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ATELECTASIS
collapse. loss of lung volume due to inadequate expansion of airspace
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Resorption atelectasis
occurs when obstruction prevents air from reaching distal airways. Air already present gradually becomes absorbed, and alveolar collapse follows
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most common cause of resorption atelectasis
obstruction of a bronchus by a mucous or mucopurulent plug
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resorption atelectasis most commonly occurs...
postoperatively but may also complicate bronchial asthma, bronchiectasis, chronic bronchitis, tumors, vascular aneurysms, enlarged lymph nodes or the aspiration of foreign bodies, particularly in children
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compression atelectasis
passive or relaxation atelectasis. accumulations of fluid, blood, or air within the pleural cavity, which mechanically collapse adjacent lung
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common causes of compression atelectasis
- Frequent occurrence w/ pleural effusions, caused most commonly by CHF.
- Leakage of air into the pleural cavity (pneumothorax)
- Basal atelectasis resulting from elevated position of diaphragm commonly in bedridden pts, in pts with ascites, and in pts during and after surgery
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Micro-atelectasis (nonobstructive atelectasis)
generalized loss of lung expansion
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common causes of Micro-atelectasis (nonobstructive atelectasis)
loss of surfactant, acute respiratory distress syndrome (ARDS), interstitial inflammation, post-surgical
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Contraction atelectasis
occurs when either local or generalized fibrotic changes in the lung or pleura hamper expansion and increase elastic recoil during expiration
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only type of atelectasis that is NOT reversible
contraction atelectasis
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Hyaline membranes lining distended alveolar ducts and neutrophils (if lung injury) are seen in...
acute respiratory distress syndrome
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ratio of FEV1 to FVC is characteristically decreased
obstructive dz: emphysema, chronic bronchitis, asthma, and bronchiectasis
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chest wall disorders in presence of normal lungs (severe obesity, dz of pleura, & neuro-muscular dz, such as Guillain-Barré syndrome, that affect respiratory muscles)
restrictive dz
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FEV1 to FVC is near normal
Restrictive lung dz
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Interstitial infiltrates are found in...
acute and chronic interstitial lung dz (restrictive dz)
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classic acute restrictive dz
acute respiratory distress syndrome
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chronic restrictive dz
pneumoconioses, interstitial fibrosis, sarcoidosis
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2 groups of emphysema pts
Non bronchitic pts are pink puffers because they have oxygenated Hb w/ dyspnea.
Bronchitic pts are blue bloaters because they have no prominent dyspnea/respiratory effort à retain CO2 à hypoxic & cyanotic. Pts tend to be obese
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centriacinar emphysema
involves central/proximal parts of acini, mainly upper lobes affected, common in smokers
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panacinar emphysema
more common in those w/ alpha 1 antitrypsin deficiency. involves lower lung zones, acini are uniformly enlarged from the level of the respiratory bronchiole to terminal blind alveoli
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Distal Acinar (Paraseptal) Emphysema
proximal portion of the acinus is normal but the distal part is primarily involved
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distal acinar emphysema characteristics
i.
emphysema is more striking adjacent to the
pleura, along the lobular connective tissue septa, and at the margins of the
lobules
ii.
adjacent to areas of fibrosis, scarring, or
atelectasis and is usually more severe in the upper half of the lungs
iii.
cystlike structures referred to as bullae.
probably underlies many cases of spontaneous
pneumothorax in young adults
emphysema is more striking adjacent to the pleura, along the lobular connective tissue septa, and at the margins of lobules. adjacent to areas of fibrosis, scarring, or atelectasis and is usually more severe in the upper half of the lungs bullae.
