23M with Shortness of breath

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Case presentation:

A 23 year old male who is a food supplier,

 CAME WITH C/O COUGH SINCE 1 WEEK AND SHORTNESS OF BREATH SINCE 4 DAYS

PATIENT WAS APPARENTLY ASYMPTOMATIC 1 MONTH BACK AND  THEN HE DEVELOPED COUGH WITH EXPECTORATION AND SHORTNESS OF BREATH, ASSOCIATED WITH DECREASED PERCEPTION OF SMELL.

COUGH WAS INCIDIOUS IN ONSET RAPIDLY PROGRESSIVE ASSOCIATED WITH EXPECTORATION OF SPOONFUL SPUTUM WHICH IS WHITE IN COLOUR ODOURLESS.

IN THE MIDDLE OF THE PANDAMIC WITH THIS SYMPTOMS HE REACHED NEAREST HEALTH CARE CENTER FOR FURTHUR EVALUATION OF HIS SYMPTOMS.

IN FURTHER EVALUATION, HE WAS TESTED POSITIVE FOR (RT-PCR).  COVID-19 WHICH IS CORROBORATED WITH HIS CHEST IMAGING.

COURSE IN THE HOSPITAL 1

Pt came with complaints of SOB &cough since 5 days and was admitted and evaluated. COVID test was done on 15/09/20 which came to be positive.

 HRCT-CORADS 5.

O/E : RR-38, HR-92/MIN, BP-110/70MMHG, SPO2-68%@ROOM AIR.

HRCT DONE ON 23/09/2020

  INTERPRETATION:

CRAZY PAVING PATTERN IN BILATERAL LUNGS: 

VIRAL PNEUMONIA (CORADS 5)

EXTENSIVE SUB CUTANEOUS EMPHYSEMA)

PNEUMO MEDIASTINUM

POSSIBLE SPONTANEOUS RUPTURE OF SUBPLEURAL BULLA

LABS REVEALED:

TREATMENT GIVEN:

Pt was treated with oxygen support, appropriate antivirals,clexane,antibiotics,steroids and other supportive care given. Pt vitals were monitored regularly, surgical emphysema resolved. As Pt is maintaining saturation’s on room air and improvement in his symptoms the Pt is discharged on 1/10/2020.

In the view of furthur observstion and management patient came to our hospital on 2/10/2020.

COURSE IN THE HOSPITAL 2 :

Patient presented with complaints of cough with expectoration, shortness of breath intermittently, low grade fever on & off.

cough was gradual in onset progressive associated with odourless whitish expectoration. patient denied blood in sputum & blood while coughing.

COMPLETE BLOOD PICTURE (CBP)   08-10-2020 02:31:PM
HAEMOGLOBIN	14.3 gm/dl
TOTAL COUNT	12800 cells/cumm
PLATELET COUNT	1.50
SMEAR	Normocytic normochromic with leucocytosis

CHEST X RAY ON 8/10/2020 :

patient was daily monitored for 10 days where NO adverse events took place, and medication was continued.

on 11/10/2020 the patient suddenly developed shortness of breath with cough associated with BLOOD IN SPUTUM with sudden fall in saturations to 75% with in 15min, then patient was immediatly shifted to MEDICAL ICU (ICCU)

COURSE IN MEDICAL ICU:

VITALS AT THAT TIME ON 11/10/20 AT 12 30 PM ARE BP 130/80MMHG

PR 127BPM

SATURATION ON ROOM AIR 82%

RR 36/MIN

RESPIRATORY SYSTEM: DECREASED AIR ENTRY ON RIGHT SIDE

                                       ABSENT AIR ENTRY ON LEFT SIDE

                                       HEMOPTYSIS AROUND 50ML

With the high clinical suspicion the treating doctors team ordered chest xray which revealed PNEUMOTHORAX

Treating team immediatly consulted pulmonology department for their opinion on INTER COSTAL DRAIN (ICD) TUBE PLACEMENT for this patient.

Team Pulmonology with treating physicians have decided to place an ICD for this patient.

INTERCOSTAL DRAIN IS PLACED ON 11/10/20

PROCEDURE:

UNDER STRICT ASEPTIC CONDITIONS,BETADINE IS PAINTED OVER LEFT HEMITHORAX AND LOCAL ANESTHESIA WAS GIVEN WITH  2% XYLOCAINE WHICH IS INSTILLED IN 5TH INTERCOSTAL SPACE IN MID AXILLARY AREA. AN ICD TUBE OF 24 F IS INSERTED AND IS PLACED AT MARK 8. PROCEDURE WAS  UNEVENTFUL.

POST PROCEDURE VITALS

BP 110/70

RR 38CPM

Post procedure Xray

COMPLETE BLOOD PICTURE (CBP)   11-10-2020 12:43:PM
HAEMOGLOBIN	14.6 gm/dl
TOTAL COUNT	16200 cells/cumm
PLATELET COUNT	1.74
SMEAR	Normocytic normochromic with neutrophilic leucocytosis.

