Case Discussion || Pneumonia

Summary

This medical transcript details a 63-year-old male's emergency room visit for fever, chills, and breathlessness, indicative of pneumonia. The patient, with a history of COPD and prostate hypertrophy, presents with low oxygen saturation and a thick-walled lung cavity. The discussion covers diagnostic steps, potential malignancy concerns due to low hemoglobin, and treatment strategies, including antibiotics for pseudomonas infection and the importance of physiotherapy and postural drainage.

Takeaways

• 🌡️ The patient presented with high fever, chills, and breathlessness, indicative of a severe infection.
• 🏥 Initial assessment revealed the patient was conscious, with no issues in airway or breathing, but had a respiratory rate of 30 breaths per minute and low oxygen saturation at 92%.
• 🩺 The patient's low blood pressure and heart rate could suggest sepsis, a serious complication of infection.
• 🌡️ The patient's temperature was noted, which is crucial in managing sepsis as hypothermia can be a poor prognostic sign.
• 🧬 The patient had a history of COPD and benign prostate hypertrophy, which complicates the clinical picture.
• 🫁 Auscultation revealed bilateral equal air entries with basal crepitations, suggesting pneumonia.
• 🩸 Hemoglobin levels were lower than expected for a COPD patient, potentially indicating malignancy.
• 🦠 Sputum culture grew Pseudomonas, a gram-negative bacteria often found in patients with compromised lung function.
• 💊 Treatment included oxygen therapy, nebulization, and antibiotics targeting pseudomonas.
• 🔍 Follow-up will involve monitoring inflammatory markers, hemoglobin levels, and imaging to assess resolution of the lung cavity.

Q & A

What are the initial symptoms presented by the 63-year-old male patient?

The patient presented with high-grade fever, chills, dry cough, productive cough with mucopurulent sputum, and breathlessness for one week.

What are the common conditions that can produce chills according to the script?

Common conditions that can produce chills include urinary tract infection, malaria, and pneumonia.

What was the patient's respiratory rate and oxygen saturation upon initial assessment?

The patient's respiratory rate was 30 breaths per minute, and his oxygen saturation was 92% in room air.

What are the common causes of tachypnea in the emergency room as mentioned in the script?

Common causes of tachypnea include hypoxia, metabolic acidosis, and hyperventilation syndromes.

What is the significance of the patient's blood pressure being 90/70 mmHg?

A blood pressure of 90/70 mmHg is considered low for a 63-year-old male, which could indicate a long-term condition or be due to the current infection.

What could be the reasons for the patient's heart rate not increasing despite low blood pressure?

Reasons could include the patient being on beta blockers, myocarditis, hypothyroidism, or inaccuracies in examination or documentation.

Why is maintaining body temperature important in a septic patient?

Hypothermia is a dangerous prognostic factor in sepsis. Maintaining body temperature is crucial as hypothermia can increase mortality.

What does the ABG result indicate about the patient's respiratory status?

The ABG results show a reduced pH (7.51), pCO2 (29.4), and pO2 (62.2), indicating hypoxemia with hypocarbia, which could be a sign of respiratory distress.

What is the significance of the patient having a history of COPD?

A patient with COPD is more susceptible to pneumonia, and the type of pneumonia they develop might be different from someone without COPD, often involving gram-negative organisms.

What does the sputum culture report indicate about the patient's infection?

The sputum culture report indicates the presence of Pseudomonas, which is typically found in damaged lungs and suggests a more severe infection.

What treatment approaches are suggested for the patient with a lung cavity?

Treatment includes oxygen therapy, nebulization with hypertonic saline or ambroxyl, and physiotherapy including percussion, vibration, and postural drainage.

What are the follow-up considerations for this patient after discharge?

Follow-up should include monitoring inflammatory markers, checking for a normal or increasing hemoglobin level, and possibly performing an FNAC for the left supraclavicular node, as well as ultrasound examinations of the abdomen and testes.

