A 28yr/F by name___resident of ___Home maker by occupation from a low socioeconomic class , presented with complaints of fever( low grade ,intermittent ) associated with generalized weakness for the duration of 2 days , Shortness of Breath (Acute , Sudden in Onset, Grade 4 type according to MRC scale of Dyspnea, aggravated on walking) since morning.
Negative History to rule out other systems
No History of Cough with expectoration ,Loss of weight, Travel to endemic places, Food allergy, TB contact, animal exposure
No history of Orthopnea, Paroxysmal Nocturnal Dyspnea, Chest pain, palpitations, syncope
No history of Pedal Edema, Polyuria/oliguria, burning micturition, Diarrhoea, vomiting
Past History
No history of Bronchial Asthma/DM/HTN/Seizures/TB
Drug History
History of COVISHIELD Vaccination 2nd dose 3days back, No other relevant medical history
Family History
No similar complaints in the family/ No TB suspected cases/Pneumonia/allergies
Personal History
Doesn't smoke and doesn't take alcohol
Mixed diet , loss of appetite,
Sleep duration- regular,
Bowel and bladder habits- normal
Occupational History- Not relevant (Home maker)
*Consent Should be taken and explain what you are doing
General Examination
Patient is conscious, coherent, well built and nourished
{EYE Signs- Horners Syndrome, Phylcten, Iridocyclitis, Chemosis.
External markers for TB- Taenia versicolor, epididymo orchitis, scrufuloderma, Lupus vulgaris, erythema nodosum
External markers for Cor Pulmonale- JVP, pedal edema, Ascites, Liver enlargement
Muscle wasting, Staining of Tobacco, Asterixis to be ruled out.
Vitals
BloodPressure- 104/68mm Hg , supine position (Rt -arm)
SP02- 99% at Room Air ,Post Exercise- 98% at Room Air
Temp-febrile (99.8°F)
Pulse Rate- 138/min, Regular rhythm, Normal Volume and character, No vessel wall thickening,No Radio radial Delay
No Signs of Pallor, Icterus, Cyanosis, Clubbing, Pedal Edema and Generalized Lymphadenopathy.
Systemic Examination
Respiratory System Examination
Inspection- Normal
Shape of the Chest Normal AP to Transverse Diameter-5:7 (Hutchinson Index)
Flat chest- PTB/ Fibrothorax
Barrel Chest - AP:T- 1:1(Infants/old age/Emphysema/COPD)
Pectus Carinatum(Pigeon Chest)- forward protrusion of sternum- Childhood Astma,Rickets,Marfans Syndrome
Pectus excavatum(Cobblers/Funnel) -exaggeration of Normal hollowness over lower end of sternum- Marfans Syndrome
Harrison sulcus- indrawing of ribs to form grooves along the coastal margin to form sulcus around the diaphragm- rickets, asthma
Scorbutic rosary- backward displacement of sternum- Vit C deficiency
Rickety rosary-bead like costochondral junction
Symmetry of the Chest- dropping of the shoulder, wasting, supra clavicular and infra clavicular hollowing, crowding or bulging of the ribs
Trachea - midline/any deviation
Apex beat- Visible
Accessory muscles- Intercostal muscles indrawing, Sternocleidomastoid , subcostal retraction
Spine- Central /Kyphosis(Forward bending)/Scoliosis (lateral bending)/ kyphoscoliosis
Any Visible scars, pulsations, dilated veins, sinuses
Movement in all areas- equal/not
Areas
Supra clavicular
Infra clavicular
Mammary
Inframammary
Axillary
Infra axillary
Supra scapular
Inter Scapular
Infra Scapular
Palpation- 22/min, thoraco abdominal type
Rate- 14-18/min adults
Type- thoraco abdominal (females)
Abdomino thoracic (male)
Pulse to Resp rate- 4:1
Tachypnoea- >20/min
Fever/Hypoxia/Nervousness/Pul.Edema/Pul.embolism/Pneumonia/ARDS
Bradypnoea- Alkalosis/Narcotics drug poisoning/Raised Intra cranial pressure/Hypothyroidism
Hyperpnoea- Acidosis/Hysteria/Brain Stem Lesion
Rhythm
Inspiration - contraction of external Intercostal and diaphragm- active process
Expiration- passive- elastic recoil of lungs
Accessory muscles-Inspiration- Scalene, Trapezius, Pectoral
Accessory muscles-Expiration- Lattissimus and Abd Muscles
Abnormal breathing pattern
Regular abnormal
Cheyne Stokes- Hyperpnoea followed by apnoea
Renal/Cardiac Failure, Narcotics drug poisoning, Raised ICT.
