Fibrosis

Fibrosis

4 Personal history

سيد زينهم male pt., 38 years old, painter, from Cairo, married and has 3 off springs, the youngest is 3 years old. He is moderate cigarette smoker, he used to smoke 20 cigarettes per day for 15  years with no other special habits of medical importance. he is Rt. handed.

4 c/o

Shortness of breath 1 month duration.

4 HPI

In a known diabetic patient, The condition started 15 years ago by acute onset, progressive course of night fever, night sweat which was associated with dry cough with no special character, no postural, seasonal or diurnal variation. 4 days later, he experienced stitching right sided chest pain which was localized, increased with cough and inspiration, relieved by rest, holding breath, lying on Rt. Side, not related to exertion. It was associated with gradual onset and progressive course of  dyspnea at rest with no orthopnea or PND. The patient was admitted to Ain-Shams University Hospital, investigated by CXR, pleural fluid analysis and was diagnosed as massive pleural effusion. He was treated by antibiotics, aspiration of 1.5 liters of turbid yellowish fluid with no complications.

The patient remained symptoms-free for one and half month, then he re-experienced similar attack of dry cough, dyspnea at rest  and right sided localized stitching chest pain. The patient was re-admitted to Ain-Shams University Hospital, re-investigated by CXR, CBC, Tuberculin test which was positive. The patient was treated by aspiration of yellowish turbid fluid and he received medications in the form of tablets, capsules and injections. He was advised to follow this regimen for one year and he completed the course of treatment.

The patient remained quite well till one month ago when he developed gradual onset, progressive course of dyspnea on less than ordinary effort, relieved by rest with no orthopnea, no PND.         

No Symptoms of systemic congestion.

No cyanosis, No haemoptysis.

No pressure symptoms.

No nocturnal diarrhea, no palpitation, no unsteadiness with sudden standing, no gustatory sweating, no impotence  (symptoms of autonomic neuropathy)

4 Past history

-         Past history of D.M. since he was 10 years, manifested by polyuria, polydipsia, polyphagia, investigated by fasting blood sugar, and treated with insulin for life.

-         No History of Drug intake.

-         No History of HPN.

-         No history of operations.

4 Family history

-          No consanguinity.

-          No similar condition in family.

-          No common disease in family.

4 General exam

-          The patient is fully conscious, well oriented for time, place and person. Average mood and memory. The patient is co-operative with average intelligence.

-          Temperature: 37.2^o c.

-          Bl. Pressure: 130/80 (in both standing and recumbent position).

-          Resp. Rate: 16/minute, regular, average depth, abdomino-thoracic.

-          Pulse: Regular, 60 beat/minute, average volume, no special character, equal on both sides, intact peripheral pulsation, vessel wall is not felt, no radio-femoral delay

-          The patient looks well, average built, no cyanosis, pallor or jaundice. He is lying free flat comfortable in bed.

-          Head & Neck: nicotine stain on his lips with no sub-conjunctival hemorrhage, no working ala nasi or pursing of lips. Neck veins are pulsating not congested.

-          Upper limb: No flapping tremors, No clubbing.

-          Lower Limb: No L.L. edema, with some scars (traumatic), some trophic changes, diabetic dermopathy.

4 Local Examination:

4 Inspection__

-         Chest Wall: No scars, no dilated veins, no pigmentation.

-         Resp. Movement:

§   Rate: 16/minute, regular, average depth, abdomino-thoracic.

§   Expansion: Limitation in chest expansion on the Rt. Side.

§   Signs of action of accessory Muscles of respiration: No suction of supraclavicular fossa, no inspiratory indrawing of lower intercostal spaces with no visible contraction of sternomastoid or elevation of thoracic cage (No working accessory muscles of inspiration). The patient is not  pursing his lips or grasping a chair (Signs of action of accessory muscles of expiration). No hoover's sign or tracheal tug (Signs of low flat diaphragm).

