CLUBBING

Definition :

Clubbing of the fingers designates the selective bulbous enlargement of the distal segments of the digits due to an increase in soft tissue.

Mechanism :

1.The circulating megakaryocytes and large platelet particles present in the venous circulation normally break up in the pulmonary vascular bed. Megakaryocyte or platelet clusters, lodged in the peripheral vasculature of the digits, release platelet-derived growth factor (PDGF) and lead to the increased vascularity, permeability, and connective tissue changes that are the hallmark of clubbing.

Release of VEGF and PDGF occurred after platelet impaction and is enhanced by hypoxia. VEGF along with PDGF induces the pathological changes of digital clubbing.

Unilateral clubbing :-

Anomalous aortic arch 
Aortic or subclavian artery aneurysm 
Pulmonary hypertension with patent ductus arteriosus 
Brachial arteriovenous aneurysm or fistula 
Recurrent shoulder dislocation 
Superior sulcus (Pancoast) tumor 

Unidigital :- 
Median nerve injury 
Sarcoidosis 

Clubbing of toes without fingers (differential clubbing) :- 
Coarctation of aorta

From LUNG INDIAMalay Sarkar¹, DM Mahesh², Irappa Madabhavi^3
1 Department of Pulmonary Medicine, Indira Gandhi Medical College, Shimla, India

ORTHOSTATIC HYPOTENSION

 DEFINITION :

reduction in systolic blood pressure of at least 20 mmHg or 

diastolic blood pressure of at least 10 mmHg 

within 3 min of standing or head-up tilt on a tilt table,

It is a manifestation of sympathetic vasoconstrictor (autonomic) failure.

Ref : Harrison

SUBPULMONIC EFFUSION

 The first place for pleural fluid to accumulate in an erect patient is the space between the inferior surface of the lower lobe and the diaphragm. Only after filling this space, it will spill over into the costophrenic angles.

In CXR, the subpulmonic effusion stimulates diaphragmatic elevation thus called as pseudo diaphragmatic contour.

1. PA view :-The peak of pseudo diaphragmatic configuration is lateral to that normal hemidiaphragm being situated near the junction of middle and lateral third of diaphragm.

2.PA view :-On the left side, subpulmonic effusion is suspected if the distance between the gastric air bubble shadow and pseudo diaphragmatic shadow is more than 2cm.

3.Lateral view ;-upper margin of fluid meets the major fissure.

4.PA view: thin triangular opacity in the left paramediastinal zone with apex half way upto the mediastinum and its base continuous with pseudo diaphragmatic shadow.

5.PA view : The pulmonary vessels normally visible below the diaphragmatic contour, cannot be seen through the pseudo diaphragmatic contour of the subpulmonic effusion. 

Ref : Fraser

CAVITY

 

According to Fleischner Society, 

pulmonary cavities are defined as "a gas-filled space, seen as a lucency or low-attenuation area, creating wall thickness >2-4 mm , within pulmonary consolidation, a mass, or a nodule" 

CYST/BULLA/BLEB

                             Bleb                             Bulla                                         Cyst

Site : Within visceral pleura             Arises within secondary lobule        Lung parenchyma or mediastinum

Size  :          1–2 cm                              1 cm to 75% of a lung                                     2–10 cm

Lining :Elastic laminae of  pleura        Connective tissue septa                             Epithelium

Associated: Spontaneous pneumothorax     Bronchogenic carcinoma                  Respiratory infection

condition

BULLA:

A bulla is an air-containing space within the lung parenchyma that

arises from destruction, dilatation, and confluence of airspaces

distal to terminal bronchioles and is larger than 1 cm in diameter

BLEB:

A bleb is an accumulation of air between the two layers of the

visceral pleura that arises when the thin covering of the bleb ruptures

and permits entry of air.

