CBBLE UDHC SIMILAR CASES

RICU admission 
Bed 3 
70 y old male , rtc mechanic by occupation for 30 years , retired 7 years back .

Pt came with the chief complaints of breathlessness since 20 days.

HOPI : 
Pt was apparently asymptomatic 20 days back then developed breathlessness which was sudden in onset, gradually progressed from MMRC grade I to grade II. 
Breathlessness aggrevated during exertion and relieved on taking rest. No positional variation , not associated with wheeze .
No c/o cough , chest pain, chest tightness,  haemoptysis. No fever spikes. 

PAST HISTORY: 
No Similar Complaints in the Past.
Pt had history of bronchial asthma 40 years back for which he used medication and it was cured after 5 years.
N/K/C/O  DM, HTN, CAD, EPILEPSY. 
No h/o TB in the past.

PERSONAL HISTORY: 
Diet : normal 
Appetite : normal 
Bowel and bladder movements : normal
No known allergies 
Chronic smoker for 20 years - 1 beedi pack/day , stopped 7 years back.
Occasional alcoholic , stopped 7 years back.

O/E : Patient is C/C/C 


Pallor - 


Icterus  -


Cyanosis - 


Edema of feet - 


Lymphadenopathy  - 


Clubbing -



VITALS :  


Temp :  Afebrile 


PR : 112 bpm


BP : 160/100 mmhg 


RR : 28 cpm 


SPO2 : 97 % at RA 



SYSTEMIC EXAMINATION : 


CARDIOVASCULAR SYSTEM :  


S1 and S2 heard, no murmurs heard 


RESPIRATORY SYSTEM : 


BAE + , UBS + , decreased breath sounds noted in Lt. side SSA, SCA, ICA, IMA, ISA, INTER SA.


CNS : NAD 


PA :  soft, non tender 


FAMILY HISTORY: Not significant 




INVESTIGATIONS: 


                              CXR : 


CXR  POST ICD : 



TUBE THORACOSTOMY DONE ON 02/05/22: 


 
ICD NOTES : 

Tube : patent 
Drain : Nil
Air column movement : 4cm H2O
Air leak : + 
Subcutaneous emphysema : + Lt.ISA and above tube


            HRCT DONE ON 03/05/22 : 



GM REFERRAL DONE ON 03/05/22 : 





PROVISIONAL DIAGNOSIS:

LT.SIDED PRIMARY SPONTANEOUS PNEUMOTHORAX WITH COPD WITH DENOVO HTN.



TREATMENT: 

01. O2 support with 2L o2/min with nasal prongs
02. Inj. Augmentin 1.2 gm iv/Tid ( D4 )
03. Inj. Hydrocortisone 100 mg iv / od ( D4 ) 
04. Inj. Pantop 40 mg iv/od/bbf
05. Inj. Lasix 20 mg / Bd if SBP > 110 mmhg
06. Tab. Cinad 110/40 mg /po/od
07. Tab. Mucinac 600 1 Tab in 1 glass of water BD
08. T. Pcm 650 mg sos
09. Syrup Grillinctus 2 tbsp Tid
10. Neb with duolin , budecort 6th hrly BD
11. Tab. Diclofenac 75 mg sos
12. Milking of Subcutaneous emphysema 
13. Monitor vitals - BP, PR, RR, TEMP, SP02
14. ICD care - airway open, check for air column movement,  maintain water seal.








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