A good respiratory case on post TB Fibrosis

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

1. Respiratory system

2. 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

3. 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

4. COUGH Cough with expectoration Not associated with blood No diurnal variation of cough No postural variation of cough Relieved by medications

5. SPUTUM Minimal quantity Whitish in colour Non foul smelling Not associated with blood

6. 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

7. 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 .

8. PERSONAL HISTORY Non smoker, Occasional alcoholic Loss of Apetite No loss of weight Normal sleep ,bowel and bladder habits

9. 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

10. 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

11. 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

12. GENERAL EXAMINATION Conscious ,oriented Tachypnoeic Afebrile BMI : 25.4 kg/m 2 No pallor No icterus Pan digital Clubbing +(Grade 3) No cyanosis ,no lymphadenopathy Bilateral Pedal edema + No external markers of tuberculosis

13. Pandigital Clubbing Bronchiectasis Mesothelioma TOF Eissenmenger Infective endocarditis Sarcoidosis Tuberculosis

14. 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

15. Blood pressure : 130/90 mm Hg in right upper limb in supine posture Respiratory rate : 28/min , abdominothoracic JVP : Elevated

16. 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

17. Dental caries –on respiratory system Dental caries can cause Pneumonias

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. Where do you get dull note/impaired resonance Consolidation Fibrosis Collapse Thickened pleura Pulmonary tumor

25. Where do you get stony dullness Pleural effusion Massive pulmonary growth Massive pleural growth

26. Where do you get hyperresonance Emphysema Pneumothorax Over emphysematous bullae Over a large superficial cavity

27. Liver dullness is pushed down Traubes space not obliterated

28. 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

29. Causes for absence or decreased breath sounds Bronchial obstruction with/without collapse Consolidation with obstruction atelectasis Fibrosis Thickened pleura Emphysema Pleural effusion Pneumothorax

30. Bronchial breath sound - conditions Lung collapse Atelectasis Pneumonia Lobar pneumonia Bronchiectasis Bronchogenic carcinoma

31. 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

32. 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

33. 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

34. 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

35. Causes for wheeze Asthma Congestive heart failure Chronic bronchitis COPD Pulmonary oedema

36. Where do you get fine crepitations Early phase of pneumonia Tuberculosis infiltration Fibrosis Early pulmonary edema Chronic bronchitis Partial collapse

37. Conditions of coarse crepitations Pulmonary edema Bronchiectasis Resolving pneumonia Lung abcess Interstitial lung disease ARDS

38. CVS S1S2 present ,loud p2 + ABDOMEN Soft ,no organomegaly CNS No flaps,no deficits

39. 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

40. Pulmonary fibrosis-conditions Idiopathic pulmonary fibrosis ILD Asbestosis/Silicosis Infections- tuberculosis Connective tissue disorder

41. 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

42. 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

43. 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

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. 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

46. 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

47. 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

48. COMMON CAUSES OF FIBROTHORAX Empyema Pleural effusion Traumatic hemothorax tuberculosis

49. Uncommon causes of fibrothorax Benign asbestos pleural effusion Connective and collagen vascular disorders Uremia Paragonimiasis Drug induced

50. Drugs causing pleural fibrosis Ergot alkaloids Bromocriptine Pergoline Methysergide Methotrexate Drugs can cause associated parenchymal and peritoneal fibrosis

51. Clinical features of fibrothorax Marked limitation of chest movements Mediastinal shift to same side Decrease in size of hemothorax Crowding of ribs