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St. Clair College *
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MISC
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Medicine
Date
Dec 6, 2023
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docx
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Uploaded by AmitMarwaha
CONSULTATION REPORT
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 admitted through the ER on December 10 with recurrent right pneumothorax. Patient is known to have COPD with emphysema and has multiple admissions for problems concerning this. At the time of initial evaluation, a small calibre chest tube was inserted in the anterior axillary line, which improved the patient's respiratory distress but did not completely resolve the pneumothorax. I was called to the ICU to place a second small calibre chest tube in the posterior axillary line below this. This further improved the patient's pulmonary status with his saturation improving from 76% to 89%. Since admission he has felt better but complained of pain at the chest tube insertion site. He has continued to leak air through the Pleur-evac underwater seal, and beginning yesterday he developed subcutaneous emphysema, which has gotten progressively worse. Earlier he began having increased respiratory difficulty again with his saturation dropping down to approximately 80% despite oxygen per nasal cannula. Chest X-ray today showed a worsening of the right lower lobe loculated pneumothorax, and on examination today he is not only leaking air through the Pleur-evac system but also 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.
EXTREMITIES:
Pedal edema is present. There was bubbling from both Pleur-evac 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 revealed an 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, I would recommend a CT scan of the chest and/or bronchoscopy to rule out associated malignancy and consideration of chemical pleurodesis.
Once the larger chest tube was placed, the patient's status improved. His saturation increased to 94%.
RECOMMENDATION:
Transfer to Forest General Thoracic Unit for evaluation, closure of bronchopulmonary fistula, and aggressive treatment of the patient's morbid respiratory distress. The patient's 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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