patho

Question 1

Respiratory failure due to multiple pulmonary insults
▪Injury to Type1 pneumocytes and capillary endothelial cells of the lung

▪ Can result from burns, near-drowning, dialysis, Lyme disease, and viral infections

▪ Causes respiratory distress, hypoxemia, pulmonary fibrosis, poor pulmonary
compliance, pulmonary edema

▪ Develops between 24-48 hours after an injury
▪ Very low PaO2, normal or low PaCO2, and elevated pH
▪ Diffuse bilateral alveolar infiltrates

Answer 1

ARDS (Acute Respiratory Distress Syndome)

Question 2

● Resp failure w/ widespread rapid inflammation of the lungs
● Etiology: direct/indirect lung injury from airway (pneumonia) or circulation (sepsis)
● Sx: severe resp distress within 24-48 hrs, cyanosis, intercostal retractions, hypoxemia, pulmonary edema
o Initial hyperventilation -> respiratory alkalosis (low PO2, high pH, low or normal PCO2 since its being expelled at faster rate)
● Dx: CXR shows bilateral alveolar infiltrates or opacities, but cardiac shape is normal

Answer 2

ARDS (Acute Respiratory Distress Syndome)

Question 3

▪ Excessive collagen levels in the connective tissue matrix of the lungs

▪ Causes progressive restriction of the lungs leading to dyspnea, cyanosis, weight loss, chronic disability

● Excess collagen in CT matrix of lungs -> difficult for lungs to expand (worsens)
● RFs: differ for upper vs lower lobes

o Upper (CHARTS): Coal worker pneumoconiosis, Histiocytosis X, Ankylosing spondylitis, Radiation, TB, Sarcoidosis/Silicosis
o Lower (SCAR): Systemic sclerosis, Cryptogenic fibrosing alveolitis, Asbestosis, Rheumatoid arthritis
● Sx: dyspnea, cough, cyanosis, weight loss, chronic disability; 2-5 yr life expectancy

Answer 3

idiopathic pulmonary fibrosis

Question 4

● Systemic; Autoimmune; rare; noncaseating epithelioid granulomas everywhere in the body

granuloma of immune cells desrtoying pathogens form -> accumulate in lymph nodes, esp. hilum of lungs

in severe cases can lead to pro-inflamm. cytokines -> fibrosis

● RFs: 20-40 y/o, Northern European & African American descent
● Sx: fever, weight loss, arthralgia, peripheral lymphadenopathy, skin lesions, impaired organ function d/t fibrosis or granuloma presence, erythema nodusum (red, on legs)

Answer 4

Sarcoidisis

Question 5

Interstitial fibrosis from inhalation of inorganic dust/braod category that involve occupational exposure
o Anthracosis (black lung) – inhalation of carbon dust in urban areas (no damage)
o Coal worker’s pneumoconiosis – coal dust containing carbon & silica
o Silicosis – silica dust
o Asbestosis – asbestos fibers (construction/shipyard workers)

Answer 5

pneumoconiosis

Question 6

extrinsic or intrinsic asthma:

childhood, type I hypersensitivity w/ IgE bound to mast cells

▪ Hyperresponsive airway -> immune response -> swelling -> broncho-constriction -> air trapped (wheezing) -> intra-alveolar pressure rises -> decreases hydrostatic pressure -> fluid leaves capillaries -> airway edema -> chronic airway remodelling (BUT asthma can be reversible)

Answer 6

extrinsic

Question 7

intrinsic or extrinsic asthma:

adulthood, not associated w/ allergies but a neural reflex to a chronic insult or inflammation -> recurrent bronchoconstriction & increased mucus

Answer 7

intrinsic asthma

Question 8

● Episodic irritation & constriction of the bronchioles; chronic inflammation & narrowing of airways

RFs: idiopathic, Western world, lack of breastfeeding, pollution, high omega 6 intake, lack of childhood infections, sedentary lifestyle; young boys in poverty often affected
Sx: episodic cough, chest tightness, wheezing, dyspnea < at night or w/ triggers
Complications: recurrent infection, disease progression -> fatal, pneumothorax, atelectasis, status asthmaticus (asthma bout lasts for days, unresponsive to tx)

Dx: spirometry shows reduced FEV1 (like COPD)

Answer 8

asthma

Question 9

Curshmann spirals and Charcot Leyden crystals are seen in which cdx?

