CASE PRESENTATION on

Respiratory Medicine

Presenter:

Tanoy BosePost Graduate Trainee

Department of MedicineAssam Medical College &

Hospital

Moderator:Dr. B. LaskarProfessor & HeadThe Department of MedicineAssam Medical College & Hospital Dibrugarh

PATIENT PARTICULARS

KHAGEN BARUAH• 68 years; Male; Hindu• Retired Clerk from Assam State Electricity Board• Address: Doom Dooma, Dist: Tinsukia, Assam

• Bed: 88; Unit: Male Med Unit V• Date of Admission: December 5th, 2008• Date of Examination: December 14th, 2008

CHIEF COMPLAINS

1. Cough for last 1month

2. Chest pain for last 1month

History of Present Illness: COUGH

• Gradual onset, progressive• Harsh, forceful, wheezy and in frequent bouts• Persistant thro’out the day, more at night• Minimal mucoid expectoration with one episode

of blood tinging

History of Present Illness: COUGH

• Not assocatied with• Profuse expectoration• Alteration is quality of cough• Fever, night sweats• Post nasal drip, hawking, irritation in neck• PND• Audible wheeze by the family members

History of Present Illness: CHEST PAIN

• Gradual onset, Slowly progressive, Dull aching• Located over anterior chest, w/o radiation or

referral• Persistent thro’out the day , w/o any variation• Aggravated on coughing/deep breath w/o change

in character• No postural, diurnal, temporal variation• Symptomatically improved after admission for

last 5 days

History of Present Illness: CHEST PAIN

• Not associated with:• Sweating, palpitation, radiation to arms or neck• Sudden severe attacks requiring emergent care• Superficial skin eruptions• Trauma• Chest heaviness or tightness• Regurgitation of food, hawking• Exertional dyspnea

History of Present Illness: Positive History

• The above symptoms were associated with:• Weight loss over last 1 month• Malaise, muscle pain, headcahe• Pain in the back of neck… dull aching ,

aggravated by extremes of movement for last 14 days

• Mild hoarseness of voice for last 14days• Hospitalisation for these complains 15 days

back from where he was refferred

History of Present Illness: Negative History

• There was no history of• Fever, recurring drenching night sweats• Pain abdomen,LBP,Bleeding from natural

orifices• LOC, seizure, syncope• Flushing, diarrhea, skin eruptions• Swelling or mass in any part of body• Not known to be a diabetic or hypertensive

History of Past Illness

• Recurrent episodes of Malena : 4 episodes in last 35years requiring multiple hospitalisation and 2 units of Blood Transfusion

• + H/o exposure to TB @ work place• No H/o TB, Jaundice, Contact, Surgery, Drugs, • No history of nasal polyps, allergy or

hypersensitivity to dust, drugs or any other stimuli• No h/o of persistent cough or winter exacerbation

of cough

Personal History

• Decreased appetite• Disturbed sleep due to nocturnal cough• Normal bowel & bladder habits, no c/o of

hesitancy or urgency• Smoker; smoked for 55 years (cigarettes)

• 110 pack years of smoking• Age of initiation: high school

• Non alcoholic

Family, Socio economic& Occupational History

• All the family members are enjoying good health

• No significant family history noted among parents and grand parents

• Lower middle class Family

• Discontinuous exposure to areas dealing with processing of electric cables for last 40 years

SUMMARY OF THE HISTORY

• A 68 yrs old,hindu,male,retired clerk from Tinsukia with a h/o 110 pack years of smoking presented with persistent dry cough with nocturnal exacerbation with one episode of hemoptysis and dull aching chest pain that exacerbates on coughing with weight loss,malaise, anorexia for last 1month with a backgound history of Recurent upper GI bleed requiring blood transfusion, exposure to TB, long term discontinuous exposure to cable processing industry & absence of similar illness in past, DM, HTN.

General examination• Concious , alert , cooperative & oriented• Decubitus: Of choice; Facies: Normal• Average built, Normal nutrition• Weight:48 Kg, height: 154cms: BMI: 20.253• Tongue: Thickly coated, moist• Oral cavity: Poor hygeine• Teeth: Stained in the inner and upper surface• Hairs: sparse with frontal baldness• Nails : Yellow pigmented, deformed and thickened• Skin: Healthy • Palm & soles: normal

General examination

• Pallor: Moderate• Cyanosis/ Edema/ Clubbing/ Jaundice: Absent• Neck glands: Right supraclavicular node

palpable: approx 1cm, soft, mobile, nontender, solitary: Thyroid: Not enlarged

• JVP: Not raised• Pulse: 112/min;Reg, N vol, N character, Art.

