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TB CAVITY & FIBROSIS

- Question:
- Why did you diagnose your case as TB cavity ??
- Answer:
- It is TB because:
 There is history suggestive of TB toxemia at the onset: night fever …… etc…
 There is history of hemoptysis which is so common in TB.
 There is history of admission to a TB sanatorium.
 There is history of receiving drugs for one whole year ( anti-TB drugs ).
 There are clinical signs more apparent in the upper lung field (left supramammary).

- It is complicated by cavitation & fibrosis on the left side

because:

Inspection
Shape: There is retraction on the left hemithorax.
Movement: There is diminished movements on the left hemithorax.

Palpation
Trachea: There is shift of the trachea to the left side ( same side of the lesion ).
TVF: There is increased TVF in the upper lung field supramammary
region (cavity).
There is decreased TVF in the lower lung field ( excessive
fibrosis ).

Percussion
Note: There is heterogenous dullness on the left side.

Auscultation
Breath sound:
1. Bronchial with bronchophony & whispering pect. in the upper lung field
supramammary region (cavity).
2. Diminished intensity in the lower lung field ( excessive fibrosis ).

Additional sounds:
- Inspiratory medium-sized crepitations in the left side ( cavity & fibrosis ).

- Question:
- Are there any other findings in this patient ??
- Answer:
- Yes, there is chronic asthmatic bronchitis, because:

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 History of asthmatic attacks ( with dyspnea ) on exposure to allergens ( asthma ).

 History of heavy smoking ( chronic bronchitis ).
 Signs of bronchial obstruction:
o Prolonged vesicular breathing with expiratory rhonchi on the right side.
o Expiratory rhonchi on the left side.

- Question:
- What is important to examine in the eyes of this patient ??
- Answer:
- Jaundice, because some anti-TB drugs are hepato-toxic as INH, Rifampicin
and Pyrazinamide.

- Question:
- What is the effect of INH on the liver??
- Answer:
- Hepato-toxic causing CAH & Cirrhosis.

You should be fully ready to answer any question related to anti-TB drugs

- Question:
- Why would you like to look in the conjunctiva & face??
- Answer:
- To look for pallor which might be present in patients with pulmonary TB.

- Question:
- What other chest diseases may present with pallor ??
- Answer:
- Other infective chest diseases as: pneumonia, lung abscess.
- Pulmonary embolism.

- Question:
- Would you expect to find pallor in this patient ??
- Answer:
- No, because:
1. TB is old and not active now.
2. There is evidence of chronic asthmatic bronchitis.

- Question:
- Why don’t you expect to find pallor in chronic asthmatic bronchitis ??
- Answer:
- Because in such case, there is usually secondary polycythemia due to the
presence of CHRONIC HYPOXIA which will stimulate the release of
Erythropoetin to induce polycythemia.
- OR: in severe cases of hypoxia, there will be cyanosis.

- Question:
- What is important to examine in the neck of this patient ??

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- Answer:
- Cervical LN for: TB lymphadenopathy for the possibility of recurrence.
- Trachea for: position.
- Neck veins for: congestion in case of development of RVF.

- Question:
- What investigations do you think were done to the patient when the doctors
suspected TB ??
- Answer:
- Enumerate the investigations of pulmonary TB.

- Question:
- What do you think Tuberculin test will be in this patient now ??
- Answer:
- Positive because he got TB before ( old TB ).

- Question:
- What makes Tuberculin test positive ??
- Answer:
 Infection with TB ( whether active or old ).
 Vaccination with BCG .

You should be fully ready to answer any question related to Tuberculin test

- Question:
- What do you expect to find in the CXR of this patient on the left side ??
- Answer:
 Heterogenous opacity with reticulations.
 The mediastinum moves towards the fibrosis ( tracheal shift ).
 The diaphragm moves towards the fibrosis ( tenting of the diaphragm ).