Answer 9

asthma

Question 10

● Wide airways (bronchi) -> mucus forms -> can’t clear -> stinky sputum

● RFs: COPD or infection (main causes) + A SICK AIRWAY…

o Airway lesion/obstruction, Sequestration (unattached piece of lung tissue), I nfection, Cystic Fibrosis, K artagener syndrome (genetic, triad w/ situs inversus & chronic sinusitis), Aspergillosis (mold), Immunodeficiency, Reflux, William’s Campbell Syndrome (congenital, no cartilage in bronchi), Aspiration, Yellow nail syndrome (swollen arms/legs from lymph accum., nails yellow)

● Sx: longstanding cough, stinky sputum; Complications: abscess or bronchial obstruct.

Answer 10

Bronchiectasis

Question 11

● “Blue Bloater”; overweight and cyanotic; RFs: smoking, occupational exposure
● Chronic obstruction of terminal airways (NOT alveoli) from excess mucus
o Initial insult -> impaired -> bacteria colonize -> chronic inflammation (cycle)

● Sx: mild dyspnea, productive cough, cough w/ hemoptysis, purulent sputum, cyanosis, clubbing, use of accessory muscles for respiration, barrel chest (lung hyperinflation)
● Complications: recurrent acute bronchitis, cor pulmonale (RHF)

● Dx: productive cough > 3 months OR > 2 years
● Spirometry: decreased FEV1, increased PCO2, v low PO2

Answer 11

Chronic Bronchitis

Question 12

“Pink Puffer”; permanent enlargement & destruction of air spaces (alveolar walls) -> increased RV w/out fibrosis

causes: smoking, A1AT def.
o Centrilobular emphysema: dilation of respiratory bronchioles
o Panacinar emphysema: dilation of entire acinus (gas exchange unit including resp. bronchioles, alveolar ducts/sacs, alveoli)
o Paraseptal emphysema: dilation at distal acinus
o Irregular emphysema: irregular involvement of acinus

● RFs: smoking, occupational exposure, biomass fuel cooking exposure
● Sx: significant dyspnea!, minimal cough, tachypnea, pink skin, cachexia, barrel chest (lung hyperinflation)
● Complications – weight loss, pneumothorax

Answer 12

Emphysema

Question 13

● Accumulation of milky, lipid-rich fluid in the pleural cavity d/t lymphatic obstruction

Answer 13

Chylothorax

Question 14

● Blood in pleural space d/t trauma or vessel rupture (ex: rib fracture, clotting disorder)

Answer 14

Hemothorax

Question 15

▪ Collapse or closure of a lung resulting in reduced or absent gas exchange.
▪ Can affect part or all of a lung
▪ Usually unilateral
▪ Cough, chest pain, dyspnea, low oxygen saturation, pleural effusion, cyanosis (late stage), increased heart rate
▪ Most commonly occurs after surgery

Answer 15

OBSTRUCTIVE ATELECTASIS

Question 16

▪ Fibrosis of the visceral pleura so that part or all of a lung becomes covered with a plaque or a thick layer of nonexpansible fibrous tissue

Answer 16

PLEURAL FIBROSIS

Question 17

▪ Chronic inflammatory and scarring disease of the lung tissue
▪ Severe shortness of breath
▪ Increased risk for certain cancer

Answer 17

Pleural Fibrosis - Asbestosis

Question 18

Passage for air to travel between pleural layers
o Closed – air accumulates between alveoli & visceral pleura
o Open – chest wall trauma; could be just parietal or also visceral

● Etiology: traumatic (stab wound, fracture) or spontaneous (ruptured air-filled lesion)

Sx: acute onset pleuritic chest pain, dyspnea
o PE: + trachea deviated AWAY (air occupying space) + decreased breath sounds + hyper resonant + decreased tactile fremitus + friction rub

Complications: free entry of air into lungs -> lose (-) pressure gradient -> lung collapse
o If pneumothorax severe enough, mediastinum shifts -> compresses other lung

Answer 18

Pneumothorax

Question 19

▪ Pleural cavity contains air.
▪ Due to perforation of the pleura from outside the lung or from inside the lung
▪ Causes loss of negative pressure and collapse of the lung.
▪ If severe enough it can cause the mediastinum to shift to the other side and cause a tension pneumothorax of the opposite lung.

