Lecture X: Consolidation Syndromes
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What are the four criteria for a pulmonary consolidation to be accessible to a physical examination?

The four criteria for a pulmonary consolidation to be accessible to a physical examination are: (1) size of the lesion should exceed 4 cm, (2) location must be close to the thoracic surface, (3) there must be sufficient thickness of the consolidation, (4) the bronchus corresponding to the consolidation must be permeable.

Pulmonary consolidation can be produced by any pathological process that increases the density of the ______ by replacing the alveolar air.

lung parenchyma

What are the two types of pectoriloquy?

  • Bronchophony (correct)
  • Egophony (correct)
  • Whispered Pectoriloquy
  • Tactile Fremitus

    • Bronchophony is a type of pectoriloquy that refers to a high-pitched nasal or bleating quality of the voice.

    <p>False</p> Signup and view all the answers

    Which of the following is NOT a type of pneumonia?

    <p>Hydrothorax</p> Signup and view all the answers

    What are the four major etiological categories of pneumonia?

    <p>The four major etiological categories of pneumonia are: (1) bacteria, (2) viruses, (3) atypical agents (including bacteria like Legionella and Mycoplasma), and (4) fungi.</p> Signup and view all the answers

    Which of the following is a common symptom associated with bronchopneumonia?

    <p>Altered Mental Status</p> Signup and view all the answers

    What are the four prominent physical examination findings in bronchopneumonia?

    <p>The prominent physical examination findings in bronchopneumonia include: (1) superficial breaths, (2) tachypnea, (3) wheezing, and (4) augmented tactile and vocal fremitus, particularly with confluent consolidations.</p> Signup and view all the answers

    Atypical pneumonia is caused by organisms that can be detected on Gram stain and cultured using standard methods.

    <p>False</p> Signup and view all the answers

    What are the three phases of lung abscess development?

    <p>The three phases of lung abscess development are: (1) Phase I, mimicking an acute pneumonia with possible consolidation, (2) Phase II, presenting with high quantity of sputum, (3) Phase III, characterized by periods of suppuration and fluctuating symptoms.</p> Signup and view all the answers

    Which of the following is NOT a typical symptom associated with lung abscess?

    <p>Severe Pleuritic Chest Pain</p> Signup and view all the answers

    Pulmonary infarction is always caused by pulmonary embolism.

    <p>False</p> Signup and view all the answers

    What is the name of the wedge-shaped opacity on chest X-ray that is a classic sign of pulmonary infarction?

    <p>The wedge-shaped opacity on chest X-ray indicative of pulmonary infarction is called the Hampton hump.</p> Signup and view all the answers

    What is the preferred imaging technique for diagnosing pulmonary embolism?

    <p>Computed Tomography Pulmonary Angiography (CTPA)</p> Signup and view all the answers

    What are the main three purposes of echocardiography in diagnosing pulmonary infarction?

    <p>Echocardiography is used to stratify risk, guide management (particularly for those with unstable conditions), and assess the prognosis in patients with pulmonary infarction.</p> Signup and view all the answers

    Acanthosis nigricans is a disease itself, primarily affecting the skin.

    <p>False</p> Signup and view all the answers

    What are the two main mechanisms behind the development of acanthosis nigricans?

    <p>Acanthosis nigricans develops due to two primary mechanisms: (1) overproduction of skin cells, and (2) an increase in skin pigmentation.</p> Signup and view all the answers

    Match the following paraneoplastic syndromes with their associated hormonal abnormalities:

    <p>Cushing's syndrome = ACTH, CRH Acromegaly = GHRH, GH Hypercalcemia = PTHrP, PTH Hyponatremia = ADH, ANP Gynaecomastia = hCG Hypoglycemia = Insulin, IGF1, big IGF</p> Signup and view all the answers

    Pancoast-Tobias syndrome is primarily associated with tumors located in the central part of the lung.

    <p>False</p> Signup and view all the answers

    What are the five key components of Claude Bernard Horner's syndrome?

    <p>The five key components of Claude Bernard Horner's syndrome are: (1) miosis, (2) enophthalmos, (3) ptosis, (4) anhidrosis, (5) ipsilateral loss of sweating.</p> Signup and view all the answers

    Paraneoplastic syndromes are always directly caused by local effects of the tumor or its metastases.

