A case of hydropneumothorax.

This is an online e-log book to discuss our patient de-identified health data shared after taking his / her / guardian's 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.

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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. 

Introduction: A 29yr old female housewife resident of miryalguda came to our old with complaints of                    cough, fever and breathlessness.

Chief complaints: severe cough since 7 days 

                             Breathlessness since 7 days.

History of presenting illness:patient was asymptomatic 9 days back,then she developed fever which was intermittent and aggrevated during night,fever was associated with chills.

Fever subsided on 3rd day.

She then started developing cough which was non productive and breathlessness which now progressed to grade 4, aggrevated on lying down

Patient also complains of diffuse chest pain of dragging type.

On 4th day of illness she went to an RMP and received injections for 3 days,as her symptoms were not subsiding she was reffered to our hospital.

1/12/22: she arrived at our opd with severe breathlessness,chest pain which was dragging type non radiating diffuse pain associated with chest tightness and cough.

Breathlessness associated with wheeze,palpitations and sweating.

No h/o weight loss.

Past history:no h/o asthma and inhaler use.

No h/o tuberculosis

No h/o hypertension , diabetes 

No h/o heart diseases

No h/o cornary artery disease, peripheral vascular disease.

No know allergies to drugs, 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:

On 1/12/22

Temperature: afebrile

Pulse rate : 144bpm

Respiratory rate : 42/min

Bp: 130/90 mmHg

Spo2 : 96 % at RA

GRBS : 151 mg %

On 2/12/22

Temperature- afebrile

BP:110/70mmHg

PR:110 bpm

RR:26cpm

SPO2 : 94%at Room atmosphere 99% with o2 supply.

GRBS : 189 mg/dl

On 3/12/22

Temperature- afebrile

BP:120/80mmHg

PR:130 bpm

RR:30 cpm

SPO2 : 95% at Room atmosphere 

GRBS : 155 mg/dl

On 4/12/22

Temperature- afebrile

BP:100/60 mmHg

PR:116 bpm

RR:26cpm

SPO2 : 98% at Room atmosphere 

GRBS : 112 mg/dl

On 5/12/22

Temperature- afebrile

BP:110/70mmHg

PR:110 bpm

RR:30cpm

SPO2 : 98% at Room atmosphere 

GRBS : 116 mg/dl

EXAMINATION OF RESPIRATORY SYSTEM:

UPPER RESPIRATORY TRACK

oral cavity: oral hygiene maintained

no ulcers,no dental caries,

No tonsillars hypertrophy

Nose:no DNS,NO POLYPS.

No congestion on posterior pharyngeal wall.

LOWER RESPIRATORY TRACK

Inspection:

Position of trachea-appears to be central

Chest is symmetrical,elliptical in shape

Reduced depth of movement on left side

Increased spino scapular distance on left side.

RR:30(tachypnea)

Accessory muscle usage is present

No drooping of shoulders,wasting of muscles

Palpation:

Trachea is central.

Apex beat not felt

TVF reduced on left is reduced in the Infrascapular area,interscapular area,inferior clavicular area,mammary area,inferior axillary area.

Reduced chest movements in infra SA,ISA,IAA,ICA,MA.

Percussion:

Dull note over infra scapular, and inferior axillary

AUSCULTATION:

Reduced breath sounds on left over infra SA,ISA,IAA,ICA,MA.

Provisional diagnosis:left sided hydro pneumothorax. 

Hemopneumothorax left sides. 

Investigations:

Chest x ray

Chest x ray findings

CHEST USG.

THORACOSTOMY DONE AND PLEURAL FLUID ANALYSIS on 1/12/22

Pleural fluid analysis on 2/12/22

Pleural fluid sugars were 35(normal 60 to 90).

PRESENT DAY ICD

Provisional diagnosis:Hydropneumo thorax as the fluid drained was straw colored. 

Liver function test

THORACOSTOMY FINDINGS:

ICD :

On 1/12/22

Tube - patent 

Drain - 200ml

Air column - 3.4cms

Air leak +

Subcutaneous emphysema-

On 2/12/22

Tube - patent 

Drain-nil

Air column movement : 3-4 cm H20

No subcutaneous emphysema 

Air leak absent  

Post procedure Vitals:

PR 128bpmBP 120/70mmHgRR 36 cpmSPO2 99%at RA

ECG FINDINGS: T wave inversion in v3 lead 

Provisional diagnosis:pericarditis ( tubercular)

Left sided hydro pneumothorax secondary to TB. 

DISCUSSION:

_ 

_TREATMENT:

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