LPmnc
BP. 120/80
HR 94 b/m

General Examination
Patient conscious, oriented alert
and stable.
Lean tall patient.
Skin examination : NAD
HEENT examination : NAD , no
jaundice, no pallor, no cyanosis no
LN swelling, JVP normal
Cardiovascular examination :
normal S1, S2
Extremities : no clubbing, no
tremors, pulsation well felt, no LL

Local Examination
Inspection:
Trachea shifted to the right side.
No dilated veins
There is intercostal tube in the left 6th intercostal space in the maxillary
line.
Limitation of movement in the left side with plugging.
Palpation:
Trachea shifted to the right side.
Absent apical pulsation.
Limited movement of left side of the chest.
Absent tactile vocal fremitus

CON
Percussion:
Hyper resonant left side anteriorly and posteriorly.
Auscultation:
Vesicular breathing in the right side.
Absent breathing on the left side with no added sounds.

Investigations
Lab.
WBC.
x109
CBC ---- Hct.
%
Hb.
g/dl
PH.
Platelets.
ABG----- Po2.
x109
-mmHg
Pco2.
mmHg
HCO3.
mmol/L

4.5
52.0
16.5
282

7.5
88.6
32.1
25.3

Creatinine.---mg/dl
Sodium. ---mmol/L
Potassium.---4.2mmol/L

0.9
140

Con
CXR

Chest CT
scan

Large left sided pneumothorax with

left lung partial collapse
Clear right lung with acute right
costo-phrenic angle .
Normal bony cage
Normal heart size , shape and
configuration
To be ordered

CXR on admission

After chest tube insertion

next day after chest tube insertion

Today after chest tube clamping

Final
Diagnosis

Pneumotho
rax

Management
Insertion of intercostal tube
Oxygen
Medication:
Analgesic: diclofenac sodium
Low molecular weight heparin: clexane
incentive spirometry
Follow-up after 1 week

THANK YOU

Provisional Diagnosis
gastritis
peptic ulcer
pancreatitis
Cholelithiasis and cholecystitis

Con
CXR

MRCP

Multiple gall bladder minilithiasis.

Heterogeneous moderate
hepatic stenosis
Gallbladder calculi with wall
thickening but with no edema.
Calculi seen on distal common
bile duct.