    <p>False</p> Signup and view all the answers

    What are the five main categories of paraneoplastic syndromes based on the affected organ system?

    <p>The five main categories are: (1) endocrinological, (2) neurological, (3) rheumatological, (4) glomerular diseases, (5) dermatological.</p> Signup and view all the answers

    Histological examination is not essential for diagnosing pulmonary tumors.

    <p>False</p> Signup and view all the answers

    Which of the following is NOT a potential complication of lung cancer that can be detected on chest X-ray?

    <p>Pleural Effusion</p> Signup and view all the answers

    What are the three main methods used in bronchoscopy to obtain samples for histological analysis of lung tumors?

    <p>The three main methods are: (1) washing, (2) brushing, (3) biopsy.</p> Signup and view all the answers

    Lung ultrasound is primarily used for central tumors in the lung.

    <p>False</p> Signup and view all the answers

    What are the three main patterns of lung consolidation observed on chest X-rays?

    <p>The three main patterns are: (1) lobar consolidation involving a single lobe, (2) diffuse consolidation spread across multiple lobes, (3) multifocal ill-defined consolidation.</p> Signup and view all the answers

    Which of the following is a common X-ray sign that often necessitates further investigation?

    <p>Solitary Pulmonary Nodule</p> Signup and view all the answers

    A deviated trachea on chest X-ray can be a sign of pneumothorax.

    <p>True</p> Signup and view all the answers

    What are the five key areas of the chest X-ray that should be examined systematically to ensure a thorough review?

    <p>The five key areas are: (1) airway, (2) breathing, (3) soft tissues, (4) circulation, (5) diaphragm.</p> Signup and view all the answers

    Study Notes

    Lecture X: Consolidation Syndromes

    • Consolidation syndromes involve increased density in the lung parenchyma. This occurs when alveolar air is replaced by exudate or neoplastic cells.
    • Possible causes include pneumonia, bronchopneumonia, pulmonary infarction, fibrosis (interstitial lung diseases), lung tumors, and lung abscess.

    Contents

    • Pneumonia
    • Bronchopneumonia
    • Pulmonary infarction
    • Fibrosis - interstitial lung diseases
    • Lung tumors
    • Lung abscess

    Pulmonary Consolidation

    • Caused by any pathological process increasing lung density.
    • Density change is due to replacement of alveolar air with exudates or abnormal cells.

    Criteria for Physical Examination Accessibility

    • Lesion size must exceed 4 cm.
    • Lesion must be near the thoracic surface.
    • Consolidation must have sufficient thickness.
    • Corresponding bronchus must be permeable.

    Clinical Diagnosis and Final Diagnosis

    • Clinical diagnosis (syndrome) is established after a history and physical examination.
    • Additional tests, such as blood tests, ECG, X-ray, ultrasound, magnetic resonance, computer tomography, and endoscopy help form a final diagnosis.

    Pulmonary Consolidation Syndrome - Possible Underlying Conditions

    • Pneumonia
    • Pulmonary infarction
    • Aspiration pneumonia
    • Lung cancer

    Pneumonia Definition

    • Inflammation of alveolar space and/or interstitium.
    • Results in pulmonary consolidation.
    • Diverse causes, not a single disease.

    Pneumonia Classification

    • Community-acquired (typical or atypical)
    • Hospital-acquired (HAP), also known as nosocomial
    • Ventilator-associated (VAP)
    • Lobar
    • Bronchopneumonia
    • Interstitial

    Pneumonia Etiology

    • Bacteria (Streptococcus pneumoniae, Haemophilus influenzae, Staphylococcus aureus, Klebsiella pneumoniae)
    • Viruses (Respiratory syncytial virus [RSV], Adenovirus, Influenza A, B and C viruses, Parainfluenza viruses type 1, 2, 3, and 4, Coronavirus)
    • Atypical agents (Bacteria: Legionella, Mycoplasma pneumoniae, Chlamydia pneumoniae, Chlamydia psittaci)
    • Fungi (Aspergillus, Cryptococcus, Pneumocystis, Candida)

    Pneumonia Symptoms

    • Fever
    • Cough (productive or non-productive, with possible blood/purulent sputum)
    • Pleuritic chest pain (severe)
    • Chills or rigors
    • Dyspnea
    • Herpes
    • Headache
    • Nausea
    • Vomiting
    • Diarrhea
    • Myalgia
    • Arthralgia
    • Fatigue