-         Shape of the chest: asymmetrical, Retraction on Rt. Side, acute subcostal angle.

-         Mediastinum: shifted trachea to the Rt. side (trail's sign), No tracheal Tug, the Apex is in Lt. 5 space MCL.

-         Pulsations: There is visible epigastric pulsations(probably aortic).

4 Palpation__

-         Limitation in chest expansion on Rt. Side.

-         Central Trachea with decreased tracheal length but no tracheal tug.

-         Apex is in the left 5^th space MCL & epigastric pulsations (Probably Aortic in origin).

-         TVF: increased on Rt. Side specially at basal parts!!!! (it is supposed it is decreased but  may be attributed in this case to  tracheal shift to the right side).

-         No palpable Rhonci or rub.

-         No chest wall tenderness.

4 Percussion__

-         Hepatic dullness at Rt. 5^th Space MCL.

-         Heart: impaired note to the right border of sternum, both aortic and pulmonary areas are resonant, preserved waist of the heart, no dullness outside the apex, lower end of the sternum is impaired note.

-         Lung:

·         Front: Resonant clavicles, infra-clavicular areas, Heterogeneous dullness is detected from 3^rd space downwards in Rt. MCL.

·         Lateral: Heterogeneous dullness at 4^th space downwards in Rt. MAL.

·         Back: Heterogeneous dullness at Rt. SL.

·         Bare area: impaired note, Resonant Kronig's isthmus.

·         By Tidal Percussion à Diaphragm is freely mobile.

·         No Shifting dullness.

    

4 Auscultation__

Normal breath sound on Lt. side, diminished air entry on Rt. Side with decreased V.R with pan inspiratory fine crepitations not changed with cough at Rt. Infra-mammary area.

4 Other System Examination

See neurology for Diabetic Peripheral neuropathy (P.N) (All signs of diabetic peripheral neuropathy are present in this case )

4 Investigation

-   For etiology: Tuberculin test, CBC, ESR.

-   For Functional Diagnosis: ABG, ECG, CXR, ECHO

-   For main diagnosis: Pleural fluid analysis, CXR, Biopsy, Pulmonary Function Test.

4 Treatment

-   Control of diabetes and treatment of peripheral neuropathy(see neuro)

-   Treatment of T.B (if still active).

-   Supportive ttt for fibrosis

4 Diagnosis :

A Case of Rt. Sided pleuro-pulmonary fibrosis secondary to T.B. The patient is compensated, complicated with cor pulmonale.

4 Why Fibrosis ??

On the Rt. Side there is::

1. ↓ Expansion by inspection.

2. ↓ TVF by palpation.

3. ↓ Resonance by percussion.

4. ↓ Breath sound by auscultation.

So, It's a syndrome of multiple negatives either:

-    Pleural Effusion (excluded by retraction and mediastinal shift to Rt.)

-    

D.D by percussion

Collapse                                         Homogenous

-    Fibrosis                                          Heterogeneous

4 Why Rt. sided ?? from History (site of pain & aspiration) and examination.

4 Why Secondary to T.B ?? from History (T.B toxemia) and from Tuberculin test.

4Why compensated/not Complicated ?? à No Cor Pulmonale or R.F.

4No Cor Pulmonale ::

1-      From History: No systemic congestion.

2-      Examination: No neck veins, L.L edema, No tender hepatomegaly, No signs of Rt. V. hypertrophy.

4No R.F ::

1-      History: No cyanosis.

2-      Clinically: No flappy tremors ,no cyanosis or disturbed consciousness.

3-      Lab. : ABG (The most important as RF is a lab. Diagnosis).

Cor Pulmonale

Differs from COPD in:

1-      From History : Symptoms of systemic congestion.

2-      Examination :

§         Congested neck veins with expiratpry filling.

§         Bilateral pitting L.L edema.

§         Enlarged tender liver in abdominal exam.

Otherwise, It's the same.