29F WITH LEFT SIDED HYDROPNEUMOTHORAX
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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and coming up with diagnosis and treatment plans. is an online e-log book to discuss our patient's de-identified health data shared after taking his / her / guardians' signed informed consent. Here we discuss our individual patients' problems through a series of inputs from the available global online community of experts with an aim to solve those patients' clinical problems with collective current best evidence-based information.
A 29 year old female, homemaker, resident of miryalguda came to OPD with chief complains of cough and breathlessnes since 5 days
History of presenting illness:
Patient is apparently asymptomatic 5 days back,then she developed cough which is non- productive and aggravated during night , also complained of shortness of breath which was initially grade 2 and then progressed to grade 3 associated with Wheeze.
On 27/12/22 she went to local hospital ,there doctor gave injections for 3 days and referred to tertiary care center. On 1/12/22 she came here with severe shortness of breath and chest pain which was dragging type , non radiating associated with chest tightness . Tube thoracostomy is done and 200ml of fluid is drained.
No h/o night sweats and palpitations,hemoptysis.
No h/o fever, neck pains
Past history
No similar complaints in the past
No h/o inhaler usage
Not a known case of diabetes, hypertension,epilepsy,asthma,seizures,coronary artery disease,tuberculosis.
Allergic history:
Not allergic to known drugs
Not allergic to dust,pollen ,specific food
Personal History
Diet: mixed
Appetite normal
Bowel and bladder movements: regular
Sleep: disturbed,past 3 days she couldn't sleep properly and gets up from bed due to breathlessness.
No addictions
Menstrual History:
Age of menarche -12 yrs
Cycle-3/28
Not associated with pain and clots.
Lmp-1/11/22
Obstetric History:
Age at marriage - 18yrs
Age at first child birth- 19yrs
Para -2 (one male child in 1st delivery and one male+one female in 2nd delivery)
No. Of children -3 delivered by LSCS
Family History:
Not significant
DAILY ROUTINE
She wakes at 6 AM in the morning and does her morning routine , household works and have breakfast by 9 AM after sending her kids to school and husband to work. She watch TV from 10 am to 12 pm and then prepares lunch by 12:30 .Eat lunch at 1PM .She sleeps from 2 pm to 4pm,wakes up at 4 pm, talks with neighbours. Her kids and husband returns home by 5PM . At 5'o clock he Drinks tea with some Snacks like biscuits. From 5: 30 pm she talks to her and husband and asks about their day, prepares dinner at 7 pm and eats at 8pm , watch TV for one hour and Sleeps by 10pm.
General physical examination:
Patient is conscious,coherent,cooperative. Moderately built and nourished.Well oriented to time ,place ,person.
Pallor-absent
Icterus - absent
Clubbing - Absent
Cyanosis- Absent
Lymphadenopathy- absent
Edema - absent
Vitals:
2/12/22
Temperature- afebrile
BP:110/70mmHg
PR:110 bpm
RR:26cpm
SPO2 : 93% at Room atmosphere
GRBS : 189 mg/dl
On 1/12/22
Temperature: afebrile
Pulse rate : 144bpm
Respiratory rate : 42/min
Bp: 130/90 mmHg
Spo2 : 96 % at RA
GRBS : 151 mg %
Systemic Examination:
Respiratory system:
On inspection:
Upper respiratory tract:
No dns,polyps,turbinate hypertrophy
Oral cavity: no ulcers
Lower respiratory tract:
Shape: elliptical
Trachea:deviated to right.
No drooping of shoulders
No wasting of muscles
Accesory muscle usage : present
Spinoscapular distance: increased on left side
Apical impulse:not seen
No khyphoscoliosis
No hyperpigmentated patches or scars
Palpation:
No local rise of temperature
No tenderness
All inspectory findings are confirmed
Tactile vocal fremitus:
Decreased in left infraclavicular,mammary ,infra scapular area,infraaxillary
Chest movements:
decreased at infraclavicular,mammary,infra scapular, infraaxillary.
Percussion:
Hyperresonant in infraclavicular, mammary, infra scapular, infraaxillary regions
Shifting dullness: present
Auscultation:
Breath sounds:amphoteric
Airway entry decreased on left side
Wheeze: present.
Rhonchi : present
Saccusion splash: positive
Cardiovascular system :
S1 S2 heard
No murmurs heard
Per abdomen :
Soft, non-tender no organomegaly
CNS:
No focal neurological deficits
CLINICAL IMAGES :
Provisional diagnosis
Left sided Hydropneumothorax
INVESTIGATIONS
CT scan findings : (on 27/11/22)
Large non homogenous opacities with air bronchogram and surrounding ground glass opacities in the superior segment of left lower lobe.
Rest of lung parenchyma appear normal in attenuation.
Treatment
On 1/12/22
High flow o2 at 12-14 lit/min with face mask
Inj tramadol 1 amp in 100ml NS stat.
On 2/12/22
• Inj PIPTAZ 4.5 mg IV/TID
• Inj PAN 40mg IV/OD/BBF
• Inj Tramadol 1 amp in 100 ml NS (stat)
• Syp GLILLINCTUS -Dx 2 tsp TID
• Inj Zofer 4mg /I.v /Stat
• Monitor Vitals BP,RR,PR,SPO2
• T.Dolo 650mg PO BD
ICD CARE -
Bag always below waist
Cap always open
Check Air column movement
Maintain under water seal
• Neb with Duolin and Budecort
• Tab Azee 500 mg Pod
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