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

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/m2
• 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

20. 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

21. 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

22. 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

23. 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

24. 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

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

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

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

28. • Liver dullness is pushed down
• Traubes space not obliterated

29. 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

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

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

32. 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

33. 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

34. 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

35. 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

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

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

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

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

41. 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

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

45. 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

46. 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

47. 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

49. 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

50. 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

51. 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

52. 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

53. COMMON CAUSES OF FIBROTHORAX
• Empyema
• Pleural effusion
• Traumatic hemothorax
• tuberculosis

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

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

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