Kussmaul's - increase in rate and depth of breathing
Acidosis, Pontine Lesions
Irregular Abnormal
Biots breathing- apnoea between shallow or deep inspiration- meningitis
Ataxic breathing- Brain Stem Lesions- irregular shallow and deep breaths.
Apneustic breathing pattern - pause at full inspiration and followed by pause at full expiration for 2-3sec - Pontine Lesions
Any location rise of temperature- yes
Trails sign - undue prominence of clavicular head of SCM to the side of deviated trachea
Any Tracheal Deviation- No
Towards the lesion- collapse of lung/Pnuemonectomy/fibrosis
Away from the lesion of lung- massive Pleural Effusion/tension pneumothorax
Upper mediastinal mass- lung cancer/lymphoma/Retrosternal goitre
Apex beat- shifted towards the side of mediastinal shift
Palpable Rub/Rhonchi/Crepitus- No
Bony rib/chest wall tenderness- empyema/amoebic liver abscess/inflammation of parietal pleura/osteomyelitis
Vocal fremitus- ulnar border of hand in all areas by vocal cord in action.
Increased in consolidation
Decreased in Pleural Effusion
Measurements
Chest Circumference
AP and Transverse Diameter
Chest expansion in inspiration and expiration
Hemithorax and hemithorax expansion- B/L
Normal expansion- 5-8cms
Severe Emphysema<1cm
Restricted expansion of chest
Systemic sclerosis (hide bound chest)
Ankylosing spondylitis
ILD
COPD
Asymmetric expansion of chest
Pneumothorax
Pleural effusion
Pulmonary fibrosis
Pulmonary collapse
Movement in all areas- normal
Percussion- Resonant note heard
Anterior Chest Wall
Direct percussion- within medial 1/3rd of clavicle
Supraclavicular fossa region (Kronigs isthmus)- direct percussion on supraclavicular fossa band of 5-7 cm size of resonance to assess the lung apices
2nd to 6th ICS
Liver Dullness
5th rib down Mid clavicular line (Right side)
Lateral Chest Wall
4th - 7th ICS
Liver Dullness
8th rib( right) downward mid axillary line
Posterior Chest Wall
Suprascapular- above spine of scapula
Interscapular
Infrascapular- till 11th rib
Liver Dullness percussion from 10th rib down along the mid scapular line
Percussion note
Resonant- Normal
Hyperresonant- Pneumothorax
Dull- Pulmonary collapse/severe-pulm.fibrosis/consolidation
Stony dull- pleural effusion/Haemothorax
Liver span
8-12cms in mid clavicular line
Tidal percussion
To differentiate dullness caused by liver enlargement in the 5th rib on deep inspiration, previous dull note become resonant- indicates dull note is because of liver pathology which is pulled down by right hemidiaphragm in absence of diaphragm paralysis
If still dull note - rt sided parenchymal/pleural pathology
Shifting dullness-
Shift of Dullness in hydropneumothorax- dull note in axilla on sitting becomes resonant on lying down on healthy side
Traube space - 6th rib superior, lateral-left mid axillary line and left Coastal margin inferiorly
*Dull note in
Massive pericardial effusion
Left side Pleural Effusion
Fundus mass
Enlarged left lobe of liver
Splenomegaly
Shifted upwards in
Left Lung collapse/fibrosis/diaphragm paralysis
Auscultation- Bilaterally Normal vesicular breath sounds heard over all areas of auscultation.
Vocal Resonance- equal in all areas.
Amplitude and quality of VR.
