LEFT SIDED HYDROPNEUMOTHORAX
A 28 year old female who is a home maker, resident of Nalgonda, came to the OPD with complaints of
- Cough since 1 week
- Sob since 1 week
HISTORY OF PRESENTING ILLNES:
Patient was apparently asymptomatic 1 week back. Then she developed cough since 1 week which was non productive and aggravated at night.
She also complained of breathlessness since 1 week which was insidious in onset, gradually progressed from mMRC grade II to grade III, associated with wheeze, palpitations, sweating and Orthopnoea.
C/o chest pain which was dragging type, non radiating on the left side associated with chest tightness
C/o fever 1 week back, subsided with medication.
There is no h/o loss of appetite, reduced urine output or loss of weight
PAST HISTORY:
No similar complaints in the past
No h/o inhaler usage
No past h/o TB
N/K/C/O HTN, DM, epilepsy, CAD, asthma
H/o 2 previous LSCS.
PERAONAL HISTORY:
Diet: non vegetarian
Appetite: normal
Bowel: regular
Micturition: normal
No addictions
No known allergies
FAMILY HISTORY: not significant
MENSTRUAL HISTORY:
Age of menarche: 12 years.
Cycle: 3/28
Not associated with pain or clots
LMP: 1/12/22
OBSTETRIC HISTORY:
Age of marriage: 18 years
Age at first child birth: 19 yrs
Para: 2
Number of living children:3
Birth history: LSCS
GENERAL EXAMINATION:
No pallor, icterus, cyanosis, clubbing, koilonychia, lymphadenopathy or edema
No malnutrition or dehydration
VITALS:
Temp: 99 F
PR: 144 bpm
BP: 130/90 mm Hg
RR: 42 cpm
SPO2: 96% @ RA
GRBS: 151 mg/dl
SYSTEMIC EXAMINATION:
URT:
Nose: no DNS, polyps, turbinate hypertrophy
Oral cavity: no ulcers
LRT:
Shape of chest: elliptical
Trachea: appears to be central
Supraclavivular and infraclavicular hollowness absent
No drooping of shoulders
No wasting of muscles
Accessory muscles usage +
Spinoscapular distance increased on the left side
Apical impulse not seen
No kyphoscoliosis
No hyperpigmented patches, scars
PALPATION:
All inspectors finding confirmed
No local rise of temperature
Trachea: shifted to left side
Apex beat no felt
Tactile vocal fremitus: reduced at left ICA, MA, ISA, Infra SA
Chest movements: reduced on the left ICA, MA, ISA, IAA, Infra SA.
PERCUSSION:
Direct: resonant
Indirect: hyper resonant in the left ICA, MA, ISA, Infra SA, IAA
AUSCULTATION:
BAE +, VBS
Absent BS at left ICA, MA, ISA, Infra SA, IAA
CVS:
S1 S2 +
No murmurs heard
PER ABDOMEN:
Soft, non tender
No organomegaly
CNS: no focal neurological deficits
PROVISIONAL DIAGNOSIS:
Left sided hydro pneumothorax
INVESTIGATIONS:
CBP, CXR PA VIEW, ECG, 2D ECHO, SEROLOGY, RFT, LFT
DAY 1: 1/12/22
ICD inserted:
Tube: patent
Drain: 200ml
Air column: 3-4cm
Air leak +
Subcutaneous emphysema-
Post procedure vitals:
PR: 128bpm
BP: 120/70mmhg
RR: 36cpm
SPO2: 99% with 12-14 litres/min of oxygen
TREATMENT:
1. High flow O2 @ 12-14 litres/min with face mask
2. Inj PIPTAZ 4.5mg IV/TID
3. Inj PAN 40 mg IV/OD/BBF
4. Inj TRAMADOL 1 amp in 100ml NS stat
5. Syrup GRILLINCTUS-DX 2tsp TID
6. Inj ZOFER 4mg IV/STAT
7. T. DOLO 650mg PO BD
8. Monitor vitals- BP, PR, RR, SPO2
DAY 2: 2/12/22
DIAGNOSIS: Left sided hydro pneumothorax
C/o breathlessness reduced
C/o pain at ICD site
No c/o cough, fever, chest tightness, hemoptysis
O/E:
Patient is conscious, coherent, cooperative
Temp: a febrile
PR- 110 bpm
BP- 110/70 mmhg
RR- 40 cpm
SPO2- 98% with 4 litres of Oxygen, 93% @ RA
GRBS- 189 mg/dl
RS: BAE+, VBS
Crepts + - left MA, ISA, infra SA
Rhonchi + - left MA, ISA, infa SA
qSOFA score: 1
ICD NOTES:
Tube: patent
Drain: nil
Air column movement: 3-4cm H2O
No subcutaneous emphysema
Air leak- absent
Advice:
Troponin I, sputum for CBNAAT, blood culture, urine culture, pleural fluid analysis, TC, DC, ADA, cytology
TREATMENT:
1.O2 inhalation @ 2-3l/min to maintain saturation >94%
2. Inj PIPTAZ 4.5mg IV/TID
3. Inj PAN 40 mg IV/OD/BBF
4. Inj TRAMADOL 1 amp in 100ml NS stat
5. Syrup GRILLINCTUS-DX 2tsp TID
6. Inj ZOFER 4mg IV/STAT
7. T. DOLO 650mg PO BD
8. Monitor vitals- BP, PR, RR, SPO2
9. ICD care:
- Bag always below waist
- Cap always open
- Check air column movement
- Maintain under water seal.
11. Tab. AZEE 500mg PO OD
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