Respiratory system

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

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

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

SPUTUMMinimal quantityWhitish in colourNon foul smellingNot associated with blood

• 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

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 .

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

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

FAMILY HISTORYNo history of tuberculosis in the family and no

respiratory illness in the family members

TREATMENT HISTORYTreated for pulmonary TB twenty years backOn and off bronchodilators for the last two years

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

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

Pandigital Clubbing

• Bronchiectasis• Mesothelioma• TOF• Eissenmenger• Infective endocarditis• Sarcoidosis• Tuberculosis

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

• Blood pressure : 130/90 mm Hg in right upper limb in supine posture

• Respiratory rate : 28/min ,abdominothoracic

• JVP : Elevated

RESPIRATORY SYSTEM EXAMINATION• Upper respiratory system normalNASAL CAVITY• No DNS /No polyps• No sinus tendernessTHROAT• No congestion • no tonsillar enlargementORAL CAVITY :• Dental caries +• No oral thrush

Dental caries –on respiratory system

• Dental caries can cause Pneumonias

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

Bilateral supraclavicular hollowing present(left > right)Left infraclavicular hollowing present Respiratory movements appear diminished on left

hemithoraxVertebral border of scapula is prominent on left side Inspiratory retraction of lower interspaces on left

sideNo scars ,sinuses , dilated veins over chest wall

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

VOCAL FREMITUSAREAS 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

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

PercussionAREAS 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

Where do you get dull note/impaired resonance

• Consolidation• Fibrosis • Collapse• Thickened pleura• Pulmonary tumor

Where do you get stony dullness

• Pleural effusion• Massive pulmonary growth• Massive pleural growth

Where do you get hyperresonance

• Emphysema • Pneumothorax• Over emphysematous bullae• Over a large superficial cavity

• Liver dullness is pushed down• Traubes space not obliterated

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

Causes for absence or decreased breath sounds

• Bronchial obstruction with/without collapse• Consolidation with obstruction • atelectasis• Fibrosis• Thickened pleura • Emphysema • Pleural effusion• Pneumothorax

Bronchial breath sound - conditions

• Lung collapse• Atelectasis• Pneumonia• Lobar pneumonia• Bronchiectasis• Bronchogenic carcinoma

Vocal resonanceAREAS 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

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

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

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

Causes for wheeze

• Asthma• Congestive heart failure• Chronic bronchitis• COPD• Pulmonary oedema

Where do you get fine crepitations

• Early phase of pneumonia• Tuberculosis infiltration• Fibrosis • Early pulmonary edema• Chronic bronchitis• Partial collapse

Conditions of coarse crepitations

• Pulmonary edema• Bronchiectasis• Resolving pneumonia• Lung abcess• Interstitial lung disease• ARDS

CVS S1S2 present ,loud p2 +ABDOMEN Soft ,no organomegalyCNSNo flaps,no deficits

FINAL DIAGNOSISBilateral chronic parenchymal lung disease in

Left upper lobe fibrocavitatory lesion right upper lobe cavity ,with right compensatory emphysema

Etiology : post tuberculosis sequelaeComplications : Cor pulmonale

Pulmonary fibrosis-conditions

• Idiopathic pulmonary fibrosis• ILD• Asbestosis/Silicosis• Infections- tuberculosis• Connective tissue disorder

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

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

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

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

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

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

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

COMMON CAUSES OF FIBROTHORAX

• Empyema• Pleural effusion• Traumatic hemothorax• tuberculosis

Uncommon causes of fibrothorax

• Benign asbestos pleural effusion• Connective and collagen vascular disorders• Uremia• Paragonimiasis• Drug induced

Drugs causing pleural fibrosis

• Ergot alkaloids• Bromocriptine• Pergoline• Methysergide• Methotrexate Drugs can cause associated parenchymal and

peritoneal fibrosis

Clinical features of fibrothorax

• Marked limitation of chest movements• Mediastinal shift to same side• Decrease in size of hemothorax• Crowding of ribs