A good respiratory case on post TB Fibrosis

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Bilateral chronic parenchymal lung disease in Left upper lobe fibrocavitatory lesion right upper lobe cavity ,with right compensatory emphysema …

Bilateral chronic parenchymal lung disease in Left upper lobe fibrocavitatory lesion right upper lobe cavity ,with right compensatory emphysema
Etiology : post tuberculosis sequelae
Complications : Cor pulmonale

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  • 1. HISTORY • Mr. X • 56 /male • Place : Chennai • Occupation : Tailor Chief complaints : • Breathlessness x 2 years • Cough with expectoration x 2 years • Facial puffiness x 1 month • Pedal edema x 1 month
  • 2. HISTORY OF PRESENTING ILLNESS BREATHLESSNESS • Duration x 2 years • Gradual in onset • Progressive in nature • Exertional dyspnea • MRC class 3 • Relieved by rest and medications • No orthopnea/PND
  • 3. COUGH Cough with expectoration Not associated with blood No diurnal variation of cough No postural variation of cough Relieved by medications
  • 4. SPUTUM Minimal quantity Whitish in colour Non foul smelling Not associated with blood
  • 5. • History of facial puffiness and history of pedal edema present for the past 1 month • No h/o fever, • No history of wheezing, • No h/o chest pain, • No h/o Hemoptysis • No h/o Decreased urine output, abdominal distention, no h/o jaundice. • No h/o altered mental status
  • 6. PAST HISTORY • H/o of pulmonary tuberculosis twenty years back ,completed treatment and cured • Not a diabetic,asthamatic, cardiac ailments ,no h/o any exposure to occupational hazards • No h/o any surgical procedures in the past ,no h/o trauma .
  • 7. PERSONAL HISTORY • Non smoker, • Occasional alcoholic • Loss of Apetite • No loss of weight • Normal sleep ,bowel and bladder habits
  • 8. What is Alcoholic lung • Chronic alcohol abuse dsirupts the proteins that keeps fluid out of lung • Lowers protective antioxidant effects • Disrupts immune defences • Results in pneumonias and ARDS
  • 9. FAMILY HISTORY No history of tuberculosis in the family and no respiratory illness in the family members TREATMENT HISTORY Treated for pulmonary TB twenty years back On and off bronchodilators for the last two years
  • 10. History summary 56 /male with past history of tuberculosis, with h/o cough with minimal expectoration and exertional breathless for two years and with h/o of pedal edema for one month ,with no exposure to occupational hazards ,nonsmoker, with no h/o respiratory illness in the family Probable chronic parenchymal lung disease ,which is secondary to post TB sequelae ,progressing to respiratory failure
  • 11. GENERAL EXAMINATION • Conscious ,oriented • Tachypnoeic • Afebrile • BMI : 25.4 kg/m2 • No pallor • No icterus • Pan digital Clubbing +(Grade 3) • No cyanosis ,no lymphadenopathy • Bilateral Pedal edema + • No external markers of tuberculosis
  • 12. Pandigital Clubbing • Bronchiectasis • Mesothelioma • TOF • Eissenmenger • Infective endocarditis • Sarcoidosis • Tuberculosis
  • 13. Vitals • Pulse : 90 /min • Sinus rhythm • Normal volume and character • All peripheral pulses are felt well • No radio radial/radiofemoral delay • No vessel wall thickening
  • 14. • Blood pressure : 130/90 mm Hg in right upper limb in supine posture • Respiratory rate : 28/min ,abdominothoracic • JVP : Elevated
  • 15. RESPIRATORY SYSTEM EXAMINATION • Upper respiratory system normal NASAL CAVITY • No DNS /No polyps • No sinus tenderness THROAT • No congestion • no tonsillar enlargement ORAL CAVITY : • Dental caries + • No oral thrush