Outlines

00:00

🌡️ Initial Assessment and Symptoms of Sepsis

The paragraph discusses the case of a 63-year-old male admitted to the ER with a high fever, chills, and breathlessness for a week. The patient's symptoms suggest possible conditions such as urinary tract infection, malaria, or pneumonia. The initial assessment reveals the patient is conscious, with no issues in the airway, and able to speak in full sentences, indicating no severe respiratory distress. However, he exhibits tachypnea with a respiratory rate of 30 breaths per minute and low oxygen saturation at 92%. The paragraph also explores potential reasons for tachypnea, including hypoxia, metabolic issues, and hyperventilation syndromes. The patient's circulation is assessed with a heart rate of 100 beats per minute and low blood pressure, which is unusual for his age, suggesting a possible sepsis-induced drop in blood pressure.

05:00

🏥 Detailed Examination and Sepsis Management

This section delves deeper into the patient's examination, noting a heart rate that is unexpectedly low for his blood pressure, which could be due to medication like beta blockers or conditions such as myocarditis. The importance of maintaining body temperature in septic patients is emphasized, as hypothermia can be a poor prognostic indicator. The patient's ABG results show respiratory acidosis with low pH and pCO2, indicating issues with oxygen and carbon dioxide levels. The secondary survey reveals a history of COPD, benign prostate hypertrophy, and smoking, with the patient's condition progressing from mild to severe over a week. The paragraph also discusses the differences in pneumonia presentation between patients with normal lung function and those with COPD.

10:01

🔎 Further Diagnostics and Differentials

The paragraph focuses on further diagnostics, with the patient's hemoglobin level indicating potential hypoxemia and the possibility of malignancy if lower than expected for a COPD patient. The patient's white blood cell count shows a high neutrophil percentage, suggesting infection. Creatinine, urea, liver enzymes, and bilirubin levels are also noted, along with the patient's negative sputum AFB culture but positive for Pseudomonas, indicating a secondary infection often seen in damaged lungs. The discussion highlights the difference between upper lobe cavities, often due to TB or fungal infections, and lower lobe cavities, typically due to bacterial pneumonias like necrotizing pneumonia.

15:04

💊 Treatment Approach and Considerations

This section outlines the treatment approach for the patient, including the use of oxygen due to low saturation, nebulization with hypertonic saline and bronchodilators for COPD, and mucolytics for thick lung secretions. The choice of antibiotics for Pseudomonas infection is discussed, with options like ceftazidime or meropenem, and the potential need for long-term nebulization with Tobramycin if the cavity persists. Postural drainage and physiotherapy are recommended to help clear the lung cavity. The paragraph also covers the importance of monitoring the patient's condition, including inflammatory markers, hemoglobin levels, and the potential need for further diagnostic tests like FNAC for the left supraclavicular node.

20:05

📈 Follow-up and Prognosis

The final paragraph discusses the importance of follow-up care for the patient. It highlights the need to monitor the patient's recovery, including checking for decreasing inflammatory markers and performing a chest X-ray after six weeks to assess lesion resolution. The paragraph also emphasizes the need to reevaluate the patient's hemoglobin levels to rule out malignancy and to perform additional tests like ultrasounds of the abdomen and testes to check for any metastatic spread, considering the initial finding of a left supraclavicular lymph node.

Keywords

💡High grade fever

High grade fever refers to a significantly elevated body temperature, usually above 102°F (38.9°C). In the context of the video, it is one of the primary symptoms reported by the 63-year-old male patient, indicating a severe infection or inflammatory response. The script mentions the patient experiencing high grade fever along with chills and dry cough, which are typical symptoms of serious medical conditions like pneumonia.

💡Pneumonia

Pneumonia is an infection that inflames the air sacs in one or both lungs, causing symptoms such as cough, chest pain, fever, and difficulty breathing. In the video script, pneumonia is identified as the likely cause of the patient's symptoms, including fever, chills, and productive cough with mucopurulent sputum. The script discusses the differential diagnosis and management of pneumonia in both normal and compromised lungs, such as in COPD patients.

