GOLJAN - Special Pathology (Resp)

7/29/2019 GOLJAN - Special Pathology (Resp)

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Respiratory systemArterial blood gas (ABC) interpretation:1. review Fluids and Hemodynamics and Acid-Base2. respiratory acidosis :

A. pH < 7.35O. PCO,> 45c. compensation is metabal ic alkalosis:

(1) HCOl ~ o mEq/L is aellie respiratory acidosis(2) HCO l >30 mEq/L is chronic resp irato ry acidosis3. respiratory alkalosis:

A. pH > 7.45B. PCO,


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Secondsa 1 2 3 412

RV FRCt t 6FIGURE 11-1. Schematic of the normal lung volumes and Cil-pacities and the forced expiratory volume 1 second (FEVt.,.Jand forced vital capacity (FVC) I.n a normal penon (A) , a personwith restrictive lu.ng disease (8), and a person with obstructivelung disease (C). me (functional residual capacity) representsthe volume of gas that remains in the lung at rest at the end of anormal respiration and Is the most reproducible part of a p u J m ~nary function test, since It does not require patient effort. PersonA (nonnal Individual) has an FEV,_ 01 4 L and an FVC of 5 L,with FEVu.JFVC ratio = 0.80 . Person B with restrictive lungdisease has a "mlniaturlfed" curve of person A. Note that theFEV t- : and FVC are the same (3 L) owing to the lncrease Inelasticity In the lungs. hence FEVb.JFVC ratio::; 1.0 . Person Cwith the obstructive pattern Is having dlificulty in expelllng airfrom the lungs owing to decreased lung elasticity. FEV t....: = I L,FVC ~ 3 L, and FEVb..fFVC , . tio ~ 0.33. Both people B and Chave _educed values for FEVtocc and FVe when compared withthe normal person; however. person B with restrictive lung dis-ease has values between those of the normal Individual andperson C With obstruction. Person B has decreased complianceIn the lungs. hence less air enters the lungs. but owing to the


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(1) FEV IJ is how much air a person can expel from the lungs in I second after ama.ximal inspiration

(2) normal FEYhe: is 4 liters(3) usually


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B. perfus ion without ventilation:(1) e.g ., puLmonary embolus(2) increased dead space(3) giving 100% O2 does increase POl since nomall)' ventilated lung can make upthe differenceC. diffusion abnonnalities: e.g., interstitial fibros is

D. right to left shunts in the heart: e.g., cyanotic congen ital hean di seaseJ. rormulo used to caltuhue A-a gradient-A. I'AO, - % oxygen (713) - PaCO,! 0.8:B. using norma l values- PAOl "" 0.2 1 (7 13 ) 40/0.8 . 100 mm Hg

4. caUJ6 orbypoumia " 'ilh a Dormat A-a gradinl-A. depression of the respiratory center in the medulla:(1) e.g blU'bilurates

(2) CNS injuryB. obs truction of upper airway:(1) e.g., cafe coronary(2) epiglon il is(3) croup

C. chest bellows dysfunction: c.g., paralyzed diaphragmani polyps!

1. aUergic-A. MC type8 . occ urs in adults

2. aspirin-re.lated-A. clllled triad asthma:(I ) take aspirin(%) develop asthma(3) nasal polyps

B. usually occurs in patients with chronic pain syndromesC. non-immune mechanism:,( I) aspirin blocks cycloo1C.ygenase and leaves the lipoxygenast pathway open(2) LTC-, D-. E. are increased., which cause bronchoconstriction

3. cystic fibrosis- any child with nasal polyps and a history of repeated respiratory infectionsand diarrhea should have a sweat (est

Laryngeal nrdooma :I. eausC5 -A. smoking: MCCB. alcohol

C. asbestos2. sile-

A. supraglottic area is MC locationB. squamous cell carcinoma

3. cUnieal-A. hoarseness

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r Alelecta5i,,:I. MCC of revu 24 hs arter surgery2. palbophysiology-

A. collapse of alveoli due to mucus blocking terminal bronchiolesB. distal resorption of air through the pores of Kohnl . dinical- signs o f consolidation:A. increased tactile m:mirus (lAJA.hc ,.L i


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C. intraventricular hemorrhageO. patent ductus arteriosis with machinery murmur: due to persistent hypoxemia

5. JU olRDS-A. positive end. exp iratory pressu re PEEP)-keeps airways from co llapsing on expirationB. deliver)' of surfactan t via PEEP therapyC. oxygen

Adult ) i r a o ~ dis l.ress syndrome (ARDS):I. (,Iluses-

2.

3.

