Code Status case · Advanced · Premium
Chest pain in a 27-year-old man
“I have a sharp pain on the left and I can't take a full breath.”
“Sudden sharp left-sided chest pain and shortness of breath started about two hours ago at rest. No trauma or fever. He's speaking in full sentences. Heart rate 104, oxygen saturation 92% on room air.”
Your challenge
Mateo is 27, and two hours ago, while doing nothing at all, a sharp pain hit the left side of his chest. Now he cannot take a full breath, his heart is a little fast and his oxygen is a little low, but he is talking in full sentences. A strained chest wall, a panic attack, inflammation around the heart, a chest cold or a collapsed lung could all be the answer. The image may look less dramatic than he feels, but size is only part of the decision. You have to judge what needs treatment, and whether the next step is a procedure you perform yourself.
After the case, Attending’s Notes explains the decisions that mattered, backed by 10 sources.
Ready to make the call?
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Spoiler: the diagnosis and what this case teaches
Diagnosis
Primary Spontaneous Pneumothorax
Lesson 1
Tension Pneumothorax Is a Bedside Emergency
The first question is not how big the pneumothorax is. It is whether the patient is unstable.
- Tension pneumothorax impairs circulation
- A pleural line borders air without lung markings
- Lung sliding excludes pneumothorax at that site
- If unstable with tension, decompress now
Lesson 2
Symptoms and Stability Guide Air Removal
Some stable cases are observed.
- Primary pneumothorax has no apparent lung disease
- Observe if stable with few symptoms
- Drain persistent symptoms or hypoxemia
- Decompress tension, then place a chest tube
- Size guides treatment, not severity
Lesson 3
Place the Chest Tube Safely
The entry site and the technique are what make it safe.
- Enter the safe triangle just above a rib
- Place a pigtail chest catheter over a guidewire
- Persistent pneumothorax can signal tube malfunction
- Control insertion depth to reduce organ injury
Lesson 4
Assess Drain Function With Symptoms and Imaging
The drain lets trapped air out.
- Water seal lets air out and prevents return
- Suction helps draw air out through the chest tube
- Water moves if tube is open. Bubbles show airflow.
- Symptoms with no tidaling may mean blockage
- If drainage changes, assess patient and tubing first
In the app, every line above opens into the detail behind it: doses, pitfalls and the evidence, with 10 sources linked to the originals.
Mateo is a fictional patient. Code Status is for training only and is not intended for real-world patient care, diagnosis, treatment, or clinical decision-making.