Concluded Case

pulmonary tuberculosis

COMMENT ON CXR.. Will reveal the history subsequently in discussion..

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CXR: Trachea shifted to right slde Pleural thickening right upper zone Fibrosis wlth bronchiectasis right mid zone Pleural calcifications noted in right base Patchy opacities noted in left lung Cardia within normal limits. Right C.P. angle blunted

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44 YEAR FEMALE HISTORY OF PRESENTING ILLNESS : PATIENT WAS APPARENTLY NORMAL 6 MONTHS BACK WHEN SHE NOTICED LOSS OF WEIGHT AND LOSS OF APPETITE ASSOCIATED WITH EARLY SATIETY. PATIENT ALSO COMPLAINS OF HOARSENESS OF VOICE ,CHANGE IN CHARACTER OF VOICE SINCE THE LAST 3 MONTHS NOTICED AFTER BOUT OF COUGH. NO DIFFICULTY IN SWALLOWING, NO OTHER CRANIAL NERVE DEFICITS. SHE ALSO GIVES H/O OF INCREASED COUGH WITH MINIMAL MUCOID EXPECTORATION, NO HEMOPTYSIS. H/O OF BREATHLESSNESS SINCE PAST 6 MONTHS , NON PROGRESSIVE. NO H/O OF ORTHOPNEA,NO H/O PND NO H/O OF PALPITATION, NO H/O OF CHEST PAIN. NO H/O OF SYNCOPE. H/O INTERMITTENT FEVER SINCE LAST ONE MONTH. PAST HISTORY: k/c/o of TB lymphadenitis 10 years back and received treatment for 6 months. H/o of multiple episodes of coryza followed by cough. No history of Diabetes Mellitus, Hypertension, Asthma or IHD SYSTEMIC EXAMINATION: RS: Trachea shifted to right, accessory muscles not in use, chest movements are asymmetrical decreased movements on rightside, VF increased on right side apical area. Percussion impaired dullness on right side all areas. Normal vesicular breath sounds heared in both side, decreased intensity of breath sounds on right side, apical area. Coarse crepts present in whole of left hemithorax. VR decreased on right side. CVS: No precordial bulge, JVP not elevated, apex beat palpable in left 5th ICS 1/2 inch medial to MCL. Cardiac borders percussed WNL. 51 and $2 heard. No murmurs P/A: Soft, non tender, no guarding, no distension, No palpable mass / organomegaly. Bowel sounds heard. CNS: Higher Mental Functions Normal. Speech Normal, Cranial Nerves Intact, Motor and Sensory systems Normal, Reflexes Normal, No meningeal signs of irritation

there is no effusion Dr.pranali..

Left chest shows reticular shadows with few cystic spaces. Left costo phrenic angle not included Right lung shows opacity suggesting pleural calcification in the middle and lower zone Trachea is shifted to right side..? Sequele to an old fibrotic upper lobe lesion or a collapse due to a growth Right lung shows few cystic lesions in the middle zone with associated fibrotic strands.. Possibility of fresh pleural effusion can not be ruled out as right diaphragm is not delineated..

To conclude This is a case of Post tubercular right upper lobe fibrosis with broncheictasis. Left vocal cord palsy secondary to mediastinal traction. Thankyou all for being a part of this discussion and sharing your valuable opinions...

Nice case Dr. Ravi .. And excellent way to present.. People needs learn from you how to present a case...

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Possible right upper lobe collapse consolidation with possible pleural effusion.. Left lung possible extensive bronchiectasis.. Perform USG screen and if pleural fluid present.. Should be aspirated for diagnosis.. Cect thorax is next step investigation...

Thank you doctor

CT CHEST: Diffuse pleural thickening with calclflcation are seen on the right side. There ls evidence of tubular bronchiectasls changes with fibrotic changes in upper lobe causing atelectasis, volume loss and mediastinal shift to the right side. Flbrotic changes are also seen in the subpleural right middle and lower lobe. There is evidence of fissural and septal thickening. Similar changes are seen in the left apical, posterior segment and In left lower lobe. There Is evidence of ground glass opacity with mosaic appearance. Para aortic lympyhnode measuring 11x8mm noted. Mild flattening of left true vocal cord noted. Remaining report normal. lMPRESSlON: Right upper lobe bronchiectasis with right pleural calcification and chronic infectious changes as described ? tubercular etiology. Thoracic esophagus diverticulum as described traction. Flattening and thickening of left vocal cord secondary to paralysis.

CXR: Trachea shifted to right slde Pleural thickening right upper zone Fibrosis wlth bronchiectasis right mid zone Pleural calcifications noted in right base Patchy opacities noted in left lung Cardia within normal limits. Right C.P. angle blunted

I m not that much into x Ray's,, but trying a bit There is tracheal deviation to right,, pulled because of the fibrosis There are probably some bronchiectactic changes in the right lower lobe Compensatory emphysematous changes in left lung Multiple non homogenous opacities in left lung Etiology: tuberculosis

CXR Ap view s/o Soft Tissue swelling in the Neck... ? Cervical Lymphadenopathy ?? Thyroid enlargement Collapse in Right upper zone with Tracheal pull with ?B/L breast calcifications Rt>Lt with blunting of cp angle... 1) Medullary ca of Thyroid 2) Ca Breast

Extensive fibrosis of the Rt. lung with Tracheal pull to Rt side. D/D Tuberculosis Ca lung. Lobectomy on Rt side. Dr Brahmananda.

Dear Ravi, Very impressive case presentation...keep it up!! At the end of history as well as examination , u have to mention Ur D/D's based on clinical context

thankyou Dr.Sandeep
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