A. endotoxic s hoc k MCCB. gastr ic aspirationC. traumaD. pn eumoniaE. smoke inhalationpath ophysiology-A. non.card iogenic pulmonary edemaD. ne utrophil-relnted injury with destruction of' ty pe II pncumocytes (loss of surfactant)and damage to pulmonary capi llaries ("leaky capil lary syndrome"C. massive intrapu lmonur)' shunling from loss of surfactant is the mos t importantabnormal ityD. hyaline membranes from protein leaking from capi llariesseparate from cardiogn i c pulmonary edema by pulmonary capillary wedge pressure(measure of left ventricular end-diastolic pressure)-A. low in PCWP in ARDS8. increased PCWP in card iogenic shock

4. h igb morta litySpoD t.aneous pneumothorax:1. causes-A. id iopathic:(I) MCC

(2) tall, th in males ,(3) .!l!plUt


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B. tension pneumatocysts :(1) occur in patients with S. alll'eUS pneumonia (e.g . cystic fibrosis)(2) intrapleural blebs occur thai may rupture2. pa lhophysiology-A. tear in the pleura allows air in to the pleural cavity bUI prevents its exitB. in creased intrapleura l pressure sbifu tbe medias linal Sl rUCI ures to tbe oppos iteside: compromises blood flow int'O the heart and OUI of the heartC. diaphragm is depressed on the affected sideD. breath sounds absent on affected sideE. tympanitic percussion notc

3. Rt- insert needle into the pleura l cavity to relieve press ureTypical VI atypi cal pneumooia:I. typk . l-A. sudden onset of symptomsB. high feverC. productive cough: usually pos itive gram stain for bnctcrinD. s igns of conso lidation on physica l exam and x-ray

E. StreplococCW; pneumolliae MeCF. chest x-ray is first step in management2. atypical-A. insidious onsetB. low grade feverC. non to mildly productive coughD. no signs ofconsolidation (interstitial pneumonia)E. Mycoplasma pneumonioe MCC followed by Chlamydia pnelimoniQe (TWAR agent)

Community-acquired \ '5 nosocomial pneumonia:t . community c q u i ~ d - MC due toSrreplococcus p"eumo"iae2. nosocomial-A. develops while in the hospital

B. organisms in descending order:( I ) E. coli(2) P. aeruginosa (Me i f a respi rator is involved)(3) S. allreus

Differential for rusty colored sputu m:1. Streptococcus pneumonioe pneumonia2. chronic congesti ve beart failure- heart failure ce lls3. mit ra l stenosis4. Goodpas ture's syndromeSummarY tables of infectious d isease

robial Epidem io logyboeeninol,irus MCC (25-30%) of common cold. Ma inreservo ir are school children. Direct hand tohand transfer of infected materiaVrespiratory

droplet infection. -100 serotypes (vaccine

ClinicalIncreased mucus secretions. sneezingand coughing. URI Me infection inclinical practice.

I

unlikely). J


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lia/ virus

lor

Mec of interstitia.) pneumonia (20%) andbronchiolitis with wheezing (50%) in infants.Late falVwinter. Hand [0 hand transfer ofinfected materiaVrespiratory droplet infection.Significant cause of monality especiallyamong those over 55 years of age who haveunderlying renal, cardiac or lung problems.Type A virus produces pandemics andepidemics (most severe form). Type Bproduces epidemics. Type C is involved insporadic cases. Hemagglutinins bind the virusto cell receptors in the nasal passages.Neuraminidase dissolves mu cus andfacilitates the release of vira l particles fromthe infected cell. Local epidemics resuh fromminor changes in the antigenic iry or theorganisms, called antigenic drifts (pointmutations). Pandemics are due [0 Jlntigenjclb.i&. whi ch involve mutations inhemaJlJllutinin (need new a c c i ~ ~ )Symptoms of rubeola begin to appear after the7- 14 d incubation pe riod is finished .

Ornithosis, or psittacosis, is a zoonosis (adisease contracted frpm animalS). lnhalationof C. pS;lIocl from p a c i n e birds (parrots,

Ox with direct immunonuorncenttechniques or ELISA test onnasopharyngeal swabs . Rx: ribavirinfor very severe infections.Mild cold to bronchitis to severepneumonias (with exudate). Pneumonia allen has a superimposedbacterial pneumonia (Staphylococcusaureus) . Vacci ne is effective inpreventing Du in 10 to 90% of healthyyoung people. 1n older people. it isonly 50% effective in preventing flubut 85 % effective in preventingdeath. Reye syndrome may occur inchildren. R.x: amantad ine (inhibi tsviral uncoating or transcription ofvi ral RNA) .

