spurious and pseudo hemoptysis

Spurious hemoptysis

Spurious hemoptysis means there is real blood in the sputum, but it comes from the upper respiratory tract (above the larynx), such as from an upper‑airway infection, epistaxis, or gingival bleeding, rather than from the lungs or bronchi.

The blood is genuinely present under the microscope, but the source is not the lower respiratory tract (below the glottis).

Pseudo‑hemoptysis

Pseudo‑hemoptysis (or pseudohemoptysis) refers to blood‑like sputum that may look like blood but sometimes does not actually contain blood cells; for example, red pigment (prodigiosin) from Serratia marcescens infection can stain sputum red without true bleeding.

It can also include situations where blood is aspirated from the upper aerodigestive or gastrointestinal tract (e.g., hematemesis aspirated into the lungs) and then expectorated, so the bleeding source is extrapulmonary

kilip classification

Heart failure and predict mortality in patients with acute myocardial infarction (AMI), especially in the first 24–48 hours. 

Killip classes (I–IV)

Class I: No clinical evidence of heart failure.

Vital signs and physical exam are normal; no pulmonary rales, no S₃, no jugular venous distension. 

Class II: Mild to moderate left‑ventricular (LV) failure.

Rales/crackles in the lungs, S₃ gallop, elevated jugular venous pressure, or combination

Class III: Severe LV failure – acute pulmonary edema.

Frank pulmonary edema with marked dyspnea, frothy sputum, diffuse rales; oxygenation is impaired. 

Class IV: Cardiogenic shock.

Hypotension (systolic BP ≤90 mmHg), tachycardia, cold clammy skin, oliguria, and evidence of peripheral hypoperfusion; often with pulmonary edema. 

Higher the class , there increased risk or short term mortality 

Post TB sequelae

 -Airway-related

Bronchiectasis

Bronchial stenosis / stricture

Tracheobronchomalacia

-Parenchymal (lung tissue)

Fibrosis (fibro-cavitary disease)

Destroyed lung

Residual cavities

-Pleural

Pleural thickening

Fibrothorax

-Vascular

Pulmonary hypertension

Rasmussen aneurysm (pulmonary artery aneurysm in cavity wall)

-Infective / colonization

Aspergilloma (fungal ball)

Functional consequence

Chronic respiratory failure / COPD-like picture

Aggravating factors of cough

PDFCE 

Pollution, Pollen, Posture

Drugs, Diurnal, Dry air

Food

Cold weather, Common cold

Exercise

Aggravating factors of cough

PDFCE 

Pollution, Pollen, Posture

Drugs, Diurnal, Dry air

Food

Cold weather, Common cold

Exercise

Tidal percussion on the left side

 Tidal percussion is a clinical percussion technique used to detect early splenomegaly by observing changes in percussion note during respiration.

Site

Over Traube's space. Typically along the left mid-axillary line

Boundaries of Traube’s Space

Superior: Left 6th rib

Inferior: Left costal margin

Lateral: Left anterior axillary line

This area overlies the fundus of the stomach (normally tympanic due to air). In splenomegaly, this area becomes dull → basis of tidal percussion.

Technique 

Patient lies supine

Start percussion over Traube’s space (normally tympanic)

Ask patient to take a deep inspiration

Continue percussion during breathing

 - Interpretation

Normal:

Remains tympanic during inspiration

Positive tidal percussion:

Tympany → dullness on inspiration

Indicates splenic enlargement (spleen descends and occupies the space)

 Mechanism

During inspiration, the diaphragm descends

Enlarged spleen moves inferiorly & anteriorly

Replaces air-filled stomach → dull note

Ctd criteria from Murray and nadal

 Systemic Sclerosis (Scleroderma)

CRITERIA FOR DIAGNOSIS*

Major

Thickening of the skin of the hands

Minor

Sclerodactyly (i.e., the changes of the major criterion but limited to

the fingers)

Digital pitting scars or loss of substance from the finger pad:

depressed areas at tips of fingers or loss of digital pad tissue as a

result of ischemia

Bibasilar pulmonary fibrosis

LUNG MANIFESTATIONS

Interstitial pulmonary fibrosis

Organizing pneumonia

Isolated pulmonary vascular disease

Aspiration pneumonia (secondary to esophageal dysmotility)

Chest wall restriction

*The major or ≥ 2 minor criteria required for diagnosis.

Rheumatoid Arthritis

CRITERIA FOR DIAGNOSIS*

Morning stiffness (lasting at least 1 hr)

Arthritis (soft tissue swelling or fluid) of 3 or more joints (PIP, MCP, 

wrist, elbow, knee, ankle, MTP joints)

Arthritis of hand joints (swelling of at least 1 wrist, MCP, or PIP joint)

Symmetrical arthritis (i.e., simultaneous arthritis of the same joints on 

both sides of the body)

Rheumatoid nodules

Serum rheumatoid factor positivity (at a level such that < 5% of 

normal controls are positive)

Radiographic hand or wrist changes typical of rheumatoid arthritis

LUNG MANIFESTATIONS

Interstitial pulmonary fibrosis

Organizing pneumonia

Obliterative bronchiolitis

Follicular bronchiolitis

Bronchiectasis

Vasculitis

Nodules

Pleural disease

Lymphocytic interstitial pneumonia

Drug induced

*At least 4 criteria for a minimum of 6 weeks.