💡COPD

COPD (Chronic Obstructive Pulmonary Disease) is a group of lung diseases that block airflow and make it difficult to breathe, including chronic bronchitis and emphysema. The script mentions the patient's history of COPD, which is significant because it complicates the diagnosis and treatment of pneumonia. COPD patients are at higher risk for pneumonia and may require different antibiotic coverage compared to patients with normal lung function.

💡Tachypnea

Tachypnea is an abnormally rapid breathing rate. The script notes the patient's respiratory rate of 30 breaths per minute, which is indicative of tachypnea. This symptom is associated with the patient's pneumonia and is a sign of respiratory distress, which is a common finding in patients with severe lung infections.

💡Hypoxia

Hypoxia refers to a deficiency of oxygen in body tissues. The patient's oxygen saturation of 92% in room air suggests mild hypoxia, which is a common consequence of pneumonia as the infection impairs the lungs' ability to oxygenate the blood. The script discusses hypoxia as a potential cause of the patient's tachypnea.

💡Hypothermia

Hypothermia is a condition where an individual's body temperature is below the normal range, typically below 95°F (35°C). The script emphasizes the importance of maintaining body temperature in septic patients, as hypothermia can be a dangerous prognostic factor and increase mortality rates. The patient's temperature is noted as 97.8°F, which is within the normal range.

💡Sepsis

Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. The script discusses the possibility of sepsis in the context of the patient's low blood pressure and tachycardia, which can be signs of septic shock. The video underscores the importance of recognizing and treating sepsis promptly.

💡Malignancy

Malignancy refers to cancer, which can cause a variety of symptoms and complications, including the formation of cavities in the lungs. The script suggests that the patient's low hemoglobin level and left supraclavicular lymph node could potentially indicate malignancy, which would be a significant factor in the patient's overall health and treatment plan.

💡Pseudomonas

Pseudomonas is a genus of bacteria, specifically Pseudomonas aeruginosa, which is an opportunistic pathogen often associated with hospital-acquired infections. The script mentions that the patient's sputum culture grew Pseudomonas, indicating that this gram-negative bacteria is the cause of the patient's pneumonia, which requires specific antibiotic treatment.

💡Necrotizing pneumonia

Necrotizing pneumonia is a severe form of pneumonia where lung tissue dies and forms cavities. The script describes the patient's condition as necrotizing pneumonia due to the presence of cavities in the lungs, which is a serious complication that requires aggressive treatment and may indicate a poor prognosis.

💡Postural drainage

Postural drainage is a therapeutic technique used to help clear mucus and secretions from the lungs. The script suggests that postural drainage, along with other physiotherapy techniques, would be an important part of the patient's treatment plan to help drain the pus and fungal elements from the lung cavities.

Highlights

63-year-old male patient presents with high-grade fever, chills, and dry cough for one week.

Patient also complains of productive cough with mucopurulent sputum and breathlessness.

Initial assessment reveals the patient is conscious and oriented.

No abnormalities found in the airway or breathing during primary survey.

Patient is able to talk normally, indicating no severe respiratory distress.

Bilateral equal air entries with basal crepitations noted on auscultation.

Respiratory rate is 30 breaths per minute, and oxygen saturation is 92% in room air.

Tachypnea could be due to hypoxia, metabolic acidosis, or anxiety hyperventilation syndrome.

Circulation shows a pulse rate of 100 beats per minute and blood pressure of 90/70 mmHg.

Glasgow Coma Scale (GCS) is 15, indicating the patient is alert and responsive.

Low blood pressure could be due to the infection or long-term physiological conditions.

Heart rate is not increased despite low blood pressure, possibly due to beta blockers or myocarditis.

Temperature is 97.8°F, which is crucial in managing sepsis.

