Tantoco, Justin Laree D.

SOL – Pulmonary Hour

Today’s pulmonary hour was very high yield for as I consider this field to be one of the
important must knows in medicine. Pulmonary diseases occur often and it’s important to know
the different clinical manifestations, diagnostics, diagnosis and treatment in how to approach
them. Being in clerkship, one of the most important things we should be learning is the
approach in a practical setting with the knowledge we’ve been building towards.

For example, one of the things that I’ve always struggled with is interpreting
radiographs. It is important to check all sides of the chest radiograph and to monitor after
surgery. In interpreting it is important to start at the midline, differentiate left to right of the
costophrenic angle. The physician should look at the signs of collapse in order to identify
atelectasis. In cases of space occupying and consolidation, if there is a cystic fluid mass, the
mediastinum is shifted away from the affected area. Make sure to look at the ICS which may be
widened in cases of effusion and most importantly always to look at the mediastinum. If this is
a case of consolidation, everything may be in place with no signs of collapse unlike atelectasis.

In cases of collapsed lung, the trachea and apex beat may be displaced to the side of the
collapse and the movement of affected is reduced with diminished breath sounds. Other
conditions the lead towards the white out include pneumonectomy and pulmonary agenesis. In
cases that are far from the white out they could be pleural effusions, huge lung masses and
diaphragmatic hernia. As mention in pleural effusions, the trachea and apex beat may be
displaced away from the white out if the effusion is large. In cases where the movement of the
affected side is reduced, we may consider consolidation. Other conditions that include an
unchanged position are chest well tumors, pleural tumors, pulmonary edema and acute
respiratory distress syndrome.

Another important topic discussed by Dr. Tabladillo is the mechanism of pleural fluid
accumulation along with the relationship between increased formation and decreased
absorption. Diagnostic thoracentesis is critical in the diagnosis and management of pleural
effusion as it is often simple and safe. It is diagnostic in 75% of cases and confirms the need for
closed tube insertion and surgical drainage. One thing that piqued my interest is the technique
of how would approach this and something I would certainly hope to observe during the clinical
face to face based section of clerkship. The importance of Light’s Criteria was also discussed in
order to determine the difference between transudate and exudate fluid. Finally, for the
management of empyema, the aim of treatment is to sterilize the pleural fluid and restore lung
function. VATS is only indicated if there is no improvement after thoracentesis and chest tube
drainage. A step further beyond that is that if VATS shows no improvement, open decortication
may be considered which allows the flow of pleural fluid without the tube. Intrapleural
streptokinase may also be used as it promotes drainage, decreases fever and lessens the need
for surgical intervention and hospitalization.