Everything You Need to Know (at least) for

Name Year Matric no. Academic Session -

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EDITORIAL
Permulaan perkara yang dihisab seseorang hamba pada hari kiamat ialah solat (Hadis Riwayat at-Tirmizi)

Dengan nama ALLAH yang MAHA PEMURAH lagi MAHA PENYAYANG

Most of the block involving one system in our body, like respiratory block, cardiovascular block and gastrointestinal block have one thing in common, which is, youll never understand the pathological condition of the disease involving unless you know the normal process first. Therefore, knowledge of normal thing is very important. So, take your time to open and revise 1st year medical syllabus in each of the system before entering the abnormal one. Good luck.

Onn Azli Puade Medic 4 20011/2012

A medical chest specialist is long winded about the short winded (Kenneth T Bird)

Time is a great teacher, unfortunately, it kills all its pupils

(Medden 2005/2006)

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FEVER (PYREXIA) Definition Is a sensation of feeling cold despite the rising in body temperature above normal body temperature. Causes Bacterial Bacterial endocarditis Tuberculosis Typhoid Leptospirosis Protozoal Malaria Amoebiasis Toxoplasmosis Granulomatous disease Sarcoidosis Crohns disease

Viral Influenza Glandular fever HIV CMV Neoplasia Hypernephroma Lymphoma Hepatoma Leukaemia Drug induced Post immunization

Fungal Candidiasis Aspergillosis Pneumocitis carinii Connective tissue disease SLE Polyarteritis nodosa Rheumatoid arthritis Temporal arthritis Others Myocardial infarction Pulmonary embolism Munchausens disease

Further history regarding Fever 1. Associated with chills and rigors? If yes may indicates high grade fever in the case of Community Acquired Pneumonia If no may indicates low grade fever in the case of Influenza, TB or even malignancy 2. Associated with cough? Indicates Upper Respiratory infection, COPD, Community Acquired Pneumonia, tuberculosis, pulmonary embolism 3. History of diabetes mellitus or any contact with TB patient before? DM increase risk of getting myocardial infarction and pulmonary embolism. Contact with TB patient may increase risk of getting secondary tuberculosis 4. Any recent surgery? Any type of surgery especially abdominal surgery may prone to get nosocomial infection 5. Any history of family getting cancer? Malignancy can cause fever in which a condition we call as Paraneoplastic Syndrome
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Pathogenesis and Pathophysiology

Infectious agent enters body Release of endogenous pyrogenes or leukocytes pyrogenes IL-1 The interleukin enters blood circulation and reach hypothalamus Bind to the endothelial cell wall and microglial cell Stimulate the conversion of amino acid to prostaglandin E2 via arachidonic acid pathway Reset the thermoregulatory setpoint of the body by increasing it to certain level Malignancy Releasing toxins called exogenous pyrogenes Either bacteria or breakdown products of the bacteria engulfed by macrophage

Body gets the sensation of feeling cold

Compensatory mechanism to reach the new setpoint Stimulation of sympathetic nervous system

Low grade fever

Vasoconstriction at skin Repeated muscle contraction, excessive sweating High grade fever Muscle spasm Chills

Rigors

Further investigaton regarding fever FBC and ESR Low Hb malignancy, anaemia of chronic disease High WCC infection, leukaemia High ESR malignancy, connective tissue disease, tuberculosis CXR to look out for lung consolidation, lymphadenopathy, fibrosis etc Viral antibodies hepatitis B, hepatitis C, HIV, CMV Sputum culture for gram staining and acid fast bacilli
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COUGH (TUSSIS) AND SPUTUM Definition Is a reflex explosive expiration that prevents aspiration as well as to remove foreign particles and secretion from the lung. Productive cough is cough with sputum and vise versa for nonproductive cough Causes Acute non-productive cough Inhalation of foreign material Respiratory tract irritant Respiratory tract infection

Chronic cough Non-productive Asthma ACE inhibitor Gastro-oesophageal reflux Postnasal drip Sarcoidosis Productive COPD Bronchiectasis Pulmonary oedema Lung ca Tuberculosis Pulmonary embolisme Smoking Pneumonia

