33M PTB ICD

CHIEF COMPLAINTS:
A 33 year old male patient resident of suryapet presented to OPD with complaints of 
Cough since 20days.
Fever since 1week.
Shortness of breath since 5days.
Right chest pain since 2days.

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 20days back then he develped cough sudden in onset, Productive, mucord, non foul Smelling , non blood. No aggravating and relieving factors.

No pleural and postural variation.

C/O Fever-high grade since 1week , no evening rise of temp relieved on medication, not associated with chills. 

C/O shortness of breath since 5 days grade II MMRC progressive to grade III MMRC from 2days.

No wheeze.

Aggrevating on exertion, relieved on rest.

 NO Orthopnea, NO PND. 

C/O Right sided chest pain since 2 days dull aching type, non radiating, Not associatid With sweating and palpitations 

No C/O hemoptysis,chest tightness,palpitations 

H/O weight loss: 2months (Loosening of clothes) & loss of appetie 2 months.

HISTORY OF PAST ILLNESS:

No H/O similar complaints in past

No H/OTB in past [H/O Exposure to TB Contact +(Friend)

NO H/O Inhaler Usage

H/O DM : 6month (Irregular usage of medication)

N/K/C/O HTN, CAD, Epilepsy, Bronchial Asthma, thyroid disorders.

FAMILY HISTORY:

No significant family history.

PERSONAL HISTORY:

Diet-Mixed.

Appetite-Lost

Bowel&Bladder Movements-regular.       

Sleep-adequate.


Addictions-Alcohol:daily since 10years

                   Tobacco-since 10years.

GENERAL EXAMINATION:

patient is conscious,coherent and cooperative. 

well oriented to time,place and person.

thin built and Moderately nourished. 

Pallor-no.

Icterus-no.

No cyanosis, clubbing, lymphadenopathy.

pedal edema-present.

VITALS:

BP-110/60 mmhg.

TEMP- afebrile.

RR-36cpm.

PR-126bpm.

spO2- 94%@ra.

GRBS-250mg/dl.

SYSTEMIC EXAMINATION:

CVS- S1S2 heard, no murmurs. 

CNS- No focal deficits. 

PA- soft, tender(right hypochondriac).

        free fluid is present.

       Bowel sounds are present.

RS-BAE+

      Decreased Breath sounds in right ISA,IAA.

 URT:

Nose-No DNS/Polyp

Oral cavity normal.

Post.Pharyngeal wall-normal.

Decrease in ISA,IAA,MA,INTER SA

LRT:

Inspection:

Shape of chest : bilateral symmetrical,elliptical.

trachea: central.

no supra and infra clavicular hollowness.

chest expansions equal on both sides.

Spinoscapular distance equal on both signs.

no crowding of ribs.

no drooping of shoulders.

no wasting of muscles.

no usage of accessory muscles of respiration.

apical impulse not seen.

no scars,sinuses, engorged veins,visible pulsations.

no kyphosis ,scoliosis.


Palpation:

all inspectory findings are confirmed.

no local rise of temperature. 

no tenderness. 

trachea central.

TVF increased at right ISD

 

Percussion:

Direct:resonate,

Mediated:Hyper resonant in right ISA, IAA

                  Inter SA,MA

Auscultation:

Bae+

VBS

Decrease intensity of BS right inter SA,MA

Absent Breath sounds right ISA,IAA

Crests + right SSA,ICA.


PROVISIONAL DIAGNOSIS:

Right sided hydro pneumothorax with right UL fibrocavity disease,

Left UL&LL consolidation with Diabetes type II































                         ICD INSERSTION 

Under Strict aseptic conditions, 2%(5ml)

Xylocaine was infitualid in 4th ICS in the safety triangle at Mid Axillary line and

24F ICD tube was placed and secured at mark ‘6’

column mort present. Dressing was

done and procedure went uneventful.

post procedure vitals

PR- 98bpm

BP - 110/70 mmHg

RR - 20 Cpm

Spo2-98% on 8lits

Rx 

    1) High flow oxygen @8-10lit/min

    2) Inj.Tramadol IV in 100 ml NS soS

    3) CST

    4) Monitor vitals / Inform SOS.

TREATMENT:

                 On 03/08/2023

Right sided hydro pneumothorax with right UL fibrocavity disease,

Left UL&LL consolidation with ICD insitu Day0 with Diabetes type II


C/O cough(non productive → productive)+

SOB decreased , chest pain Right side+& pain @ ICD site+

No C/O chest tightness, hemopysis

Pt is c/c/c

PR - 110 bpm

BP - 100/60mmhg

RR - 26 Cpm 

Spo2-98%on 8lito2

  1.   Inj.Ceftriaxone 1gm IV BD
  2.   Inj.Pan 40 mg IV OD (BBF)
  3.   Inj.Tramadol 1gm IV in
    100 ml NS sos
  4. Tab.PCM 650 mg TID
  5. Inj.Neomal 1gm in100ml NS Over 1hr if temp > 100°c
  6. High flow O2& face mask@8 lit /min
  7. High protein diet / 2egg whites per day
  8. Syp. Ascoril 2TBS TID Po.

