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ICU Unit
Prof. Ahmed EL Hadidy
Prof. Mostafa EL Shazly
Prof. Mohammed A.Hakeem
Prof. Amani Abuzeid
Prof. Mohamed Wafai
Complaint
Right side chest pain
Personal History
 Male patient
 16 years old
 Born and living in ELfayoum.
 student.
 No special habits of medical importance.
Present history
 The condition started 1 year ago by gradual
progressive dyspnea on moderate exertion with no
orthopnea or PND or chest wheezes .
 The condition was associated with dry cough .
 He sought medical advice several times and received
non specific medications with no improvement.
 3 months ago the patient experienced acute left
inframamary stitching chest pain increased with
respiration, referred to the back and associated with
acute dyspnea
 The patient saught medical advice at El fayoum chest
hospital where CXR and CT chest were done and
revealed left side pneumothorax.
 ICT was inserted and the patient was referred to
cardiothoracic surgery where bullectomy operation
was done with no available data.
 1 week before admission , the patient experienced right
inframamary stitching chest pain referred to the back
and increase with respiration , the patient sought
medical advice at Elfayoum chest hospital where CXR
and CT chest were done and revealed right side
pneumothorax.
 ICT was inserted and the patient was referred to our
department .
 No history of hemoptysis or wheezes
 No history of jaundice ,right hypochondrial pain or
lower limb oedema
 No history of dysphagia or hoarseness of voice
 No history of skin or joint manifestations.
 No history of fever, anorexia or loss of weight .
 The patient is not diabetic or hypertensive
Past history
• No history of TB or contact with TB case
• No history of previous operation , blood transfusion or
drug allergy.
Family history
His sister was admitted in our
department with recurrent
pneumothorax
Examination
General examination
 Patient is fully conscious ,alert, cooperative
oriented to time, place ,and person , of average
mood and intelligence
 lying flat in the bed
Vital sign
 Pulse: 100 beats /minute ,regular ,equal on both sides
 Blood pressure:110/70
 Temperature: 37˚c
 R.R: 30breaths /minute
 BMI : 15 kg/m2
Head and neck
 No Pallor
 No jaundice
 No cyanosis
 No palpable lymph node or thyroid swelling
 No congested neck veins
Upper limb examination
 No clubbing
 No cyanosis
Lower limb examination
 No clubbing
 No lower limb oedema
 Calf muscle lax not tender
 Intact Peripheral pulsation
Abdominal examination
 lax not tender
 No organomegaly or ascites can be detected clinicaly
Cardiological examination
The apex in left 5th space MCL
Normal heart sounds
No additional sounds
Mahmoud hassan 1 1
Inspection
Shape: symmetrical with ICT inserted
on the right side
 Respiratory movement: thoraco
abdominal.
Expansion: restricted on the right side
Palpation
Trachea: central
Chest expansion: diminished on RT
side
TVF: diminished on RT side
No tenderness
No palpable rub or rhonchi
Percussion
 Upper border of the liver: couldn't be
detected.
 Chest percussion :resonant
 Kronig’s isthmus: resonant.
 Clavicle :resonant.
 Bare area: dull
 Traub’s area : tympanic resonant
Auscultation
• Bilateral vesicular breathing with no
additional sounds.
• Despine sign: -ve
Mahmoud hassan 1 1
CXR 18- 7- 2014 before admission
2-7
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CT chest (6-10-2014)before
admission
Mahmoud hassan 1 1
CXR 13-10-2014 on admission
HRCT 19-10-2014
Mahmoud hassan 1 1
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HRCT CHEST
Multiple variable sized thin walled dilated cystic air
spaces are noted within both lung fields as well as
scattered patches of air trapping .
Mild right apical pneumothorax is seen with chest tube
seen within it.
Lung parenchyma show mosaic pattern .
No pleural effusion.
Suspected hilar lymphadenopathy for post contrast
study.
