case present by intern 劉一璋. patient data name: 陳 ○ 富 sex: 男 age: 71 歲 date of...
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Case present
By Intern 劉一璋
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Patient data
Name: 陳○富 Sex: 男 Age: 71 歲 Date of admission: 96/08/09
Chart No: 04095119
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Case present
Chief complaint Sudden onset of R’t chest pain
followed by dyspnea this morning.
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Present illness (1)
This 71 y/o male has a history of pulmonary TB with medical treatment from 96/06/18.
This morning (96/08/09), after breakfast, he sat on a chair for rest. At that time, he had mild cough. Then, sudden onset of R’t chest pain followed by dyspnea was noted.
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Present illness (2)
Therefore, he was sent to our ER at 9:30 am.
According to his statement, the chest pain and dyspnea was partially relieved by setting up and was exacerbated by lying flat.
Besides, he denied fever, chills or abdominal pain.
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Flow chart (1)
9:30 am Arrived at ER
10:30 am At ER, chest X-ray was performed and showed pneumothorax in the right side at 10:30 am. Therefore, chest tube was inserted.
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CXR at 10:30 am
Right pneumothorax with collapse of right lung
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CXR on 96/5/31
No change of postinflammatory fibrosis, calcified granulomas and emphysema of both lungs.
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Flow chart (2)
12:05 am However, poor function of the chest tube
was noted. Then, CXR was performed again.
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CXR at 12:05 am
Interval mild worsening of right pneumothorax with collapse of right lung.
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Flow chart (3)
13:30 pm Then, chest CT showed: (1) Right hydropneumothorax post right chest tube insertion. (2) the tip of chest tube was within right inner chest wall. (not insertion into pleural space
yet). (3) pleural effusion in bilateral lung with the R’t side much more than L’t side.
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Chest CT at 13:30 pm (1)
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Chest CT at 13:30 pm (2)
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Chest CT at 13:30 pm (3)
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Chest CT at 13:30 pm (4)
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Flow chart (4) Due to malposition of chest tube, chest tube was revised.
18:55 pm CXR showed: The lung expanded partially after the second
chest tube inserted. Then, he was transferred to
chest ward for further treatment.
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CXR at 18:55 pm
1.Right hydropneumothorax with collapse of right lung S/P right chest tube insertion. 2. Mild progression of left pleural effusion.
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CXR 8/10 -- 11:10 am
Persistent insertion of right chest tube and interval partial resolution of right pneumothorax.
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Past history
1. DM: denied 2. Hypertension: denied 3. Pulmonary TB (+): treatment was started on 96/06/18 4. Smoking: 1 PPD/day for more than 40 years, have quitted for 2 years. 5.Alcohol: social, have quitted 6.Allergy: denied
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Physical examination (1)
Consciousness: clear, E4V5M6Conjunctiva: not pale, sclera: not ictericNeck: lymphadenopathy (-)Chest: symmetric expansion Breathing sound: decreased in the R’t side Percussion of chest: hyperresonance in R’t
lung field normal resonance in L’t
side Heart sound: RHB, no murmur
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Physical examination (2)
Abdomen: soft and not distended Palpation: no tenderness point, impalpable liver or spleen Percussion: tympanic Bowel sound: normoactive Costovertebral angle knocking pain: (-)
Extremities: no pitting edema Sin: ok, no dry
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Lab data (96/08/09)
pH 7.287 ( <7.4)
Pco2 59.3 mmHg ( >40 )
Po2 31.4 mmHg
HCO3 27.7 mmol/L
TCO2 25.1 mmol/L
So2 51.4 ﹪
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Diagnosis
1. Pneumothrax in the Right side 2. COPD 3. Pulmonary TB
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Plan
1. Insert chest tube
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Thanks for your attention