CYST:

Cysts are epithelial-lined cavities that may resemble bullae on radiographs

(FISHMAN)

BRONCHOPULMONARY SEGMENTS

 

• Bronchopulmonary segments of human lung.
•  Left and right upper lobes: (1) apical, (2) posterior, (3) anterior, (4) superior lingular and (5) inferior lingular segments.
•  Right middle lobe: (4) lateral and (5) medial segments.
•  Lower lobes (6): superior (apical), (7) medial–basal, (8) anterior–basal, (9) lateral–basal, and (10) posterior–basal segments
• The medial–basal segment (7) is absent in the left lung. 

(FISHMAN)

Minimum fluid to visualise pleural effusion on CXR

 Effusions first become apparent on lateral upright radiographs with blunting of the posterior costophrenic angle. An accumulation of 200 ml of fluid is necessary for the effusion tp affect the lateral angles of frontal standing radiographs. Lateral decubitus radiograph with the affected side down is the more sensible view to identify an effusion of 5 to 15 ml. 

Pneumatocele

 Are thin walled, air filled structures that often develop early in the course of staphylococcal pneumonia, particularly in infants and young children, and usually disappear over the course of a few months. These cystic spaces are believed to be the consequence of check valve opening between a peribronchial abcess and an adjacent bronchus. 

BRONCHIAL ARTERIES

 The right bronchial artery usually (78% of people) arises within a common stem, with the first aortic intercostal (inter-costobronchial artery) from the posteromedial aspect of the descending aorta.

 On the left side, there is generally a superior and an inferior branch, both arising from the anterior aspect of the descending thoracic aorta.

The bronchial arteries run into the hilum, where they branch in a parallel manner and close to the bronchus to the peripheral airways.

 The diameters of these arteries are small, usually 1–1.5 mm at its origin within the mediastinum. 

Tongue in HIV

Leukoplakia 

Oral thrush

Atypical kaposi sarcoma.

Oral hairy leukoplakia.

White coated tongue

Harrison sulcus

 It is due to the indrawing of ribs to

form symmetrical horizontal grooves above the

costal margin, along the line of attachment of

diaphragm due to hyperinflation of the lungs and

repeated strong contraction of the diaphragm as

occurs in chronic respiratory disease in childhood,

childhood asthma, rickets and blocked nasopharynx

due to adenoid enlargement

PRE RENAL AKI

 Pre renal AKI 

BUN/ Creat ratio >20

FeNa < 1%

Urine specific gravity> 1.018

Urine osmolality >500mOsm/kg 

PRESSURES IN 4 HEART CHAMBERS

 

Right atrium	0-4
Right ventricle	25 systolic; 4 diastolic
Pulmonary artery	25 systolic; 10 diastolic
Left atrium	8-10
Left ventricle	120 systolic; 10 diastolic
Aorta	120 systolic; 80 diastolic

Significant weight loss

 More than 5% in 1 month or 

More than 10% in 3 months 

Reg- Harrison 

Empyema Necessitans

 

Presence of pus in pleural space is defined as empyema thoracis.

If this empyema is left undrained or untreated, it may extend beyond the pleural cavity with pointing occurring in the intercostal space close to the sternum where chest wall is thinnest.

Empyema necessitans denotes lesion that has ruptured through the chest wall to the subcutaneous tissue ultimately reaching the surface through the skin to form a discharging sinus. It is seen in tuberculosis and actinomycetes.

Treatment:- 

Surgical dilatation of fistulous tract may assist drainage which can be collected in colostomy bags followed by decortication.

Ref : Crofton

PYREXIA OF UNKNOWN ORIGIN

Pyrexia of unknown origin (PUO) is defined as a temperature persistently above 38.0°C for more than 3 weeks, without diagnosis, despite initial investigation during 3 days of inpatient care or after more than two outpatient visits (DAVIDSON)

Sputum colors

 Yellow sputum- Presence of leukocytes

Green sputum - Due to stagnation of sputum, liberation of green enzyme- Verdoperoxidase or myeloperoxidase 

Yellow and green- usually due to infection, can be occasionally seen in early morning sputum in chronic bronchitis (due to nocturnal accumulation)

Rusty sputum- pneumococcal pneumonia 

Anchovy sauce- Ruptured amebic abscess 

Meloptysis(black sputum)- Necrotic massive fibrosis of Coal miners

Reg- Crofton and Douglas 

Parasternal heave

 A parasternal heave is detected by placing the heel of the hand over the left parasternal region. In the presence of a heave the heel of the hand is lifted off the chest wall with each systole.

