Chest:

Bronchial asthma -> .

Sudden onset, wheezing & ++ expiratory phase, NOCTURNAL COUGH

Atopy……familial, early onset, with other forms of asthma e.g: hay fever,
allergic rhinintis

Exam…….Harsh vesicular breathing with prolonged expiration

Expiratory wheezes

INV:

spirometry……..the best

Most imp to asses in spirometry……..FEV1

Tests:

Clinical improvement and increase FEV1 after bronchodilators

TTT:

Management of acute attack???

Most imp inv if the patient is hypoxic ………ABG

1st step………inhaled salbutamol

If no response……. Cortisone

If not responding to salbutamol and cortisone ….. iv Mg Sulphate

Most absolute indication to intubation……increased paco2

Most common SE of inhaled cortisone…..oropharyngeal candida

Ladder of Long term management:

First line………….SABA

If still symptomatic…….inhaled cortisone

If still symptomatic………LABA
Prevention:

Best way……..avoid dust and smoking

Asthma with exercise….sodium cromoglycate

( cromoglycate and nedocromil are mast cells stabilizers )

Paracetamol is the analgesia of choice in asthma

In asthma review the medications that the patient uses

When to say critical case of asthma

Critical Confused/drowsy, AGITATION…………MOST IMP

Maximal work of breathing accessory muscle use/recession

Exhaustion

Unable to talk

TTT of nocturnal asthma:

1st line……….LABA

2nd line……….cromoglycate

Pulmonary embolism ->

Sudden onset & Clear lungs

CP……..Dyspnea, chest pain and may be hemoptysis

High risk…..pregnant, bed ridden, long flight

Inv:

D-dimer…….if (-)…….exclude PE

Ecg…….sinus tachycardia, S1Q3T3

X-RAY……..usually normal or wedge shaped infarction

ABG……….hypoxia and hypocapnea

CTPA……..inv of choice,,,,imp

V/Q SCAN………MISMATCH

WHEN V/Q scan in the inv of choice?

1-renal impairment (high creat.,low GFR)

If V/Q scan (+)………start heparin ( LMWH )

TTT……..

WARFARIN 3-6 months

Target INR (2-3)

When to use IVC filter?......contraindication to anticoagulant

PE and pregnancy:

D-dimer……NOT used

Inv of choice ……half dose V/Q scan

TTT ….immediate start heparin if high probability

Pneumonia ->

Most common organism……strep.pneumoniae( Gram(+) diplococci)

If alcoholic………klebsiella

Pneumonia with skin lesions……..mycoplasma pneumonia

Pneumonia with GIT symptoms…….legionella

AIDS ( if CD4 less than 200)……..pneumocystitis carnii

After influenza ……staph

If cavitation ……….staph ( gram + cocci )

FEVER, cough, sputum coloration

Percussion ……..dullness

Tactile vocal fremitus…….increased (only disease in the chest)

Dullness + absent breath sounds + BRONCHIAL breathing = pneumonia

Most common organism………strep. Pneumonia

Signs of severity: ( CURB 65 )

CURB 0-1……….Outpatient ttt………Amoxycillin oral

CURB 2…….Inpatient ttt………… Amoxycillin oral +clarithromycin oral

CURB 3-5…ICU admission…….co-amoxclav IV + clarithromycin IV

MRSA………. Add vancomycin

How to do FU in pneumonia …..x-ray

Mycoplasma pneumonia…..atypical pneumonia:

Dry cough and headache

Skin……erythema multiform
Blood ……hemolytic anemia, cold agglutinin

Ear ……bullous myringitis…imp ….vesicles on TM

X-ray……bilateral interstitial infiltrate

TTT……tetracycline, doxycyclin

Legionella pneumonia:

Situations suggesting Legionella disease :

 Travel and staying in a hostel and exposure to air conditioning

 hyponatremia
 Pneumonia with prominent extrapulmonary manifestations (eg,
diarrhea, confusion, other neurologic symptoms)

Labs…..hyponatremia…..ttt is normal saline

Impaired liver enzymes

TTT: erythromycin

Klebsiella pneumonia:….friedlander's pneumonia

Associated with alcoholics and diabetics

Cp……..blood-stained sputum

Lobe affected….upper lobe (cavity)….imp

Pneumocystitis carnii pneumonia:

Pneumonia + HIV ( if CD4 less than 200 ) …..key word

Pneumonia + desaturation on exercise …..key word

X-ray……bilateral interstitial infiltrate

Inv of choice……..broncho-alveolar lavage

TTT…..TMP-SMX + iv pentamidine

Prophylaxis…..trimethoprim-sulphamethoxazole if CD4 less than 200

If CD4 less than 200 + HIV………..PCP

If CD4 more than 20 + HIV………strep.pneumoniae

Chlamydia psittaci pneumonia:

Related to exposure to birds and pets

Person to person transmission can occur

TTT : tetracyclin

Spontaneous pneumothorax:

Risk factor……..tall male smoker

Cp…..sudden acute chest pain……..IMMEDIATE CHEST-RAY

Management:

Less than 2 cm ( 30%)……discharge and F/U in outpatient clinics

More than 2 cm…..chest tube

3-Secondary pneumothorax:

Causes:

Emphysematous bullae, Severe asthma

Management:

If more than 2cm ( 30%)..............chest drain

If 1-2 cm ( 15-30%)...........aspiration and admission for 24 hs

If less than 1 cm ( 15%)……admission for 24 hs

Pleural effusion ->

Exam:

Trachea…..shifted to opposite side

Dullness to percussion at lung bases

Most imp inv…..thoracocentesis

Main ttt………chest tube

N :B:

TTT of tension pneumothorax……..needle decompression

TTT of pleural effusion…….tube decompression

Site of needle……..2nd intercostals space midcalvicular line

Site of tube…….5th space mid axillary line

During insertion of chest tube structures liable to injury ….intercostal

.nerve, artery and vein

Emphysema:

smoking………most common risk factor

Exam:

Puffiness of the eyelid

Barrel chest

Percussion……..resonant

Decreased breath sounds bilateral

wheezes with prolonged expiration

Sign of distress……pursing lips

X-ray:

hyperinflation …vvv imp

Low flat diaphragm

Elongated heart
Most imp Spirometry… imp

Obstructive lung disease:

FEV…….decreased

FVC…….decreased

FEV/FVC…..decreased

Residual volume…..increased

Total lung capacity……increased

Lung compliance……increased

ABG……HYPOXIA, HYPERCAPNEA

CBC…….polycythemia

How to decrease mortality?

1-Home o2 therapy

2-Vaccination

3-Stop smoking………….most imp

How to expect superimposed infection????

Fever or yellowish sputum

First step……. O2 and antibiotics

Common scenario : COPD patient with marked dyspnea in the ER

First step……..O2 ( 24%) 1st inv ………ABG …..Imp

How you know that you caused o2 toxicity????

By ABG……….. HIGH O2, HIGH CO2 ACIDOSIS

First step …………decrease the flow of oxygen

Types of ABG WITH COPD pt??

When he comes with EXAGGERATED SYMPTOMS in the ER:??

PO2……….decreased

PCO2……..INCREASED)

PH………..RESPIRATORY ACIDOSIS

If you by mistake give the pt high flow oxygen?????

PO2……..INCREASED

PCO2…….INCREASED

PH…….RESPIRATORY ACIDOSIS

First step…….decrease the O2 flow

Indications of O2 therapy in COPD???

FEV1 less than 30%.....most imp

Cyanosis, polcythemia

peripheral edema, increased JVP

N:B:

Most absolute indication for NIV ( CPAP ) in COPD……acidosis

Chronic bronchitis:

Chronic productive cough for at least 3 months per year for at least 2
successive years

bronchiectasis:

Permanent dilatation of the bronchi

Most common cause of hemoptysis

Can be Congenital………..immotile cilia syndrome:

bronchiectasis
Sinusitis

Male sterility

dextrocardia…..kartagner syndrome

Acquired….foreign body, tumour, secretions

Bronchiectasis is associated with huge amounts of sputum ….imp

Investigation:

Spiral CT……of choice …dilatation of bronchi

X-ray….honey comb appearance

Main TT is physiotherapy and postural drainage ….imp

If infection………amoxicillin-clavulanate or doxycycline

Acute bronchitis:

Most common cause of blood stained mucous

Most common cause…..viral infection

Cp…..fever, cough and hoarseness of voice …..NO inv needed ….NO ttt
Tuberculosis:

Organism….acid fast bacilli

Risk factors:

Immigrant

Nurses and physicians and IVDA

Most common site…….upper lobe

Cp:

Night sweat

Night fever

Loss of weight and Loss of appetite

Investigation:

1st inv……mantoux test or quantiferon test

If any of them (+)………chest x-ray

Definitive inv……….sputum analysis

If patient doesnot produce sputum ……get gastric wash …imp

How to deal with results?