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almost invariably assoc w/ scarring. May be the most common form of emphysema
irregular emphysema
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compensatory emphysema
compensatory dilation of alveoli in response to loss of lung substance elsewhere
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produces large subpleural blebs or bullae. They represent localized accentuations of one of the emphysemas, are most often subpleural, and may rupture leading to pneumothorax
bullae emphysema
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emphysema that may occur spontaneously w/ sudden incr in intra-alveolar pressure (vomiting or violent coughing) that causes a tear. Sometimes
in children w/ whooping cough. Pts on respirators who have partial bronchiolar obstruction or in persons who suffer a perforating injury
mediastinal (interstitial) emphysema
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chronic bronchitis criteria
persistent productive cough for at least 3 consecutive months in at least 2 consecutive years
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Common at night and/or early in morning. attacks last from 1 to several hours. Thickening of basement membrane of bronchial epithelium. Hypertrophy of bronchial muscle walls
asthma
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histological diagnostic features of asthma
Curschmann spirals and Charcot-Leyden crystals
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Bronchospasm is much more severe and sustained. A positive family history is uncommon, serum IgE levels are normal, and there are no associated allergies
Non-atopic asthma
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drug induced asthma
usually aspirin. recurrent rhinitis and nasal polyps, urticaria, and bronchospasm
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permanent dilation of bronchi & bronchioles (may be to pleural surfaces) caused by destruction of muscle & elastic supporting tissue
bronchiectasis
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affecting lower lobes bilaterally, resulting from or associated w/ chronic necrotizing infections (may lead to abscess)
bronchiectasis
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features of bronchiectasis
- desquamation of lining epithelium --> extensive areas of ulceration
- peribronchialar fibrosis
- severe, persistent cough with expectoration of mucopurulent, sometimes fetid, sputum. The sputum may contain flecks of blood; frank hemoptysis can occur
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bronchial obstruction subtype of bronchiectasis caused by...
Congenital or hereditary conditions(Kartagener’s and cystic fibrosis)
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conditions that predispose people to bronchiectasis
Necrotizing, or suppurative, pneumonia: Staph aureus or Klebsiella spp.. childhood pneumonias that complicated measles, whooping cough, and influenza. TB.
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In full-blown active case, an intense acute and chronic inflammatory exudate within the walls of bronchi and bronchioles and the desquamation of lining epithelium cause extensive areas of ulceration
bronchiectasis
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mixed flora of bronchiectasis
staphylococci, streptococci, pneumococci, enteric organisms, anaerobic and microaerophilic bacteria, and (particularly in children) Haemophilus influenzae and Pseudomonas aeruginosa.
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reduced compliance, hypoxia, Chest radiographs show diffuse infiltration by small nodules, irregular lines, or "ground-glass shadows."
diffuse interstitial (restrictive) dz
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most chronic restrictive lung diseases, irrespective of etiology, shows up as
diffuse interstitial pulmonary fibrosis with or without honeycombing
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earliest common manifestation is alveolitis --> proliferation of fibroblasts
diffuse interstitial (restrictive) lung dz. progressive interstitial fibrosis
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diffuse interstitial fibrosis. Males are affected more often than are females, pts older than 60
Idiopathic pulmonary fibrosis, also known as cryptogenic fibrosing alveolitis. also called usual interstitial pneumonia.
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Idiopathic pulmonary fibrosis or usual interstitial pneumonia
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usual interstitial pneumonia
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Sarcoidosis. more common in African Americans and Scandinavians. Hilar lymphadenopathy
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Asteroid bodies are found in...
sarcoidosis. more common in African Americans and Scandinavians. Hilar lymphadenopathy
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extrinsic allergic alveolitis. Goes away when leaves site of exposure
Bird fancier’s lung
Air conditioner/hot tub lung
Farm’s (silo fillers) lung
Byssiniosis
Suberosis
hypersensitivity pneumonia
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acute eosinophilic pneumonia
Rapid onset fever, dyspnea, hypoxia, pulmonary infiltrates. Bronchoalveolar lavage: 25% eosinophils
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Loffler’s syndrome (simple pulmonary eosinophilia)
eosinophilia in blood, transient pulmonary lesions. benign
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tropical eosinophilia
Infection with microfilirial parasites
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idiopathic chronic eosinophilia
High fever, night sweats, dyspnea. Lymphocytes & eosinophils within alveolar spaces, septal wall
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Idiopathic pulmonary fibrosing conditions
usual interstitial pneumonia, pneumonia, collagen vascular dz, Pneumoconiosis
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granulomatous fibrosing dz
hypersensitivity pneumonia, sarcoidosis
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eosinophilic fibrosing dz
tropical eosinophilia, acute eosinophilic pneumonia, idiopathic chronic eosinophilia, Loffler’s syndrome (simple pulmonary eosinophilia)
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smoking related fibrosing dz
desquamative pneumonia and Respiratory bronchiolitis
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desquamative pneumonia. Ground glass infiltrates predominantly in lower lobes
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lymphoid interstitial pneumonia. Rare lymphoplasmacytic infiltrate. Associated w/ collagen vascular disease, dysproteinemia, immunodeficiency, infection
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drug associated w/ pneumotitis and fibrosis
amiodarone
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anticancer agent, causes pneumonitis and interstitial fibrosis, as a result of direct toxicity of drug and by stimulating influx of inflammatory cells into alveoli
bleomycin
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pulmonary hypertension in main elastic artery
atheromas similar to those in systemic atherosclerosis
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pulmonary hypertension in medium-sized muscular arteries
proliferationof myointimal cells and smooth muscle cells, causing thickening of intima and media with narrowing of the lumina
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pulmonary hypertension in smaller arteries and arterioles
thickening, medial hypertrophy, and reduplication of the internal and external elastic membranes.
