A 62 year old male with breathlessness

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 CBBLE UDHC SIMILAR CASES 


"This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box"

PULMONOLOGY BLOG

A 62 year old male came to casualty with c/o breathlessness since 3 days. 

HOPI:
Patient was apparently alright 3 days back then he sustained injury due to fall from wall on 25 /04/22. Breathlessness was sudden in onset gradually progressing from G I to G II. No postural variation present. 
No c/o cough, fever, chest pain, chest tightness, haemoptysis. 
No c/o burning micturition. 

No h/o similar complaints in the past. 
Diagnosed with pulmonary TB 4 months back by sputum CBNAAT (started ATT 3 tablets/day). 
N/K/C/O DM, HTN, EPILEPSY, CAD. 

PERSONAL HISTORY: 
Diet : normal 
Appetite : normal 
Bowel and bladder movements : normal
No known allergies 
Non smoker 
Occasional alcoholic

O/E : Patient is C/C/C 


No Pallor, Icterus, Cyanosis, Edema of feet, Lymphadenopathy, Clubbing 
Malnutrition present 

VITALS :  

Temp :  Afebrile 


PR : 78 bpm


BP : 130/90 mmhg 


RR : 30 cpm 


SPO2 : 94 % at RA 


Systemic examination:

PER ABDOMEN:
-Scaphoid.
-No scars.
-NO Tenderness.
-No guarding.
-Bowel sounds heard.

CARDIOVASCULAR SYSTEM:
-S1 S2 heard.
-No murmurs.

RESPIRATORY SYSTEM:
Inspection- 
- Shape of chest: Trachea appears to be central.
- Accessory muscle use for respiration- present.
- Drooping of shoulder- present.
-Wasting of muscle- present.
- Apical impulse @ 5th ICS.

Palpation-
-All inspecting findings are confirmed
-No local rise of temperature
-Tenderness present at right clavicular area
-Take a centre in position
-Chest moments decreased in right side

Percussion-
Direct -hyper resonant
Indirect -hyper resonant

Auscultation-
BAE- present 
Decreased breath sounds in rt SCA, ICA, ISA, IMA

Investigations:

RBS- 180

LFT-
TB 0.79
DB 0.20
AST 45*
ALT 19
ALP 177
TP 6.5
ALB 3.4

RFT-
Urea 21
Creatinine 0.6*
S. Sodium  142
S. Potassium  3.4*
S. Chloride 102

D-DIMER- 1190*

BT- 2min 30sec
CT- 5min
PT- 18sec
INR- 1.33
APTT- 35sec

CBP-
Hb- 10.8*
TC- 6,000
N/L/E/M/B- 91/5/2/2/0 
PLT- 2.37

Serum electrolytes on 6/5/22
Na- 138
K- 44
Cl- 98

Ortho referral
ICD notes 
2D echo
GM referral
ECG

Culture report 

Xray after removing ICD
Diagnosis:
Right sided moderate pneumothorax secondary to pulmonary TB.

Treatment:
1. Continue ATT
2. Tab.Azee 500mg OD
3. Inj.Pan 40mg IV/OD
4. Inj.ZOFER 4mg IV/OD
5. Tab.Diclofenac 50mg PO/OD
6. Tab.Orofer XT PO/OD
7. Tab.MVT PO/OD
8. O2 inhalation @ 2-4 L/min, maintain SpO2  > 92%
9. Tab.Pregaba M 75mg HS/OD
10. Neb with Duolin TID, Budecort BD, Mucomyst TID
11. High protein diet
12. Incentive spirometer 
13. Inj.augmenting 1.2gm IV/TID

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