 ICD Notes

Tube: Patent

Drain: 50ml

Column movement-6-8cm H2O

Air leak+on FE

Subcutaneous Emphysema 

ICD Care

  •   Bag below waist
  •   Cap always open
  •   check for Air column must
  •   Maintain underwater seal.
                        On 4/08/2024 

Right sided hydro pneumothorax with right UL fibrocavity disease,

Left UL&LL consolidation with ICD insitu Day 1 with Diabetes type II


C/O cough(non productive)+

SOBsubsided , pain @ ICD site+

Fever spike + in the morning

No C/O chest tightness, hemopysis

Pt is c/c/c

PR - 110 bpm

BP - 100/70mmhg

RR - 24 Cpm 

Spo2-98%on 8lito2

  1.   Inj.Ceftriaxone 1gm IV TID
  2.   Inj.Pan 40 mg IV OD (BBF)
  3.   Inj.Tramadol 1gm IV in
    100 ml NS sos
  4. Tab.PCM 650 mg TID
  5. Inj.Neomal 1gm in100ml NS Over 1hr if temp > 101°F
  6. High flow O2& face mask@8 lit /min
  7. High protein diet / 2egg whites per day
  8. Syp. Ascoril 2TBS TID Po.
  9. Inj.HAI S/C TID acc to GRBS
  10. Inj.NPH S/C BD acc to GRBS
  11. Spirometry 
  12. Syp.Grillinetus D 2tsp/TID

 ICD Notes

Tube: Patent

Drain: 250ml

Column movement-5-6cm H2O

Air leak+ FE

Subcutaneous Emphysema -ve

ICD Care

  •   Bag below waist
  •   Cap always open
  •   check for Air column must
  •   Maintain underwater seal.
                           On 05/08/2023

Reinsertion of ICD tube


Under Strict aseptic conditions, 2%(5ml)

Xylocaine was infitualid in 4th ICS in the safety triangle at Mid Axillary line and

24F ICD tube was placed and secured at mark ‘8’ After removal of previous tube.

column movement present. Dressing was

done and procedure went uneventful.

post procedure vitals

PR- 94bpm

BP - 100/60 mmHg

RR - 21 Cpm

Spor - 98% on 8lits

Rx 

    1) High flow oxygen @8-10lit/min

    2) Inj.Tramadol IV in 100 ml NS soS

    3) CST

    4) Monitor vitals / Inform SOS 


Right sided hydro pneumothorax with right UL fibrocavity disease,

Left UL&LL consolidation with ICD insitu Day 2 with Diabetes type II


C/O cough(non productive)+

SOBsubsided , pain @ ICD site+

Fever spike + in the morning

No C/O chest tightness, hemopysis

Pt is c/c/c

PR - 96 bpm

BP - 110/70mmhg

RR - 30 Cpm 

Spo2-98@RA

GRBS-107

  1.   Inj.Ceftriaxone 1gm IV TI
  2. Inj.Pan 40 mg IV OD (BBF)
  3.   Inj.Tramadol 1gm IV in 100 ml NS sos
  4. Tab.PCM 650 mg TID
  5. Inj.Neomal 1gm in 100ml NS Over 1hr if temp > 101°F.
  6. High flow O2& face mask@8 lit /min
  7. High protein diet / 2egg whites per day
  8. Syp. Ascoril 2TBS TID Po.
  9. Inj.HAI S/C TID acc to GRBS
  10. Inj.NPH S/C BD acc to GRBS
  11. Spirometry 
  12. Syp.Grillinetus D 2tsp/TID

ICD Notes

Tube: Patent

Drain: nil

Column movement-5-6cm H2O

Air leak+ FE

Subcutaneous Emphysema -ve

ICD Care

  •   Bag below waist
  •   Cap always open
  •   check for Air column must
  •   Maintain underwater seal
                         On 06/08/2023

Right sided hydro pneumothorax with right UL fibrocavity disease,

Left UL&LL consolidation with ICD insitu Day 2 with Diabetes type II


C/O dry cough+

SOBsubsided , pain @ ICD site+

Fever spike + in the morning

No C/O chest tightness, hemopysis,Palpitations 


Pt is c/c/c

PR - 86 bpm

BP - 120/70mmhg

RR - 31 Cpm 

Spo2-94@RA

           98@8lit O2

GRBS-84mg/dl.

RS:BAE+,VBS+

      Decrease intensity of breath sounds at Right MA,ISA,IAA

      Crepts+ right ICA,IAA,ISA,INFRA SA.

Rx:

  1. Inj.Ceftriaxone 1gm IV TI
  2. Inj.Pan 40 mg IV OD (BBF)
  3.   Inj.Tramadol 1gm IV in 100 ml NS sos
  4. Tab.PCM 650 mg TID
  5. Inj.Neomal 1gm in 100ml NS Over 1hr if temp > 101°F.
  6. High flow O2& face mask@8 lit /min
  7. High protein diet / 2egg whites per day
  8. Syp. Ascoril 2TBS TID Po.
  9. Inj.HAI S/C TID acc to GRBS
  10. Inj.NPH S/C BD acc to GRBS
  11. Spirometry 
  12. Syp.Grillinetus D 2tsp/TID
  13. UNDER NTEP ATT 4 TABS/DAY 

ICD Notes

Tube: Patent

Drain: 150ml

Column movement-5-6cm H2O

Air leak+ FE

Subcutaneous Emphysema -ve

ICD Care

  •   Bag below waist
  •   Cap always open
  •   check for Air column must
  •   Maintain underwater seal
PATINT COMPLETED ATT REGIMEN AND IS DOING WELL.

OUTCOME - COMPLETED TREATMENT

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