Lobectomy and pneumonectomy

 

Thank you for asking me to examine Harry who presented with SOB. I would have like to have completed my examination by taking pulse oximetry and peak flow measurements.

 

My salient findings were a thoracotomy scar on the left/right with decreased chest expansion in the upper/lower/both zones and reduced/absent breath sounds consistent with a previous right/left lobectomy/pneumonectomy.

 

I will now present my findings in full before commenting on potential aetiology, and complications.

 

The patient was comfortable at rest with normal/increased WOB with/without evidence of accessory muscle use. There was no evidence of CO2 narcosis with no asterixis. There was / was not supplemental oxygen. The patient had a dry/loose/productive cough on prompting. There was / was no sputum cup at the bedside.

 

The respiratory rate was ___, and the pulse was ___ and regular/irregular.

 

On examination of the hands, there was / was not clubbing, nicotine staining, or peripheral cyanosis.

 

On examination of the face, there was / was not conjunctive pallor, ptosis, or central cyanosis.

 

The trachea was displaced (towards the affecting side) with/without tracheal tug. There was / was not cervical, supraclavicular or axillary lymphadenopathy.

 

On inspection of the chest, there was a thoracotomy scar on the left/right chest wall. The ribs were drawn inward (regionally in lobectomy) / the chest wall was flattened. There was / was no obvious deformity with / without kyphoscoliosis, pectus carinatum, pectus excavatum. There were / were not radiotherapy skin changes.

 

Chest expansion was reduced asymmetrically. There was hyper-expansion of the other lung.

 

Percussion showed reduced resonance (or dull if filled with fluid post pneumonectomy).

 

On auscultation, there was decreased / absent breath sounds (locally in lobectomy, throughout in pneumonectomy. The opposite lung showed may have disease findings of underlying pathology here.

 

In regard to potential indication of lobectomy

• There was / was not features of bronchiectasis - purulent cough, clubbing, coarse crackles

• Malignancy - radiotherapy changes

• Cystic fibrosis

• Other differentials include tuberculosis or a previous lung abscess, however I could not ascertain specific evidence for these.

 

In regard to potential indication for pneumonectomy:

• There was / was not features of bronchiectasis - purulent cough, clubbing, coarse crackles

• Malignancy

• Tuberculosis

 

In summary, Harry is a patient who presented with SOB. My findings are suggestive of a right/left upper/lower lobectomy/pneumonectomy, possibly due to underlying ____.

 

I would proceed from here by:

• Confirming the diagnosis by clarifying medical records and taking a history, but if not available, by pursuing a CXR.

 

What are the indications for a lobectomy?

• Cancer

• Infection (bacterial, mycobacterial, mycotic) - such as aspergilloma, TB

• COPD with bullae

• Bronchiectasis with haemoptysis

• Trauma

 

What are indications for thoracotomy scar?

• Lobectomy or pneumonectomy

• Open lung biopsy

• Lung volume reduction or bullectomy

• Cardiac

  • Right anterolateral can be used for some minimally invasive cardiac surgeries

• Other:

  • Oesophageal surgery

 

Common indications for VATS include

• Bullectomy and lung volume reduction surgery in emphysema.

• Correction of spontaneous primary pneumothorax.

• Lobectomy and pneumonectomy (in some centers)

• Lung parenchymal biopsy.

• Wedge resection.

• Pleurodesis

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