Further history regarding cough 1. How does it occurs and for how long? To differentiate between chronic cough and acute cough. Normally, chronic cough is a cough that has persisted for more than 3 weeks and it does indicates some disease as stated above. Sudden onset of an unrelenting bout of violent coughing may be due to inhaled foreign object or pulmonary embolisme 2. Anything produce with the cough? Yellowish/greenish indicates infection involving WCC like pneumonia and TB Mucoid/purulent COPD, bronchiectasis Pink and frothy pulmonary oedema due to alveolar granule Haemoptysis TB, lung ca, pulmonary embolisme Clear probably saliva Black carbon specks due to smoking 3. Associated symptoms? Fever indicates infection Night sweats indicates tuberculosis Dyspnoea sudden onset due to pulmonary embolisme, at night may due to asthma Orthopnoea may suggest pulmonary oedema Wheezing due to asthma Chest pain pleuritic chest pain, cardiac chest pain (see Chest Pain symptoms)
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Pathogenesis and pathophysiology

Irritant, bacteria or foreign object and secretion Stimulate the receptor of the airway Bronchi and trachea for light touch1 Larynx and carina are the most sensitive Terminal bronchiole and alveoli for corrosive chemical stimuli

Ascend via vagus nerve (CN X) Reach the cough center located at the medulla of the brain Processed and sent back to the Glossopharyngeal nerve Closure of glottis Phrenic nerve Contraction of diaphragm

Intercostals nerve Contraction of intercostals muscle

Increase intrathoracic pressure Opening of glottis Explosive air going out Expectoration of desquamated cells, dead neutrophils and bacterial debris Cough

Productive cough

Further investigaton regarding cough and sputum Respiratory function test Obstructive Lung disease- FEV1/FVC ratio is less than 80% Restrictive Lung disease- FEV1/FVC ratio is normal or higher Sputum culture for gram staining and acid fast bacilli CXR to look out for lung consolidation, lymphadenopathy, fibrosis, collapse, hyperinflated lung etc

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CHEST PAIN Definition The uncomfortable (angina) or pain sensation of the chest area Causes Cardiovascular Myocardial infarction Acute aortic dissection Pericarditis Musculoskeletal Persistent cough Chest wall injuries Costochondritis Rib tumour, fracture Herpes Zoster Gastrointestinal Gastro-esophageal reflux Peptic ulcer disease Gastritis Oesophageal spasm Pulmonary Pneumonia Pulmonary embolisme Pneumothorax Central bronchial carcinoma Inhaled foreign body

Further history about the chest pain 1. Character of the chest pain Sharp chest wall injuries, pleuritic chest pain Tearing acute aortic dissection Burning gastro-oesophageal reflux 2. Location of the pain Localize and anywhere pleuritic chest pain Retrosternally and radiates to jaw and left arm cardiac chest pain and oesophageal reflux Centrally located and radiates to shoulder pericarditis Radiates to back aortic dissection 3. Precipitating factor Inspiration (due to movement of thorax) pleuritic chest pain Effort, cold, food and emotion cardiac chest pain Posture gastro-oesophageal reflux 4. Relieving factor GTN oesophageal spasm and cardiac chest pain Antacid gastro-esophageal reflux Aspirin pleuritic chest pain
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Pathogenesis and Pathophysiology (respiratory pathology)

Blood clot in the pulmonary vessels Distal part of the clot does not received blood supply Ischaemia at the distal part of the clot Endothelial cell release chemical mediators like bradykinin, serotonin due to oxygen depressed Chemical mediator enters blood circulation Reaches pain receptor located at the pleural cavity Send signal up to sensory cortex Via lateral spinothalamic tract Pain is appreciated CHEST PAIN

Further investigation regarding chest pain FBC Elevated white cell count will be expected with a pneumonia, and to a lessen extent in a myocardial infarction Serum cardiac markers Following a myocardial infarction, cardiac troponin rises within 6 hours and remains elevated for up to 2 weeks CXR Consolidation of lung can be seen in bronchopneumonia. Wedge-shaped shadow can be observed in pulmonary infarction. Rib fractures or secondary deposits in ribs can be seen in chest X-ray. ECG Non-specific ECG changes in pulmonary embolisme such as tachycardia, right axis deviation, right ventricular strain and atrial fibrillation. Elevated ST segment in myocardial ischaemia, T wave inversion in myocardial injury and abnormal Q wave in myocardial infarction can be observed.

