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2
Marc Imhotep Cray, M.D.
A 35-year-old woman presents with acute chest pain and a
nonproductive cough. Review of systems reveals a history of
malar rash, fatigue, and migratory polyarthritis. On
physical examination, she is found to have a friction rub
and distant heart sounds and she complains of increased
pain when supine. An increased jugular venous pressure is
noted with inspiration and diffuse ST elevations are seen on
most ECG leads. You initiate therapy with corticosteroids
and refer her to a rheumatologist and a cardiologist.
3
Marc Imhotep Cray, M.D.
Inflammation of pericardium [ A , red arrows]
Causes include idiopathic (most common= Tao Le T and Bhushan V. First Aid for the
presumed viral), confirmed infection (eg, USMLE Step 1 2017. New York, NY:
McGraw-Hill ,2017.
Coxsackievirus), neoplasia, autoimmune (eg,
SLE, rheumatoid arthritis), uremia,
cardiovascular (acute STEMI or Dressler
syndrome), radiation therapy 4
Marc Imhotep Cray, M.D.
A 75-year-old woman with a history of metastatic breast
cancer presents to the emergency department complaining
of weakness and difficulty breathing. On physical
examination, her blood pressure is 90/50 and her heart
sounds are distant and faint. You also note that she has
an increased JVP. When an ECG reveals a QRS complex
height that varies from one heart beat to the next, you
prepare for an immediate pericardiocentesis.
5
Marc Imhotep Cray, M.D.
Compression of heart by fluid (eg, blood,
effusions [arrows in A ] in pericardial
space) ↓CO.
Equilibration of diastolic pressures in
all 4 chambers
7
Marc Imhotep Cray, M.D.
Fever (most common symptom), new murmur,
Roth spots (round white spots on retina surrounded by hemorrhage (A)
Osler nodes tender (painful ) raised lesions on finger or toe pads (B) due to
immune complex deposition
Janeway lesions (small, painless, erythematous lesions on palm or sole) C ,
glomerulonephritis, septic arterial or pulmonary emboli,
Splinter hemorrhages D on nail bed
Tao Le T and Bhushan V. First Aid for the USMLE Step 1 2017. New York, NY: McGraw-Hill ,2017.
11
Marc Imhotep Cray, M.D.
A consequence of pharyngeal infection
with group A β-hemolytic streptococci
Late sequelae include rheumatic
heart disease, which affects heart
valves—mitral > aortic >> tricuspid
(high-pressure valves affected most)
Treatment/prophylaxis: penicillin
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Marc Imhotep Cray, M.D.
Lung volumes
Inspiratory reserve volume
Air that can still be breathed in after normal inspiration
Tidal volume
Air that moves into lung with each quiet inspiration,
typically 500 mL
Residual volume
Air in lung after maximal expiration; RV and any lung
capacity that includes RV cannot be measured by spirometry
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Marc Imhotep Cray, M.D.
Lung Capacities
Inspiratory capacity IRV + TV
Air that can be breathed in after normal exhalation
Tao Le T and Bhushan V. First Aid for the USMLE Step 1 2017. New York, NY: McGraw-Hill ,2017.
16
Marc Imhotep Cray, M.D.
Obstructive lung volumes > normal (↑ TLC, ↑ FRC, ↑RV)
Restrictive lung volumes < normal (↓ TLC, ↓ FRC, ↓ RV)
In obstructive, FEV1 is more dramatically reduced compared with
FVC decreased FEV1/FVC ratio
In restrictive, FVC is more reduced or close to same compared
with FEV1 increased or normal FEV1/FVC ratio
Tao Le T and Bhushan V. First Aid for the USMLE Step 1 2017. New York, NY: McGraw-Hill ,2017.
17
Marc Imhotep Cray, M.D.
1. Obstructive Pulmonary Diseases (OPDs)
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Marc Imhotep Cray, M.D.
Baron SJ and Lee CI. Lange Pathology Flash Cards. New York: McGraw-Hill, 2009.
19
Marc Imhotep Cray, M.D.
Obstruction of air flow air trapping in lungs
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Marc Imhotep Cray, M.D.