*Pleurodesis was done & the patient was
discharged
*3weeks later the patient presented to us
with right side stitching chest pain
associated with dyspnea on mild
exertion
22-11-2014 (readmission)
Mahmoud hassan 1 1
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2 weeks later the patient experienced
sudden dyspnea with rt sided stitching chest
pain referred to the back
Mahmoud hassan 1 1
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ICT was inserted on the right side and
follow up CT chest was done
Mahmoud hassan 1 1
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Complete blood count
 TLC 9.5 10*3 /cmm (4-11)
 Hemoglobin 11.8 g/dl (12-15)
 Hematocrit (PCV) 36.2% (35-45)
 M.C.V 61.2 fl (80-101)
 M.C.H 19.9 pg (27-32)
 Platelet count 193 10*3/cmm (150-450)
Clinical Chemistry Report
 AST 26 U/L (UP TO 50)
 ALT 44U/L (UP TO 45)
 Serum albumin 4.7 mg/dl (3.5-5)
 Serum creatinine 0.7 mg/dl (0.3-1.2)
 Blood urea 27.8 mg/dl (7-50)
 Serum calcium 8.1 mg/dl (8.4-10.2)
PT 13.6 sec
PC 95%
INR 1.03
ESR 1st hour 58
ESR 2nd hour 95
COLLAGEN PROFILE
RF +VE
ANCA -VE
normalAlpha one antitrypsin
PULMONARY FUNCTION TEST
FEV1/FVC 93
FVC 25%
FEV1 28% 0.75 L
ECHO normal
CT abdomen & CT brain normal
RHEUMATOLOGY CONSULTATION
The patient has thin inelastic skin and tall finger high
arched foot with hypermobility suspected of Ehlerdanlos
syndrome
Recomendation
Fundus examination for ectopia lentis (normal)
Xray hand ( normal)
As regard his sister :
* 14 years old
* 2weeks before admission , the patient experienced left
side pneumothorax, ICT was inserted for 1 week then
removed
* 1 week later , she was admitted with bilateral
pneumothorax & bilateral ICT was inserted
* Pleurodesis was done on the right side then she was
referred to cardiothoracic surgery due to persistent air
leak
Mahmoud hassan 1 1
Mahmoud hassan 1 1
Mahmoud hassan 1 1
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Pathology report
Gross
2 irregular rubbery greyish brown flattened tissue pieces
,measuring 2.5x1.5x0.5 cm and 2.5x1x0.5cm both bisected
and totally submitted.
Microscopic
Section examined from the specimen received reveal lung
tissue with evidence of emphysema with marked ,
congestion interstitial lymphocytic infiltrate and mild
anthracosis .
No evidence of specific granuloma.
No evidence of malignancy .
diagnosis
Lung biopsies ,chronic venous congestion , emphysema
,ruptured bulla.
Pathology report(revision)
Microscopic
Examination of the received slides reveal lung tissue
showing moderately edematous alveolar walls with
areas of mild to moderate interstitial fibrosis and
diffuse interstitial infiltration by lymphoplasmocytic
cellular infiltrate .some lymphoid aggregates and few
neutrophils.many calcified bodies are detected in the
interstitium .few alveoli show bubbly exudate
entangling inflamatory cells. Areas of anthracosis are
also seen.
Diagnosis
Picture suggestive of hypersensitivity pneumonitis
Mahmoud hassan 1 1

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Mahmoud hassan 1 1

  • 1. ICU Unit Prof. Ahmed EL Hadidy Prof. Mostafa EL Shazly Prof. Mohammed A.Hakeem Prof. Amani Abuzeid Prof. Mohamed Wafai
  • 3. Personal History  Male patient  16 years old  Born and living in ELfayoum.  student.  No special habits of medical importance.
  • 4. Present history  The condition started 1 year ago by gradual progressive dyspnea on moderate exertion with no orthopnea or PND or chest wheezes .  The condition was associated with dry cough .  He sought medical advice several times and received non specific medications with no improvement.
  • 5.  3 months ago the patient experienced acute left inframamary stitching chest pain increased with respiration, referred to the back and associated with acute dyspnea  The patient saught medical advice at El fayoum chest hospital where CXR and CT chest were done and revealed left side pneumothorax.
  • 6.  ICT was inserted and the patient was referred to cardiothoracic surgery where bullectomy operation was done with no available data.  1 week before admission , the patient experienced right inframamary stitching chest pain referred to the back and increase with respiration , the patient sought medical advice at Elfayoum chest hospital where CXR and CT chest were done and revealed right side pneumothorax.  ICT was inserted and the patient was referred to our department .
  • 7.  No history of hemoptysis or wheezes  No history of jaundice ,right hypochondrial pain or lower limb oedema  No history of dysphagia or hoarseness of voice  No history of skin or joint manifestations.  No history of fever, anorexia or loss of weight .  The patient is not diabetic or hypertensive
  • 8. Past history • No history of TB or contact with TB case • No history of previous operation , blood transfusion or drug allergy.