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HAEMOPTYSIS Definition Is an expectoration of blood and bloodstained sputum. Causes Respiratory Bronchial carcinoma Pneumonia Tuberculosis Chronic bronchitis Pulmonary oedema Goodpastures syndrome Wegeners granulomatosis

Vascular Pulmonary embolism Pulmonary hypertension Hereditary haemorrhagic telangiectasia

Systemic Coagulation disorder

Further history regarding haemoptysis 1. Onset of the symptoms Sudden or acute onset may be due to the pulmonary embolisme or acute respiratory infection. Long standing haemoptysis often associated with chronic bronchitis or bronchiectasis 2. Volume Volume of blood expectorated are needed to be ask to confirm that it is haemoptysis rather haematemesis 3. Associated symptoms Dyspnoea may associated with pulmonary embolisme or chronic lung disease or mitral stenosis Orthopnoea may be due to pulmonary oedema Sputum purulent sputum stained with blood may indicates chronic bronchitis or bronchiectasis Weight loss suggestive tuberculosis and bronchial carcinoma Night sweats tuberculosis 4. Other site of bleeding Other site of bleeding should be excluded as haematuria may be due to Goodpastures syndrome 5. Past medical and drug history Anticoagulant drugs Congenital like haemophilia or acquired like usage DIC

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Pathogenesis and pathophysiology Emboli stuck in the pulmonary circulation Distal part of the endothelial does not receive blood supply Bronchial carcinoma Rapid growth of malignant neoplasm Invasive growth Blood vessel eroded Blood escape from eroded blood vessel and enters the alveoli Irritate receptor of the airway Stimulate the cough reflex (see cough) Expectoration of blood HAEMOPTYSIS Further investigation regarding haemoptysis Sputum Analysis Sputum should be collected for microscopy, culture and cytology. When TB is suspected, serial culture should be taken from sputum, urine, bronchial washing or lung biopsy FBC Decrease Hb with chronic haemoptysis resulting in normocytic normochromic anaemia. Increase WCC may be due to acute bleeding or respiratory tract infection. Monocytosis may be due to tuberculosis. Clotting screen A clotting screen to identify any impairment that may prolong the PT and APTT ECG Non-specific ECG changes in pulmonary embolisme such as tachycardia, right axis deviation, right ventricular strain and atrial fibrillation. CXR Consolidation of lung can be seen in bronchopneumonia. Wedge-shaped shadow can be observed in pulmonary infarction.

Infection Involving macrophage Secretes -TNF

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SHORTNESS OF BREATH (DYSPNOEA) Definition Is an uncomfortable awareness of breathing or can be described as breathlessness Causes Sudden (second to minute) Pneumothorax Pulmonary oedema Pulmonary embolisme Aspiration Anaphylaxis Anxiety Chest trauma Further history about dyspnoea 1. Onset Sudden, acute or chronic onset may indicates different type of disease the patient suffers from 2. Precipitating factors Position like recumbency may indicates pulmonary edema secondary to cardiac failure. Seasonal and in cold weather may be due to asthma and exercising also can worsen dyspnoea in heart failure 3. Relieving factor Sitting upright as in pulmonary edema and cardiac failure Beta agonist as in asthma 4. Associated symptoms Productive cough yellowish/greenish sputum indicates chest infection Haemoptysis may be due to pulmonary embolisme or bronchial ca Wheezing due to asthma or inhaled foreign body

Acute (hours to days) Asthma Respiratory tract infection Lung tumours Pleural effusion Metabolic acidosis

Chronic (months to years) COPD Cardiac failure Fibrosing alveolitis Anaemia Arrhythmia Valvular heart disease Pulmonary hypertension

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Pathogenesis and pathophysiology

Alveoli surface covered with fluid/blood

Fibrosing alveoli/consolidated

Destruction of lung parenchyma

Lung is ventilated but not perfuse V/Q mismatch Respiratory acidosis Increase carbon dioxide (indirectly) and reduce oxygen (directly) level below 30 mmHg Stimulate the chemoreceptor mainly the aortic and carotid body Ascend via vagus and glossopharyngeal nerve Terminates at the nucleus of the tractus sollitarius Stimulate the medullary respiratory area Increase the respiratory effort as a compensatory mechanism of respiratory acidosis DYSPNOEA Further investigation regarding dyspnoea 1. Arterial Blood Gas To recognize the respiratory failure and the metabolic profile of the patient 2. Peak expiratory flow rate Reduce in peak flow may indicates asthma or chronic airflow limitation 3. ECG Eliminates probability of cardiac disease related to the symptoms 4. FBC To rule out any pulmonary infection as well as anemia ONN08/09

SPECIAL SYMPTOMS WHEEZING Definition Is defined as continuous abnormal added sound either high pitch or low pitch (rhonchi) and have a musical quality. It can be heard in both expiration and inspiration which it tends to be louder on expiration because of the narrower airways during expiration Causes High pitch asthma, inhaled foreign body Low pitch Chronic Obstructive Pulmonary Disease Pathogenesis and pathophysiology Obstructed/narrowed airway Airflow during respiration Turbulent airflow when passes through obstructed area WHEEZING