  • 16. Dental caries –on respiratory system • Dental caries can cause Pneumonias
  • 17. Lower respiratory tract infection Inspection Flattening of the chest on left side  Trachea appears to be deviated to left  Apical impulse not visualised Accessory muscles of respiration are used  Drooping of shoulder to left
  • 18. Bilateral supraclavicular hollowing present (left > right) Left infraclavicular hollowing present Respiratory movements appear diminished on left hemithorax Vertebral border of scapula is prominent on left side Inspiratory retraction of lower interspaces on left side No scars ,sinuses , dilated veins over chest wall
  • 19. Palpation • Trachea confirmed to be shifted to left • Apex beat could not be localised • Diminished anterior ,posterior ,upper thoracic movements on left side • No localised tenderness • No lymphnode enlargement
  • 20. VOCAL FREMITUS AREAS RIGHT LEFT SUPRACLAVICULAR NORMAL INCREASED CLAVICULAR NORMAL INCRAEASED INFRACLAVICULAR NORMAL INCREASED MAMMARY NORMAL NORMAL AXILLARY NORMAL INCREASED INFRAAXILLARY NORMAL INCREASED SUPRASCAPULAR NORMAL INCREASED INTERSCAPULAR NORMAL INCREASED INFRASCAPULAR NORMAL INCREASED
  • 21. Measurements • Total chest circumference : 82 cms • Right hemithorax : 44 cms • Left hemithorax : 38 cms • Chest expansion : 2 cms • Anterio posterior diameter : 22 cms • Transverse diameter : 34 cms • No localised tenderness • No crepitus/no lymphnode enlargement
  • 22. Percussion AREAS RIGHT LEFT SUPRACLAVICULAR IMPAIRED IMAPIRED CLAVICULAR HYPERRESONANT IMPAIRED INFRACLAVICULAR HYPERRESONANT IMPAIRED MAMMARY HYPERRESONANT IMPAIRED AXILLARY HYPERRESONANT RESONANT INFRAAXILLARY HYPERRESONANT RESONANT SUPRASCAPULAR HYPERRESONANT IMPAIRED INTERSCPULAR HYPERRESONANT IMPAIRED INFRASCAPULAR HYPERRESONANT RESONANT
  • 23. Where do you get dull note/impaired resonance • Consolidation • Fibrosis • Collapse • Thickened pleura • Pulmonary tumor
  • 24. Where do you get stony dullness • Pleural effusion • Massive pulmonary growth • Massive pleural growth
  • 25. Where do you get hyperresonance • Emphysema • Pneumothorax • Over emphysematous bullae • Over a large superficial cavity
  • 26. • Liver dullness is pushed down • Traubes space not obliterated
  • 27. AUSCULTATION • Bilateral air entry present • Left suprascapular and interscapular bronchial breathing + • Left supraclavicular, infraclavicular ,axillary cavernous bronchial breathing • Right suprascapular cavernous bronchial breathing + • Harsh vesicular breath sound heard in all other areas on the right
  • 28. Causes for absence or decreased breath sounds • Bronchial obstruction with/without collapse • Consolidation with obstruction • atelectasis • Fibrosis • Thickened pleura • Emphysema • Pleural effusion • Pneumothorax
  • 29. Bronchial breath sound - conditions • Lung collapse • Atelectasis • Pneumonia • Lobar pneumonia • Bronchiectasis • Bronchogenic carcinoma
  • 30. Vocal resonance AREAS RIGHT LEFT SUPRACLAVICULAR NORMAL INCREASED CLAVICULAR NORMAL INCRAEASED INFRACLAVICULAR NORMAL INCREASED MAMMARY NORMAL NORMAL AXILLARY NORMAL INCREASED INFRAAXILLARY NORMAL INCREASED SUPRASCAPULAR NORMAL INCREASED INTERSCAPULAR NORMAL INCREASED INFRASCAPULAR NORMAL INCREASED
  • 31. In what conditions VF/VR is increases • Consolidation of the lung Pneumonia Tuberculosis Pulmonary infarction Malignancy of lung • Collapse with patent bronchus • Superficial thick walled cavity with surrounding consolidation
  • 32. In what conditions VF/VR are decreased • Pleural diseases Pulmonary diseases Pleural effusion Emphysema Pneumothorax Pulmonary fibrosis Thickened pleura Thin walled cavity • Bronchial diseases Obstruction Bronchial asthma