Wall N,No RR , RF delay, all per pulses N

• BP: 128/76mm Hg

General examination

• Resp @: 24/min Regular, AT• Temp: 98.6ºF• Axillary & Inguinal Glands: Not significantly

palpable• Eyes: Normal Examination

Systemic Examination: Respiratory System

• Upper Resp Tract:• Nostril, nasal cavity, vestibules: Normal• Pharynx : Normal, no congestion or drip• Larynx: Laryngoscopy not done• Ala nasi: Not working during respiration

Systemic Examination: Respiratory System• Inspection:

• Normal shape, no deformity• No focal restriction / paradoxical movement • Levels of shoulders: Normal• No abnomal pulsation/ veins/ pigmentation• Puncture mark at Right 5th ICS at MAL• Spino scapular distance: Equal• Accessory muscles of resp: Not working• Spine: Normal curvature, No deformity• Overall respiratory excursion of chest: Mildly

decreased

Systemic Examination: Respiratory System• Palpation:

• Trachea : Midline, no tracheal tug• Crico-sternal Distance: 4 finger breadth• Apex beat: Left 5th ICS in MCL, Normal, No thrill• No localised rise of temperature• Tenderness on right 5th ICS in MAL• Chest movement: Equal on both sides• Chest expansion: 1.8 cms • No palpable rub/ crepts/ abnormal pulsation• Vocal Fremitus: diminished over right 5th ICS in MAL• Spine: No tender points/ deformity

Systemic Examination: Respiratory System

• Percussion:• Normal resonant percussion note all over chest

except Impaired resonance over right 5th ICS in MAL

• Clavicular percussion: Normal• Sternal percussion: Normal• Upper border of liver dullness: Right 5th ICS in

MCL• Tidal percussion: Normal

Systemic Examination: Respiratory System

• Auscultation:• Bilateral Vesicular Breath sounds except

Diminished vesicular breath sounds over Right 5th & 6th ICS in MAL

• No added sounds ( e.g Crepitations/ Rhonchi)• Bronchophony, Whispering pectoroloqouy,

Aegophony: Absent• Vocal resonance: Diminished over Right 5th & 6th

ICS in MAL

Systemic Examination: Cardiovascular System

• Apical impulse: Not visible• Apex beat: Described • No abnormal pulsations/ thrills/ heaves• S1, A2, P2: normal; No added sounds

Systemic Examination: Gastro intestinal System

• Upper GI: Described• Abdomen: Normal shape, contour, flanks, no venous

engorgement, tenderness; Hernial sites: normal• No hepatosplenomegaly• Genitalia & scrotum: Normal

Systemic Examination: Central Nervous System

• HMF: normal• No cranial neurodeficit, Cranium & spine: Normal• No sensorymotor neurodeficit• Meningial & cerebellar signs: Absent

Systemic Examination: Locomotor System

• Normal GALS screen

Provisional Diagnoses

• A chronic inflammatory or destructive process of the lung parenchyma with focal pleural involvement suggestive of:

• Carcinoma Lung with Ipsilateral Nodal metastasis

• Pulmonary Tuberculosis with Pleuropulmonary adhesion & pleural thickening or encysted pleural effusion

• Interstitial lung disease with localised pleural thickening

Investigations: Hematology & BiochemistryDate: 9.12.2008

Blood:

Hb: 9.8 gm %

ESR: 130 mm Aefh

TLC: 7800/cu.mm

DLC: N65 L 30 E3 M2

Urine:

Clear,Aromatic, No deposits

Albumin: Nil

Sugar: Nil

Epith cells: +

Pus cells: Nil

Date: 9.12.2008

Biochemistry:

Random Bl. Sugar: 93mg/dL

Bl. Urea: 33 mg/dL

Ser. Creatinine: 0.9 mg/dL

Urea/ Creatinine ratio: 36.9

Investigations: ECG & Radiology

• ECG: Sinus tachycardia : 108 b/m

• Mantoux Test: Negative

• USG Abdomen: Early Fatty Changes in Liver

Chest X ray: as on 3.12.2009

Homogenous opacity in Right Mid ZoneImp: ? Encysted effusion

? SOL

? Consolidation

Chest X ray: as on 3.12.2009

HRCT Thorax: as on 5.12.2009

HRCT Thorax: as on 5.12.2009

HRCT Thorax: as on 5.12.2009

HRCT Thorax: as on 5.12.2009• Area of parenchymal consolidation ( 4X3.8 cms) in

Right Lower Lobe with subcarinal peribronchial adenopathy• ? Malignant Lesions• ? Consolidation

• Patchy Areas of Ground glass opacities in Right lower lobe

• Pleuropericardial & pleurodiaphragmatic adhesions in B/L bases

• Degenerative changes of Dorsal vertebrae• Aortic calcifications

CT guided FNAC : 9.12.2008

• MCG Staining of the smear shows:• Groups of mesothelial cells with mild cellular

atypia along with scattered histiocytes & multinucleated giant cells

• No S/o Malignancy seen

• Impression: Mesothelial Hyperplasia

Thank You