Fever. cough, conjun ctivitis, andcoryza (excessive nasal mucusproduction) initially occur. K2R.I..ik}IKU1 in the mouth precede the onsetof the maculopapular rash. Pneumonia is the Me coo. WanhinFinkeldy multinucleated Riant cells.Prim arily resu lts in interstitialpneumonitis. Rx: erythromycin .

IDarakeets. Di.eons, and turkeys).- m - ~ ~ I ~ a - - - - ~ D ~ m p ~ l ~ e l ~ ~ ~ n f i ~ ~ ~ t i ~ o n ~ ~ ~ " " ~ i l i ~ o ~ u t ~ - a n - - - - . - v 7 i M - - ~ R x ~ - , - e t r ~ . - C - Y C ~ I i - - - - - - - - - - - - - - ~intermediate. 5% of community acquiredatypical pneumonias. SeroeDjdemiologic~ ~ ~ __ I ~ . " I ~ w m l S h w w w w i ~ I C ~ o f ( o ~ n ~ v ~ a ~' N . v ~ s . ~ . , s e ~ , __ ~ ____ ~ ______ ~ __mydia Newborn pneumonia. -10 to 20% of Presents with 51accaro cough. can

clromatls newborns that pass through an infected birth juncti .. it'is , tachypnea, bilateral lnspircanal develop pneumonia. 8tory crackles, scattered expiratorywheezes. and hyperinnation (trap air).Afebrile . Eosinophilia. Rx: erylhro-mycin.k D ~ l y U r i ~ c ~ k . ~ n s Y J ! ! l U i t r a i n r u s m i i i i ] j ~ n ~ e d ~ W I ~ i l i ~ o ! i i u i : 1 ! . ~ v ! i e < : ; i ! I O ! [ r S ~ u ~ d f c d ~ e ~ C O ~ Q s . s e c o J r i i h ~ i g h ~ ~ f i : ; e v ; ' e ; ; r , ~ b ~ e a d ; a ; i . ; ; c ~ h ~ e(Q Inhalation. Contracted by dairy fanners, chest pain, myalgias. Interstitialveterinarians associated with the birthing pneumon ia. Other problems: granu1o-process of infected sheep, cattle and goats and matous hepatitis (50%), infective

hand ling of milk in these animals. USMLE: endocarditis. Rx : doxycycline.________ I ~ ~ s o ~ ~ o ~ v . ~ ~ i n ~ . s ~ e ~ e ~ d ~ ~ n n . ~ .___________L______________________--"

84


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umoniae

MicrobialPathogen

StaphylococcusIlIre,u

Hemophilusinjluetrzoe

Pseudomonasaerugitto.ra

Klebsiellapneumonlae

NocardiaQs reroiduActinomycesIsraeliLegionellapneumophila

MCC of primary atypical pneumonia. INonproductive cough. Uppe r respira-15- 20% of pneumo nias in adolescents . 50% lOry tract symptoms (pharyngitis.of pneunlonias in military recruits. earache) precede pneumonic manifestlncubation period 1- 2 wks ations. Interstitia l pneumonia. Low

Gram StainGram + lancel-shapeddiolococcusGram + coccu s

Gram-rod

Gram - thin rod .

Gram - fat rod withcapsule

Sirict aerobe. Gram +filnmentous bacteria.Panially acid fastAnaerobe. Gram +filamentous bacteria.Gram - rod (need IFstaiD or Dieterle silverstain

Co mments

grade fever. Complications: bullousmyringitis (hemorrhagic vesicles onthe membranes), erythema mulriforme(target-like leSions), and StevensJohnson syndrome (involves skin andmucus mem branes in a disseminatedmanner), col d autoimmune hemolyticanemia due to anti J. Lab : inc rea.sedcold agglutinin titers. Rx: e r y t h r ~mvcin or tetracvcline.

Mec of community acqu ired tyPjcal pneumoniaI (bronchooneumoniB or lobar oneumonia). Rx: erYthromycin .Pneumonia commonly foIlQ''''s influenza infections (Mebacterial pathogen), Major pathoge n in cys tic fibrosis .Com mon cause of nosocomial pneumonia. HemorrhagicpuJmonary edema, abscess formation, and tensionpneumatocyslS (intrapleural blebs), which may rupture andI produce oneumotborax. y,.l lnw I'!nlor,.d c.nutum .

