Introduction To Clinical Medicine

Pulmonary Diseases
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basic science to diagnostic and therapeutic medicine.

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• Gas exchanger

• Pump

• A conduction system (airways-ventilation)

• The central controller

 Onset
Duration

Aggravating/Alleviating factors
Associated factors
Severity?)
SH
SH
– airway obstruction
- Heart failure
– airway obstruction
– Heart Failure
– COPD
– thrombophlebitis/DVT
– pneumothorax Pericardial
– possible pericarditis
– metabolic acidosis
In the last 24 hours he has noted difficulty in
breathing and now has developed severe chest
pain worse with inspiration. He has become
increasingly tachypneic. An ECG reveals sinus
tachycardia and non specific ST and T wave
changes. A chest x-ray reveals right lower lobe
atelectasis and questionable pleural effusion.
 post-op
gastric carcinoma
difficulty in
breathing severe chest
pain worse with inspiration
tachypneic sinus
tachycardia specific ST and T wave
changes right lower lobe
atelectasis questionable pleural effusion
•Post- operative status
•Hx of gastric carcinoma
•Acute dyspnea !
•Chest pain  pleurisy
•Tachycardia and tachypnea
•Nonspecific ST-T wave changes
•RLL atelectasis
•? Pleural effusion
 Venous doppler ultrasound
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D-dimer
Pulse Oximetry/Arterial •
Blood Gas
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• BNP-B Type natriuretic peptide

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ECG
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Troponin
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• CXR

• Computed Tomographic Pulmonary Angiography

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V/Q
scan
Ventilation perfusion scan
The areas at the tip
of the arrows are
slightly darker than
normal indicating a
decreased ability for
the contrast to
enter the
pulmonary artery
and its branches
Who needs to have a CT pulmonary
angiogram test done to rule out PE? This
is an expensive test. About $1500
 From: Evaluation of Patients With Suspected Acute Pulmonary Embolism: Best Practice Advice From the
Clinical Guidelines Committee of the American College of Physicians

Ann Intern Med. 2015;163(9):701-711. doi:10.7326/M14-1772

Wells Prediction Rule for Pretest Probability for PE

Date of download: 5/10/2016 Copyright © American College of Physicians. All rights reserved.
From: Evaluation of Patients With Suspected Acute Pulmonary Embolism:
Best Practice Advice From the Clinical Guidelines Committee of the
American College of Physicians

Ann Intern Med. 2015;163(9):701-711. doi:10.7326/M14-1772

Pathway for the evaluation of

patients with suspected PE.
PE = pulmonary embolism;
PERC = Pulmonary
Embolism Rule-Out Criteria.
* Using either a clinical
decision tool or gestalt.

Date of download: 5/10/2016 Copyright © American College of Physicians. All rights reserved.
From: Evaluation of Patients With Suspected Acute Pulmonary Embolism: Best Practice Advice From the
Clinical Guidelines Committee of the American College of Physicians

Ann Intern Med. 2015;163(9):701-711. doi:10.7326/M14-1772

Date of download: 5/10/2016 Copyright © American College of Physicians. All rights reserved.
 post-op gastric
carcinoma
difficulty in breathing severe chest
pain worse with inspiration.
tachypneic sinus tachycardia
specific ST and T wave changes reveals right
lower lobe atelectasis and questionable pleural effusion
From: Evaluation of Patients With Suspected Acute Pulmonary Embolism:
Best Practice Advice From the Clinical Guidelines Committee of the
American College of Physicians

Ann Intern Med. 2015;163(9):701-711. doi:10.7326/M14-1772

Pathway for the evaluation of

patients with suspected PE.
PE = pulmonary embolism;
PERC = Pulmonary
Embolism Rule-Out Criteria.
* Using either a clinical
decision tool or gestalt.

