Pulmonary Embolism

Risk factors :- (learn them.. these are very important)
Trick - BOL HOT FAT PP
• Old
• Fat
• Pregnancy
• Oestrogen
• Homocystinemia
• Trauma / Surgery
• Pelvic cancer
• Leg paralysis
• Bechet's disease

C/F :-
• Dyspnoea (MC)
• Chest pain
• Tachypnea
• Neck vien distension
• DVT/ Immobilization
• Heart rate >100/min

Diagnosis :-
• D-dimer (Used for screening mainly)
• CT with IV contrast (Investigation of choice)
• Lung perfusion scan (2nd line test)
• Selective pulmonary angiography (most specific)
• CXR :-
  Trick - West Ham se pallas le ao
  Westermark's sign
  Hampton's sign

Watermark sign (R) Hampton's sign (L)

  Palla's Sign
• ECG - Sinus Tachycardia (always present)

T/t :-
• O2 and mechanical ventilation
• IV fluid 500-1000 ml (Slow perfusion is must else it can lead to right ventricular failure)
• Anticoagulant (mainstay)
• Thrombolytics
• Embolectomy
• Vana Cava filter
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VanaCaval Filter

Pleural Effusion

• CXR - Homogenous opacity

Trnasudative Pleural Effusion :-
• Pleural membrane is intact
• Increased pulmonary hydrostatic pressure
• Decreased systemic colloid osmotic pressure
• Low protein
• Low LDH

Exudative Pleural Effusion :-
• Pleural membrane involved
• Increased capillary wall permeability
• Elevated protein level

Pleural Effusion with low glucose :-
Trick (BMR)
• Bact. Infection
• Malignancy
• Rheumatoid Arthritis

Amylase elevated in Pleural fluid :-
Trick (PREM)
• Pancreatitis
• Ruptured Ectopic Pregnancy
• Esophageal rupture
• Malignancy

Diagnosis :-
PF protein / serum protein > 0.5
PF LDH / serum LDH > 0.6
PF LDH > 2/3 upper normal serum limit
TB pleural effusion :-
• Hemorrhagic fluid
• Adenosine deaminase > 45 IU/L
• Interferon gamma > 140 pg/ml
• Positive polymerase chain reaction

Cholesterol in Pleural effusion :-
Trick (HAT)
• Hypothyroidism
• Rheumatoid Arthritis
• TB
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Neoplasm of lung

• MC lung cancer in non smokers.
• Squamous cell carcinoma and small cell carcinoma are strongly associated with Cigarette smoking.
• MC histological type - Adenocarcinoma.
• MC in India - Squamous cell carcinoma.

Adenocarcinoma :-
• Peripheral lesions
• Grows slowly than SCC.
• MC lung cancer in women.
• No symptoms in early stages.
• Pain due to pleural involvement.

Mucinar type of Adenocarcinoma

Squamous cell carcinoma :-
• Arise in central airways.
• Presents with pulmonary symptoms.
• Hemoptysis (blood streaking with mucous)
• Pneumonia
• Lung abscess
• Cough, dyspnea, wheezing

Keratin pearls visible

Pancoast syndrome :-
• Apical chest wall or shoulder pain
• Horner syndrome
• Redicular arm pain

Bronchial adenoma :-
• Hypervascular
• Recurrent hemoptysis.

Oat cell carcinoma - Pure small cell carcinoma

Ectopic hormone production.
• Small cell carcinoma - ACTH, ANP, Calcitonin and Gonadotropins.

Clubbing (MC) - Non small cell carcinoma
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Tuberculosis (TB)

Military TB

1. Primary TB
2. Secondary TB

Asymptomatic Primary TB -
• Caseous granuloma - Ghon's focus (in lung parenchyma)
• Ghon's focus + Perihilar lymph node granuloma = Ghon's / Ranke's complex
• No cavitation
• Pleural involvement is common and U/L
• Pleural effusion

Symptomatic Primary TB -
• Affects children, elderly and immunocompromised.
• Cavitary lesions.

Secondary TB -
• Reactivation
• Hilar lymphadenopathy is not a primary character


Diagnosis :-
Tuberculin test
• Positive test - Induration >10mm in 48 hours
• False negative - (very imp, learn them all)
1. Miliary TB
2. Measles
3. Severe Malnutrition
4. Sarcoidosis
5. Lymphoraticular malignancy

CXR - Upper lobe disease with cavities and infiltration.

Upper lobe + Perihilar involvement

Polycythemia Vera / Osler Vaquez disease

• Increased production of RBC, WBC and Platelets.
• Differntiation is normal therefore all the cells produced are normal.

C/F :- these are very imp remember them all
• Hyperuricemia - Increased turnover of cells
• Intense Itching - Due to histamine release (Increase in Basophil causes this)
• Gouty Arthritis - Hyperuricemia
• Peptic Ulcer disease - Histamin & H.pylori
• Erythromelalgia (Burning pain and reddish bluish discoloration of skin) - Increased Platelet aggregation
• Deep Vein Thrombosis - Megakaryocytosis
• Hypertension
• Neurological - Headache, Vertigo, Tinnitus

Erythromelalgia

Erythromelalgia

Diagnosis :-
• Tyrosine Kinase (JAK2) gene mutation
• RBC >6 million/cu mm
• Hematocrit > 0.52 in men > 0.48 on women
• Hb > 18 gm%
• ESR is reduced
• Increased NAP, Increase in transcobalamine
• Increased Platelet count

• Incidence of infection is not Increased

Tumours associated :- Questions are frequently asked from these. Learn them all
1. Hypernephroma
2. Hepatoma
3. Adrenal adenoma
4. Pheochromocytoma
5. Cerebellar Hemangioblastoma
6. Uterine Fibromyoma
7. Meningioma
8. Cushing Syndrome