Answer 19

Pneumothorax

Question 20

● RFs: smoking (1st or 2nd hand), asbestos exposure, occupation exposure, radiation

● Sx: asx for long time ->
1. Bronchial sx: hemoptysis, chronic cough, dyspnea, chest pain
2. Intra-thoracic spread: chest wall invasion, reflux, hoarse (from recurrent laryngeal nerve paralysis), Horner syndrome, Pancoast’s tumor (located at apex), pleural effusion, phrenic nerve paralysis, SVC obstruction
3. Extra-thoracic spread: fatigue, anorexia, bone pain & fractures, seizures, confusion, personality change (brain meta), high alk phos, headache, N/V, LNs
● Complications: metastasis to hilar & mediastinal LNs, nerve compression

Answer 20

lung cancer

Question 21

Pathophysiology:

Bronchial Adenoma: benign, from glandular tissue of bronchi, rarely carcinoma

Adenocarcinoma: most common, arises in bronchi, non-smoking (radiation, toxins),
o Originates peripherally, good prognosis & responds to removal

Squamous Cell Carcinoma: begins centrally & strong association w/ smoking
o May cause hypercalcemia by secreting parathyroid-like substance

Small Cell Carcinoma: most aggressive, w/ smoking, highly malignant
o Responds well to chemotherapy
o Can cause hyponatremia & Cushing’s syndrome from inappropriate ADH secretion

● Large Cell Carcinoma: unclear precursor, minimal association w/ smoking

Bronchial Carcinoid Tumor:
o Unrelated to smoking, excellent prognosis; occurs in patients < 40 yoa
o Sx: mass sx (cough, hemoptysis) + flushing, cyanosis, tachycardia, diarrhea

Answer 21

lung cancer

Question 22

Types:
Adenocarcinoma
1. Cells of mucus-secreting glans in the esophagus
2. More common in lower part of the esophagus

Squamous cell carcinoma
1. Typically in the middle of the esophagus

Sxs: dysphagia, UWL, chest pain (burning or pressure), indigestion, GERD, cough, hoarseness

RFs: alcohol, bile reflux, drinking hot fluids, GERD, Berrett’s esophagus, smoking

Answer 22

esophageal cancer

Question 23

● Squamous cell carcinoma m/c (in larynx)

RFs: men > 40 yoa, smoking & alcoholism together

● Types: glottic (m/c, arises from true vocal cords), supra- & sub-glottic (poor prog)

Answer 23

Laryngeal Cancer

Question 24

● Highly aggressive malignant tumor located in the pleura (not actual lung)
● RFs: asbestos exposure, not smoking; very poor prognosis (lung enclosed in tumor)

Answer 24

Mesothelioma

Question 25

● Squamous cell carcinoma; m/c East Asia (adults) & Africa (children) ● RFs: **strong** **association w/** **EBV** & high salted vegetable intake

Answer 25

Nasopharyngeal Carcinoma

Question 26

● From chronic voice abuse, allergies or irritants (ex: smoking) -> hoarseness / whisper

Answer 26

Vocal Cord Polyps

Question 27

● Autosomal recessive disorder affecting endocrine glands -> viscous mucus d/t **chloride channel dysfunction** -> recurrent resp infections & steatorrhea (grey, greasy stool from excretion of digestion enzymes)

Answer 27

Cystic Fibrosis

Question 28

- autosomal recessive - CFTR gene defect (chromosome 7) - genetic defect -> impaired sodium, **chloride transport** across epithleal cell surface -> thick, tenacious secretions ● RFs: Caucasians (1 in 20 a carrier), FHx, heterozygotes may have mild or isolated sx (ex: infertility, nasal polyps) ● Sx: **meconium ileus** (bowel obstruct bc meconium thick/sticky), FTT, hypertrophy of accessory respiration muscles, cough, **sweaty salt**, infertility (male), large appetite, dyspnea, **steatorrhea**, colicky pain, recurrent sinusitis w/ nasal polyps

Answer 28

CF

Question 29

● Inappropriate connection btwn trachea & esophagus (may also occur d/t surgery) ● Sx (neonates): hypersalivation, choking, cough, **cyanosis when eating**