NIGHT SWEATS Definition Is a copious sweating during sleep. An etiology of fever may be an etiology of night sweats Causes Tuberculosis, AIDS, Hodgkins disease, brucellosis, lung abscess, bacterial endocariditis Pathogenesis and pathophysiology

Low grade fever

Increase temperature up to 8 folds during sleep (3-5 am)

Increase sweating as a sympathetic nervous system effects

NIGHT SWEATS

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CYANOSIS Definition Is an abnormal bluish discoloration of the skin and mucus membranes resulting from presence of 5 g/dl or more reduced haemoglobin in the blood. It can be classified to central and peripheral cyanosis. Causes Central cyanosis Decrease O2 saturation Abnormal haemoglobin Severe respiratory disease Methaemoglobinaemia Pulmonary oedema Sulphaemoglobinaemia Pulmonary embolisme Cyanotic congenital heart disease Peripheral cyanosis All causes of central cyanosis Cold exposure Acrocyanosis Arterial occlusion Venous occlusion

Further history and examination 1. Onset Birth to few months of life congenital cyanotic heart disease Sudden onset pulmonary embolisme, cardiac failure (precipitated by pneumonia/asthma) Slow progressive chronic obstructive pulmonary disease 2. Associated symptoms Chest pain (pleuritic) as in pneumonia, pulmonary embolism Chest pain (cardiac) pulmonary edema secondary to myocardial infarction Dyspnoea sudden onset in pulmonary oedema and pulmonary emboli, more gradual in asthma Fever as in pneumonia and pulmonary emboli 3. Associated signs Clubbing cyanotic congenital heart disease Elevated JVP congestive cardiac failure Poor chest expansion chronic bronchitis, asthma Unilateral reduce chest expansion lung consolidation secondary to pneumonia Crepitation (localized) lobar pneumonia Crepitation (widespread) bronchopneumonia, pulmonary oedema, chronic bronchitis

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Pathogenesis and pathophysiology

Altered lung parenchyma Lung cannot function normally Occlusion of the blood vessel V/Q mismatch Increase carbon dioxide (indirectly) and reduce oxygen (directly) level below 30 mmHg Poor oxygen saturation to bind with haemoglobin Increase reduced haemoglobin more than 5 g/dl Area distal to the blockage does not receive blood supply

Hypoxic state Bluish discoloration of the mucus membrane CENTRAL CYANOSIS

Hypoxaemic state Poor blood supply especially to the extremities Bluish discoloration of the skin PERIPHERAL CYANOSIS

Further investigation regarding Cyanosis Oxygen Saturation usually below 85 %in the cyanosis patient Arterial Blood Gasses decrease pO2 in severe lung dsease Full Blood Count increase Hb in long standing cyanosis, increase WCC in Pulmonary embolisme ECG elevated ST-segment in Myocardial Infarction, non specific St segment in pulmonary embolisme CXR abnormality in lung field

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CHEST EXAMINATION FOR RESPIRATORY AND ITS SIGNIFICANT (check Clinical Examination textbook for the method) 1. INSPECTION OF THE CHEST Shape of the chest Shape Character

Pigeon chest Outward bowing of the sternum

Funnel chest Localized depression of the lower end of the sternum

Pathogenesis

Syndrome/disease

Repeated strong contraction of the diaphragm while the thorax is still pliable Childhood respiratory illness, rickets

Developmental defects

Harrisons sulcus Linear depression of the lower ribs just above the costal margin at the site of attachment of the diaphragm Rapid and labored breathing during childhood Asthma in childhood, rickets

Developmental defect

Movement of the chest during respiration Neither reduced, poor, bilateral or unilateral (see palpation of the chest) 2. PALPATION OF THE CHEST Chest expansion Normal expansion thumb move symmetrically at least 5 cm apart Reduced chest expansion in; a) One side localized pulmonary fibrosis, consolidation, collapse, pleural effusion, pneumothorax b) Both sides COPD, diffuse pulmonary fibrosis Lung is not ventilated at the affected side Diminished movement during inspiration

Lung collapse/lobar consolidation

Asymmetrical chest expansion

Apex beat Normal apex beat located at the 5th intercostals space at the left midclavicular line, 2 cm medially Displaced apex beat due to Cardiomegally as in congestive cardiac failure secondary to systemic hypertension Mediastinal shift as in hyperinflated lung in COPD, lung collapse

