SOAP PNTHX

 A

Here's a detailed SOAP note for the case of Spontaneous Pneumomediastinum in a Healthy Adolescent:

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🧾 SOAP Note

S – Subjective

• Patient: 15-year-old previously healthy female

• Chief complaint: Chest pain and neck swelling

• History of Present Illness:

  • Onset: Sudden, occurred the day before presentation

  • Symptoms:

    • Chest pain, back pain, and sore throat while sitting in class

    • Later that day: noticed raspy voice and neck swelling

  • No history of trauma, coughing fits, vomiting, or exertion

  • No shortness of breath or fever reported

• Past Medical History: Unremarkable

• Medications: None

• Allergies: NKDA

• Social history: No smoking, vaping, or drug use

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O – Objective

• General: Well-appearing adolescent in no acute distress

• Vitals: (assumed normal unless otherwise stated)

• HEENT: Mild neck swelling, palpable crepitus over anterior neck (suggestive of subcutaneous emphysema)

• Chest:

  • Mild tenderness on palpation of the anterior chest wall

  • Possible Hamman’s sign (crunching sound synchronous with heartbeat)

  • Lungs clear to auscultation, no respiratory distress

• Voice: Raspy, no stridor

• Cardiovascular: Normal heart sounds, no murmur

• Neurologic/Abdomen: Normal

• Imaging: Chest X-ray or CT reveals air in the mediastinum without pneumothorax or other pathology (if available)

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A – Assessment

• Spontaneous pneumomediastinum (SPM) in a healthy adolescent

  • Likely due to sudden increase in intrathoracic pressure (Valsalva-like event, even without a clear trigger)

  • Accompanied by subcutaneous emphysema and voice change (dysphonia)

• No signs of complications (e.g., tension pneumomediastinum, pneumothorax, infection)

• Differential diagnoses considered:

  • Pneumothorax

  • Retropharyngeal abscess (less likely without fever)

  • Esophageal rupture (Boerhaave’s, unlikely here—no vomiting)

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P – Plan

1. Monitoring and Supportive Care

• Admit or observe for 24–48 hours if symptoms are moderate or if imaging is concerning

• Supplemental oxygen (may help reabsorb free air more quickly)

• Analgesia for chest discomfort (e.g., paracetamol or ibuprofen)

2. Activity Restriction

• Avoid strenuous activity, Valsalva maneuvers, or airway pressure changes for 1–2 weeks

3. Education & Reassurance

• Explain benign, self-limiting nature of SPM

• Reassure that full recovery is expected in healthy patients

• Educate on signs of deterioration: worsening chest pain, shortness of breath, dysphagia, fever

4. Follow-Up

• Outpatient follow-up in 1 week or sooner if symptoms worsen

• Repeat chest imaging only if symptoms persist or worsen

5. No Antibiotics Needed unless evidence of infection or concern for secondary causes

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