Answer 29

Tracheoesophageal Fistula

Question 30

● “Walking pneumonia”; **highly contagious**; common young adults ● Etiology: Mycoplasma or viral (influenza, adenovirus) ● NO neutrophils/consolidation – **atypical involves lymphocytes** -> thicken alveolar septa, hyaline membranes & **type II alveolar proliferation** (DDx: ARDS) ● Sx: w/ or w/out dry cough, dyspnea (from thickened blood/air barrier)

Answer 30

**Atypical Pneumonia**

Question 31

what type of pneumonia: Primary form can be caused by viruses, Mycoplasma ▪ Involves lymphocytes and results in thickened alveolar septa, hyaline membranes, and proliferation of Type II alveolar cells like in ARDS. ▪ Dyspnea with or without a dry cough

Answer 31

**atypical pneumonia**

Question 32

● “Chest cold”; inflammation of medium sized airways d/t infection (viral 80%) ● RFs: asthma, chronic lung disease, immunodeficiency, CF ● Sx: cough, fever, myalgia, fatigue, dyspnea, **wheezing** & rhonchi (from narrowing) “Chest cold”; virus enters lower resp. tract; lasts 3-4 weeks; viral 80% o **Strongest rule IN is cough/wheezing; rule OUT is nausea** ● Complications: bacterial superinfection, unable to work/go to school

Answer 32

Acute Bronchitis

Question 33

etiology for which pneumonia: SHKS PEML CC – **SH**aKe, **SPE**nd **M**oney, **L**ove **C**uddly **C**ats o **Strep pneumoniae (most common in neonates) – CAP & lobar pneumonia** o Haemophilus influenza b – CAP o Klebsiella pneumoniae o Staph aureus – STAMP FOMES o Pseudomonas aeruginosa o E coli o Moraxella catarrhalis o Legionella pneumophile o Coxiella burnetiid o Chlamydia pneumoniae

Answer 33

Bronchopneumonia

Question 34

● Patchy consolidation in alveoli around bronchioles -> alveoli packed w/ neutrophils, exudate & bacteria ● Often secondary to conditions causing pulm. congestion, damage to mucociliary escalator, impaired immunity, or loss of cough reflex

Answer 34

Bronchopneumonia

Question 35

● Often from *Strep pneumoniae*, involves entire lobe of the lung (more serious form)

Answer 35

Lobar Pneumonia

Question 36

● Local anaerobic infection; leads to pus-forming cavity -> necrosis; m/c R lung ● RFs: aspiration of infected material (ex: alcoholics, coma), infected emboli, bacterial pneumonia, congenital malformation, obstructions ● Sx: productive cough, purulent & **bad smelling sputum, high fever > 38, consolidation**, chest pain, anorexia, weight loss, fatigue

Answer 36

Lung Abscess

Question 37

incubation: 1-4 days ● RNA virus w/out neuraminidase or hemagglutinin; **F glycoprotein fuses infected cells** -> formation of **syncytium** (fusion of 2 or more cells); NO immunity against this infection (can infect again) Presentations: Respiratory disease: **pneumonia & bronchiolitis**, children & adults ▪ Sx: rhinitis, worsening cough -> wheezing, resp distress -> fatal 1% ▪ Dx: CXR shows infiltrates & collapse Severe pharyngitis: older children & adults ▪ Sx: croup, URTI sx, severe pharyngitis sx

Answer 37

Respiratory Syncytial Virus (RSV)

Question 38

Primary TB (initial infection) often asx -> establishment of granuloma w/ central cheesy necrosis (Ghon focus or Gong complex) o Only 10% of primary TB manifest into secondary TB w/ several granulomas -> coughed up to spread elsewhere OR disseminate in body (miliary TB) ● RF: immunocompromised, HIV+, diabetes, malnourished, travel, smokers, lab ● Sx: prolonged cough, night sweats, weight loss, hemoptysis, fever, chills, sweats, malaise, weakness, Gong complex (cheesy necrosis CXR)

Answer 38

Tuberculosis

Question 39

● *Histoplasmosis capsulatum*; **airborne spores spread by wind, bird & bat droppings**; found in Ohio & Mississippi soils; can mimic TB Presentations: o Acute pneumonia – self-limiting, flu-like illness w/ lymphadenopathy & rashes o Chronic pneumonia – like secondary TB, RFs: chronic lung disease o Disseminated – immunocompromised -> multi-organ failure o Carrier – asx infection only found on CXR showing **calcifications** & skin test ▪ Carriers DO NOT spread infection

