Case 10 Report 7 Consultation
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Medicine
Date
Dec 6, 2023
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Uploaded by EarlComputerTurtle15
Tenisha Gatlin
Patient Name: J. Randy Rolen
Patient ID: 115037
Consultant: Simon Williams, MD, Pulmonary and Thoracic Services
Requesting Physician: Leon Medina, MD, Internal Medicine
Date of Consult: 12/15
Reason for Consult: Continued deterioration with COPD, subcutaneous
emphysema, and recurrent pneumothoraces. Evaluate for possible transfer
to Forrest General Medical Center thoracic unit.
The patient is a 61-year-old white male who conceded through the ER on
December 10 with intermittent right pneumothorax. The patient is known to
have COPD with emphysema and has numerous affirmations for issues
concerning this. At the hour of beginning assessment, a little type chest tube
was embedded in the front axillary line, which worked on the patient's
respiratory pain, however, didn't totally determine the pneumothorax. I was
called to the ICU to place a second little-type chest tube in the back axillary
line beneath this. This further superior the patient's pneumonic status with
his immersion improving from 76% to 89%. Since confirmation, he has felt
improved however grumbled of agony at the chest tube inclusion site. He
has kept on spilling through the Pleur-evac submerged seal, and starting
yesterday he created subcutaneous emphysema, which has
deteriorated.Prior he started having expanded respiratory trouble again with
his immersion dropping down to roughly 80% notwithstanding oxygen per
nasal cannula. Chest X-beam today showed a deteriorating of the right lower
curve loculated pneumothorax, and on assessment today he isn't just spilling
air through the Pleur-evac framework yet additionally around the 2 chest
tubes.
PAST HISTORY: Patient has had previous right pneumothorax but never any
beyond the left side. He has undergone some type of attempted pleural-
ablation therapy. Sputum cultures from this admission have grown
Pseudomonas and Streptococcus and he has been treated with ciprofloxacin.
PE: Patient has a heart rate of 100, respiratory rate of 30, and appears
moderately uncomfortable and cyanotic.
HEENT: Otherwise unremarkable.
CHEST: Breath sounds decrease bilaterally and cannot be heard in the right
chest wall because of the crackling sounds from subcutaneous emphysema.
Heart tones distant, I hear no murmurs or gallops, rate seems regular.
ABDOMEN: Unremarkable.
EXTREMETIES: Pedal edema is present. There was bubbling from both
Pleurevac systems and both chest tubes. When I removed the dressing, the
upper chest tube, which was the initial one placed, fell out with the
dressing.Patient suddenly became markedly more uncomfortable, there was
escape of air from the chest tube site. The saturation decreased to 59%.
Chest X-ray increase in the pneumothorax from what was seen earlier today,
measuring approximately 10%.
IMPRESSION: Bronchopleural fistula with recurrent pneumothorax.
PLAN: Small calibre chest tubes are not adequate to contain the leakage, and
therefore a larger chest tube needs to be placed. If the pleural fistula does
not close spontaneously with controlled infection,
CONSULTATION:
I would recommend CT scan of the chest and/or bronchoscopy to rule out
dissociated malignancy and consideration of chemical pleurodesis. Once the
larger chest tube was placed, the patients’ status improved. His saturation
increased to 94%.
RECOMMENDATION: Transfer to Forest General Thoracic Unit for evaluation,
closure of bronchopulmonary fistula, and aggressive treatment of patients’
morbid respiratory distress. The patients’ family was notified of the emergent
nature of the situation and they agreed with the plan.
_____________________________________________
Simon Williams, M.D, Pulmonary and Thoracic Services
SW:xx
D: 12/15
T:07/14
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