  • 33. Added sounds • Wheeze present in left mammary region • Fine inspiratory crackles present in left mammary, axillary, infrascapular areas • No Bronchophony • No Egophony • NoWhispering pectorileqy • No pleural rub
  • 34. Causes for wheeze • Asthma • Congestive heart failure • Chronic bronchitis • COPD • Pulmonary oedema
  • 35. Where do you get fine crepitations • Early phase of pneumonia • Tuberculosis infiltration • Fibrosis • Early pulmonary edema • Chronic bronchitis • Partial collapse
  • 36. Conditions of coarse crepitations • Pulmonary edema • Bronchiectasis • Resolving pneumonia • Lung abcess • Interstitial lung disease • ARDS
  • 37. CVS S1S2 present ,loud p2 + ABDOMEN Soft ,no organomegaly CNS No flaps,no deficits
  • 38. FINAL DIAGNOSIS Bilateral chronic parenchymal lung disease in Left upper lobe fibrocavitatory lesion right upper lobe cavity ,with right compensatory emphysema Etiology : post tuberculosis sequelae Complications : Cor pulmonale
  • 39. Pulmonary fibrosis-conditions • Idiopathic pulmonary fibrosis • ILD • Asbestosis/Silicosis • Infections- tuberculosis • Connective tissue disorder
  • 40. What is rounded atelectasis and its relation with pleural fibrosis • When pleural fibrosis is significant, contguous to it pripheral atelectasis occurs, merely representing lobar collapse mistaken for tumor
  • 41. What is focal fibrosis and what are the causes Extent of fibrosis may vary from nodular lesions to extensive areas- causes are • coal worker’s pneumoconiosis • Asbestosis • silicosis
  • 42. What is replacement fibrosis and what are the causes • Fibrous tissue replaces the lung parenchyma by suppuration or infarction Common causes of replacement fibrosis- • Pulmonary tuberculosis • Bronchiectasis • Lung abcess • Pulmonary infarct • Necrotizing pneumonias
  • 43. Clinical features of replacement fibrosis • Common cause is pulmonary tuberculosis • Upper lobes are affected most frequently • Fibrosis is usually associated with bronchiectasis • History of cough/ with or without expectoration and dysnoes/sputum may be blood tinged
  • 44. Clinical features of replacement fibrosis • Common cause is pulmonary tuberculosis • Upper lobes are affected most frequently • Fibrosis is usually associated with bronchiectasis • History of cough/ with or without expectoration and dysnoes/sputum may be blood tinged
  • 45. What is interstitial fibrosis and what are the causes • Diffuse fibrosis of lung parenchyma which is the end result of interstitial lung disease:- • Connective tissue disorders • Radiation injury to lung • Cryptogenic fibrosing alceolitis • Extrinsic allergic alveolitis • Idiopathic pulmonary hemosiderosis • Drugs:NFT/amiodarone/methotrexate/bleomycin • busulphan
  • 46. Auscultation in fibrosis • In extensive fibrosis the intensith of breath sound is diminished and vesicular in character with prolonged expiration • VR ↓ • Coarse crepitations are heard
  • 47. COMMON CAUSES OF FIBROTHORAX • Empyema • Pleural effusion • Traumatic hemothorax • tuberculosis
  • 48. Uncommon causes of fibrothorax • Benign asbestos pleural effusion • Connective and collagen vascular disorders • Uremia • Paragonimiasis • Drug induced
  • 49. Drugs causing pleural fibrosis • Ergot alkaloids • Bromocriptine • Pergoline • Methysergide • Methotrexate Drugs can cause associated parenchymal and peritoneal fibrosis
  • 50. Clinical features of fibrothorax • Marked limitation of chest movements • Mediastinal shift to same side • Decrease in size of hemothorax • Crowding of ribs