A previously healthy 20-year-old male is admitted to the hospital with acute onset of lest-sided chest pain. Electrocardiographic findings are normal, but chest x-ray shows a 40% left pneumothorax. Treatment consists of which of the following procedures? a- Observation b- Barium swallow c- Thoracotomy d- Tube thoracostomy e- Thoracostomy and intubation Answer: d. (Schwartz, 7/e, pp 711-713, 781) Spontaneous pneumothorax usually results from the rupture of subpleural blebs in young men (age 20 to 40), which is often signaled by a sudden onset of chest and shoulder pain. Pneumothorax of more than 25% requires placement of chest tube; thoracotomy with bleb excision and pleural abrasion is generally recommended if spontaneous pneumothorax is recurrent. Small pneumothoraxes in patients with minimal in symptoms usually resolve and therefore can simply be observed. A spontaneous perforation of the esophagus (Boerhaave syndrome) can result in hydropneumothorax as well as the more usual pneumomediastimun, but would not present with an isolated 40% pneumothorax. Barium swallow is an appropriate diagnostic test for evaluation of a suspected leaking esophagus.