Answer 39

Histoplasmosis

Question 40

● “San Joaquin Valley Fever”; *Coccidiodides immitus*; endemic to Western USA ● Sx: asx OR acute pneumonia w/ fever, cough, chest pain, erythema nodosum

Answer 40

Coccidioidomycosis

Question 41

● Mold w/ V-shaped branching & hyphae; also opportunistic mycoses (fungus infect.) ● Colonizes wounds, cornea, external ear & sinuses -> disseminate to lungs (immunocomp.) -> hemoptysis & granuloma (makes “fungus balls”) ● RFs: antifungals & Abx can cause overgrowth of commensals in lungs

Answer 41

Aspergillosis

Question 42

● Rare; caused by Pneumocystis jirovecii; Normal flora in lungs that develops into opportunistic infection, RFs: HIV ● Sx: sudden fever & dyspnea; Dx: diffuse patches on CXR

Answer 42

Pneumocystis jirovecii pneumonia

Question 43

● Lodging of clot in the pulmonary arteries; usually from periphery (DVT) o **Suspect (this cdx)** if patient collapses 1-2 weeks post-surgery ● RFs: **Victor’s Triad** – stasis (surgery, obesity, CHF), endothelial damage (trauma, surgery), hypercoagulable state (cancer, hormone therapy, Hx DVT, pregnancy)

Answer 43

Pulmonary Embolism

Question 44

● Sx: **tachypnea, dyspnea, pleuritic chest** pain, tachycardia, fever, cough, diaphoresis, S3 or S4 gallop, thrombophlebitis, peripheral edema, cardiac murmur, cyanosis, hemoptysis (coughing up blood) ● Dx: **test D-dimer** (by-product of fibrinolysis, GOLD standard)

Answer 44

Pulmonary Embolism

Question 45

● Often from Pulmonary Embolism; prolonged ischemia of lung tissue -> irreversible necrosis ● RFs: trauma, surgery, sickle cell disease (clots lodge), DVT, smoking, Western life ● Sx: **sudden sub-sternal pain**, syncope, dizziness, hemoptysis, diaphoresis, cyanosis, fever, tachycardia, tachypnea (FTT) o PE: **crackles + friction rub** ● Complications -> cor pulmonale -> RV failure

Answer 45

Pulmonary Infarction

Question 46

● Acute inflammation of larynx -> edema of vocal cords ● RFs: bacterial/viral, irritants, overuse of voice; Sx: hoarseness, throat pain

Answer 46

Laryngitis

Question 47

▪ ***Corbeobacterium diphtheriae*** is transmitted via respiratory droplets -> adheres to mucosal epithelial cells & creates diphtheria toxin -> forms **grey-white membrane** on **tonsils** (debris) ▪ Toxigenic strains produce a toxin that kills surrounding cells and results in local inflammation of the throat. ▪ A tough **grey “pseudomembrane”** forms across the airway opening which can extend from the oropharyngeal area to the trachea. ▪ Severe flu-like symptoms with dyspnea, grey pseudomembrane

Answer 47

Diphtheria

Question 47

Pathophysiology: Viral inoculation of respiratory tract mucosa -> cell damage -> release of cytokines (IFN-gamma, IL-1, IL-6, IL-12) -> inflammation, increase secretions ● Causes severe respiratory syndrome ● Direct contact, airborne droplets, fomites ● RFs: immunosuppression, healthcare occupation, comorbid conditions ● SXs: prodrome: fever, malaise, headaches, myalgia, chills; non-productive cough, dyspnea, chest pain, diarrhea, rhinorrhea, sore throat

Answer 47

Coronavirus (SARS)

Question 48

▪ Common cold ▪ Most often caused by **adenovirus** ▪ Runny nose, sneezing, nasal congestion, mild sore throat ▪ Allergic rhinitis (type 1 hypersensitivity reaction) ▪Chronic rhinitisis due to super imposed bacterial infection