Common cause of pneumonja in cystic fibrosis and COPO .Rx : TMP/SMX . Acute epiglottis in ch ildren . Decreasedincidence due to immunization . Cause of inspiratQry stridor.Thumbprint sil!;tl on lateral x-ray of neck. Rx: cefuroximeWater lovi ng bacteria transmitted by respirators. Commoncause of nosocomial pneumonia and MeC of pneumonia incystic fibrosis. Me pneumonia in ICU/CCU (due torespirators). Blood vessel invader (hemorrhagic infarctions).Green colored sputum (pyocyanin). Rx : antipseudomonalj3-lactamase susceptib.le oenjoiUins . mezlocill in)'Pneumonia co mm only associated with alcoholics and Mepneumonia in nursing homes. Blood-tinged. mucoid sp utum .Tends to involve the upper Jobes and cavjtales likereactivation lB. Lobar consolidation and abscess formationare common . Rx: third generation cephalosporinGranulomatous microabscesses in the lun gs inimmunocompromised patients . Rx : TMP /SMXDraining sinuses in the jaw. chest cavity, and abdomen .Sulfur granUles contain bacteria. R.x: ampicillin or penicillinG.Water lovi ng bacteria (water coolers). Pneumonia with drycough. malaise, fluHke symptoms, bloody sputum , andsttikinR. fever . Other flndintts : anhrule.ias renal and CNS

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lerium

dioidesmil is

IOCOCCUSojormolls

islopifUmoulolum

Strict aerobe. Acidfast

Not dimomhjc. Sudding yeastS and pseudohypha. Lung di seasecontracted from infections of indwelling catheters.Djm orphic. Spberuleswith endospores in tissues. Inhaling arthrospores whil e living orpassing through theSou th west or San Joaquin vaHey in Califor-nia ("valley fever").

Not dimornbjt. Sudding yeast with narrowbased buds. Found inpigeon eXcreta (aroundbuildings, outside office windows, under bridges) .Me fungalopportunistic infection.Dimorphic. Me systemi c fungal infection.Me in Midwest Inhalation of spores. Association wilh ~ lUrm(Starlings), cave em:lorers (spelunkers),abandoned warehousn. yeaSt fonus in macroPhaacs .~ o~ 0 0 8

00

findings. Macrophage rather th an a neutrophil response intissue. Can produce hyponatremia second nry to hypo-reninemie hypoaldosteroojsm from interslitial nephritis. Rx:erythromycin or tetracycline + ri fump in.Droplet infection. Primary IB : upper pan o ~ r lobe, lowerpan of upper lobe. Ghan complex. Us ually resolves.Reactivation IS : upper lobe, cavitary lesion. Kidney Meexuapulmonary site.Vessel invasion produces hemorrhagicamphotericin S or fluconazole infarcts. Rx:

Flu-like symptoms and erythema oodosum (pai nful noduleson lower legs). Pneumonia may be localized (egg shellcavity in lower lobes). "coin lesions". miliary spread in thelungs and lor th ro ugh oUi the body. African-Americans3Mexicans, and Filipinos have severe infections . Lab :culture, direct visualization of the spherules withendospares, skin test (usefu l), and sero logic tests (useful).Rx: fluconazole

Primary lung disease (40%). Produces a granulomatousreaction. if immunity is intact but no in'flammatory ~ a c t i oifimmunocompromise


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BlastomYCl!s Dimorphic . Yeasts lnyolves skin (skin has a verrucoid appearance resembHngdermatitidis have b[oad based bud s. squamous can:: inoma) and lor .lung. Male dominance. Lab :Primarily along the culture, direot visualization of the yeast forms in tissue. R.x:Southeast coast and itraconazo leinto Midwest. AJonginland waterwa.ys withbeaver darns. Inhalation.

Aspergillus No t dimol]hic. Fru iting Aspcrgilloma, refers to a fungys ball (v isible on :Nny) offumigatus .QQQy and narrow angl matted hyphae and fruiting bodies that deve lops in a~ b r a l l ~ i l ] g sel2tate preexisting cavity in the lung (e.g., old TB site). Ca use ofhl!l1hae. massive hem!:H2lY:ti5:. Allergic Q[Q(lcbol2ulmonm disenseinvo lves both type J and type III hypersensitivity reac tions.IgE levels increased. Vessel invader with hemorrhagicinfarctions and a necrotizing bronchopneumonia. Comm onsinu s infection in AlDS. Lab: culture, direct visualiza tion.Rx : amphotericin B or itraconazole

Absidi . ~ o t diwQmb iSl, Wide Clinical settings: diabetes, immunosuppressed patients.Mucor. angled h:mhae withoy! Vessel invader and produ ces hemorrhagic infa rcts in theRhizopus septa . lung. Invades tbe frQntal Jobes in diabetic k e r o n c i d o 5 i ~ . Lab :culture, direct visualization. Rx.: amphotericin BPneumocyslis Reclassified as fungu s. Opponunjslic infection. Me initial AIDS-defining infection.carinil CySts attach to type I Lungs are dry and consolidated. Patients present with low-pneurnocytes. Poorly grade feve r, dyspnea an d tachypnea. Bronchoalveolarvisualized with gram lavage and lung Bx identify organisms. Chesl xray: diffusestains but stajn well alveolar and interstitial infiltrates. Rx: TMP /SMX. Givenwith silver and Qiemsa prophylactically when CD 4 counts