Systemic Lupus Erythematosus

CRITERIA FOR DIAGNOSIS*

Malar rash

Discoid rash

Photosensitivity skin rash

Oral or nasopharyngeal ulceration

Nonerosive arthritis involving ≥ 2 peripheral joints

Serositis (pleuritis or pericarditis)

Renal disorder (persistent proteinuria or cellular casts)

Neurologic disorder (unexplained seizures or psychosis)

Hematologic disorder (hemolytic anemia, leukopenia, lymphopenia, 

or thrombocytopenia)

Immunologic disorder (positive LE cell, anti-DNA antibody, anti-Sm 

antibody, false-positive syphilis serology)

Elevated antinuclear antibodies

LUNG MANIFESTATIONS

Acute lupus pneumonitis

Interstitial pulmonary fibrosis

Pulmonary vasculitis

Diffuse alveolar hemorrhage

Pulmonary hypertension

Shrinking lung syndrome

Antiphospholipid antibody syndrome

Organizing pneumonia

Pleural disease

*Minimum of 4 criteria required.

Polymyositis with Dermatomyositis

CRITERIA FOR DIAGNOSIS

Symmetrical proximal muscle weakness

Muscle biopsy specimen showing myositis

Elevation of serum skeletal muscle enzymes

Characteristic electromyographic pattern of myositis

Typical rash of dermatomyositis

LUNG MANIFESTATIONS

Interstitial pulmonary fibrosis

Acute pneumonitis (with diffuse alveolar damage)

Organizing pneumonia

Aspiration pneumonia

Pulmonary vasculitis and alveolar hemorrhage

Respiratory muscle weakness

Behçet Syndrome

CRITERIA FOR DIAGNOSIS

Major (required)

Recurrent aphthous ulceration at least 3 times in a 12-mo period

Minor (2 of 4)

Recurrent genital ulceration

Ocular disease

Skin lesions (erythema nodosum, skin ulcers)

Positive pathergy test (a 2-mm erythematous papule or pustule at

the prick site 48 hr after the application of a sterile hypodermic

20- to 22-gauge needle that obliquely penetrated avascular

antecubital skin to a depth of 5 mm)

Cardinal symptoms of Gastrointestinal system & Tree in bud opacities

Cardinal symptoms of Gastrointestinal system

 Abdominal pain

Dysphagia 

Heartburn

Nausea and vomitting 

Alteration of bowel habits

GI bleeding 

Abdominal distension 

Jaundice

Loss of appetite and weight 

Mechanism of tree in bud opacities 

They occur due to infectious bronchiolitis leading to filling of terminal bronchioles with mucous, pus, or fluid

They indicate endobronchial spread of infection 

1)Cardinal symptoms of cns 2) Acceptble pH range in type 2 respiratory failure

 1) Cardinal symptoms of CNS disease:

Headache, vomiting, seizures, altered consciousness, focal neurological deficit (motor or sensory), visual disturbance, and gait or balance disturbance.

2) Acceptable pH range in Type 2 respiratory failure:

pH 7.25 – 7.35 (permissive hypercapnia range during management).

Massive hemoptysis

Massive hemoptysis - definition

      Massive hemoptysis is blood loss of 400 mL in 24 hours or 100–150 mL expectorated at one time.

Causes-

Bronchiectasis, 

Bronchogenic Carcinoma,

Eroding Tuberculous cavity,

Rasmussen's aneurysm,

mycetoma

Ref: Harrison's principles of internal medicine(20th edition)

TYPES OF FEVER

Types of fever 

Continuous (Sustained) Fever

Definition:

Fever in which the temperature remains above normal throughout the day and does not fluctuate more than 1°C in 24 hours.

2. Remittent Fever

Definition:

Fever in which the temperature fluctuates more than 1°C in 24 hours but never returns to normal

3. Intermittent Fever

Definition:

Fever in which the temperature elevation is present only for several hours of the day and returns to normal for the remaining hours.

4. Relapsing Fever

Definition:

Fever characterized by episodes of fever lasting several days separated by periods of normal temperature lasting several days.

Causes of Trepopnea and platypnea

Platypnea - Dyspnea in upright position 

Always associated with Orthodeoxia

Occurs in 

- Hepatopulmonary syndrome

- Pulmonary AV malformations

Trepopnea- Dyspnea in Lateral decubitus position 

- Unilateral severe pneumonia or pleural effusion 

Patient feels better on lying on normal side to improve V/Q matching 

Define small airways and % of small airways in lungs, Terminal vs Respiratory bronchioles

 Small airways are defined as airways with an internal diameter less than 2 mm and lacking cartilage, consisting mainly of the terminal bronchioles and respiratory bronchioles located distal to the segmental bronchi. Although individually small, they collectively contribute to about 98–99 % of the total cross-sectional airway area of the lungs, which is why they normally produce little airflow resistance and are called the “silent zone” of the lung. Terminal bronchioles represent the last part of the conducting zone, are lined by simple cuboidal epithelium with club (Clara) cells, contain smooth muscle, do not have alveoli in their walls, and therefore do not participate in gas exchange. In contrast, respiratory bronchioles are the first part of the respiratory zone, arise from terminal bronchioles, have scattered alveoli opening from their walls, and therefore participate in the beginning of gas exchange, eventually continuing as alveolar ducts and alveolar sacs.