Step 2

Pulmonary 10

A 32-year-old man presents to the emergency department with sudden-onset, right-sided chest pain and shortness of breath which began one hour ago. He denies fever but complains of palpitations and has difficulty completing sentences while talking. He was diagnosed with ankylosing spondylitis 10 years ago and is managed successfully with an anti-tumor necrosis factor (TNF) blocker as well as naproxen for joint pains. He does not smoke cigarettes or drink alcohol. Family history is significant for hypertension in his father at age 52 years and diabetes in his mother at age 46 years. Vital signs are blood pressure 110/75 mmHg, pulse rate 109 beats/min, respirations 36/min, and temperature of 37.5° C (99.5° F). Pulse oximetry shows 89% on room air. Physical examination reveals decreased breath sounds in the right upper lung field as well as hyperresonance and reduced vocal fremitus. There is no jugular venous distention. Systolic blood pressure does not fall more than 10 mmHg on inspiration. He is started on 100% oxygen.

Which of the following is the most appropriate next step in the management of this patient?

  • A) Bedside ultrasound of the chest
  • B) Chest tube placement
  • C) Close observation with outpatient follow-up
  • D) Computed tomography (CT) scan of the chest
  • E) Ventilation-perfusion (V/Q) scan


Min Gyu Kim


Dr. Ted O'Connell