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6. dilHles wbere StreplOC:OC:cUJ paeumoa.iae is MCC-A. community acquired pneumoniaB. meningitis in adults > 18C. otilis mediaD. spontaneous peritonitis in children with asci tesE. ~ p s i s in children with HbSS disea.RF. sinusi tis7. dlieuetl "lIere PSt!lIIiolftDnas ae'''IiJrosa is MCCI-A. ICU pneumonia (respirators)n. COD in bum patien tsC. CO D in cystic fibros isD. cellul itis/osteomyelitis in puncture wounds of foot in patient's with rub ber footwearE. malignant external otili s in diabetesf . ec thyma gangrenosumG. hot tube folliculiti s

8. di.Hatet wbere BC!mophUus IDOueDZIIe ".MCC - nc ute epiglottit is d ~ due to Hibimmunization)9, Me !JDs-denDiDg IDfeedOD !... Pneumocyslis cari" U pneumonia10. eldetty mIlA, wlio lives .1 bome wlda It.ia wife. develops pDe.moDia- Slreprococcils

pnellmoniaII. ellat Jr.y'Widt ricIIt middle lobe p.eamo .. . (o bsc ures right ma rgin of the hea rt )-

A. probably related 10 obstruction by a bronchogenic ca rcinoma8 . could also be aspiration with the patient lying down on the right side11 . dell"le le'aat wfth mttllto cough, 'igas of hype.. . . . atioa. r o D j U D C t i v t ~ ChlamydiatrocMmalis pneumoniaLung a b 5 c e s ! l ~I. ca USe5-A. aspiration o f oropharyngeal male rial Is MCC: mixed acrobe/anaerobe infection8. lobar pneumoniaC. hematoge nous spread2. lIi rlnuid level on x-rayLung locations wilh aspi ration :I. standing/s il'ting- pos lerobasal segmeDl right lower lobe2. lyi ng down on back- s uperior segment rigbt lowe r lobe (MC s ite for abscess)3. lyi ng on right side-

A. right middle lobeB. posterior segmenl of right upper lobe

4. lying on len side- lingulaPulmoDaryem bolus:I . sou rce- femoral vein2. pathopbys lology-

A. perfusion defect: increases dead spaceB. majoriry of peripheral emboli do nOI in farct the lungsC. produce mild hypoxem ia

3. dinical se tting-A. postpartumB. p e r o . l v e


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4. clio lcal-A. sudden onset of dyspnea and tachypnea:Me symptom and sign. respectivelyB. feverC. pleuritic chest pa in

S. lab-A. perfusion scan firs t step in work-upB. respiratory alkalosisC. mild hypoxemiaD. increased A-a gradientE. pulmonary angiogram go ld standard for Ox .

6. 118MLE e a ~ gross photo of a large saddle embolus in a patient on prolonged bed rest;usua lly die of acute right heart strainPulmonary hyperlension:I. causes-

2.

l .

A. chronic hypoxemia:(1) hypoxemia vasoconstricts pulm onary vessels and vasod iJates peripheral vessels(2) high altitude residents(3) chronic lung diseaseB. loss of pulmonary vasculature: e.g.,(I ) COPD(2) restrictive lung diseases

C. left to right shunts with eventual vo lume overload of right heanD. mitral stenosis with backup of blood in to pulmonary veinspatbology-A. atherosclerosis of pulmonary arteriesB. smooth mu scle hypertrophy of pulmonary ve sselsC. angiomatoid lesionsclinieal- ,A. accentuated P28. cor pulmonale:

(1) pu lmonary hypertension (PH) leads 10 righl ventricular hypertrophy(2) definition applies to pr imary PH of pu lmono.f)' Ilrlel)' or PH due to lung disease(3) does not ap ply to PH and RVH ofcardiac origin of primary origina. e.g., mitral stenosis

b. left to right shuntsC. primary PH occurs mainly in yo une women: progressive dyspnea, chesl pa in.syncopal e p i ~ eD. pruning of pulmonary arteries noted on x- ray

Immotlle cilia syndrome (Kartagener's syndrome):1. abse_DI dynein arm in cilia2. dinical-A. situs inversus:(1) vessels and chamber in the hean are Slill nonnal (USMIZ)(2) not a complete transposi tion