Arterial Blood Gas (ABG) shows respiratory acidosis with low pCO2 and pO2.

Past medical history includes COPD and benign prostate hypertrophy.

Left supraclavicular lymph node is enlarged, hard, and fixed, which could indicate malignancy.

Hemoglobin level is lower than expected for a COPD patient, suggesting possible malignancy.

Sputum culture grows Pseudomonas, indicating a damaged lung is more susceptible to gram-negative infections.

Chest X-ray shows cavities in the left upper lobe and lower lobe, suggesting necrotizing pneumonia.

Treatment includes oxygen therapy, nebulization with hypertonic saline, and antibiotics for pseudomonas infection.

Postural drainage and physiotherapy are advised for the patient to help drain the cavity.

Follow-up care includes monitoring hemoglobin levels, inflammatory markers, and possible malignancy.

Transcripts

foreign

[Music]

63 year old male was brought to the ER

with complaints of high grade fever and

chills and dry cuffs since one week it

was associated with productica and

breathlessness since one week initial

conditions you get chills along with

fever

urinal tract infection

my lady

malaria

pneumonia pneumonia consolidation mostly

pneumococcaline then

abscess pass somewhere in the body these

are the common conditions which can

produce chills okay initial 10 second

assessment patient was conscious and

oriented obey comments primary survey

coming to Airway patient with no pooling

of secretion or abnormal Airway sounds

can pneumonia produce altered sensory

listen

wait

[Music]

um

it's called as toxic hypoxemia itself

can produce sometimes

altered Behavior

he was able to talk normal and be able

to complete full sentence

spine appear normal the importance of

able to complete one sentence

you are telling every case

what is important

so whenever there is distrust patient

will not be able to talk properly that's

why we are telling patient is able to

talk full sentence so that means he is

not in respiratory distress but he's

having respiratory problem

will not be able to talk at all

breathing on auscultation just

bilaterally equal air entries

with bile with bilateral basic and

repetition plus let's say more than

Right Said

see that condition you have to ask the

patient to cough and you have to

ascultate again then only you you have

to confirm your finding okay

he had respiratory rate of 30 per minute

and oxygen saturation of 92 percentage

in room air

coming to circulation good peripheral

pulses respiratory rate is 30 oxygen

saturation is 92. what are the reasons

for tachypnea in emergency room

hypoxia one of the common cause here

hypoxemic hypoxemia is there then

metabolicism metabolical storage is the

next important cause then

hyperventilation syndromes

can be psychological it can be due to

Central cause

these are the common condition what we

see in Amazon zero like mostly it is

hypoxia second thing is

metabolic acidosis third one is anxiety

hyperventilation syndrome okay

circulation good peripheral pulses pulse

rate of 100 per minute and blood

pressure of 90 70 millimeter Market

disability GCS E4 B5 M5 M6 15 bar 15 90

by 70.

do you think that this baby is normal

for this patient

slightly low normally a 60 year old male

patients will have slightly higher BP or

even if it is normal it will be upper

upper limit of the normal because of the

arteriosclerosis many will have a

slightly higher systolic BP here it is

90 by 60 70.

so you think it is normal

what what happened

what is happening to the BP BP is low

you think it is low is it

physiologically you know or that means

he is having low BP for a long time or

due to this infection it is due to this

infection what is the first sign of

hypertension

here we are telling uh pulse rate is

only 100 normally when the BP is very

low like this you get a higher heart

rate either the like whatever your

documented is wrong or there may be some

other reason to reduce the heart rate

what are the reasons which can reduce

the heart rate in asepsis

like you are telling 100 only heart rate

but BP is very low comparing its normal

BP may be 130 90 or something it is low

we don't know what this is BP but even

then mostly this type of radiation level

BP of 130 by 90.