    Pneumonia Physical Examination (General)

    • Fever (drops "in crisis")
    • Tachycardia
    • Red face/facial flushing (slap sign)
    • Labial herpes
    • Sleepiness
    • Confusion

    Pneumonia Physical Examination (Pulmonary)

    • Inspection: normal/tachypnea
    • Palpation: reduced chest expansion, increased tactile and vocal fremitus
    • Percussion: dullness over affected area
    • Auscultation: whispered pectoriloquy, egophony, bronchial breath sounds/harsh vesicular breath, crackles (in congestion and resolution phases)

    Tactile Fremitus

    • Vibration of chest wall
    • Result of sound transmission through lung tissue
    • Decreased fremitus suggests excess air in lungs or thickened chest wall.
    • Increased fremitus indicates lung consolidation.

    Pectoriloquy, Egophony, Bronchophony

    • Pectoriloquy: increased vocal resonance through lung tissues
    • Egophony: enhanced transmission of high-frequency voice sounds, altered sound quality (high-pitched nasal or bleating)
    • Bronchophony: increased intensity and clarity of spoken voice heard during auscultation.

    Vocal Fremitus/Resonance

    • Bronchophony: Auscultate soft muffled sound (normal), loud sound (consolidation)
    • Egophony: Evaluates spoken voice sound (normal: muffled sound; Consolidation: "aaa" sound heard)
    • Whispered Pectoriloquy: Listen to whispered "one, two, three" (normal: faint, muffled; Consolidation: clear)

    Pneumonia: Stages of Evolution (Images)

    • Stages of pneumonia shown with illustrations of alveolar/tissue changes

    Pneumonia: Special Forms

    • Abortive (pulmonary congestion)
    • Prolonged
    • Hypertoxic
    • Central
    • Massive

    Pneumonia Complication

    • Parapneumonic pleural effusion
    • Recurrent pneumonia
    • Bronchiectasis
    • Abscess, empyema
    • Mediastinitis
    • Endocarditis
    • Meningitis
    • Sepsis

    Pleural Effusion vs. Parapneumonic Effusion

    • Parapneumonic effusion: Pleural effusion due to adjacent pneumonia (inflammation).
    • Empyema: A complication of parapneumonic effusion. Microorganisms infect the pleural space.

    Pneumonia Investigations (Chest X-ray)

    • Posteroanterior (PA) and Lateral views
    • Opacity of segment/lobe related to physical exam findings
    • Possible complications detected

    Pneumonia Investigations (CT Scan)

    • Needed in some cases for better localization/characterization
    • Helps rule out or provide evidence to support a diagnosis.

    Pneumonia Investigations (Laboratory Tests)

    • Complete Blood Count (Leukocytosis, neutrophilia, "left shift")
    • High C-reactive protein (CRP)
    • Arterial Blood Gas (ABG) for diagnostic and prognostic information
    • Sputum microscopy and cultures (quantity issues possible)
    • Blood cultures (for children/severe cases)
    • Lower respiratory samples (e.g., bronchoalveolar lavage)
    • Urine tests (e.g., Legionella antigen)
    • PCR Testing (when needed)

    Bronchopneumonia Definition

    • Multiple focal areas of consolidation in one or more lobes.
    • Bilateral pulmonary involvement.
    • Common in the elderly, infants and patients with debilitated conditions (like heart failure, cancer, or cerebrovascular disease).

    Bronchopneumonia Symptoms

    • Chills or rigors, fever (40°C), altered mental status,
    • Atypical thoracic (chest) pain,
    • Dyspnea, cyanosis,
    • Cough (productive or non-productive),
    • Headache,
    • Nausea,
    • Vomiting, diarrhea, myalgia, arthralgia
    • Fatigue

    Bronchopneumonia Physical Examination

    • Similar to pneumonia features, but higher intensity.
    • Discordance exists between altered general status and physical exam findings.
    • Inspection: superficial breaths, tachypnea, wheezing
    • Palpation: reduced chest expansion, augmented tactile and vocal fremitus (for confluent consolidations >10-12 cm)
    • Percussion: dullness
    • Auscultation: lack of normal breath sounds, crackles, rales, increased loudness of whispered speech

    Bronchopneumonia Investigations

    • Similar to pneumonia investigations
    • Bronchoalveolar lavage
    • PCR testing

    Atypical/Interstitial Pneumonia Definition

    • Lung parenchyma inflammation (alveoli, alveolar walls, capillary endothelium, spaces between tissues).
    • Caused by atypical organisms undetectable on Gram stain, and uncultivatable using standard methods (e.g., Mycoplasma pneumoniae, Chlamydia species ,Legionella species, Coxiella burnetii).