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Tactile fremitus Normal tactile fremitus vibration on both sides of the chest at the comparable site is detected while the patient repeats ninety-nine Increase in tactile fremitus Lobar consolidation as in pneumonia Compressed lung or tumour Decrease in tactile fremitus Hyperinflated chest emphysema Massive pulmonary oedema Bronchial obstruction Lung consolidation/pleural effusion High pitched sounds travel to the chest area upon saying the words ninety-nine Sound travel faster in fluid and fastest in solid compared to the travelling via the air

Increase tactile fremitus

3. PERCUSSION OF THE CHEST Normal percussion on the areas of lung is resonance. However, dullness can be percussed at the right midclavicular line in the 5th rib due to the organ liver and at the left side of the chest due to the organ heart. Hyperresonance Hyperinflated chest such as emphysema Pneumothorax Bronchial asthma Dullness Atelectasis Pleural effusion Pneumothorax Absence of liver dullness Hyperinflated chest Absence of cardiac dullness Emphysema or asthma

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4. AUSCULTATION OF THE CHEST Abnormal breath sound i) Continuous breath sound Wheeze is defined as continuous abnormal added sound either high pitch or low pitch (rhonchi) and have a musical quality. The causes of rhonchi and wheeze is just the same except for that high pitched wheeze is produced in the smaller bronchi and can be heard without the aid of the stethoscope, vise versa for the rhonchi (see wheezing) Stridor 1 is a rasping or croaking noise loudest on inspiration which indicates obstruction of the larynx, trachea or large airways. These causes include; Sudden onset (minutes) Anaphylaxis Toxic gas inhalation Acute epiglottitis Inhaled foreign body Gradual onset (days, weeks) Laryngeal or pharyngeal tumour Criciarytenoid rheumatoid arthritis Bilateral vocal cord palsy Tracheal carcinoma Paratracheal compression by lymph nodes Post tracheostomy

ii)

Discontinuous breath sound Pleural friction rub can be defined as when thickened, roughened pleural surfaces rub together as the lung expands or contracts. It can be distinguished from pericardial rub base on its existing during respiratory cycle. Causes pleurisy secondary to pneumonia or pulmonary infarction, malignant involvement of the pleura, spontaneous pneumothorax or pleurodynia

An intense continuous monophonic wheeze loudest over the extrathoracic airways and can be heard without the aid of stethoscope ONN08/09

Crackles are discontinuous, explosive popping sound originated from the airways. In order to help with the clinical diagnoses, the timing and pitching of the crackles is important as stated below; CRACKLES

Early-inspiratory crackles (Cease before the middle of inspiration) Medium coarseness Fine/Rales (high pitched, discrete and can be cleared by cough)

Pan-inspiratory crackles

COPD, disease of the small airways Pulmonary fibrosis

Medium crackles (presence of alveolar fluids disrupt the function of the normally secreted surfactant) Left ventricular failure with pulmonary oedema

Coarse/crepitation (loud bubbly noise, unpleasant gurgling quality and not cleared by cough)

Bronchiectasis

Vocal resonance (see tactile fremitus)

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SPECIAL signs NICOTINE STAINING Definition Staining of the finger due to tar content of the cigarettes, not the nicotine as nicotine is colorless Causes cigarettes smoking

MUSCLE WASTING Definition Wasting of the small muscles of the hand especially thenar and hypothenar muscle. Causes tumour compressing the brachial plexus Tumour compressed the brachial plexus Cut off innervations of the hypothenar muscle

Muscular atrophy

MUSCLE WASTING

FLAPPING TREMOR (ASTERIXIS) Definition The excessive shivering or vibrating of the hand Causes hypercapnia in COPD

DISPLACEMENT OF THE TRACHEA Normal trachea is located centrally and slightly to the right Abnormal displacement is due to the Towards the lesion Upper lobe collapse Upper lobe fibrosis Pneumonectomy

Away from the lesion Massive pleural effusion Tension pneumothorax Hyperinflated lung

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PNEUMONIA Definition Inflammation of the lung causes by bacteria or virus which the alveoli becomes fills with inflammatory cells and solid Causes Pathogen Streptococcus pneumoniae Haemophilus influenza, Mycoplasma pneumonia Staphylococcus aureus, Legionella sp., Moraxella catarrhalis, Klebsiella pneumonia Corxiella bunetii, anaerobes, viruses Host Mucociliary tract impairment as in smoking Loss or suppression of cough reflex coma, sedatives, drugs Disturbed pulmonary circulation Interfered immune response immunodeficiency patient, alcohol, anoxia Common

Rare

Classification PNEUMONIA

Clinical classification

Morphology classification

Community Acquired

Hospital acquired/nosocomial

Bronchopneumonia

Lobar pneumonia

Typical

Atypical

Acquired in the places other than hospital Common pathogens is as stated above 1. S pneumonia 2. H influenza Etc.