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plexogenic pulmonary arteriopathy
Individuals w/ severe, long-standing primary pulmonary htn may develop capillary formations, producing a network, or web, that spans the lumens of dilated thin-walled, small arteries
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Goodpasture syndrome
proliferative, usually rapidly progressive, glomerulonephritis & hemorrhagic interstitial pneumonitis. Both renal & pulmonary lesions are caused by Abs against collagen IV
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Features of Goodpasture syndrome
diffuse alveolar hemorrhage, fibrous thickening of the septa, hypertrophy of septal lining cells. hemosiderin, linear pattern of immunoglobulin deposition (usually IgG, sometimes IgA or IgM)
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bronchopneumonia
patchy distribution of inflammation that generally involves more than one lobe
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lobar pneumonia
airspaces of part or all of a lobe are homogeneously filled w/ exudate that can be visualized on X ray lobar or segmental consolidation. Streptococcus pneumoniae (>90%)
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Community-acquired acute pneumonia
S pneumoniae most common. abscess formation, infective endocarditis, meningitis, arthritis, empyema
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bronchopneumonic pattern of community-acquired pneumonia
foci of inflammatory consolidation are distributed in patches thru out 1 or several lobes, most frequently bilateral and basal. Lesions up to 3 or 4 cm in diameter are slightly elevated and are gray-red to yellow
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other common causes of community-acquired pneumonia
H influenza, Moraxella, Staph aureus, Klebsellia pneumonae, pseudomonas, legionella
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stages of community-acquired pneumonia
first stage--congestion, proteinaceous fluid, scattered neutrophils, and many bacteria in alveoli.
W/in a few days, stage of red hepatization: lung lobe has a liver-like consistency; alveolar spaces are packed w/ neutrophils, red cells, and fibrin.
In gray hepatization, lung is dry, gray, & firm, cuz red cells are lysed, while fibrinosuppurative exudate persists w/in alveoli.
Resolution: follows in uncomplicated cases. granular, semifluid debris ingested by macs, coughed up, or organized by fibroblasts growing into it. pleural rxn (fibrinous or fibrinopurulent pleuritis) may resolve or undergo organization, leaving fibrous thickening or permanent adhesions
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community-acquired atypical pneumonia
moderate amts of sputum, absence of consolidation, moderate elevation of WBCs, lack of alveolar exudates. Mycoplasma pneumoniae most common (particularly common among children and young adults). Viruses, including influenza types A and B, respiratory syncytial viruses, adenovirus, rhinoviruses, rubeola, and varicella viruses; Chlamydia pneumoniae and Coxiella burnetti (Q fever)
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Acute infections of upper resp (common cold) etiology
most common pathogens are rhinoviruses, but coronaviruses, respiratory syncytial viruses, parainfluenza and influenza viruses, adenoviruses, enteroviruses, and sometimes even group A β-hemolytic streptococci
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More severe forms w/ tonsillitis, marked hyperemia and exudates, occur w/ β-hemolytic strep and adeno-virus infections
acute pharyngitis
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strep tonsilitis can develop into...
