A 51-year-old man was admitted to the hospital with hydropneumothorax, multiple bone fractures, and bronchopleural fistula following a motorcycle accident. Imaging revealed fractures in his lower limbs and ribs as well as hydropneumothorax. He underwent bronchoscopy and glue injection to repair the bronchopleural fistula. During his hospital stay, he received treatment and monitoring for his injuries and complications. His condition gradually improved and he was discharged after regaining mobility and resolution of pain.

1. II Pharm . D
REG NO :
381710525.
2018-2019.
1

2. 2

3. 3

4. A 51 year old man was admitted in our KMCH hospital on 23/7/19 as
secondary treatment due to accident in two wheeler on 16/7/19. He was
treated in primary set up on 16/7/19 ICD on both sides and ORIF were done
@palani .HRCT revealed the hydropneumothorax on the right side of the
lung &bronchopleural fistula then numerous bone fractures on the lower
limb. Bronchoscopy and thoracoscopic guided glue injection was planned
for to prevent the air leak in the lungs on 26/7/19.
4

5.  REG NO: 1547418.
 IP NO: F08833.
 AGE & SEX: 51 years old male.
 MARRITAL STATUS: Married.
 DATE OF ADMISSION: 23/7/19 @8:42am.
 DATE OF DISCHARGE: 31/7/19 @2:50pm.
 PRIMARY CONSULTANTS: Dr. Santha kumar (pulmonologist) &
Dr. DMI. Saravana (cardiologist).
 RTA : 2wheeler vs 2wheeler on 16/7/19 primarily treated in native place.
5

6.  Present diagnosis: Rt. Hydropneumothorax.
 Previous procedure surgery: ICD ORIF Done on 16/7/19.
 Provisional diagnosis: COPD & bronchopleural fistula.
 Multiple conditions :
Rt. Intertrochanteric fracture (ORIF).
Rt. Metatarsal fracture.
Flial chest.
 Procedure’s undergone: (previous)
Rt. ICD persistent air leak .
Lt. ICD removed.
6

7. 7
ORIF: open reduction internal fixation.
Internal plates(internal splints)
and screws were placed.

8. 8
Social history: smoker & alcoholic.
Past history : No comorbidities.
Family history: No comorbidities.
Drug allergy : No history of known drug allergy.
1 pack year= 1/2pack/day X 1 yr
= 10 cigarettes/1/2pack
=10X 365.24packs
= 3652.4cigarettes.

9. 9

10. Suggested to perform:
ABG ,CBC, ESR, Urea ,Creatinine, Na+, K+, HRCT, RBS,
HIV- ELISA, PT/INR, ECHO.
ECHO report:
 No regional wall motion abnormality.
Normal LV systolic function.
Trivial mitral regurgitation.
Mild and Moderate pulmonary arterial hypertension(RVSP- 50mmHg).
Inferior vena cava 1.9cm dilated.
No pulmonary embolism/clot.
10

11. 11
contents 23/7/19 24/7/19 25/7/19 26/7/19 27/7/19 28/7/19 29/7/19 30/7/19
Hb 7.8g/dL 7.4g/dL 7.6g/dL 7.6g/dL 7.8g/dL 8.4g/dL 8.6g/dL 8.4g/dL
Tc(cells/cumm) 13900cells/cumm.
Total RBC ↓2.62million/mm3
DC P
L
E
B
M
↑74%
↓21%
02%
00%
03%
PCV ↓22.6%
MCV 86.4fL
MCH 29.9pg/cell.
MCHC 34.6g/dL
ESR(mm/hr) ↑76mm/hr
Platelet 363000cells/µl
Urea -
creatinine 0.5mg/dL

12. 12
content 23/7/19
Sodium 137mEq/L
Potassium 4.8mEq/L
HIV Negative
Blood group &Rh typing O+
Prothrombin Pt value -16.
Control -12 sec.
INR -1.43.

