The facilitator's notes provided in this case serve only as a guide and not as a directive.

Block I - Case 1
Case 1 (AN-1:1): Jack Craig (Session 1)

You are at the Family Practice Clinic in a small rural community. You are spending the day
with your future preceptor, Dr. Weiler. His next patient is Jack Craig, a 15-year-old young man,
who is accompanied by his father. He complains that he has experienced "chest pain and a
shortness of breath" since earlier today when he was involved in a minor automobile accident.

~Break~

[Modified from University of New Mexico School of Medicine Primary Care Curriculum Cases 101, copyright 1990 by
the University of New Mexico School of Medicine. Modified by Drs. William Burdick, Sandra P. Levison, Nancy
Minugh-Purvis and Ms. Lucia Beck Weiss, along with members of the Block I Committee. No part of this document
may be reproduced, stored, or transmitted in any form without prior written permission of MCP Hahnemann University
(formerly known as Allegheny University of the Health Sciences, MCP Hahnemann School of Medicine), Program for
Integrated Learning.]6/00
Case 1 (AN-1:1): Jack Craig (Session 1) Page 2

History

Jack tells you that while driving his father's car that afternoon, he had rear-ended another vehicle
slowing down for a red light. Since then, he has found it painful to breathe, and feels he cannot
"get enough air." His father informs you that this is the second time that he knows of that Jack
has taken his car without his knowledge and banged it up. Jack is too young to have a driving
license.

~Break~
Case 1 (AN-1:1): Jack Craig (Session 1) Page 3

You ask to interview Jack privately. He states that he is in generally good health, does not
smoke, and has no allergies or history of cardiovascular or respiratory disease. Jack reports that
he has no siblings. He drinks "an occasional beer" with his friends. He shrugs the accident off,
stating, "What's the big deal? Anyway, my parents weren't that upset last time." When you ask
him about wearing a seat belt, Jack responded that "he does not wear seat belts." He states he is
not sexually active, saying "girls don't seem much interested in me" but he feels he gets more
attention in his dad's sports car. He does not use prescription drugs. When asked, he states he
smokes a joint about 1-2 times a month but says he wasn't "stoned" today. Jack had been an
A&B student in elementary and Junior High School, but this year his grades have fallen
dramatically.

Facilitator Notes:

1. How would you question this patient? How would you introduce yourself? How
would you address him?

2. Do you think Jack is in trouble? What further information do you need to get?

3. How might one's own background and socialization affect one's ability to
recognize any abnormalities in adolescent behavior?

4. If this patient were a young woman, would this behavior be interpreted

differently? Are there gender differences in risk taking behaviors during
adolescence?

~Break~
Case 1 (AN-1:1): Jack Craig (Session 1) Page 4

Physical Findings

General: Jack is a thin, acyanotic, white young man who seems to be in moderate
respiratory distress. He appears anxious, but is alert and cooperative, as he holds
the table edge, obviously using his accessory muscles of respiration.

Vital signs:
Temperature: 37C
Respiration: 28/min.
Pulse: 108/min.
BP: 138/90mmHg
Height: 165cm (65 inches)
Weight: 50Kg (110 lbs)

Pulmonary Exam: Hyperresonant to percussion on left side

Breath sounds absent on the left side
Vocal fremitus absent on left side
Trachea midline

Hematoma and tenderness noted on the left costal margin at the midaxillary line.

Facilitator Notes:

1. How is breathing accomplished by the lungs?

2. Are any musculoskeletal elements of the thorax important as well?

~End of Session 1~
Case 1 (AN-1:1): Jack Craig (Session 2) Page 5

A chest film was ordered.

Facilitator Notes:

1. How are radiographs read?

2. How symmetrical is thoracic anatomy?
3. What might account for the differences between the right and left?
4. Which side is normal? Why?
5. Aside from the obvious abnormality, does everything else appear normal?

******************************************************************************
X-RAY DESCRIPTION:

Please Note: This X-ray is not taken directly from the patient. This X-ray should be used only
as an example.

A. Chest x-ray (erect PA): Normal

B. Chest x-ray (erect PA - expiratory, meaning that x-ray was shot with patient in
expiratory phase of breathing):

Note: X-ray is generally light - this is a function of either a large patient or

slightly inadequate kilovolt energy setting when the film was taken

Note: pleural reflection line in left lung field near the periphery of the chest
cavity; no lung markings are visible peripheral to this line; consistent
with left pneumothorax (some may estimate size as a percent - in this case
about 20-30% - but this is neither very accurate nor very helpful.