peritonsillar abscesses ("quinsy") or result in post-streptococcal glomerulonephritis and acute rheumatic fever
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Acute bacterial epiglottitis is a syndrome predominantly of young children who have an infection of the epiglottis by
Haemophillus influenza
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can result from inhalation of irritants or may be caused by allergic reactions. It may also be caused by agents that produce the common cold and usually involve pharynx and nasal passages as well as the larynx
acute laryngitis
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type of acute laryngitis that shows sloughing and aspiration of the pseudomembrane (causing obstruction of major airways) and absorption of bacterial exotoxins (producing myocarditis, peripheral neuropathy, or other tissue injury)
diptheritic. inhaled Corynebacterium diphtheriae
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types of acute laryngitis
diptheritic and tuberculosis
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laryngotracheobronchitis, more commonly known as croup
more common in children, most common cause is parainfluenza virus. inspiratory stridor and harsh, persistent cough. secondary bacterial infection, by staphylococci, streptococci, and H. influenzae
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benign laryngeal tumors
vocal cord nodules and laryngeal papilloma (squamous papilloma of larynx)
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vocal cord nodules
smooth, hemispherical protrusions located on true vocal cords. Nodules are composed of fibrous tissue & covered by stratified squamous mucosa. lesions occur chiefly in heavy smokers or singers (singer's nodes), suggesting that they are the result of chronic irritation or abuse
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laryngeal papilloma or squamous papilloma of larynx
benign neoplasm, usually on true vocal cords, that forms a soft, raspberry-like excrescence. Multiple, slender, finger-like projections supported by central fibrovascular cores & covered by an orderly, typical, stratified squamous epithelium. trauma may lead to ulceration that can be accompanied by hemoptysis
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laryngeal papilloma or squamous papilloma of larynx
Papillomas are usually single in adults but are often multiple in children, in whom they are referred to as recurrent respiratory papillomatosis (RRP). Caused HPV types 6 and 11, do not become malignant (rare), and often spontaneously regress at puberty.
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2% of all cancers. It most commonly occurs after age 40 years and is more common in men (7 : 1) than in women
carcinoma of larynx
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persistent hoarseness. Glottic region has a sparse lymphatic supply, and spread beyond larynx is uncommon. supraglottic larynx is rich in lymphatic spaces --> metastasize to regional (cervical) lymph nodes
carcinoma of larynx
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Subglottic tumors tend to remain clinically quiescent, usually presenting as advanced disease. 1/3 die of dz
carcinoma of larynx
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occurs in smokers, alcoholics, and asbestos exposure. typical squamous cell lesions. Tumor develops directly on cords (glottic tumors) in 60% to 75% of cases, but it may arise above the cords (supraglottic; 25% to 40%) or below the cords (subglottic; less then 5%)
carcinoma of larynx
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a certain change in the way the tongue looks. whitish, well-defined mucosal patch caused by epidermal thickening or hyperkeratosis
leukoplakia
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more frequent among older men
Risk Factors: tobacco, chronic friction, alcohol abuse
3% - 6% transformation risk to squamous cell carcinoma. Much higher risk of transformation if it is red
leukoplakia
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Mostly are squamous cell carcinomas. difficulty chewing, asymptomatic, or pain. can be caused by chewing Paan
oral and tongue cancers
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risk factors for oral/tongue cancers
- Leukoplakia (particularly if it is a reddish leukoplakia)
- HPV 16 &18 oral sex
- Tobacco and Alcohol (prognosis is better in HPV patients, compared to tobacco-induced carcinomas)
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Waldeyer's ring
ring of lymphoid tissue in the back of the throat, the nasopharynx. It contains the tonsils, the adenoids
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eustachian tube is close to the..
adenoids. --> otitis media infections
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otitis media needs to be treated immediate to avoid..
meningitis
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distinguishing features (for etiology) of pharyngitis
water blisters = viral cause. Whitish pharynx w/ red specks = bacterial cause
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"barking" cough, inspiratory stridor, and hoarseness. It is often worse at night. most commonly between 6 months and 6 years of age. It is almost never seen in teenagers or adults
Croup (laryngotracheobronchitis)
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Croup. Steeple sign is due to epithelial edema --> blocking airway
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medical emergency that may result in death if not treated quickly. ... complete blockage of the airway may occur
epiglottitis
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etiology of epiglottitis
haemophilus influenza B. can be pertussis --> whooping cough
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Positive stranded RNA viruses
- a. small: picorno viruses (Polio, Echo, Coxsackie)
- b. large: Arboviruses (Equine encephalitis, West Nile encephalitis)
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negative stranded RNA virus
influenza, Parainfluenza (aka Myxovirus, Paramyxovirus; measles)
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Double stranded circular RNA viruses
Rheo virus, Rotavirus (infantile diarrhea)
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laryngeal carcinoma
accts for 25% of head and neck cancer but 1-2% of all cancers. Most prevalent in the 6th and 7th decades of life. 4:1 male predilection. Patients considered cured after being disease free for five years. Most laryngeal cancers reoccur in the first two years
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features of progressive respiratory failure in ARDS
- honeycomb appearance of lung, acute onset of dyspnea, decreased arterial oxygen pressure (hypoxemia) , bilateral pulmonary infiltrates on
- radiographs, absence of primary left-sided heart failure, caused by damage to the alveolar capillary membrane, most common cause of non cardiogenic pulmonary edema
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phases of ARDS
Exudative phase (0 to 7 days): capillary congestion, necrosis of alveolar cells, alveolar edema and hemorrhage. Alveoli collapse. Fibrin thrombi in capillaries and large vessels. most characteristic finding is hyaline membranes.
