HISTORY:
Sudden onset of for
, ,
,
, up to °, over
Worsening factors:
Treatments tried: ,
Other elements:
EXAM:
General appearance:
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Neck:
Heart: ,
Lungs: ,
Chest: on
Abdomen: , , ,
Extremities: , , cap refill , pulses ,
ASSESSMENT:
DDx:
PLAN:
- Chest X-ray
- CT scan of the chest
- Immediate decompression
- Chest tube insertion
- Oxygen 2L
-
-
-
- Hydration and rest
- Smoking cessation counseling
- Referral to surgeon
- Repeat chest X-ray in
- Follow-up in
- Return if symptoms worsen or if new symptoms develop