but here it is uh heart rate is only 100

that means there is something has

reduced the heart rate or something is

preventing the heart rate to increase

either your method of examination or

your documentation is wrong or some

other reason is that what are the

reasons which can reduce the heart rate

in a hypertensive patient due to sepsis

elderly individual

beta blockers ominous causes patience on

beta blocker that is a first and

important cause which can reduce the

heart rate second thing

carditis myocarditis myocarditis can

produce both tachycardia and bradycardia

when the conduction system is involved

it can produce biodically okay so that

we have to give or

patient can have conditions like

hypothyroidism or something like that so

we have to remember all these things

VP is low but heart rate is not

increased what is the reason that is

very important okay

exposure temperature 97.8

adjacent to primary survey what is

importance of exposure and temperature

in a patient with sepsis

high fever is not a problem anybody is

having infection IP or has to be there

let everybody know

why an emergency doctor should be

concerned about exposure and temperature

in a septic patient or septicemic

patient

hypothermia hypothermia is one of the

most dangerous prognostic factor in

substitution if you keep the patient

without covering the patient in

emergency room the two AC cold MRI

mortality can be high so exposure is

very important maintaining body

temperature to higher level is very

important low temperature can actually

kill the patient what are the Triads in

sepsis or trauma patients which can

aggravate the problem one of the problem

is hypothermic okay

ABG pH

7.51 and pco2 is 29.4 by coordinate 23.5

and po2 is 62.2 creating 0.69 is

abnormal in that anything I'm down

everything is normal

trees 29th 29 pco2 standard po2 is 62

both are reduced that means what oxygen

is reduced CO2 is also reduced what do

you suspect then

suppose you have acute pneumonia cute

not uh like five six days it is acute to

three days pneumonia what is the first

sign

what is your respiratory rate here

hi so you have

but even after that oxygenation is not

increasing but what happened to the

carbon dioxide it will be washed out so

that is the first sign of respiratory

distress hypoxemia with hypocarbia after

sometimes what will happen hypoxia with

hypercarbia then what will happen

hypoxemia hypercarbia respiratory

acidosis then only compensation occurs

okay

with

no significant stt changes okay

coming to secondary survey 63 years old

male came to the emergency room with

history of high grade fever with chills

and trica since one week associated with

productive cuff with mucoperlin sputum

and breathless breathing difficulty was

initially mmrc grade one and which was

progressed to grade 3

in one week associated with

decrease up it appetite but no

significant

no history of loose tools abdomen pain

vomiting no chest why you are thinking

about loose tools Innovation with

respiratory infection

one of the presentation is loose tools

for this complaint the patient went to

nearby hospital and diagnosed as

pneumonia hence patient was referred to

our hospital for further management and

evaluation

fast medical and surgical history

history of uh is a known case of COPD

and history of benign prostate

hypertrophy

for which turp was done four months back

he said non-co-pd patient it's a smoker

non COPD patient trp has done foreign

COPD patient how do we differ from a

patient who resign or a normal length or

an infection differ from a COPD patient

to a person with normal length

a normal person is getting pneumonia a

patient who is saying COPD is getting

pneumonia what is the difference

will be triggered at exacerbation

okay all the seopd excess elevations are

infected accessories