RFT   11-10-2020 04:25:PM
UREA	41 mg/dl
CREATININE	0.8 mg/dl
URIC ACID	4.6 mg/dl
CALCIUM	8.8 mg/dl
PHOSPHOROUS	3.5 mg/dl
SODIUM	139 mEq/L
POTASSIUM	4.2 mEq/L
CHLORID CBNAAT WAS NEGATIVE FOR SPUTUM	102 mEq/L

HRCT DONE ON 14/10/2020 : 

BILATERAL LOCULATED HYDROPNEUMOTHORAX WITH PARTIAL ATELECTASIS OF BOTH LUNG LOWER LOBES

PERIBRONCHIAL AIR SPACE OPACITIES IN BOTH LUNGS LOWER LOBES(INFECTIVE)

ICD TUBE INSITU WITH ITS TIP AT APEX OF LEFT PLEURAL CAVITY

BULLA IN APICAL SEGMENT OF RIGHT LOWER LOBE

CORADS 2

2D ECHO: GOOD TO FAIR LV FUNCTION, NO LV CLOT, DIASTOLIC DYSFUNCTION PRESENT

ECG SHOWS NORMAL STUDY

Team Pulmonology adviced as there is a bilateral loculated HYDROPNEUMOTHORAX which is posteriorly located and advised thoracoscopy  for breaking loculations and decortication. 

Treating physicians explained the condition and opinion of pulmonology team to the patient. patient was not willing to go to other hospital as he was covered under some employement health scheme provided by his institution.

suddenly on 19/10/2020 he developed severe shortness of breath with decline in saturations @90 with room air. immediate xray was ordered.

AS THERE WAS A BLOCK IN THE ICD IT WAS CHANGED AND NEW ONE WAS PLACED.

TREATMENT GIVEN IN HOSPITAL 2 :

Treatment: HIGH FLOW OXYGEN@12L/MIN INJ PIPTAZ 4.5GM IV BD 6 DAYS INJ METROGYL 500MG IV TID 6DAYS TAB AZITHROMYCIN 500MG OG 5 DAYS INJ PAN 40MG IV OD INJ ZOFER 4MG IV TID INJ TRAMADOL 1 AMP IN 100ML NS/IV/BD IVF NS 1UNIT      DNS 1UNIT      RL 1UNIT @75ML/HR NEBULISATION WITH IPRAVENT,BUDECORT,MUCOMIST SYP GRILINCTUS  2 TBS/PO/TID TAB ZINCOVIT 1 TAB PO OD TAB VIT C 500MG OD ICD CARE TO BE TAKEN BP PR RR SPO2 CHARTING HOURLY TEMPERATURE 4TH HOURLY GRBS 8TH HOURLY.

The patient was reffered to higher center as adviced by pulmonology team in view of thoracoscopy for breaking loculations and decortication. 

patient went to other hospital ( not to the one to which he was reffered ) near by his hometown.

 

COURSE IN HOSPITAL 3 :

Patient vitals on arrival 

BP: 110/70mmhg, PR:82/min, TEMP: 98F, spO2: 86% on room air with bilateral crepts.

Patient was thoroughly examined and all the necessary investigations were done.

pt was diagnosed as BILATERAL HYDROPNEUMOTHORAX and treated accordingly.

ECG: 

CHEST XRAY TAKEN 

HRCT WAS DONE ON 24-10-2020 

RESOLVING INFECTIVE PATHOLOGY OF BOTH LUNGS WITH ENCYSTED PNEUMOTHORAX ON BOTH SIDES WITH PLEURAL THICKENING.

TIP OF INTERCOSTAL TUBE IS SUPERIOR TO ENCYSTED PNEUMOTHORAX ON LEFT LOWER CHEST.

2D-ECHO & USG ABD : NORMAL STUDY.

TREATMENT GIVEN :

OXYGEN SUPPLEMENTATION

INJ.ZOCYN 4.5mg IV TID

INJ.LEVOFLOX 500mg IV BD

ANTACIDS

MULTIVITAMINE

SUPPORTIVE CARE.

PT WAS IN HOSPITAL FOR 8DAYS, DAILY MONITORING WITH SUPPORTIVE CARE, PATIENT SYMPTOMS RESOLVED AND PLANNED FOR DISCHARGED.

VITALS AT THE TIME OF DISCHARGE : 

BP: 120/80mmhg, PR:80/min, RR: 20/min.

ADVICE AT DISCHARGE : 

TAB.CEPODEM 200MG BD X 1WEEK

TAB.LEVOFLOX 500MG BD X 1WEEK

TAB.PAN 40MG OD X 1WEEK

TAB.ZINCOVIT OD X 1WEEK

SYP.SUCRAL 15ML TID BEFORE FOOD.

PROGRESSION OF DISEASE : 

THANK YOU... 

Co-Author : Dr. NIKITHA GM PGY2

                      Dr. AJITH KUMAR GM PGY2

                      Dr. SREEJA BOGA (INTERN)