1. ICU Unit Prof. Ahmed EL Hadidy Prof. Mostafa EL Shazly Prof.
Mohammed A.Hakeem Prof. Amani Abuzeid Prof. Mohamed Wafai
2. Complaint Right side chest pain
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
10. Examination
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
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
17. Inspection Shape: symmetrical with ICT inserted on the
right side Respiratory movement: thoraco abdominal. Expansion:
restricted on the right side
18. Palpation Trachea: central Chest expansion: diminished on
RT side TVF: diminished on RT side No tenderness No palpable rub or
rhonchi
19. Percussion Upper border of the liver: couldn't be detected.
Chest percussion :resonant Kronigs isthmus: resonant. Clavicle
:resonant. Bare area: dull Traubs area : tympanic resonant
20. Auscultation Bilateral vesicular breathing with no
additional sounds. Despine sign: -ve
21. CXR 18- 7- 2014 before admission
22. 2-7
23. CT chest (6-10-2014)before admission
24. CXR 13-10-2014 on admission
25. HRCT 19-10-2014
26. 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.
27. *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
28. 22-11-2014 (readmission)
29. 2 weeks later the patient experienced sudden dyspnea with
rt sided stitching chest pain referred to the back
30. ICT was inserted on the right side and follow up CT chest
was done
34. COLLAGEN PROFILE RF +VE ANCA -VE normalAlpha one
antitrypsin
35. PULMONARY FUNCTION TEST FEV1/FVC 93 FVC 25% FEV1 28% 0.75
L
36. ECHO normal CT abdomen & CT brain normal
37. 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)
38. 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
39. 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 .
41. 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.
42. Diagnosis Picture suggestive of hypersensitivity
pneumonitis