13. DATE TIME HR(beats/min) RR(breaths/min) BP (mmHg) %SpO2(with O2)
23/7/19 12:50am
6:00pm
10pm
92(beats/min)
96(beats/min)
98(beats/min)
24 (breaths/min)
22(breaths/min)
26(breaths/min)
100/90(mmHg)
130/80(mmHg)
130/90(mmHg)
100
99
97
24/7/19 6am
10pm
2pm
6pm
10pm
82(beats/min)
102(beats/min)
100(beats/min)
108(beats/min)
112(beats/min)
22(breaths/min)
24(breaths/min)
24(breaths/min)
22(breaths/min)
26(breaths/min)
110/60(mmHg)
100/60(mmHg)
100/80(mmHg)
120/70(mmHg)
120/80(mmHg)
97
96
97
98
98
25/7/19 2am
6am
10am
2pm
6pm
10pm
116(beats/min)
100(beats/min)
114(beats/min)
120(beats/min)
112(beats/min)
100(beats/min)
28(breaths/min)
26(breaths/min)
22(breaths/min)
22(breaths/min)
20(breaths/min)
20(breaths/min)
130/90(mmHg)
130/80(mmHg)
120/70(mmHg)
130/90(mmHg)
130/80(mmHg)
110/60(mmHg)
96
97
98
97
98
99
26/7/19 6am
5pm
6pm
7pm
8pm
9pm
10pm
92(beats/min)
86(beats/min)
88(beats/min)
82(beats/min)
84(beats/min)
86(beats/min)
82(beats/min)
24(breaths/min)
22(breaths/min)
22(breaths/min)
20(breaths/min)
20(breaths/min)
22(breaths/min)
20(breaths/min)
120/80(mmHg)
110/80(mmHg)
120/70(mmHg)
110/60(mmHg)
120/80(mmHg)
110/60(mmHg)
120/80(mmHg)
99
100
100
98
99
98
97 13

14. 14
DATE TIME HR(beats/min) RR(breaths/min) BP(mmHg) %SpO2
27/7/19 6am
10am
2pm
6pm
10pm
100(beats/min)
102(beats/min)
100(beats/min)
104(beats/min)
100(beats/min)
26(breaths/min)
22(breaths/min)
20(breaths/min)
22(breaths/min)
24(breaths/min)
110/60(mmHg)
110/70(mmHg)
100/80(mmHg)
110/70(mmHg)
120/80(mmHg)
97%
92%
91%
91%
97%
28/7/19 6am
10am
2pm
6pm
10pm
98(beats/min)
112(beats/min)
106(beats/min)
100(beats/min)
94(beats/min)
22(breaths/min)
22(breaths/min)
24(breaths/min)
22(breaths/min)
22(breaths/min)
110/60(mmHg)
110/80(mmHg)
120/80(mmHg)
110/70(mmHg)
110/70(mmHg)
98%
96%
96%
97%
97%
29/7/19 6am
10am
2pm
6pm
10pm
116(beats/min)
112(beats/min)
112(beats/min)
110(beats/min)
108(beats/min)
22(breaths/min)
22(breaths/min)
22(breaths/min)
22(breaths/min)
22(breaths/min)
110/70(mmHg)
110/70(mmHg)
110/80(mmHg)
110/70(mmHg)
110/70(mmHg)
100%
96%
96%
97%
98%
30/7/19 6am
10am
2:30pm
6pm
10pm
102(beats/min)
114(beats/min)
116(beats/min)
102(beats/min)
84(beats/min)
22(breaths/min)
24(breaths/min)
26(breaths/min)
24(breaths/min)
20(breaths/min)
130/60(mmHg)
100/70(mmHg)
110/70(mmHg)
120/80(mmHg)
110/70(mmHg)
99%
98%
97%
98%
98%

15. 15
DATE TIME HR(beats/min) RR(breaths/min) BP(mmHg) %SpO2
31/7/19 6am
10am
72(beats/min)
120(beats/min)
20(breaths/min)
22(breaths/min)
110/60(mmHg)
100/70(mmHg)
98%
97%

16. On 23/7/19 @ 8:42am patient admitted in kmch hospital
@11:52am patient history was noted as
 Tachypnoeic . HR: 94beats/min
 ICD Insitu Rt side. RR: 24breaths/min
 S1 S2 heard. SpO2: 100%
 Pulse rate 90. Temp: 100.5F
 BP 140/90mmHg. GRBS: 99mg/dl
 Hb-7.8g/dl.
Provisional diagnosis: Rt. Bronchopleural fistula.
Plan :
 Inj. Zosyn 4.5gm IV 8hrly infusion over 30mins.
Neb. Levolin 0.63 4hrly respules.
Neb. Formonide 0.5mg BD.
Incentive spirometry.
Tab. P650 BD & Inj. Heparin 5000units S/C OD.
16