A parasternal heave is caused by:

• right ventricular enlargement, or
• rarely, severe left atrial enlargement which pushes the right ventricle forwards

EMPHYSEMA DEFINITION

 Emphysema is a condition of the lung characterized

by abnormal, permanent enlargement of the airspaces distal to

the terminal bronchiole, accompanied by destruction of their walls.

Fat embolism triad

 Hypoxemia

Neurological abnormalities

Petechiae

COPD -GOLD Definition

COPD is a common preventable and treatable disease that is characterized by persistent respiratory symptoms and airflow limitation, due to airway/alveolar abnormalities, usually caused by significant exposure to noxious particles or gases and influenced by host factors like abnormal lung development.

Medium pitched breath sounds

 Bronchovesicular breath sounds are medium pitched.

Both inspiration and expiration heard.

No pause in between.

Often heard over upper third of anterior chest wall.

Spinoscapular distance

 Measurement of distance between the inferior angle of scapula and the closest horizontal spinous process of the thoracic spine.

Skodaic resonance

Skodaic resonance is a high pitched sound elicited by percussion over a cavity just above the level of pleural effusion.

Causes of Localised bulging on chest wall

 A.Chest wall

    -Boils, Lipoma, Fibroma

B.Ribs and Cartilage

    -Osteomyelitis, Costochondritis

C.Pleura

    -Encysted pleural effusion, Epyema necessitans

D.CVS

    -Enlargement of cardiac chamber, Aortic aneurysm

E.Lungs

    -Actinomycosis of lung and chest wall

F.Swelling in pectoral area

    -Subpectoral abcess, Pectoral major tendon rupture, Post pectoral implant procedure, Post pacemaker implantation, Pectoral muscle rupture with hematoma

G.Others

    -Bony prominence, Surgical emphysema 

Post tussive - crackles

 

These crackles are not present normally on auscultation but can appear after a bout of cough. Crackles appear as the cough dislodges the thick secretions. It is present in early pneumonia, early tuberculosis, and lung abscess

Bronchophony

 Bronchophony, is the abnormal transmission of sounds from the lungs or bronchii. It is a general sign, detected by auscultation. The patient is requested to repeat a word several times  while the physician auscultes symmetrical areas of each lung. Normally, the sound of the patient's voice becomes less distinct as the auscultation moves peripherally; bronchophony is the phenomenon of the patient's voice remaining loud at the periphery of the lungs or sounding louder than usual over a disctinct area of consolidation...seen in conditions like consolidation, cavity communicating with a bronchus,above the level of pleural effusion

TERMINAL RESPIRATORY UNIT

                                                     TERMINAL RESPIRATORY UNIT 

It consists of all alveolar ducts and all of the accompanying alveoli that stem from the proximal respiratory bronchiole.

In human, one unit contains approximately 100 alveolar ducts and 2000 alveoli. It measures about 5mm diameter and 0.02ml volume at FRC. An acinus contains 10-12 Terminal Respiratory Unit(TRU). 

The gas exchange amongst the structures in TRU occurs more rapidly. All parts of the TRU participate in volume changes in respiration.

Alveoli is a complex structure with flat walls and sharp curvature at the junctions between the walls. The wall of the alveoli are predominately made of pulmonary capillaries.

 The inner lining of the alveoli are made up of cuboidal type II cells and flattened type I cells. The type I cells occupy all surface area of the lung though their number is less than Type II cells.

 Ref : Murray