B
B B
PRESENTATION
Findings: wheezing, crackles, cyanosis
(hypoxemia due to shunting), dyspnea,
CO2 retention, 2° polycythemia
PATHOLOGY
Hypertrophy and hyperplasia of mucus-
secreting glands in bronchi Reid index
(thickness of mucosal gland layer to
thickness of wall between epithelium
and cartilage) > 50%
OTHER
Diagnostic criteria: productive cough for
> 3 months in a year for > 2 consecutive The Netter Collection of Medical
Illustrations, 2E. Vol 3- Respiratory System
years
25
Marc Imhotep Cray, M.D.
P P P
PRESENTATION
Centriacinar=associated with smoking (A ,B) Frequently in upper
lobes (smoke rises up)
Panacinar=assoc. w α1-antitrypsin deficiency Frequently in lower
lobes
PATHOLOGY
Enlargement of air spaces ↓ recoil,↑ compliance, ↓ DLCO from destruction
of alveolar walls (arrow in C )
↑ elastase activity ↑ loss of elastic fibers ↑ lung compliance
Tao Le T and Bhushan V. First Aid for the USMLE Step 1 2017. New York, NY: McGraw-Hill ,2017. 26
Marc Imhotep Cray, M.D.
A63-year-old man presents to your office complaining of
worsening shortness of breath over the past year. You know
that this patient has smoked two packs of cigarettes a day
for the past 45 years. As you are talking to the patient, you
notice that he is using his accessory muscles of respiration
to breathe, that his chest is barrel shaped and that he is
breathing carefully through pursed lips. Using a spirometer,
you determine that he has a decreased FEV1/FVC ratio and
an increased TLC. You tell the patient that it is imperative
that he stop smoking and prescribe him a tiotropium
inhaler.
Tao Le T and Bhushan V. First Aid for the The Netter Collection of Medical
USMLE Step 1 2017. New York, NY: Illustrations, 2E. Vol 3- Respiratory System
McGraw-Hill ,2017.
28
Marc Imhotep Cray, M.D.
An 8-year-old girl is brought into an urgent-care clinic
complaining of shortness of breath. Her past medical
history is significant for multiple allergies. Upon physical
examination, you hear expiratory wheezes and you
observe that the patient is using her accessory muscles of
respiration. You decide to administer an inhaled β2-
adrenergic agonist for relief of her symptoms.
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Marc Imhotep Cray, M.D.
PRESENTATION
Findings: cough, wheezing, tachypnea, dyspnea, hypoxemia, ↓ inspiratory/
expiratory ratio, pulsus paradoxus, mucus plugging (E )
Triggers: viral URIs, allergens, stress
Diagnosis supported by spirometry and methacholine challenge
PATHOLOGY
Bronchial hyperresponsiveness reversible bronchoconstriction
Smooth muscle hypertrophy and hyperplasia,
Curschmann spirals (F) (shed epithelium forms whorled mucous plugs), and
Charcot-Leyden crystals (G) (eosinophilic, hexagonal, double-pointed, needle-
like crystals formed from breakdown of eosinophils in sputum)
Tao Le T and Bhushan V. First Aid for the USMLE Step 1 2017. New York, NY: McGraw-Hill ,2017. 30
Marc Imhotep Cray, M.D.
OTHER RELATIONSHIPS
Aspirin-induced asthma: COX inhibition leukotriene
overproduction airway constriction
Associated with nasal polyps
31
Marc Imhotep Cray, M.D.
Carcinoma that occurs in apex of lung
may cause Pancoast syndrome by
invading cervical sympathetic chain
33
Marc Imhotep Cray, M.D.
CLINICAL FINDINGS
V˙/Q˙ mismatch, hypoxemia, respiratory alkalosis
Sudden-onset dyspnea, pleuritic chest pain, tachypnea, tachycardia
Large emboli or saddle embolus A may cause sudden death
Lines of Zahn are interdigitating areas of pink (platelets, fibrin) and red
(RBCs) found only in thrombi formed before death help distinguish pre- and
postmortem thrombi B
CT pulmonary angiography is imaging test of choice for PE (look for filling
defects) C
Tao Le T and Bhushan V. First Aid for the USMLE Step 1 2017. New York, NY: McGraw-Hill ,2017.
34
Marc Imhotep Cray, M.D.
