Case present

By Intern 劉一璋

Patient data

Name: 陳○富 Sex: 男 Age: 71 歲 Date of admission: 96/08/09

Chart No: 04095119

Case present

Chief complaint Sudden onset of R’t chest pain

followed by dyspnea this morning.

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.

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.

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.

CXR at 10:30 am

Right pneumothorax with collapse of right lung

CXR on 96/5/31

No change of postinflammatory fibrosis, calcified granulomas and emphysema of both lungs.

Flow chart (2)

12:05 am However, poor function of the chest tube

was noted. Then, CXR was performed again.

CXR at 12:05 am

Interval mild worsening of right pneumothorax with collapse of right lung.

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.

Chest CT at 13:30 pm (1)

Chest CT at 13:30 pm (2)

Chest CT at 13:30 pm (3)

Chest CT at 13:30 pm (4)

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.

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.

CXR 8/10 -- 11:10 am

Persistent insertion of right chest tube and interval partial resolution of right pneumothorax.

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

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

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

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 ﹪

Diagnosis

1. Pneumothrax in the Right side 2. COPD 3. Pulmonary TB

Plan

1. Insert chest tube

Thanks for your attention