17. 17

18. 18
On 23/7/19 @3:20pm
Multiple rib fractures
 Right 3rd-10th&left 2nd-6th.
 Right intertrochanteric fracture.
 Right bimalleolar fracture.
 Right 4th proximal phalanx
Surgery done outside on 16/7/19.
Post operative physiotherapy given.
ECG: satisfactory cardiac status.
@5:00pm Dr. santha kumar
patient reviewed : Hb = 7.8g/dL.
PLAN:
Syp. Dexorange 10ml BD.
To do B/L lower limb venous doppler.
inj. Clexane 0.4 S/C BD.
(heparin was stopped)
inj. Tramadol 50mg IV BD.
inj. Emeset 4mg IV BD.
inj. Paracetamol 1gm IV TID
Daily to check Hb.

19. HRCT Scan of lungs:
 moderate right hydropneumothorax.
Left moderate pleural effusion.
Patchy and confluent ground glassing is noted in the bilateral lung fields.
Fractures as detailed.
Doppler study of left lower limb veins:
No evidence of deep venous thrombosis.
19

20. 20
 The patient was diagnosed with hydropneumothorax by the HRCT scan
evidence report.
 The patients ESR was found to be moderately high 76mm/Hr.
 The patients Total RBC count was extremely low to 2.62million/µL
(hemolysis).
 It can be due to accident blood loss and blood vessel injury and bone
marrow damage can also leads to this deadly conditions.
 https://www.medicalnewstoday.com

21. 21
Hydropneumothorax is treated by
ICD and bronchoscopy with glue injection .

22. 22
On 23/7/19 @12: 50pm
 Temp: 98.6F
 Pulse: 92/min
 RR : 24/min
 SpO2: 100%
 BP: 140/90mmHg.
 Pain persists
Total intake = 750ml
Total output= 2300ml
 On 24/7/19 @ 8:55am patient reviewed Plan on 23/7/19:
 Traumatic B/L pneumothorax . Inj. Para 1gram IV
 Right bronchopleural fluid ,flial chest. Inj. Augmentin 1.2 gram IV
 Right hydropneumothorax. Inj. Pan 40mg IV
BP dropped to 110/60. Inj. Emeset 4gram IV
HR dropped to 82beats/min.
RR dropped to 22breaths/min. Total intake = 850ml
%SpO2 is 97% & Temp 98.8F. Total output = 1900ml
Complaint of difficulty in breathing.
Cough with expectoration.

23. On 25th @ 8:45am
 Temp: 99bts/min
 HR: 100bts/min
 RR: 26breaths/min
BP: 130/80mmHg.
%SpO2: 97% with 5 litres of oxygen.
Complaints of : cough with expectoration & difficulty in breathing.
PLAN: D3
 Inj. Zosyn
Inj. Clexane
Neb. Levolin
Neb. Formonide
Syp. Dexorange.
Inj. Tramadol.
Plan for bronchoscopy tomorrow@ 9: 30
incentive spirometry
@4:45pm
inj. Ketorolac 3mg IV in 100ml NS (BD).
23

24.  Under general anaesthesia
bronchoscopy and thoracoscopic for BPF was done.
0.5ml of glue in each segment is injected.
NPO till 4pm. & monitoring vitals every 15mins till 4pm.
To send drain fluid for Antibiotic susceptibility test for bacterial presence of culture detection.
D4 inj. Zosyn
Neb. Levolin continue till 4pm.
Total intake = 900ml
Drain=100ml
Urine=2500ml
Total output = 2600ml.
On 27/7/19 @9:50 am
Patient is feeling better Air leak has been decreased.
Mobilise out of bed ,incentive spirometry ,Stop ketorolac ,restart inj.clexane & high protein diet.
24

25. 25
On 29/7/19 @ 8:45am
complaint of pain at the site of ICD
Not passed stools since 6 days.
Rt. ICD =30ml. No air leak.
On 30/7/19 @ 12:30pm
ICD removed with strict aseptic condition.
PLAN:
Tab. Chymoral forte (TID)
Tab. Myoril 8mg (BD)
On 31/7/19 @8:10am
Minimal pain @ICD site & patient mobilized.
stat dulcoflex 2dose @12pm rectal route.