Acquired more than 48 hours after admission to the hospital Common pathogens are; 1. Staphylococcus aureus 2. Pseudominas sp. 3. Klebsiella sp. 4. Bacteroides 5. Clostridia

Consolidation of a large portion or the entire lobe

Patchy consolidation involving one lobe or multi lobe and frequently affecting bilateral and basal.

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Pathogenesis (applied to the lobar pneumonia) 1. Congestion - Occurs in the first few days (1-2 days) - Lung become heavy, red and boggy due to the vascular engorgement as an acute inflammatory response (see acute inflammation in the foundation block) - Presents of few neutrophils and numerous bacteria 2. Red hepatization - Occurs at the 2-4 days - Lung become firm, airless and liver like consistency due to the exudation of erythrocytes, neutrophils and fibrin in the alveoli space 3. Gray hepatization - Occurs at the 4-6 days - Lung become dry and grayish brown due to the disintegration of the erythrocytes - More neutrophils and consistent exudation of the fibrinosuppurative element 4. Resolution - Occurs at the 7-9 days - Exudated material becomes consolidated and it is enzymatically digested to produce granular, semi-fluid debris - The digested material is either reabsorbed, coughed up, ingested by macrophage or organized Signs and symptoms Symptoms fever with chills and rigors productive cough pleuritic chest pain dyspnoea Signs reduce chest expansion increase tactile fremitus dullness on percussion bronchial breath sound crackles, increase vocal resonance pleural rub

Prognosis -

Lung abscess Empyema, Seeding through other part of the body Fibrosis

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PULMONARY TUBERCULOSIS Definition Is an inflammation of the lung caused by the bacillus Mycobacterium sp. and characterized by the formation of the nodular lesions (tubercles) in the tissue Causes Pathogens 1. Mycobacterium tuberculosis 2. Mycobacterium bovis 3. Mycobacterium avium 4. Mycobacterium intracellulare Classification Primary tuberculosis Secondary tuberculosis

Presence of Ghon focus with hilar lymphadenopathy usually in children

reactivating or regenerating of primary lesion usually occurs in children

Signs and symptoms Symptoms Low-grade fever Cachexia Anemia of chronic disease Dyspnoea Night sweats Haemoptysis Productive cough Signs Lymphadenopathy Tachypnoea

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Pathogenesis Mycobacterium enters body via; 1. Inhalation 2. Ingestion of sputum/contaminated milk 3. Direct penetration through abraded skin

Enters of the alveolar macrophage via receptor mediated endocytosis (mannose receptor) Mycobacterium replicates within phagosome by inhibiting the fusion of the lysosome and phagosome Infected macrophage presents the bacteria with MHC class II Production of IL-12 Maturation of TH1 cell Produce IFN- Activates macrophage by stimulation of the production of the phagolysosome of the infected macrophage Production of -TNF by activated macrophage Formation of granuloma and caseous necrosis Prognosis Apical fibrocalcific arrested Miliary tuberculosis via lymphatic channel Systemic military tuberculosis via hematogenous spread Pleural effusion, empyema Lymphadenitis Systemic amyloidosis Scar cancer

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BRONCHIECTASIS Definition Permanent dilation of bronchi and bronchioles caused by destruction of the muscle and elastic tissue resulting from or associated with chronic necrotizing infection Causes 1. Congenital primary ciliary dyskinesia, cystic fibrosis, congenital hypogammaglobunaemia 2. Acquired infection during childhood, pneumonia, allergic bronchopulmonary aspergillosis 3. Others - obstruction and severe infection, smoking Pathogenesis Anatomical defects of the ciliary tract/impaired respiratory tract clearance/obstruction and infection Pooling of secretion distal to the obstruction Inflammation of the airways Inflammatory reaction which induce the secretion of protease and TNF Destruction of smooth muscle and elastic tissue BRONCHIECTASIS Signs and symptoms Symptoms Fever Cachexia Haemoptysis Cough with voluminous, purulent, foul smelling sputum Signs Clubbing Cyanosis Widespread Crackles Sign of respiratory failure Sign of cor pulmonale