Date of download: 5/10/2016 Copyright © American College of Physicians. All rights reserved.
 Hypercoagulability
Venous stasis

Endothelial damage
Peripheral pulmonary embolus
Case # 1 Final Diagnosis

Pulmonary embolism
• Tobacco abuser
• Progressive dyspnea with wheezing and minimal cough
• Weight loss
• Barrel chest
• Decreased breath sounds
• Hyperresonant on percussion
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Bronchial mucus plug seen in chronic bronchitis
• destruction of the alveolar walls
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• Distended jugular veins
• Hepatomegaly
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• Peripheral edema
Rupture of the alveolar walls
Hyperinlation of the lung
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 Bullous emphysema
Paraseptal emphysema
Case # 2

Final diagnosis

COPD-Emphysema
Hx of Chronic bronchitis
Cigarette abuse
Shaking chills
Right chest pain
Fever
Cough with productive sputum
Dyspnea
Rales, increased tactile fremitus and dullness
to percussion in R upper lung

What do you think?

Lobar pneumonia
Bronchopneumonia
Bronchopenumonia
Alveolus filled with inflammatory cells
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Empyema of the lung
Case # 3

Final diagnosis

Lobar pneumonia
Bronchiectasis
Productive cough
Hemoptysis
Purulent nasal discharge
Positive culture for Pseudomonas
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• sweat test
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• Recurrent pulmonary infections

• Pancreatic insufficiency
• Steatorrhea

• Malnutrition

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• Hepatic cirrhosis
• Intestinal obstruction
• Salivary glands

• Male infertility
Cystic fibrosis - pancreas
Dilatation of ducts with
inspissated material
Exocrine gland atrophy
Cystic fibrosis –
lung
Meconium ileus
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Case # 4

Final diagnosis

Cystic fibrosis
What do you see?
Preceding respiratory symptoms
Hemoptysis and dyspnea
Fatigue and mild anemia
Hematuria
Fluffy bilateral pulmonary infiltrates on CXR
lungs and kidneys
Case # 5

Final diagnosis

Goodpasture’s syndrome
History of colon cancer
Severe coughing
One episode of vomiting
Fever
Increasing dyspnea
Pulmonary infiltrates w/out blunting of lung
bases
Leukocytosis
High BUN
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Foreign body giant cell reaction
Due to aspiration of gastric contents
Case # 6

Final diagnosis

Adult respiratory distress

syndrome
(ARDS)
Respiratory insufficiency (Cough, Chest
pain and SOB)
Weight loss and night sweats
Lymphadenopathy
Hepato-splenomegaly
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Case # 7

Final diagnosis

Sarcoidosis
•IV drug user
•Respiratory problems associated with
fever, weight loss, dyspnea, frothy
sputum
•Generalized lymphadenopathy
•Positive sputum culture
• M. avium intracellulare
Slide # 1
Slide # 2
Case # 8

Final diagnosis
HIV infection
Pneumocystis pneumonia
Atypical mycobacterial
infection
• 1. Cough x 1 month
• 2. sputum yellowish and now blood streaked
(hemoptysis)
• 3. occasional fever and chills
• 4. appetite “off” (anorexia)
• 5. weight loss 5-10 lbs
• 6. scattered rales on LUL
• 7. Recent return from foreign travel to Tanzania
game reserve
Case # 9

Final diagnosis

Tuberculosis
•HIV positive
•Mild fever with night sweats
•Weight loss
•Elevated LDH
•Decreased CD4 count
•Pulmonary infiltrates on CXR
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Infiltrates of pneumocystis
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Case # 10
Final diagnosis

AIDS
With
Atypical mycobacteria pneumonia
(M. kansasii)
Progressive exertional dyspnea
Expiratory wheezing
2 pillow orthopnea
Cool extremities
Cigarette abuse
Dullness and decreased breath sounds over left
chest
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Test Exudate Transudate
Pleural LDH/serum >0.6 <0.6
LDH
Pleural LDH >200 <200
Pleural >0.5 <0.5
protein/serum
protein
Gram stain/Culture Bacteria with PNA negative
WBC >1000 <1000
Glucose <60 >60
Examples Parapneumonic CHF, PE, cirrhosis,
effusion, malignancy, nephrotic syndrome
TB , mesothelioma
Case # 11

Final diagnosis

Pleural effusion
Due to
Malignancy
End of presentation