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