26. 26

27.  To reduce the pain .
 To reduce the risk and comorbidities.
 To improve the breathing trouble .
 To increase the red blood cell count.
 To prevent from infection.
 To make the patient mobilise cost effectively.
27

28. 28

29. 29
DRUG DOSE ROUTE &
FREQUENCY
TIME START DATE END DATE
Inj. Zosyn 4.5gm IV & TID 2am
10am
6pm 23/7
31/7@6am
Neb. Formonide 0.5mg Inhalation & BD 6am
6pm 23/7
31/7@6am
Tab. P.650 650mg Oral & BD 9am
9pm
23/7@2pm 23/7dose &Route
Changed
Inj. Para 1gm IV & TID 6am
2pm
10pm 23/7
31/7@6am
Inj. Heparin 5000units IV & OD 10am 23/7 23/7
Inj. Clexane 0.4mg S/C & BD 11am
11pm 23/7
24/7
Changed as OD
Inj. Clexane 0.4mg S/C & OD 11am 24/7 31/7@11am
DRUG CHART:

30. 30
DRUG DOSE ROUTE &
FREQUENCY
TIME START DATE END DATE
Neb. Levolin 0.63mg Inhalation & Q4H 2am
6am
10am
2pm
6pm
10pm
23/7
31/7@10am
Prosure protein powder 2tsp Oral & OD 6am 23/7@7pm 27/7 frequency changed
to BD
Syp. Dexorange 10ml Oral & BD 9am
9pm 23/7
31/7@9am
Inj. Emeset 4mg IV & BD 6am
6pm 23/7
31/7@6am
Inj. Tramadol 50mg IV & BD 6am
6pm 23/7
31/7@6am
Inj. Ketoral 30mg IV & BD 8am
8pm 25/7
27/7@8am
Tab. Chymoral forted’s - Oral & TID 9am
2pm
10pm 30/7
31/7@9am

31. 31
C:UsersSRI SHARIKA KUMARDownloadsInhaled corticosteroids plus long-
acting beta2-agonists as a combined therapy in asthma. - PubMed - NCBI.mhtml
PHARMACIST RECOMMENDATION:
https://www.ncbi.nlm.nih.gov/m/pubmed/27877033/

32.  There is no serious drug- drug , drug-food, drug-disease interaction.
 MILD AND FAIR RELIABILITY:
 Ondansetron will decrease the absorption of tramadol.
 Ondansetron will decrease the absorption of acetaminophen.
 Enaxoparin and Toradol administration cause enhanced effect of anticoagulant
property of enaxoparin.
PHARMACIST RECOMMENDATION:
Tramadol is an centrally acting analgesic also triggers the chemoreceptor trigger zone
so that patient have a chance to vomit , so to avoid that aceclofenac and paracetamol
combination or diclofenac combination can be used.
Antiemetics can be omitted from the treatment chart.
http://apm.amegroups.com/article/view/1038/1264
32

33.  What to avoid ? Don’t s
 smoking should be strictly
avoided.
Not to lift more than 3.5kgs
until the fractured bones get
heal.
No heavy physical activity.
 Does:
Take all the prescribed medications without fail.
Take good rest.
Use the spacer and inhaler
as instructed .
Gargle after use of spacers.
 DRUG DETAILS:
Tab. Pan 40mg- should be taken before food.
2hours gap should be given while taking Tab. Pan
& Tab. Cefakind CV 625mg.
Gap of 2mins should be given between the puffs of
spacer.
33

34. stable discharge on 31/7/19@2:50pm (spirometry to continue)
34
Medications Dosage Morning Afternoon Evening Night A/B Food Duration
Tab. Ultracet 37.5mg/325mg 1 0 0 1 AF 1 week
MDI Formonide
via spacer
200 2puffs 0 0 2puffs 1 week
Prosure protein
powder
2scoops in Water Once a day 1 week
Tab. Cefakind
CV
625mg 1 1 0 1 AF 1 week
Tab. Pan 40mg 1 0 0 0 BF 1 week
MDI Levolin 0.5mcg 2puffs 2puffs 0 2puffs 1 week
Syp. Dexorange 10ml 0 0 10ml 1 week

35. 35
 Before the second puff
Give 2mins gap.
 Atlast gargling is necessary to
avoid fungal mouth infections.