B. infenility in males/femalesC. bronchiectasisD. si nu s infections


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Restrictive lung diseues:I. decreased compliance and increaJed elasticit)' du e to Interstidal fibrosis2. tau es-A. pneumoconioses MeC: dust borne diseasesB. sarcoidosis

C. hypersensitivity lung diseasesO. drugs: see Environmental pathology notes

J. coal worker's pneumoconio5is-A. exposure to coal dustO. "black lung" diseaseC. increased Incidence afTS but not cancerD. Caplan syndrome: rheumatoid nod ules in lungs + coal worker's pneumoconiosis

4. !'Iilicosi!'l-A. exposure to s ilica dust: e.g., sandblasterB. nodular, fibrotic masses in the lungs: filled with silicA crystalsC. increased risk for TB but not cancerO. association with Caplan's syndrome

S. asbes lo sls-A. exposure: to asbestos:

( I ) pipefiner in shipyard(2) roofer for over 20 ys8. no risk for TB

C. smoker + asbestos exposure predisposes to primary lung cancer > mesotheliomaD. non-smoker + asbestos exposure predisposes to primlll)' lung cancer > mesotheliomaE. asbestos body (ferruginous body) looks like a dumbbell (fiber covered by iron)6. bypersensitivi ty pneumonilis-A. farmer'S lung:( I) inhalation of thermophilic actinomycetes

(2) see Immunopathology notesB. silo filler 's : inhalation of nitrogen dioxide fumesC. byss inosis:(1) "Monday morning blues"

(2) patient wo rks in a te:


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(4) hypercalcemiaO bstructive lun g dinuc :I . types-

A. chronic bronchitis:( I ) MC Iype(2) clinical Dx.- productive cough >3 mths for 2 consecutive yrs

B. emphysemaC. bronchial asthmaD. bronchiectasis

2. .summa n ' cb b brt CO mpa nD}! C rO Rlc h" . hone IU S w ll hmpt vsemu-Parametl!r Empb\'sema Cb ronic Bro nchitisOnset of dyspnea Progressive. constant. severe Imerminent and often exacerbateswith infectionSputum production Scanl Increased and purulentAppearance " Pink puffer" (not cyanotic), thin, "B lue bloater" (cyanotic due 1Oweight loss respiratory acidosis). obeseAP diameter increased (hyperinfla tion) Less hyperin flation than emphysemaBreath so und s Diminished o w i n ~ to hyperinflation Wheezes and sibilant rhonchiPaD , Mild hvpoxemia at rest- Moderate to severe hYPOxemiaPaCO, Normal 10 low (respiratory Increased owing 1O respiratoryalkalosis. reason for "pink puffer") acidos is- trap C02 behind tenninalbronchioles filled with mucousTotallunfl capacitY Markedly inc reased Nonnal to slighlly incrt3SCdResidual volume Markedly increased Mildlv increasedI Cor pulmonale Infrequent untillal'e in the disease Comm onl y presentVent"illltionlperfu- Matched losses of ventilation (resp- Major mismatch owing to primarysion iratory un it) Ilnd pe rfusion (loss of involvement of the tenninal bronchcapillary bed) iole (prox..imal lo the respiratory uni !.hence more units are affected)

J . types or m p b y s e ~ -A. emphysema involves ~ n i o n s : 7 f t h ei r a t Q O l ! n j l

(I) respiratory bronchiole '(2) alveolar du ct(3) alveo,Ii::-:=:-;:::==,B... ccnlrilobula r emphysema:(I) ~ s m . 2 k e(2) destruction of elastic tissue suppon in the respiratory bronchiole(3) EEper l o ~ involved

C. *" panllc inar emphysema:(1) a.-I antitrypsin (AAT) deficiencyD. primary AR diseaseb. a ~ q u i r e d in smakw;: chemicals in smoke inactivllie AA T(2) involves the enlire res irarorv unit (respiratory bronchiole. alveolar du;:t , andalveoli)

(3) lower lobe diseaseD. IlMLE . . . . . Io:( I) identify x- ray of a patient with emphysema(2) look for increased AP diameter and ~ I ? ! ! ~ ~ ~


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4. bronchiectasis-A. cystic nbrosis is the MCC in th e- United States: TB is the MCC in third world

countriesB. pathogenesis:(1) o b s t r u ~ i o a n d ~(2) ~ d broDcbi extend to the lUll!!, periphe'l'C. clinical : cough up cupfuls of foul smelling sputum

5. bronchial asthma-A. MC chronic respiratory disease in childrenB. episodic, hyperreactive, reversible, small airway di sease that primarily targets the

temlinal bronchiolesC. causes:

D.

E.