    Atypical/Interstitial Pneumonia Symptoms

    • Insidious onset with acute upper respiratory infection symptoms
    • Predominance of general symptoms (fever, chills, asthenia, headache, myalgia, arthralgia, fatigue, loss of appetite, weight loss, joint stiffness).
    • Sweating and clammy skin, diarrhea, ear and eye pain, rash, sore throat.
    • Respiratory Symptoms (persistent non-productive cough, mild dyspnea, hemoptysis, wheezing, chest pain, substernal discomfort).

    Atypical/Interstitial Pneumonia Physical Examination

    • Might be normal.
    • Inspection: tachypnea
    • Percussion: dullness
    • Auscultation: diminished vesicular breath sounds, end-inspiratory dry crackles, if bronchiolitis present: scattered late inspiratory high-pitched ronchi (inspiratory squeaks)

    Atypical/Interstitial Pneumonia Investigations

    • In some cases, extensive work-up needed.
    • Urinary Legionella antigen
    • Sputum culture for Legionella
    • Molecular testing for Mycoplasma pneumoniae or Chlamydophila pneumoniae (e.g., PCR)
    • Serology for atypical pathogens

    Chest X-ray and High Resolution CT (HRCT) Peculiarities

    • Chest X-ray can range from normal to showing consolidation and increased reticular markings (honeycombing, opacities, bilateral). Can detect complications like pneumothorax or lung abscess.
    • HRCT allows more detailed detection of subtle parenchymal or airflow disease.

    Lung Abscess Definition

    • Necrosis of lung tissue forming cavities containing necrotic debris/fluid.
    • Microbial infection is the cause.

    Lung Abscess Classification

    • Duration of disease: acute (<6 weeks) or chronic (>6 weeks).

    Lung Abscess Etiology

    • Primary: Aspiration (oropharyngeal/necrotizing pneumonia).
    • Secondary: Hematogenic dissemination, direct spread (mediastinitis, bronchogenic obstruction, infections complications from flu/measles especially in immunosuppressed individuals)

    Lung Abscess Spreading

    • Bronchogenic: due to aspiration, bronchial obstruction (tumor, foreign body), lymph node compression, or congenital issues.
    • Hematogenous: Septic source (e.g., endocarditis)

    Lung Abscess Etiology (Specific Organisms)

    • Staphylococcus Aureus, Anaerobic agents, Aspergillus, B. Fragilis. Fungi.

    Lung Abscess Phases

    • Phase I: Mimics acute pneumonia, possibly consolidation.
    • Phase II: Elevated sputum production after 8-10 days (e.g., vomique).
    • Phase III: Chronic/suppurative with ongoing symptoms

    Lung Abscess Symptoms

    • Malaise
    • Weight loss
    • Low-grade fever (often < 38.5°C except in non-anaerobic infections), chills
    • Foul-smelling sputum
    • Anorexia
    • Clubbing of fingers
    • Gingivitis/periodontal disease

    Lung Abscess Physical Examination

    • Pulmonary consolidation
    • Dull percussion
    • Reduced breath sounds
    • Bronchial breath sounds
    • Coarse inspiratory crackles
    • Rarely: amphoric/cavernous breath sounds (only with cavity formation)
    • Empyema possibility if bacteria reaches pleural space/communicates from abscess.

    Empyema Definition

    • Pus collection in pleural cavity/pleural fluid.
    • Frequently complicates pneumonia but can also occur post-thoracic surgery/trauma

    Empyema Diagnosis and Treatment

    • Thoracentesis
    • Imaging (e.g., ultrasound, CT scan, X-ray)
    • Antibiotics. Drainage of pus from pleural space.

