Dear friends and fellow colleagues, This is X Ray of a male Patient, 50 yrs old, chronic smoker, ethanolic, suffering from T2DM × 15 yrs, Old Pulmonary Tuberculosis, treated irregularly, lean with BMI of 16 kg/m2. C/O Severe Breathlessness, Cough, On & off fever × 15 days. Comments on X Ray findings & treatment. With regards, Dr Sepuri Krishna Mohan.



Dear Dr. Mohan Thanks for the nice x-ray.. I feel ..we need few more clinical findings to proceed in a better way.. Like. Presence/absence of fever, Auscultation findings of the chest ronchi/Crepitations, oxymeter status etc. X-ray shows fibrotic strands on the left apical area with few non homogeneous opacity throughout the right lung with few cystic spaces with sparing a part of right mid zone.. Diagnosis… looks like COPD Exacerbation with either (1)Non specific Bacterial infection with possible bronchiectasis (2)Reactivation of tuberculosis (3)Fungal aetiology (4)Malignancy We need to send the sputum for gram stain smear and culture.. Sputum for Xpert plus.. Sputum for fungal stain and culture.. Spirometry may be performed to confirm/exclude COPD if condition permits. Treat with antibiotics like pipercillin tazobactam combination with nebulisations as and when needed.. Once the patient is stable ...cect thorax and/or bronchoscopy may be needed to proceed further.

Very good evening dear Dr Poddar, Love to see you again on Curofy. Wonderful explanation. Nothing can match dear Dr Poddar's explanation. I mentioned in the brief history that Patient has on and off fever. Auscultation finds Ronchi over entire Right Lung zone. I have ordered all the further investigations mentioned by you. Started the same line of treatment along with Insulin with holding OHAs. Patient started improving after Antibiotics, O2 inhalation, Nebulisation. Waiting for the reports. Soon I update the reports. Thanks again dear Poddar for a wonderful explanation as usual.

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Extensive Koch's lesions rt lung ,cavities in rt apical zones and bronchoconsolidation in rt middle and lower zones.As irregularly treated likely to be MDR TB.There is fibrotic lesions in Lt side also,no tracheal deviation. Advise for AFB in sputum samples and drugs sensitivity. HIV status is also clarified as it is very common, and likely. Meanwhile treat with broad spectrum antibiotics to clear any secondary infection, with oxygen and bronchodilors particularly antichlonergic. Diabetic to be control with insulin only, with good nutritious diet,and absitism from tobacco and alcohol.

Wonderful approach with nice explanation dear Deepak. Thanks again.

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The chest x ray shows rt upper zone consolidation and rt mid and lower zone consolidation. Patients sputum should be sent for afb to rule out kochs chest. A hrct thorax should be send to rule out malignancy in view of chronic smoking.hrct will also help us to determine the enphysematous changes and complications of copd.patients rountine blood investigations like cbc to see the wbc counts along with renal function test and liver function test as patient is alcoholic and debliated( bmi 16).patient arterial blood gases should be done to rule put CO2 narcosis/ type 2 resp failure to decide whether the patient will need bipap or ventilator support. HIV test should be conducted to rule out hiv inf. Broad spectrum antibiotics( 3 gen cephalosporin plus macrolide or respiratory fluroquinilone like moxifloxacin) should be started with iv steroids and nebulization with salbutamol and budesonide. If wbc counts are very much high one can start iv carbapenams. If patient is still breathless iv terbutaline or salbutamol should be given. If on auscultation one is appreciating crepts then iv diuretics should be given to decrease pulmonary congestion though the x ray is not showing pulmonary congestion/ oedema.Sliding scale insulin should be started. Patient should be given antifungal coverage and antitubercular regimen should be started immediately once sputum afb is positive. Since the patient is having a history of previous pulmonary tb and if sputum afb is not conclusive one can ask for bactec 460 as it determines a acute tb infection in a previously treated kochs chest.Supportive therapy like amino acids and protiens will help the patient to recover well. Patient should be given influenza and pneumococcal vaccine prior to discharge. Patient should be adviced not to consume alcohol and smoke.

Wonderful analysis dear Nishant

Rt uz , Mz and Lz consolidation with apical cavity , lt fibrotic band with prominant hilum seen with copd changes in lungs , d/d are 1) re-activation of ptb 2) fungal pnemonia 3) underlying bronchogenic ca. , 4) pneumonia . 5)boop. Rbs, hiv , sputum for culture and sensitivity with Afb stain , hrct and fob sos required.

Excellent approach dear Bhagirath

Left hilum is elevated. Scarring both upper lungs. Old PTB. Bronchiactatic changes right lower lung

Thanks a lot dear sir

Excellent X-RAY and lovely discussion by all doctors

Thanks maa

X ray shows cavity lesion in RUL, consolidation in rt lower zone, fibrosis in left upper zone. Sputum AFB, C/S. Strict Diabetic control and ATT Cat 2 can b started

Thanks again dear Lakshmi

Rt. Diffuse fibronodular infeltrations with lt. Compensatory emphysema . COPD and Reactivation of old TB lesions. Start AMT with DOTS . And diabetes control with free diets and insulin. Bronchodilators and expectorant with supportive measures

Right upper & lower zone massive fibrosis, Repeat sputum exam. HIV Test.CBC Bronchodilators, Antipyretic,start with Antibiotics Cephalosporins. Then as per exams report.

Thanks again dear Yamini

I agree with Dr.K N Poddar.

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