Types: (An embolus moves like a FAT BAT)
Fat, Air, Thrombus, Bacteria, Amniotic fluid,
Tumor
Fat emboli—associated with long bone fractures and
liposuction classic triad of hypoxemia, neurologic
abnormalities, petechial rash
Amniotic fluid emboli—can lead to DIC, especially
postpartum
Air emboli—nitrogen bubbles precipitate in
ascending divers (decompression sickness) treat
with hyperbaric O2;
o or, can be iatrogenic 2° to invasive procedures (eg, central
line placement)
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Marc Imhotep Cray, M.D.
Upper respiratory infection
Most are viral: common cold, pharyngitis, etc.
Lower respiratory infection
Frequently viral
Bronchitis: cough, wheezing, dyspnea
Pneumonia: cough, fever, rapid respiration,
dyspnea, pleuritic CP
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Marc Imhotep Cray, M.D.
A 68-year-old man presents to the emergency department
complaining of a fever, dyspnea, and a cough productive of
green sputum. Physical examination reveals an ill-
appearing man, breathing heavily. On lung examination,
you note bronchial breath sounds and dullness to percussion
over the right lower lung lobe. A chest x-ray demonstrates
circumscribed opacity over the region of
his right lower lung lobe. You obtain sputum and blood
cultures and then admit this patient to the hospital for
antibiotic treatment.
37
Marc Imhotep Cray, M.D.
Tao Le T and Bhushan V. First Aid for the USMLE Step 1 2017. New York, NY: McGraw-Hill ,2017.
38
Marc Imhotep Cray, M.D.
A 21-year-old woman presents to the university health clinic
complaining of general weakness and a low-grade fever of 3
days’ duration. Upon directed history, you learn that she has
had an occasional cough and dyspnea and that her two
roommates have been suffering from similar symptoms.
When a chest x-ray reveals patchy infiltrates, you prescribe
her a course of azithromycin and schedule her for a follow-
up visit to make sure that her symptoms have resolved.
39
Marc Imhotep Cray, M.D.
(B)
(A)
Tao Le T and Bhushan V. First Aid for the USMLE Step 1 2017. New York, NY: McGraw-Hill ,2017.
Runts May
Cough
Chunky
Sputum
41
Marc Imhotep Cray, M.D.
Alcoholic Klebsiella, anaerobes usually due to aspiration
(eg, Peptostreptococcus, Fusobacterium, Prevotella,
Bacteroides)
IV drug users S pneumoniae, S aureus
Aspiration Anaerobes
Atypical Mycoplasma, Legionella, Chlamydia
Cystic fibrosis Pseudomonas, S aureus, S pneumoniae,
Burkholderia cepacia
Immunocompromised S aureus, enteric gram ⊝ rods,
fungi, viruses, P jirovecii (with HIV)
Nosocomial (hospital acquired) S aureus, Pseudomonas,
other enteric gram ⊝ rods
Postviral S pneumoniae, S aureus, H influenzae
42
Marc Imhotep Cray, M.D.
Localized collection of pus within parenchyma
(A)
Caused by aspiration of oropharyngeal contents
(especially in pts predisposed to loss of
consciousness (LOC) [eg, alcoholics, epileptics])
or bronchial obstruction (eg, cancer)
Air-fluid levels B often seen on CXR Fluid
levels common in cavities presence suggests
cavitation
Due to anaerobes (eg, Bacteroides,
Fusobacterium, Peptostreptococcus) or S
aureus.
Lung abscess 2° to aspiration is most often
found in right lung however, location depends
on patient’s position during aspiration.
Treatment: clindamycin
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Marc Imhotep Cray, M.D.
Tao Le T and Bhushan V. First Aid for the USMLE Step 1 2017. New York, NY: McGraw-Hill ,2017.
44
Antimicrobial therapy
See next slide for hypertext tools and resources for further study.
45
Companion Notes
Make the Diagnosis with Pathophysiology Q&A. pdf
eBooks
Bate’s Guide to the Physical Examination and History
Taking, Lynn Bickley (with Video)
DeGowin’s Diagnostic Examination, 9th Ed. Richard
DeGowin,et al.
Textbook of Physical Diagnosis: History and Examination,
Mark Schwartz. (with Video)
A Practical Guide to Clinical Medicine, Charlie Goldberg
and Jan Thompson.
(A PDF version of the website compiled by this presenter.)
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Marc Imhotep Cray, M.D.