23 year old 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 WAS TESTED POSITIVE FOR COVID 19 AND TOOK TREATMENT AND TESTED NEGATIVE AFTER 20 DAYS.LATER HE PRESENTED WITH SIMILAR COMPLAINTS SINCE 1 WEEK COUGH ASSOCIATED WITH EXPECTORATION WHITISH IN COLOR ASSOCIATED WITH CHEST PAIN NO AGGREVATING OR RELIEVING FACTORS  AND SHORTNESS OF BREATH PRESENT AT DAILY REGULAR ACTIVITIES

 SUDDENLY HE DEVELOPED SHORTNESS OF BREATH ON 11/10/2020 AT 12 30PM AND BLOOD IN SPUTUM AND FALLING SATURATION

ON EXAMINATION:

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

XRAY WAS TAKEN AND PNEUMOTHORAX IS REVEALED

 

PULMONOLOGY REFERRAL TAKEN IN VIEW OF LEFT PNEUMOTHORAX ADVICED FOR ICD INSERTION

LATER INTERCOSTAL DRAIN IS PLACED ON 11/10/20 @4;30 PM

UNDER STRICT ASEPTIC CONDITIONS,BETADINE IS PAINTED OVER LEFT HEMITHORAX 2% XYLOCAINE 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

INVESTIGATIONS:

D DIMER 1940 MICROGRAM/L

CRP NEGATIVE

HRCT CHEST BEFORE 1MONTH ON 23/09/2020

CRAZY PAVING PATTERN IN BILATERAL LUNGS: VIRAL PNEUMONIA (CORADS 5)

EXTENSIVE SUB CUTANEOUS EMPHYSEMA)

PNEUMO MEDIASTINUM

POSSIBLE SPONTANEOUS RUPTURE OF SUBPLEURAL BULLA

HRCT CHEST ON 14/10/2020 AFTER TESTING NEGATIVE

-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 NORMAL

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

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
CHLORIDE	102 mEq/L

LIVER FUNCTION TEST (LFT)   11-10-2020 04:25:PM
Total Bilurubin	1.00 mg/dl
Direct Bilurubin	0.19 mg/dl
SGOT(AST)	30 IU/L
SGPT(ALT)	74 IU/L
ALKALINE PHOSPHATE	157 IU/L
TOTAL PROTEINS	5.3 gm/dl
ALBUMIN	3.8 gm/dl
A/G RATIO	2.46

BLOOD UREA   12-10-2020 01:24:PM

40 mg/dl

           

SERUM CREATININE   12-10-2020 01:24:PM

0.9 mg/dl

SERUM CREATININE   13-10-2020 04:29:AM

0.9 mg/dl

COMPLETE BLOOD PICTURE (CBP)   13-10-2020 04:29:AM
HAEMOGLOBIN	11.6 gm/dl
TOTAL COUNT	7400 cells/cumm
PLATELET COUNT	1.24
SMEAR	Normocytic normochromic with thrombocytopenia

COMPLETE BLOOD PICTURE (CBP)   16-10-2020 12:45:PM
HAEMOGLOBIN	11.2 gm/dl
TOTAL COUNT	6100 cells/cumm
PLATELET COUNT	1.51
SMEAR	Normocytic normochromic with neutrophilia

15/10/20

Pulmonolgy referral on 17/10/20

A bilateral loculated HYDROPNEUMOTHORAX  is posteriorly located and advised thoracoscopy  for loculations and decortication.

On 19/10/20

Patient developed severe Shortness of breath and x ray was taken.

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 ORAL FLUIDS 3L/DAY SOFT DIET 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 FFPS TRANFUSION DONE Diagnosis:  POST COVID SEQUELAE WITH BILATERAL PNEUMONIA (MIDDLE ZONE AND LOWER LOBE) WITH BILATERAL LOCULATED HYDROPNEUMOTHORAX WITH SUBCUTANEOUS EMPHYSEMA