so a person coming from Community who is

egg pneumonia coming to your hospital

person who is already having COPD he is

also coming from Community to your

hospital with the pneumonia what is the

difference between these two pneumonias

fresh lung pneumonia that means a normal

length pneumonies are mostly

gram-positive cocky virus or gram

possible but a damaged length person who

is hanging monuments it can be gram

positive or gram negative both are

possible okay so here we have to think

about gram negative so other condition

we are not thinking about gram negative

mostly it is gram posture so that is a

major difference when you are starting

antibiotic you have to cover gram

positive in a normal length person with

pneumonia

here you have to start a antibiotic with

gram positive gram negative average okay

no history of hypertension

there is no significant past history of

relevant for his present complaint

General examination patient conscious

and oriented purely built and averagely

nourished

on examination left supraclavicular

lymph node scene left

no palette no interest no clubs you have

to tell lymph node properly what is the

size of the lymph node whether it is

hard mobile fixed mobile mobile only one

node it's a hard or soft painful

non-paintable fixed

what is importance

left

why left is very important

causes to opposite side mostly left from

where it comes

thoracic deck not only drain from the

lungs it drains from the lower abdomen

onwards so inhalation in the scrotum

abdomen everything can go directly to

the left Supra clocker this is called as

what is that not called as

which of node

so that is a sign of malignancy in the

abdomen or below like uh in the below

the diaphragm but it is all lymph nodes

are always not malignant so you have to

examine you have to suppose you have a

doubt you have to take a biopsy or a

fnacy but left-sided lymph node

supractor lymph nodes are always modern

okay you have to keep in mind

pulse rate of 100 permit and BP was 90

to 70. what is the drainage of lens

lymph node wise

where it drains suppose you have a

problem in the lungs very dry

the pleura brain to axillary

other one straight into the surprise

okay

mediation and then supracellular

systemic examination respiratory rate

to bilaterally equal bilateral

repetition and base on left side more

than right shape

cardiovascular system is

no added sound

palpable Mass

central nervous system no focal

neurologist

always examine the testis is very

important because testicular Mass

patient you miss only evidence may be

left superclipse okay

no signs of manager irritation

investigation

and hemoglobin was 12.2 and platelet was

40 lakhs what do you think about

hemoglobin percentage in this patient

is it important

why it is important

what is the expected hemoglobin in a

real COPD patient

what happened to hemoglobin

increase

increase

if it is not in decrease it is it has to

increase when there is hypoxemia what

will happen to your erythropoietin

erythropoietin will produce more and

that will increase the hemoglobin so

normally if you follow if you are

following a patients with COPD you can

see that HP percent is very high that is

because of the secondary policythemia so

in a patient who is

like somebody saying real copy and is

hemoglobin is slightly lower you have to

be very careful that indicates

malignancy okay that indicates

malignancy so we have to be very careful

when a lower

hemoglobin in a COPD patient there can

be other reasons for like a hemorrhoids

all these things can also produce uh

blood loss and anemia but always you

have to roll out a malignancy when the

HP percent is low

and neutrophil is 90 97

and lymphocyte is 8.5

creatine 0.72

urea is 16.1 sgot

29.8 and sdpt 30.9 okay

total bilirubin is 1.48

and total protein 7.4 and grbs is on 98.