proliferative phase (1 to 3 weeks): proliferation of type II pneumocytes (produces surfactant DPPC). phagocytosis of remnant hyaline membrane
Fibrotic phases: diffuse interstitial fibrosis (honeycomb lung)
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diffuse alveolar dz is the same as
hyaline membrane dz of the newborn aka- infant respiratory distress syndrome (IRDS)
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pts develop ARDS w/in ___ hrs of insult
72
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distal acinar (paraseptal) emphysema
- bullae formation, upper half of lungs, can lead to spontaneous pneumothorax in young adults, emphysema is more striking adjacent to the pleura,
- along lobular connective tissue septa, and at the margins of the lobules
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carrier is resistant to something in the environment. URIs? TB? Pneumonia? Influenza? Infections generally
panacinar emphysema. common in those w/ alpha 1 antitrypsin deficiency. lower lobe of lung
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early phase of asthma lasts...
30-60min
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late phase asthma lasts...
4-8hrs
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extrinsic asthma more often affects adult or children?
children
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intrinsic asthma more often affects adults or children?
adults
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pulmonary fibrosis
Alveolitis produces fibroblast proliferation --> destroys distal part of acinus. collagen deposition over time (Trichrome stain). Proximal part becomes dilated
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acute hypersensitivity pneumotitis is type ___
III
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chronic hypersensitivty pneumotitis is type
IV --> granulomatous formation
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chronic hypersensitivity pneumotitis
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hypersensitivity pneumotitis causes...
progressive pulmonary fibrosis. Bilateral diffuse soft nodular densities. Reflects inflammation and scarring
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pneumoconiosis
Chronic fibrosis pulmonary disorders caused by dust inhalation. > 40 inhaled minerals cause lung lesions and radiographic abnormalities. Some lead to crippling pulmonary diseases. Restrictive lung dz
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silicosis
- most prevalent chronic occupational disease in world. A dz of sandblaster, mining, ceramic manufacturing, stone cutting. Particles 0.2-2.0 mm are most dangerous. Crystalline silica (silicon dioxide) is more toxic
- Simple nodular silicosis (most common): Whirled nodule with concentrically arranged collagen Nodules are less than 1 cm
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acute silicosis
(uncommon). Diffuse lung fibrosis; no nodules. Due to heavy exposure
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coal worker's pneumoconiosis
Inhalation of coal dust causes anthracosis. Black lung dz. Asymptomatic anthracosis
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coal worker pneumoconiosis
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simple coal worker's lung
(nodules): Small lesions (1-4 mm), multiple
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complicated coal worker's lung
(aka. Progressive massive fibrosis): 2 cm or larger
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asbestos
- Chrysotile type is used mostly for commercial use. Amphibole crocidolite has high disease association than crysotile
- Asbestos (Ferruginous) bodies = coated with iron & protein
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risks associated w/ asbestos fibers
- Usually present in office & house building materials, pipe (insulation)
- Cigarette smoking increases the risk of lung cancer (not mesothelioma)
- Exposed family members: increased cancer risk
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asbestos-related dz
- asbestos
- mesothelioma (pleural & peritoneal)
- carcinoma of lung
- pleural plaque
- diffuse pleural fibrosis
- benign pleural effusion
- laryngeal carcinoma
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asbestos and pleural plaques
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mesothelioma. much later complication of asbestos
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Lymphangioleimyomatosis
- Abnormal smooth muscle proliferation in lungs, lymph nodes, & lymphatics. Growth along blood vessels, lymphatics, and bronchioles
- Rare interstitial lymphoid dz. Etiology unknown; Possible hormonal control. Women, child-bearing age
- SOB, cough, spontaneous pneumothorax, cough, hemoptysis, chylous effusion
- Special histologic stain: HMB-45 (melanoma antigen). May also be estrogen,progesterone receptor positive
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asthma morphology
- peribronchiolar cuffing, whorls of shed epithelium (Curschmann spirals). Charcot-Leyden crystals (collections of crystalloids made up of eosinophil
- proteins)
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