Keandre Butts Pulmonary Diseases Pneumothorax CTW Pneumothorax Subjective: The patient state that he coughed so much his

chest hurt around his left collar bone. Objective: A physical examination was performed on the patient. The patient was clearly in respiratory distress. He presented with an increase work of breathing and used purse-lip breathing and accessory muscles of respiration. The man had clubbing and appeared cyanotic, and had an increase A-P diameter. The patient had a strong, productive cough that expelled large amounts of thick yellowish-greenish sputum. His vital signs were BP 145/85, HR 94, and RR 20 and were slightly febrile. Palpation was unremarkable. Hyper resonant notes were percussed bilaterally. Auscultation revealed diminished breath sound and rhonchi throughout both lung fields. His heart sounds were diminished. The patient also had prolonged expiration. The patient CXR showed dark, translucent lung fields depressed and flattens hemidiaphrams, and a long, narrow heart. A small anterior pneumothorax was seen between the second and third ribs on the left. His ABG o room air was as followed: pH 7.53, PaCO2 48, HCO3 38, and PaO2 of 57. Previous ABG before the current admission was as followed: pH 7.42, PaCO2 69, HCO3 41, and PaO2 74. Assessment: The physical examination is consistent with an acute exacerbation of a chronic condition. The chronic condition is evident by the digital clubbing and the barrel chest. The thick yellow-greenish sputum suggests that an acute infection has

manifested but is also consistent with his previous diagnosis of chronic bronchitis. The patient was hypertensive, but was not tachypnic, nor tachycardic. Auscultation is suggestive of mucus throughout the airway indicated by diminished and rhonchi breathe sounds. The CXR is consistent with the pneumothorax seen in the left chest area. His ABG shows respiratory alkalosis with moderate hypoxemia superimposed on chronic ventilator failure. Plan: Based on the interpretation of the physical exam, the patient should be started on Oxygen Protocol. Start the patient on 3LNC. A sputum specimen should be obtained to rule out any infectious process. IS should be prescribed 10 times an hour. Response 2 Subjective: The patient stated he felt like hell. Objective: The patient respiratory distress had obviously worsened according to the nurse. The patient was purse-lip breathing, perspiring and was cyanotic. The patient had a weak, non-productive cough. Whenever the patient coughed he had to brace himself by pulling his left arm to his side. Rhonchi could be without a stethoscope. His left anterior chest was hyper-inflated when compared to the right. His Vital signs were: BP 95/55, HR 125 and weak, RR 28. Percussion revealed hyper-resonant notes bilaterally. Auscultation revealed rhonchi and crackles throughout the right lung. No breath sounds were noted over the left lung. His ABG was: pH 7.2, PaCO2 103, HCO3 43, PaO2 37, SpO2 62%. CXR showed the collapsed of the entire left lung. The left hemidiaphrams was depressed, mediastinum was shifted to the right, and

patches of atelectasis were seen allover the right lung. A chest tube was inserted and started with a pressure of -10. Assessment: The patient has suffered a complete left lung collapses. The rhonchi that were heard are due to the ineffectiveness of his cough. The mediastina shifts are due to the air that has built up in the pleural space and is forcing the mediastina to the right. The ABG indicates the patient is in respiratory failure. Plan: The physician has stated the patient should be kept off the ventilator. The patient should be started on a Non-rebreather with 100% O2. Patient should receive Mucomyst and albuterol q8 via SVN in combination with an acapella device to help with mucus clearance.