Bronchophony- unclear words with voice sounds heard over ear piece of stethoscope.- consolidation
Aegophony- E to A sign nasal or bleating quality
Consolidation, cavity
Whispering pectoriloqy- whisper words at the end of expiration which are heard clearly- pneumonic consolidation.
Auscultation alternative on both sides
Anterior from above clavicle to 6th rib
Lateral axilla to 8th rib
Posterior down till 11th rib
Vesicular breath sounds
Low pitched, rustling in nature, produced by attenuating and filtering effect of lung.
No pause between end of inspiration and beginning of expiration, with inspiration phase is longer than expiration in 3:1
Decreased in Pneumothorax, Collapse, COPD, obesity, thick chest wall
Bronchial breath sounds
Loud and High pitched, with passage of air through bronchi and trachea, gutteral quality , pause between inspiration and expiration with inspiration phase is short ,
Best heard over trachea and large airways between Scapular and above clavicle, lung apices
Causes- Pneumonia, Consolidation, Collapse, pulm fibrosis, complete alveolar atelectasis
Types
Amorphic- metallic quality- in tension pnuemothorax
Cavernous - high pitched and hollow- Cavitations
Tubular- low pitched in consolidation
Added sounds
Brochovesicular Breath Sounds
Moderate loud and medium pitch with rustling, heard over hilar region.
Increased inspiratory phase and short expiratory phase (I=E)
Louder in increased ventilation and consolidation
Coarse rales/crackles/crepitations-
When the mucus/fluid in the alveoli collects ,it gets sticks to the alveoli causing crackling sound on inspiration (mostly early inspiration) loud low pitched.
Heard in resolving Pneumonia, Congestive Heart Failure, Bronchiectasis, COPD.
Fine rales/crackles/ crepitations
Less loud, high pitched, heard in late inspiration
Heard in acute stages of early Pneumonia, Pulmonary fibrosis, asbestosis, Occasionally CHF
Rhonchi
Low pitched, continuous breath sounds caused by thick fluid or mucous secretion flow through large air passages like Bronchioles and bronchi
Heard in severe bronchitis and COPD
Wheeze -
Sibilant Rhonchi
Forcing air through closed airways , expiratory.
Bronchial asthma(diffuse), foreign bodies, swelling of airway and tumors ( localised wheeze-- occlusion to Bronchial tree)
Stridor
High pitched, whistling sound heard in inspiration and expiration, seen in epiglottis, croup, tumor, retropharyngeal abscess, peritonsilar abscess.
Pleural rub - creaking noise when inflamed Pleural surface rub against each other in inspiration and expiration
Seen in TB, Pulmonary infection, infarction, pleurisy of Pneumonia
Coin test - pneumothorax
Succussion splash- Hydropneumothorax
Other systems examination
CVS- S1 S2 + heard , no murmurs
Per Abd examination- soft abdomen, palpable Liver, no Ascites, no hepatomegaly and splenomegaly (no organomegaly) Bowel sounds heard .
CNS- Reflexes- Normal
No Focal Neurological Deficits
Probable Diagnosis:-Post Vaccination illness
Side -Right/left/bilateral
Lobe- Upper/Middle/lower
Pathology- infection/inflammation/Bronchiectasis
Etiology- post TB/Smoking/History
Not in Cor Pulmonale, not in respiratory failure.
Investigations:-
Haemogram
COVID test- RTPCR/Rapid Antigen Test
Chest X ray (PA view)
Differential Diagnosis
Post Vaccination illness ( most probably) -because similar complaints seen in Vaccinated people
Acute Hysterical illness association with Vaccination-(fever+ hysterical panic attack )
Pulmonary Embolism- but Saturation is normal
Covid 19 Pneumonia- to be ruled out by RTPCR but post exercise and post walk saturation is normal.
Treatment (Rx)-
Inj Hydrocortisone 50mg IV (SOS)(SOB relieved)
Tab Paracetamol 500mg BD P.O *2days
Tab B complex &Vit C OD P.O *3days
Plenty of oral fluids & Healthy diet
Evaluation and review after 2 days.