  • 9. Family history His sister was admitted in our department with recurrent pneumothorax
  • 11. General examination  Patient is fully conscious ,alert, cooperative oriented to time, place ,and person , of average mood and intelligence  lying flat in the bed
  • 12. Vital sign  Pulse: 100 beats /minute ,regular ,equal on both sides  Blood pressure:110/70  Temperature: 37˚c  R.R: 30breaths /minute  BMI : 15 kg/m2
  • 13. Head and neck  No Pallor  No jaundice  No cyanosis  No palpable lymph node or thyroid swelling  No congested neck veins
  • 14. Upper limb examination  No clubbing  No cyanosis Lower limb examination  No clubbing  No lower limb oedema  Calf muscle lax not tender  Intact Peripheral pulsation
  • 15. Abdominal examination  lax not tender  No organomegaly or ascites can be detected clinicaly
  • 16. Cardiological examination The apex in left 5th space MCL Normal heart sounds No additional sounds
  • 18. Inspection Shape: symmetrical with ICT inserted on the right side  Respiratory movement: thoraco abdominal. Expansion: restricted on the right side
  • 19. Palpation Trachea: central Chest expansion: diminished on RT side TVF: diminished on RT side No tenderness No palpable rub or rhonchi
  • 20. Percussion  Upper border of the liver: couldn't be detected.  Chest percussion :resonant  Kronig’s isthmus: resonant.  Clavicle :resonant.  Bare area: dull  Traub’s area : tympanic resonant
  • 21. Auscultation • Bilateral vesicular breathing with no additional sounds. • Despine sign: -ve
  • 23. CXR 18- 7- 2014 before admission
  • 24. 2-7
  • 28. CXR 13-10-2014 on admission
  • 33. HRCT CHEST Multiple variable sized thin walled dilated cystic air spaces are noted within both lung fields as well as scattered patches of air trapping . Mild right apical pneumothorax is seen with chest tube seen within it. Lung parenchyma show mosaic pattern . No pleural effusion. Suspected hilar lymphadenopathy for post contrast study.
  • 34. *Pleurodesis was done & the patient was discharged *3weeks later the patient presented to us with right side stitching chest pain associated with dyspnea on mild exertion
  • 38. 2 weeks later the patient experienced sudden dyspnea with rt sided stitching chest pain referred to the back
  • 42. ICT was inserted on the right side and follow up CT chest was done
  • 46. Complete blood count  TLC 9.5 10*3 /cmm (4-11)  Hemoglobin 11.8 g/dl (12-15)  Hematocrit (PCV) 36.2% (35-45)  M.C.V 61.2 fl (80-101)  M.C.H 19.9 pg (27-32)  Platelet count 193 10*3/cmm (150-450)
  • 47. Clinical Chemistry Report  AST 26 U/L (UP TO 50)  ALT 44U/L (UP TO 45)  Serum albumin 4.7 mg/dl (3.5-5)  Serum creatinine 0.7 mg/dl (0.3-1.2)  Blood urea 27.8 mg/dl (7-50)  Serum calcium 8.1 mg/dl (8.4-10.2)
  • 48. PT 13.6 sec PC 95% INR 1.03 ESR 1st hour 58 ESR 2nd hour 95
  • 49. COLLAGEN PROFILE RF +VE ANCA -VE normalAlpha one antitrypsin
  • 50. PULMONARY FUNCTION TEST FEV1/FVC 93 FVC 25% FEV1 28% 0.75 L
  • 51. ECHO normal CT abdomen & CT brain normal
  • 52. RHEUMATOLOGY CONSULTATION The patient has thin inelastic skin and tall finger high arched foot with hypermobility suspected of Ehlerdanlos syndrome Recomendation Fundus examination for ectopia lentis (normal) Xray hand ( normal)
  • 53. As regard his sister : * 14 years old * 2weeks before admission , the patient experienced left side pneumothorax, ICT was inserted for 1 week then removed * 1 week later , she was admitted with bilateral pneumothorax & bilateral ICT was inserted * Pleurodesis was done on the right side then she was referred to cardiothoracic surgery due to persistent air leak
  • 58. Pathology report Gross 2 irregular rubbery greyish brown flattened tissue pieces ,measuring 2.5x1.5x0.5 cm and 2.5x1x0.5cm both bisected and totally submitted. Microscopic Section examined from the specimen received reveal lung tissue with evidence of emphysema with marked , congestion interstitial lymphocytic infiltrate and mild anthracosis . No evidence of specific granuloma. No evidence of malignancy .
  • 59. diagnosis Lung biopsies ,chronic venous congestion , emphysema ,ruptured bulla.
  • 60. Pathology report(revision) Microscopic Examination of the received slides reveal lung tissue showing moderately edematous alveolar walls with areas of mild to moderate interstitial fibrosis and diffuse interstitial infiltration by lymphoplasmocytic cellular infiltrate .some lymphoid aggregates and few neutrophils.many calcified bodies are detected in the interstitium .few alveoli show bubbly exudate entangling inflamatory cells. Areas of anthracosis are also seen.
  • 61. Diagnosis Picture suggestive of hypersensitivity pneumonitis