If positive mantoux test:

First step…….X-RAY

If (-)…………isoniazid and vit B6 for 6-9 months

If (+)………...isolation and quadriple therapy

Treatment: Duration…..6-9 months

1-isoniazid

Most common side effect….peripheral neuropathy : give vitamin B6

2-Rifampicin

Side effect…..red urine. Hepatotoxicity

3-streptomycin

4-ethambutol……optic neuritis

5-pyrizinamide….hyperurecemia

Bronchogenic carcinoma:

Most common risk factor…….smoking

Types:

SCC…..related to smoking, central…..most common in UK

Adenocarcinoma….females, non smoker, most common, peripheral

Large cell carcinoma = sheets of polygonal or giant multinucleated cells

Small cell (oat cell)….paraneoplastic carcinoma

Cp:

Male old age smoker losing weight

Cough, dyspnea, hemoptysis

Pancoast tumour:vvvvvvvvvv imp

Site…..lung cancer at apex

Pressure the following:

Lower trunk on brachial plexus….pain and weakness at

hand

Sympathetic chain….Horner's syndrome

Venous ……congested neck veins

Arterial ….un equal pulse

Paraneoplastic syndrome:

Cause……small cell cancer

:Endocrine

Cushing syndrome

…..imp………..hyponatremiaSIADH

Hypercalcemia

Carcinoid syndrome

Hypoglycemia

Polycythemia

Neurological

Lambert-Eaton myasthenic syndrome

Polymyositis

Mucocutaneous

Dermatomyositis

Acanthosis nigricans

Pyoderma gangrenosum

Hematological

Polycythemia

Clubbing

Investigations:

First step…….CT

Best……bronchoscopy with biopsy

N:B:

Squamous cell carcinoma……….hypercalcemia

Small cell carcinoma……………….SIADH ( hyponatremia)

Lung fibrosis:

Most common cause……idiopathic

Cp…..more in females

dyspnea and cough

Clubbing and cyanosis

Crepitation

X-ray….bilateral interstitial infiltrate

ABG…..hypoxia

Spirometry :restrictive lung disease:

FEV…..DECREASED

FVC…decreased

FEV/FVC…..normal

Residual voloume…..decreased

Total lung capacity…..decreased

Lung compliance……decreased

Corpulmonale:

Right side heart failure secondary to pulmonary hypertension

Cystic fibrosis:… imp

Genetics….autosomal recessive….defect in chromosome 7

Defect …..Sweat gland…..viscid secretions

Cp:

Family history……(+)

At birth….meconium ielus

General condition…..impaired growth

Chest…….recurrent infections: pseudomonas is the most common

organism

Sinuses…..recurrent sinusitis

GIT…..malabsorption and steatorrhea or constipation

Rectum……prolapse
Pancreas……DM

Male…..absent vas deferens…..infertility….. imp

Investigation:

Sweat test…..increased sodium…..most imp inv

Pancreatic functions….impaired

Hypersensitivity pneumonitis:

Risk….environmental exposure to antigens

The patient becomes free of symptoms on the weekends

TTT……avoid antigen (change the job), cortisone

Extrinsic allergic alveolitis:

Hypersensitivity pneumonitis on exposure to certain antigens e:g: bird

Cp: dyspnea, dry cough and fever

Auscultation: fine basal creps

It is NOT allergy: no eosinohlia, no increase IgE, NO (+) skin prick

TTT: CHANGE THE JOB

Oral cortisone

Asbestosis:

Very long latent period………..15-30ys

Risk…..insulation workers, construction, ship building ( shipyard )

Increases risk of mesothelioma (rare) & lung cancer

Silicosis:

Risk….working in glass, or mines

Complication…..increased risk of TB
Mesothelioma:

Related to asbestos exposure

Risky jobs:

Manufacturers

Shipyards

Metal Works

Power Plants

Cp……chest pain, discomfort, dyspnea

x-ray…..pleural plaques

Inv ……CT

The best…biopsy

TTT…surgery and chemo

Most common complication…..pleural effusion …..if symptomatic then

aspirate or insert chest tube…..imp

Aspergilloma:
MOBILE fungus ball at the lung

Risk factor…..immunosupression

 CXR : rounded opacity

Surgical resection: is the curative ttt

Long term Itraconazole.

Allergic Broncho pulmonary aspergillosis (ABPA)

hypersensitivity reaction to Aspergillus in asthmatic people.

Steroids oral: is the mainstay of initial treatment

N:B:Effects of cortisone on eye …cataract and glaucoma…..drop of vision