98

it's a diabetic or non-diabetic

non-diabetic how do you know that he is

diabetic or not

no X3 will not be the only he is coming

to the hospital first time he doesn't

know whether he is diabetic or not how

do you rule out so you have to always

ask for a HP airnc suppose it is more

than 6.5 you can tell that there is a

possible diabetes since last three four

months or more than three months okay

and sodium is 130 potassium 3.3

130 slightly lower not normal

space 243 okay

and we did a sputum AFV his potent FB

was negative and the sputum's mere

report was showing but the yeast cell

with pseudo hyphae okay sputum culture

report has grown

pseudomonasa okay

pseudomonas is

normally occurring in a damaged link

that is very much that's why I told

previously Whenever there is a damage

length if patient develops pneumonia

there can be gram negative organs if the

patient has already gone to many many

hospitals many time then there is a high

chance for multi truck resistant gram

negative organism like pseudomonas okay

just ice today left

okay

upper lobe cavity and lower lobe cavity

what is the difference

cavity is mostly due to DB or fungal

infection lower low cavities are mostly

due to infections especially gram

negative infections

the redness is lower respiratory tract

infection probably bacterial pneumonia

here you have to use the term

necrotizing pneumonia why necrotizing

that part of the lung is damaged and

destroyed necrotizing pneumonia very few

organism will produce dexodometers all

these things produce necrotizing

pneumonia that part is lost that's why

there is a cavity there

okay

a fungal pneumonia okay we don't know

whether fungus is there or fungus is a

Associated pathogen with the pseudomonas

already there is a cavity so in that

whether the patient is growing fungus or

only oral common cell we don't know but

we had to treat the fungus also because

that also can produce a thick walled

cavity

COPD okay

and BP BPH so Etc shows a cavity

it's a thick wall cavity that in that

you are getting pseudomonas infection

sputum and you're also getting fungal

Hypha in the sputum okay

but you have anemia patient design

still it can be malignancy malignancy

itself also can produce cavity in the

lungs okay

treatment oh so what treatment do you

give for this patient

why you are giving oxygen he's already

saturation is low he's having a lung

cavity okay so you have to start oxygen

okay what toxin you have started it's an

initial prongs or nasal mask or BiPAP

what you have started Hazel Bronx okay

how much oxygen you can give through

natural prongs up to four liters you can

give more than that you should not give

through nasal funks you have to put the

mask okay

can you use BiPAP in this patient or

CPAP in this patient what are the

dangers of CPAP starting in this patient

this patient may return sometimes you'll

have to start but you have to explain

everything to the patient by Center

there is a high chance of

there is a high chance of rupture of the

cavity and that can reduce pneumothorax

okay but this is a thick wall cavity

rupture is unlikely very rarely it can

produce rupture

you want to give nebulization

what nebulization what all nebulizations

you can give

salvation

bromide that is one then

that is for COPD part and these can be

subsided with your hypertropium bromide

okay then

he's having a cavity why cavity is

formed in pneumonia because of the

was collected in the lungs first will be

very thick what do you do for that

what are the broncholites you know

mucolides

you can give ambroxyl tablet or you can

give any steel system nebulization okay

here he has got pseudomonas infection in

that so what antibiotics you give what

are Roots you'll select

what are the drugs can be given in

pseudomonas infection

we can give a prevalent as a victim

there is one drug or mirror present as a

victim the second drug can be

nebulization so suppose this cavity

remaining for a longer period Then you

have to give a longer period uh

nebulization with Tobramycin okay what

posture you advise to the patient is

postural treatment is required for this

patient physical Physiotherapy

physiotherapy or dual advice

breathing exercise is

COPD anyway we have to give breathing

access that is a different issue that we

have to advise the vision but current

problem is a cavity

which is containing pus and fungus how

do you treat that

just physiotherapy is very important

percussion of chest vibrators you can

use third thing is positional drainage

postural drainage so suppose it's a

right side cavity you ask the patient to

lag on the left side so that it will

drain fast otherwise what will happen

till soar in the cavity and it will

become a like again it will become first

in the cavity so for we have to train

the patient for postural drainage such

cavities and mucolytics can be used okay

what happened to the patient afterwards

suppose she is stable you start

injection patient has become better

patient will be discharged he'll come

back for Fallout what are the important

things you look in this patient

workers oh okay any infection we have to

see the decreasing inflammatory markers

when will you take a chest x-ray chest

exercises should be taken ideally only

after six weeks okay if you want to see

whether the lesion is increasing you can

take suppose you want to see the

resolution of the X-ray then it takes

many days so six weeks is the minimum

time so xray can be taken then

it is another important problem what is

that you have to see

hemoglobin here to see whether the

hemoglobin is getting normal or becoming

high that is very important it is not

increasing you have to roll out

malignancy then one more thing is there

left sided supraclavator node if

possibly you have to take an fnac then

roll out malignancy examine the testis

ultrasound abdomen ultrasound testis all

these things are important because

Suppose there is a testicular malignancy

this lesion can be due to malignancy but

normally malignancy with metastasis what

will be the character

uh just

to be multiple that's why you told Canon

multiple ball like this one single

editions in metastatic relation is not

common but this lesion alone can produce

a lymph node in the left side okay

normally produces lymph node on the

right side itself but sometimes it can

reduce left side also okay so all these

things you have to tell the patient on

follow-up you have to do all these

things

thanks