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T/t :-
Phlebotomy
Low dose Aspirin (75 mg)
Interferon
Erlotinib

Myxoma

Diastolic gradient present in left atria and ventricle due to mitral stenosis (Absent in normal heart)
•MC in left Atria of females
•MC benign tumour of heart

Familial myxoma :-
Carney Syndrome
•Myxoma of Breast or skin
•Spotty pigmentation
•Endocrine overactivity

C/F :-
Renal artery/ coronary artery embolism
Examination:-
•Loud and split 1st heart sound
•P2 accentuated
•Tumour plop diastolic sound

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Osteoarthritis and Charcot's foot/joint

Joints involved in Osteoarthritis :-
• DIP (not involved in RA)
• PIP
• Only 1st CMC
• Doesn't involve MCP, wrist, CMC joints

D/d :-
•Charcoat's joint (loss of pain sensations and proprioception)

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Causes :-
TRICK LSD on Table
L - Leprosy
S - Syringomyelia
D - Diabetes Mellitus
Table - Tabes Dorsalis

•Findings in Charcoat's:-
1. Fragmentations
2. Eburnation
3. Osteophyte formation
4. Intraarticular loose bodies

C/F :-
Involves single joint
Joint become unstable
Crepitus

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Various cases of Charcoat's foot

Allergic Bronchopulmonary Aspergillosis

Characterised by :-
• Pre-existing Asthma
• Pulmonary Infiltrate
• Increased Eosinophils in blood
• Elevated serum IgE
• Central Bronchiectasis

Cause :-
•Hypersensitivity to Aspergillus Fumigatus

C/F :-
•Excessive mucus production (mucus plugs)
•Aspergillus doesn't invade the blood stream
•Development of Bronchiectasis

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Radiologic features :-
•B/L Flecting opacities (mainly in Upper lobe)
•Central Ring Shadows
•Tram track bronchial walls
• Finger in glove sign

Finger in glove sign

Finger in glove sign

Imp note :-
• Aspergilus Niger - Fungal ortis externa
• Cavitary lesions - Absent in ABPA
• Cavitary lesions with fungal balls - Aspergilloma

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Fungal ball evident

Cavitary lesion with fungal ball

Bronchiectasis

• Permanent dilatation of bronchi and bronchioles
• Affects lower lobe on left side

Etiopathogenesis :-
• Obstruction
• Infection

C/F :-
• Cough and formation of tenacious sputum
• History of frequent bronchitis

Diagnosis :-
• HRCT - Investigation of choice
Airway dilatation - Tram track/Signet Ring sign
Lack of bronchial tapering
Tree in bud pattern

Conditions associated :-
TRICK - hey YOUNG Squeeze the ALLERGIC FIBROUS MAL INTO YELLOW KART.
Young syndrome
Pulmonary Sequestration
Allergic bronchopulmonary aspergillosis
Cystic fibrosis
Broncomalacia
Yellow nail syndrome
Kartagener syndrome

Complications :-
TRICK - PHERA
• Pericarditis
• Hemoptysis (massive)
• Empyema
• Respiratory failure
• Amyloidosis

ARDS / Shock Lung/ Acute Lung Injury

• Acute Diffuse Alveolar Injury
• Non Cardiogenic Pulmonary Edema

Diagnostic criteria :-
• Acute onset
• PaO2/FiO2 < 200mm of it
• Chest X-ray - B/L pulmonary infiltrate
• PCWP < 18mm hg

Pathophysiology :-
Exudative phase - Damage to capillary endothelium & type 1 and 2 alveolar cells -> Pulmonary edema -> 👇 compliance -> Stiff lung

C/F :-
• Type 1 Resp failure
• Coarse rales, Diffuse ronchi
• Right to left shunting
• Pulmonary hypertension

Diagnosis :-

B/L diffuse alveolar and reticular opacities

T/t :-
• Airway pressure release ventilation
• +ve end expiratory pressure

Ocrelizumab successfully slows the progression of MULTIPLE SCLEROSIS.

●Ocrelizumab is a humanized anti-CD20 monoclonal antibody.

●It is developed as a treatment for multiple sclerosis by Genentech (a US based Biotech company).

●Ocrelizumab is a slightly modified version of Genentech's existing therapy Rituxan/Rituximab.

Clinical trials:-
●In October 2010, Roche announced 24-week results from the PhII study in relapsing-remitting MS. The drug demonstrated a statistically significant reduction in disease activity as measured by brain lesions (measured by MRI scans) and relapse rate compared to placebo.

●On October 9, 2015, Genentech presented interim results of three Phase III clinical trials that look promising. Progression of disability was reduced at 12 and 24 weeks.

●On February 17, 2016 FDA granted Breakthrough Therapy Designation for primary progressive multiple sclerosis(PPMS).

●Genentech recently announced favorable results from a pivotal Phase 3 trial called ORATORIO, a randomized, double-blind, global and multicenter study evaluating the efficacy and safety of ocrelizumab in 732 patients with primary progressive multiple sclerosis (PPMS). The drug was administered intravenously, as two infusions of 300 mg given two weeks apart every six months.

●Data from two related Phase 3 studies, OPERA I and II, testing the efficacy of the drug in 1,656 patients with relapsing forms of MS, found that ocrelizumab was superior to interferon beta-1a, a well-established MS therapy, reducing the annualized relapse rate (the primary endpoint of both studies) by nearly 50 percent over a two-year controlled treatment period. Ocrelizumab was administered intravenously at 600 mg every six months; interferon beta-1a was given by subcutaneous injection at 44 mcg three times per week.

Source : Wikipedia, CNN, Roche