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COR PULMONALE Definition Is an enlargement of the right ventricle resulting from the diseases affecting the lungs and pulmonary vessels. Causes Primary causes Idiopathic Secondary causes Pulmonary vascular disorder pulmonary embolisme Pulmonary obstructive disorder COPD, obstructive sleep apnoea Pulmonary restrictive disorder interstitial lung disease Pathogenesis Pulmonary structures or pulmonary vascular disorder Normal flow in the pulmonary circulation obstructed Increase pulmonary vascular resistant Pulmonary hypertension (>50 mmHg) Flow of the blood obstructed especially at the right ventricle Right ventricular pressure increase Increase workload of the heart Hypertrophy of the heart as a compensatory mechanism Right ventricular hypertrophy COR PULMONALE

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BRONCHIAL ASTHMA Definition Is a condition of subjects with widespread narrowing of the bronchial airways, which changes in severity over short periods of time either spontaneously or under treatment. It is characterized by several episodes of dyspnoea, cough and wheeze caused by reversible airways obstruction Causes Bronchial muscle swelling triggered by variety of stimuli Mucosal swelling/inflammation mast cell and basophil degranulation Increase mucus secretion inflammatory mediators Precipitating factors Cold air Exercise Emotion Allergens (house dust mite, pollen and animal fur) Infection Drugs (aspirin, NSAIDs, -blockers) Further history regarding asthma 1. History of acid reflux, eczema, allergy? This has a known association with asthma 2. Exercise and disturbed sleep Quantify the exercise tolerance and quantify as nights per week as they can be a sign of serious asthma 3. Occupational history If symptoms remit at weekend or holidays, something at work may be a trigger. Certain substance such as dust, pollens can cause asthma Drugs of asthma Sympathomimetics (2 receptor agonists) Methylxanthines Antimuscarinics Corticosteroids Mast cell stabilizers Leukotriene pathway inhibitors Others anti-IgE monoclonal antibodies

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Pathogenesis Inhalation of the allergens and causative factors Immunoglobulin E (IgE) simulates Abnormal antibodies (IgE) stimulates mast cells in the lung interstitium Release histamine and SRS-A (slow reacting substance of anaphylaxis), prostaglandin SRS-A attaches to receptor sites in smaller bronchi Histamine attaches to receptor site in the larger bronchi Stimulation of mucus membrane to secretes excessive mucus Stimulation of smooth muscle swelling Further narrowing the bronchial lumen Inspiration narrowed air can still expand slightly Expiration increase intrathoracic ratio closes bronchial lumen completely Wheezing and narrowing of the airways ASTHMA Signs and symptoms Symptoms Intermittent dyspnoea Wheeze Non-productive cough Signs Tachypnoea Prolonged expiration Tachycardia Usage of accessory muscle of respiration Audible wheeze (rhonchi) Hyperinflated chest Hyperresonance percussion Polyphonic wheeze Tachycardia

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CHRONIC OBSTRUCTIVE PULMONARY DISEASE Definition Emphysema is a permanent dilation of the alveoli distal to the terminal bronchioles accompanied by destruction of their wall without fibrosis Chronic bronchitis persistent productive cough for at least 3 consecutive months in at least 2 consecutive years Causes Emphysema smoking and rarely 1-antitrypsin deficiency (functional or congenital) Chronic bronchitis smoking Pathogenesis

Tobacco smoking

Reactive oxygen species (free radical) Nicotine Activates inflammatory cell Act as chemoattractant for neutrophil Release IL-8, leukoterine B4 and TNF Inactivation of antiprotease (functional 1antitrypsin deficiency) Increase the level of oxidant Depletes the antioxidant level at the lung
Oxidant-antioxidant imbalance protease-antiprotease imbalance

More neutrophil Increase neutrophil elastase

Tissue damage

Congenital 1antitrypsin deficiency

EMPHYSEMA

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Signs and symptoms Symptoms Are not specific to distinguish between chronic bronchitis and emphysema. However, symptoms of COPD include; Productive cough Dyspnoea Weight loss Fever Signs Emphysema Chronic bronchitis Pink puffer appearance pursed lip Blue bloaters cyanosis breathing & well oxygenated Hyperinflated chest Barrel shaped chest (increase AP diameter) Reduced expansion Tachypnoea Hyperresonance on percussion Reduced expansion Reduced breath sound Hyperinflated chest Low pitched wheezes Hyperresonance and absence liver dullness Early inspiratory crackles Decrease breath sound Sign of right heart failure Early inspiratory crackles Sign of right heart failure

