C/O 28F WITH COUGH AND SHORTNESS OF BREATH
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A 28 year old female who is a housewife, resident of Miryalguda, came to the OPD with chief complaints of :
- Cough since 1 week
- Shortness of Breath since 1 week
HISTORY OF PRESENTING ILLNESS:
Patient
was apparently asymptomatic 1 week back. Then she developed cough since
1 week which was insidious in onset, gradually progressive, non productive, and aggravated at night.No known relieving factors
She
also complained of breathlessness since 1 week which was insidious in
onset, gradually progressive 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, no aggravating or relieving factors .
H/o fever 1 week back, subsided with medication.
On the day of examination (04/12/22) the patient complained of productive cough.
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.
PERSONAL HISTORY:
Build and Nourishment : Moderately built, Well Nourished.
Diet: Mixed
Appetite: Normal
Bowel and Bladder: regular
Sleep - Disturbed since last 1 week, was adequate before
No addictions
No known allergies to drugs or food
Daily Routine:
6 AM - Wake up, does morning routine, household chores
9 AM - Prepares breakfast, sends children to school, and husband to work
10 AM - 12 PM - Watches TV
1230 PM - 1 PM - Prepares and has Lunch
2 PM - 4 PM - Takes a nap
4 PM - Socialises with neighbours
5 PM - Children and husband return home, has some tea and snacks
6 PM - 7 PM - Spends time with family
8 PM - Prepares Dinner
9 PM - 10 PM - Has dinner and watches TV
10 PM - Goes to bed
FAMILY HISTORY:
No history of similar complaints in the family
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: 22 yrs
Para: 2
Number of living children:3
Birth history: LSCS
GENERAL EXAMINATION:
The patient is conscious, coherent, cooperative, and well oriented to time, place and person.
No pallor, icterus, cyanosis, clubbing, koilonychia, lymphadenopathy or edema
No malnutrition or dehydration
VITALS:
Temp: Afebrile
PR: 126 bpm
BP: 130/90 mm Hg
RR: 38 cpm
SPO2: 98% @ RA
SYSTEMIC EXAMINATION:
Patient is examined in a well lit room and in a sitting position.
Upper Respiratory Tract:
Nose: No DNS, polyps, turbinate hypertrophy
Oral cavity: No ulcers
Lower Respiratory Tract:
INSPECTION:
Shape of chest: elliptical
Trachea: appears to be central
Supraclavicular and infraclavicular hollowness absent
Accessory muscles usage - None
Apical impulse not assessed
No kyphoscoliosis
No hyperpigmented patches, scars
PALPATION:
All inspectory finding confirmed
Trachea: central
Tactile vocal fremitus: Not assessed
Chest movements: not assessed
PERCUSSION:
Direct: resonant
Indirect: not assessed
AUSCULTATION:
Bilateral Air Entry +, Vesicular Breath Sounds
CVS:
S1 S2 +
No murmurs heard
Apex beat - not assessed
PER ABDOMEN:
INSPECTION: Not Distended
PALPATION: Inspectory Findings Confirmed
Soft, non tender
No Organomegaly
PERCUSSION : Tympanic
AUSCULTATION: Bowel sounds Heard
CNS:
No focal neurological deficits
Cranial Nerves intact.
PROVISIONAL DIAGNOSIS:
Left sided HYDRO PNEUMOTHORAX
based on history and investigations on admission
INVESTIGATIONS:
CBP, CXR PA VIEW, ECG, 2D ECHO, SEROLOGY, RFT, LFT
CT - CHEST
ECG
01/12/22
02/12/22
 |
| PLEURAL FLUID CYTOLOGY |
03/12/22
TIMELINE OF EVENTS:
DAY 1: 1/12/22
The patient is conscious, coherent, and well oriented to time, place and person.
ICD inserted:
Tube: patent
Drain: 200ml
Air column: 3-4cm
Air leak +
Subcutaneous emphysema - Absent
Post procedure vitals:
PR: 128bpm
BP: 120/70mmhg
RR: 36cpm
SPO2: 99% with 12-14 liters/min of oxygen
 |
| ICD |
 |
| COLLECTED FLUID |
TREATMENT:
1. High flow O2 @ 12-14 liters/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
The patient is conscious, coherent, and well oriented to time, place and person.
DIAGNOSIS: Left sided hydro pneumothorax
C/o breathlessness reduced
C/o pain at ICD site
C/o Productive Cough
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 liters of Oxygen, 93% @ RA
GRBS- 189 mg/dl
RS: BAE+, VBS
Crepts + - left MA, ISA, infra SA
Rhonchi + - left MA, ISA, infra 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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