Answer 48

Rhinitis

Question 49

▪ Inflammation of the paranasal sinuses (allergies or viral infections) ▪ Blocked drainage causes fluid to build up and pain to occur ▪ Can spread to the orbit or penetrate the bone resulting in osteomyelitis

Answer 49

Sinusitis

Question 50

▪ Inflammation of the **palatine tonsils** , **viral of S. pyogenes** ▪ recurrent potentially; if left untreated strep infect. -> rheumatic fever, valvular disorders, glomerulonephritis, arthritis, and peritonsillar abscess ▪ Throat pain (worse swallowing), ear pain (referred), anorexia, fever, headache, malaise, vomiting, swollen erythematous tonsils (w/ or w/out exudate), tonsillar membrane that does not bleed upon removal.

Answer 50

TONSILLITIS

Question 51

▪ Inflammation of the epiglottis resulting in swelling ▪Usually caused by **H. influenza type B** but can be due to beta hemolytic strep ▪ **Life-threatening in children** ▪ Sudden onset, drooling, dysphagia, high fever, tripod position, cervical lymphadenopathy, muffled voice, respiratory distress, minimal cough, **“thumb sign”** on X-ray

Answer 51

EPIGLOTTITIS

Question 52

Pharyngitis: bacterial origin 20%, often viral origin 80% o Bacterial: high fever, purulent d/c, worsens & lasts > 7 days ● Scarlet Fever: S pyogenes can directly infect & produce erythrogenic toxin -> inflammation -> cross-reacting Abs attack normal body tissues -> autoimmunity ● RFs: endemic globally, children & early teens, poverty Sx: o Pharyngitis: sore throat, erythema, exudate, swelling of tonsils, fever, anterior cervical LN involvement, headache, leukocytosis o Scarlet Fever: strawberry red tongue, fever, deep red rash over entire face (except mouth & nose), fast pulse, red maculopapular rash on trunk ● Complications: GABHS abscess, epiglottitis, glomerulonephritis (attacks glomerular basement membrane), rheumatic fever (heart valves, brain, skin, chorea), sepsis

Answer 52

bacterial pharyngitis

Question 53

▪ Anything that causes the pulmonary interstitial fluid pressure to rise from negative to positive. ▪ Interstitial edema ▪ Alveolar edema SX: **dyspnea** ▪ Caused by **left-sided heart disease**, fluid overload/renal failure, decreased albumin, lymphatic obstruction, pulmonary capillary membrane damage

Answer 53

pulmonary edema

Question 54

Sx for? **Streptococcus pyogenes** (group A, beta-hemolytic) – Gram (+) cocci ▪ Direct infection resulting in local inflammation, exotoxin production, and elicit immunological cross-reactions with Abs attacking other body tissues (autoimmune diseases) ▪ Throat pain with erythema, pustular exudate, tonsillar inflammation, URT symptoms. ▪ Fever, leukocytosis, headache, tender enlarged head lymph nodes. ▪ Rapid strep test and culture

Answer 54

Pharyngitis

Question 55

● MOA: virus invades laryngeal mucosa -> larynx, trach., bronchi swell ● RF: **children more susceptible w/ smaller airways** ● Etiology: parainfluenza virus, RNA virus w/ 4 serotypes (type 1 attacks in fall) ● Sx – **3 S’s: stridor, seal bark, subglottic swelling**; hoarseness, dyspnea, mild fever, **< night, peaks day 2**; + respiratory distress o Chest wall retractions (inter + subcostals, supra/sternoclavicular spaces) & nasal flaring (trying to get more air in) ● Tx: **self-limiting in 5-7 days** ● Red flags! o Blue skin, difficulty breathing, severe coughing spells, whistle when breathing, retractions, inability to speak or cry; **fever > 38 C or Sxs > 7 days**

Answer 55

Croup (Laryngo-tracheobronchitis) -> Parainfluenza virus

Question 56

# **** - excess fluid accumulated in pleural space; lung expansion limited -> impaired ventilation - Caused by: HF, tumors, nephrotic syndrome, pneumonia, atelectasis, liver cirrhosis ▪ Dyspnea and pleural pain but can be asymptomatic

Answer 56

Pleural Effusion

Question 57

▪ Pleural cavity contains air ▪ Due to perforation of the pleura from outside the lung or from inside the lung ▪ Causes loss of negative pressure and collapse of the lung

Answer 57

Pneumothorax