Drugs for COPD 2-agonist (salbutamol, procaterol, fenoterol) Antibiotics (co-trimoxazole, cefprozil, cefuroxime) Anticholinergics Corticosteroids (prednisolone, prednisone) Methylxantines (doxofylline, aminophylline)

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PULMONARY HYPERTENSION Definition A condition in which there is raised blood pressure (>50 mmHg) within the blood vessels supplying the lungs Causes Pulmonary embolisme Arterial septal defect Heart failure Disease of the mitral valve Chronic lung disease Pathogenesis Pulmonary structures or pulmonary vascular disorder Normal flow in the pulmonary circulation obstructed Increase pulmonary vascular resistant Pulmonary hypertension (>50 mmHg) Signs and symptoms Symptoms Dyspnoea Cold extremities Hoarseness (pulmonary artery compression of left recurrent laryngeal nerve) Paroxysmal Nocturnal Dyspnoea Orthopnoea Signs of pulmonary oedema Signs Tacypnoea Peripheral cyanosis Small volume due to low cardiac output Increase JVP Right ventricular heave Sign of right ventricular failure

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PLEURAL EFFUSION Definition Is a collection of fluid in the pleural space Types Collection consisting of 1. Blood haemothorax 2. Chyle chylothorax 3. Pus empyema Causes

Transudate cardiac failure, hypoalbunaemia, hypothyroidism, Meigs syndrome Exudate pneumonia, neoplasm, tuberculosis, pulmonary infarction, trauma Haemothorax severe trauma, rupture of pleural adhesion containing a blood vessel Chylothorax trauma, surgery, carcinoma or lymphoma Empyema pneumonia, lung abscess, bronchiectasis, tuberculosis

Pathogenesis

Infection Exudation of inflammatory cells Exudation to the pleural surface Accumulation of fluid inside the pleural cavity Pleural effusion

Signs and symptoms Symptoms No signs

Signs Trachea and apex beat Reduce expansion on the affected site Stony dullness on percussion Reduce/absent breath sound Reduce vocal resonance

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NORMAL VALUES OF THE INVESTIGATION Haematology RBC White cell count Adult Infant (full term at birth) Infant (1 year) Basophil Eosinophil Neutrophil Monocyte Lymphocyte ESR

Male (4.6 - 6.5 x 1012 /L) Female (3.9 5.6 x 1012 /L) 4 11 x 109 /L 10 25 x 109 /L 4 18 x 109 / L 0 0.1 x 109 /L 0.01 0.44 x 109 /L 2 7.5 x 109 /L 0.2 0.8 x 109 /L 1.3 3.5 x 109 /L male (3 -5 mm/hr) Female (4 7 mm/hr)

(0 1%) (1 6%) (40 75%) (2 10%) (20 45%)

Arterial Blood Gases PaO2 PaCO2 pH HCO3 Chest X-ray Lung field Cardiothoracic ratio Peak flow meter

75 100 mmHg 35 45 mmHg 7.35 7.45 22 36 mmol/L

anterior ribs (6 7) Posterior ribs (9 10) 50 55% male (600 L/min) Female (400 L/min) FEV1/FVC ratio is 80%

Spirometry

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THANK YOU FOR ALL THE LECTURES OF PPSP USMKK FOR ESPECIALLY AS STATED BELOW FOR CHECKING, CORRECTING ALL THE FACTS WHICH WERE PUBLISHED AND FOR TEACHING MEDICAL STUDENT BATCH 2008/2009 2ND YEAR WITH HARDWORKING AND GREAT DEDICATION 1. ASSOCIATES PROF OTHMAN MANSOR 2. DR THIN THIN WIN @ SAFIYA 3. DR SAMARENDA S MUTUM 4. DR ISKANDAR ZULKARNAIN ALIAS 5. DR MOHD ASNIZAM ASARI REFERENCE 1. PPSP lectures Lecture notes 2nd year 2008/2009 2. Oxford Concise Medical Dictionary, 6th edition definition 3. Clinical Examination, 5th edition, Nicholas J Talley and Simmon OConnor clinical signs 4. Differential diagnosis, 2nd edition, Andrew T Raftery and Eric Lim clinical signs and symptoms 5. Pathology Basis f Disease, 7th Edition, Robbins and Cotran pathogenesis of diseases 6. MIMS respiratory guide, Malaysia Edition 2004/2005

ONN08/09 Al-fatihah kepada arwah bapa saya, Puade bin Mahbar yang telah