(I) exposure to allergens. MeCb. IgE-mediated type I hypersensitivity

(2) non-immunologica. aspirinfNSAID sensi tivityb. co ld temperaturec. exercised.clinical :

environmental pollutantssmoke

(I) episodic wheezing(2) nocturnal cough(3) increased AP d i ~ t e r due to air trappinglab findings: l:" ..... d l't )(1) respiratory a ! ! . - a ! Q ~ j s may progress inlo respiratory acidosis if bronchospasm(2)(3)(4)(5)Rx :(1)(2)

"fsnol relievedhypoxemiadecreased FEV l t t valueseosinophiliapositive skin tests for allergensalbuterol medihaler for mild diseasecorticosteroid medihaler for moderate to severe disease

Lung cancer:1. cause!-

2.

3.

A. see neoplasiaB. decreasing incidence in men/increasing incidence in womenC. 2nd MC cancer in men and womenD. MCC of death due to cancer in men and womenMC primary cancers in descending order-A. adenocarcinomaB. squamous carcinoma: ectopically secrete PTH-like peptide (hypercalcemia)C. small cell carcinoma: ectopically secrete ACTH (eel'opic Cushings) and ADH (SiADl:I)MC cancers of lung- metastasis:A. breast MCCB. renal adenocarcinoma


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C. choriocarcinomaD. colorectal cancers

... lung sites-A. centrally located:

( I) squamous cell(2) ,mall cell8 . peripherally located: adenocarcinomaS. smoking rehllionsbips-

A. squamous and small cell cancers: strongest relationshipn. adenocarc inoma:( I ) Me primary lung cancer in smoke rs and non-smokers(2) bronchioloalveolo.T carcinoma has no smoking relationship

6. eliniclll-A. cougb Me symptomo. weight lossC. hemoptysis : sometimes massiveD. Pancoast tumor (superior sulcus tumor):

(1 ) squamous cancer at lung npc:( invo lving brachial plexus and superior cervicalganglion (Homer's syndrome)(2) ~ ~ e includes ips ilatcrallid Illg. miosjs. anhvdr sis

E. superior vcna caval syndrome r. clubbing1. sites ror melUtas is outside bilar lymph Dodu - ad",n.I, MCC ,ite ~ " ' ~ l ; ; : . . , y ~ f3


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2. other scena rios could be an a lcoholic who is recthing o r n bulimic who is vomitingSo li ta ry coin les ions:1. ca uses-A. MCC is gran ulo matous disease; e.g .. TB. hist'oplasmosi sB. most are benign in patients 50 yea rs o ldO. calcifications and lack of growth are benign reatures1. bronchial bama rtoma -

A. solimry coin lesionB. loca lized overgrowth or cani lage : nol a neoplasmC. " popcorn type" or co nfiguration on x-ray

Mcdia"Unum :1. anterior ruediustinum M e involved with disease-A. thymoma Me tumor fo llowed by nodular scleros ing Hodgkin's disease

B. neurob lastoma in children, gang lioneuroma in adu lts Are Me ove raH mediastinnltumors: loca ted in posterior mediastinum

2. thymus ond myastbenia grav is-A. J!!y.!l1ic y p ~ [ J ) l a s i Q is Me finding in thymus; enninal fo llicles composed of B ce llsthat s nthcs ize: antibodies against acerylcholine receptors

B. th ymoma is less common finding: pure RBe ap lasia sometimes noted with thymomasC. thymectomy is sometimes used in R.lo: of myasthen ia gravis3. middle mediastioum- pericardial cyst Me disorderPleural nuid :I. la b fiodings (hat diSiinguish a transud ate from ex udate in pleural nuid -A. PF pro tei n/serum prolein ratio >0.5 is exudate

B. PF LDHlserum LOB 0.6 is exudateC. PF LOH twcrthirds the upper limit of nonnal of the serum LDH is exudate2. PF uudates -A. pneumonia MeCB. pulmonary infarction: hemorrhagic exudateC. cance r: hemorrhagic exudate3. PF transudates- congestive hea rt fai lure MeC4. PF fiodings in TB- e:


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rcoidos is . restrictive lung disease)A 45-year old woman 24 hours post-cholecystecl0my develops fever and dyspnea. Physical examrevellis decreased percussion, increased tactile fremilus. and decreased breath sounds in the rightlower lobe. The diaphragm is ele,'ated and there is inspiratory lag on the right side. The patientMOST LIKELY h . ...A. atelectasisB. B lung abscessc. bronchopneumoniaD. a pulmonary infarctionE. :I spontaneous pneumothora.lo:An afebri le 23-year-old man develops a sudden onset of left-sided, stabbing chest pa in withdyspnea . Physical exam of the left chest revea ls hyperresonance to percuss ion, deviation of thelrac hea to the left. elevatio n of the diaphragm. decreased tac tile frernirus. and decreased breathsounds . The MOST LlKEL Y diagnosis is ..A. pleural effusionB. bronchopneumo ni3C. tens ion pneum othora.tD. n pulmonary infarctionE. spontaneous pneumothoraxA newborn child develops dyspnea., tachypnea, intercosta l muscle retractions. and cyanosis 4 hoursafter binh. The mother developed gestational diabetes mell itus and was in poor glycemic controlthrou8hout the pregnancy. A chest x-ray reveals a "ground glass" appearance in both lun gs . Theprimary mechanism for this patient's respiratory problem is ..A. aspiration of amniotic fluidB. group BSlrl!ptococcus pneumoniaC. decreased production of surfactantD. Chlamydia trachomaris pneumoniaE. heart failure from congenital heart diseaseRDS)Which of the fo llowing describes 8 pneu monia due to MycoplllSf1/n pneumoniae rather thanStreptococcus pneumoniae?A. High feverB. Insidious onsetC. Productive co ughD. ln creased tactile fremitusE. Neutrophilic leukocytosis(all other choices are those ofrypica l pneumonia)A 58-year-old smoker presents with weight loss and cough. Physical eum reveals a mild lid lag onthe left and a pinpoint pupil, scanered sibilant rhonchi throughout all lung fields that clear withcoughing, and an increased anteroposterior diameter. Based on these findinl!$. you suspect thepatient has ...A. a Pancoast rumorB. a thoracic outlet syndromeC. the superior vena caval syndromeD. obstructive lun g di sease witho ut pri mary cancerE. obstructive lung disease with metastatic cancer from another primary site

95


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Homer's syndrome also present)A 6S year o ld man wilh urinary retention secondary to prostatic hyperplasia. de velops spikingfev er. and tachypnea. Physical exam reveals intercostal musc le retractions and bilateral inspiratorycrackles. A chest x ~ r a y exhibits bilateraJ interstitial and alveolar infi ltrates. ABGs demonstratesevere hypoxemia. You expect the blood cuhure reveals...A. gram positive diplococciB. grum negative diplococ.ciC. gram positive cocciD. gram negative rodsE. grnm positive rodsGram negative sepsis due to E. coli [gram negat'ive rod1 in to an AROS)Inspirotory stridor is commonly as sociated with .. .A. a respirOlory syncytial virus infectionB. 3 parainfluenza vi ru s infectionC. aspirin induced asthmaD. rhinov irus infectionsE. choanal atresiaroup or laryngotracheobronchitis due to para in fluenza vi ru s, obstruction is in the trachea, "steeple"sign on latera l xray of ne ck)Chlamydia trachoma!is and the respiratory syncytial virus are BOTH commonly a s s o c i a t ~ d with .. .A. an interslitinllype of pneumoniaB. laryngotr8chcobronchilis (croup)C. the respiratory distress syndromeD. typical community-acquired pneumoniaE. h o p a c q u i r e d (nosocomial) pneumonia

RSV MeC of pneumonia Ilnd bronchiolitis in chilrlrf!n)Which of Ihe following is more often associated with Klebsie lla pneltmoniae than P5eudomoIJa5aerugi"osa?A. Upper lobe cavitarionB. G ~ c o o r e d sputumC. Assoc iation with cystic fibrosisD. Association with re spiratorsE. Productive coughchoices B, C. 0 are fea tures of P. aeruginosa, both ha ve productive cough fchoice EDIn a 30 year o ld man who lives in Tennessee. you would expect a calcified so litary coin lesion inthe lung to represent.. .A. n foreign body8 . an old granulomaC. metastatic cllncerD. a primllty lung cancerE. 3 bronchial hamartomahistoplasmosis)


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1\ 55-ycar-o ld non-smoking coa l \\o rker ha s anhri lis and nod ulnr lesions II I the lungs Hi s PPO sl..inle:,1 b. negll livc. You suspecllhe patien t has . ..A. system ic lupus ery thematosusB. Caplan's syndromeC mctast.1tic lung diseaseD pnmary lung cancerl: miliar) tuberculosisIn a 6:! year old man who ha) been a roorer for :!5 years and a :,m" l..c:r f(l r 10 ) ears. \\ h,,:h oi Ihefo llO\\ 111 ca ncc:rs wou ld he be most likel) prone 10 dc\'clopmg7A 1)lcuralml!sOIhcliomaB. PrimaJ) lun g cancerC Laryngea l carcinomaD Oral c:mcerE. Pancrcntic cancer

fa:.bc:s lO$ exposure. same a nsw\.': r even if hc was not a smoker}

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GOLJAN - Special Pathology (Resp)