    Pulmonary Infarction (PI) Definition

    • Sudden blockage of pulmonary artery branch.
    • Not all pulmonary embolisms lead to infarction
    • Indicates a non-reversible ischemia of lung tissue.
    • Can be seen with physical signs of consolidation

    Pulmonary Infarction Etiology

    • Emboli (thrombi, septic, tumoral) that travel from venous system.
    • Other causes: infections (aspergillosis), vasculitis, malignancies, sickle cell disease, amyloidosis, in-situ pulmonary artery emboli.

    Pulmonary Infarction Symptoms

    • The major presenting symptom is dyspnea.
    • Symptoms can vary depending on the amount of occlusion, including mild symptoms or even reaching symptoms of obstructive shock.

    Pulmonary Infarction Physical Examination

    • Anxiety
    • Dyspnea
    • Fever
    • Tachycardia
    • Syncope
    • Hypotension
    • Possible signs of DVT (e.g., unilateral pitting edema, Homans' sign, Lisker's sign)
    • Haemoptysis (cough with blood)

    Pulmonary Infarction Physical Examination - Respiratory

    • Typical pulmonary consolidation findings
    • Possible complications (pleurisy) can impact assessment
    • Possible assessment abnormalities (e.g., localized chest pain, possible pleural friction rub, possible cavitary findings).

    Pulmonary Infarction Investigations

    • Elevated D-dimers
    • Chest X-ray (wedge-shaped opacity, base towards pleural cavity, bulging borders)
    • CTPA (Computed Tomography Pulmonary Angiography; shows contrast filling defects, which indicates emboli)
    • Echocardiography
    • ECG

    Lung Tumors: Definition

    • Lung tumors (benign or malignant) are potentially causing consolidation.
    • Malignant lung tumors can be primary or secondary (metastasis).

    Lung Tumors: Symptoms

    • 15% of patients are asymptomatic, detected on routine screenings.
    • Others have discreet (minimal) symptoms.
    • Symptoms vary depending the location, and include:
      • Cough
      • Chest pain
      • Dyspnea

    Lung Tumors: Symptomatic Presentations (Specific)

    • Cough (resistant to treatment; possible rust-colored/bloody sputum)
    • Chest pain (related to tumor direct contact with pleura or metastasis).
    • Dyspnea (presenting alone or worsening of existing).
    • Central tumors: cough, dyspnea, or hemoptysis,
    • Peripheral tumors: cough, dyspnea, chest pain.

    Lung Tumors: Symptoms - Pancoast Tobias Syndrome

    • Symptoms due to apical lung invasion:
      • Ipsilateral shoulder and arm pain
      • Paresthesia (numbness)
      • Paresis (muscle weakness)
      • Atrophy (muscle wasting)
      • Horner's syndrome (miosis, enophthalmos, ptosis, anhidrosis)

    Lung Tumors: Paraneoplastic Syndromes

    • Diverse symptoms associated include endocrinological, neurological, rheumatological, dermatological, and hematological symptoms.
      • Cushing's syndrome
      • Acromegaly
      • Hypercalcemia
      • Lung Cancer

    Lung Tumors: Investigations

    • Mandatory: Histological examination to confirm diagnosis (sputum cytology, bronchoalveolar lavage, transthoracic needle biopsy, or ultrasound guided transthoracic needle biopsy, bronchoscopy).
    • Chest X-ray (detect abnormalities, or complications like necrosis).
    • CT scan (shows accurate details of the tumor, possible location in hilar region).
    • Bronchoscopy with sample collection (to view the tumor's location and extent, obtain brushing/washing/biopsy samples)

    Lung Cancer Stages

    • Stage I: Tumor in the lung only
    • Stage II: Tumor in lymph nodes
    • Stage III: Tumor in surrounding tissues
    • Stage IV: Tumor in other organs

    Lung Cancer Imaging Findings - Normal CT

    • Image presentations of benign and malignant tumors. Image examples of normal lung CT.

    Lung Cancer Imaging Findings - Specific/Mandatory

    • Image examples of chest x-rays and CT images with specific findings needed to support a diagnosis. A mandatory component.

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    Lecture 10. Consolidation Syndromes PDF

    Description

    This quiz focuses on consolidation syndromes, which involve increased lung density due to various pathological processes. Explore causes like pneumonia, lung tumors, and fibrosis while understanding their clinical significance and physical examination criteria.

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