C. Chest x-ray (erect PA – inspiratory view of a woman with a partial mastectomy)

~End of Session 2~
Case 1 (AN-1:1): Jack Craig (Session 3) Page 6

Epilogue

Jack was admitted to the local hospital where a chest tube was inserted in the 4th intercostal
space at the anterior axillary line on the left side. He was then transferred to the adolescent unit
of the regional medical center where he spent three days. The chest tube was removed without
complication. While there, a consultation was obtained from the adolescent psychiatrist to
evaluate Jacks risk taking behavior. The psychiatrist felt that Jacks behavior was consistent
with an adjustment disorder of adolescence. He recommended outpatient therapy.

Pleuritic chest pain associated with dyspnea in an otherwise fit young man suffering from rib
trauma is highly suggestive of simple traumatic pneumothorax.

General Discussion about Pneumothorax

Pneumothorax occurs when air is introduced into the pleural space causing a partial or complete
collapse of the lung. If the pressure of the air in the pleural space is equal to or less than
atmospheric pressure, the condition is called a simple pneumothorax. However, if the pressure
in the pleural space is greater than atmospheric pressure, due to a one-way leak into the pleural
space ("ball valve leak") or a complication of positive pressure ventilation, a tension
pneumothorax is present. Tension pneumothorax is a medical emergency.

The etiology of pneumothorax may be either traumatic, as in this case, or spontaneous (air entry
from the tracheobronchial tree). Spontaneous pneumothorax most commonly occurs in
previously healthy adults between 20-40 years of age and likely is caused by the rupture of small
blebs on the surface of the visceral pleura, frequently near the lung apex. Patients who have
experienced a spontaneous pneumothorax should be fully informed of the problem, since more
than half are likely to experience a recurrence. Pneumothorax can also occur spontaneously in
patients with underlying lung disease such as asthma, emphysema, lung abscess, and neoplasm.

Physical signs elicited from patients with simple pneumothorax usually include diminished
expansion of the affected side of the chest, a hyperresonant percussion, reduced tactile vocal
fremitus and vocal resonance noted over the affected side, and reduced or absent air entry on the
affected side. In the case of tension pneumothorax the affected lung is compressed, the trachea
and mediastinal structures are displaced towards the unaffected side, and cardiac output may be
severely compromised due to the positive intrathoracic pressure decreasing venous return to the
heart.

Case 1 (AN-1:1): Jack Craig (Session 3) Page 7

In cases of pneumothorax, a chest x-ray should be taken in the upright position at maximal
expiration. A Chest x-ray will reveal a visible pleural edge with no lung markings between the
edge and the chest wall; in the case of tension pneumothorax, the mediastinum will be markedly
shifted to the unaffected side.

The treatment of pneumothorax depends upon the etiology and severity of the condition. In less
severe cases of simple pneumothorax, it is reasonable to wait for two or three days to see
whether the lung will re-expand on its own. If it does not, a similar procedure to that described
for a tension pneumothorax should be adopted. In cases of large, spontaneous or traumatic,
simple pneumothorax and in all cases of tension pneumothorax, an intercostal tube, called a
"tube thoracostomy," "thoracostomy tube," or commonly, a "chest tube", is inserted into the
pleural spaces and attached to suction and an underwater seal. This permits the evacuation of air
under conditions which maintain negative pressure in the pleural space. Such evacuation of air
from the pleural space should be accomplished as quickly as possible.

~End of Session 3~
Academic year: 2000-01
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Learning Objectives - Block I: Case 1 - Jack Craig

Anatomy

1. Describe the surface landmarks and other major structural features of the anterior and
lateral thoracic wall.

2. Identify the components of the axial skeleton: vertebral column, pelvic bones, ribs, and
sternum.

3. Name the contents of a typical intercostal space, their position relative to each other.

4. Name the subdivisions of the pleura and lungs and describe their surface projections.

5. Identify important structures on a plain film "chest x-ray" and on CT and MRI sections.

6. Define a bronchopulmonary segment.

7. Describe the process of breathing: name the primary and accessory muscles involved and
their innervation.

8. Describe the major types of epithelia and how their structure relates to their function.

9. Identify the various portions of the respiratory system on histological slides.

10. Describe the development of the trachea, bronchi, lungs, and pleural cavity.

11. Describe the structural organization and functions(s) of the three major portions of a
neuron (soma, dendrites, axon).

12. Describe the structure of myelin and its role in impulse conduction.

13. Identify the components of a typical animal cell, and describe the function of each
component.
Learning Objectives - Block I: Case 1 - Jack Craig

Behavioral Science

1. Describe the physical, emotional, social and cognitive characteristics and tasks of the
early, middle, and late stages of adolescence.

2. Summarize some common indications for psychosocial intervention in adolescents.

3. List topics for anticipatory guidance for adolescents and their families during different
developmental phases.

4. Describe the common concerns about and responses to illness in adolescents.

5. Know the differences in the way adolescent men and women engage in risk taking.

Patient as a Person (PAP)

1. Know guidelines for the approach to interviewing adolescent patients.

Academic Year: 2000-01

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