Make the Dx_ A Case-based Intro to Select Cardiovascular and Respiratory Diseases

A Case-based Introduction to Select
Cardiovascular and Respiratory
Diseases
Marc Imhotep Cray, M.D.

 Acute pericarditis
 Cardiac Tamponade
 Acute infective endocarditis
 Acute rheumatic fever
 Bronchial asthma
 Chronic bronchitis
 Emphysema
 Pancoast tumor
 Pulmonary embolism
 Pneumonias and Lung Abscess
2

3
A 35-year-old woman presents with acute chest pain and a
nonproductive cough. Review of systems reveals a history of
malar rash, fatigue, and migratory polyarthritis. On
physical examination, she is found to have a friction rub
and distant heart sounds and she complains of increased
pain when supine. An increased jugular venous pressure is
noted with inspiration and diffuse ST elevations are seen on
most ECG leads. You initiate therapy with corticosteroids
and refer her to a rheumatologist and a cardiologist.
WHAT IS THE DIAGNOSIS?

4
 Inflammation of pericardium [ A , red arrows]
 Commonly presents with sharp pain,
aggravated by inspiration, and relieved by
sitting up and leaning forward
 Often complicated by pericardial effusion
[betw. yellow arrows in A ]
 Presents with friction rub, ECG changes
include widespread (diffuse) ST-segment
elevation
 Causes include idiopathic (most common=
presumed viral), confirmed infection (eg,
Coxsackievirus), neoplasia, autoimmune (eg,
SLE, rheumatoid arthritis), uremia,
cardiovascular (acute STEMI or Dressler
syndrome), radiation therapy
Tao Le T and Bhushan V. First Aid for the
USMLE Step 1 2017. New York, NY:
McGraw-Hill ,2017.

5
A 75-year-old woman with a history of metastatic breast
cancer presents to the emergency department complaining
of weakness and difficulty breathing. On physical
examination, her blood pressure is 90/50 and her heart
sounds are distant and faint. You also note that she has
an increased JVP. When an ECG reveals a QRS complex
height that varies from one heart beat to the next, you
prepare for an immediate pericardiocentesis.

6
 Compression of heart by fluid (eg, blood,
effusions [arrows in A ] in pericardial
space)  ↓CO.
 Equilibration of diastolic pressures in
all 4 chambers
 Findings: Beck triad (hypotension,
distended neck veins, distant heart
sounds), ↑ HR, pulsus paradoxus*
 ECG shows low-voltage QRS and
electrical alternans (due to “swinging”
movement of heart in large effusion)
*Pulsus paradoxus= ↓ in amplitude of
systolic BP by > 10 mm Hg during
inspiration
 Seen in cardiac tamponade, asthma,
obstructive sleep apnea, pericarditis, croup
McGraw-Hill ,2017.

7
A 30-year-old man presents to the emergency room with
sudden high fever and shaking chills. A new murmur
localized to the mitral valve is heard. The patient has
bilateral nail-bed hemorrhages, painful nodules on the tips
of his fingers and toes, an erythematous rash on his palms
and soles, and white spots surrounded by hemorrhage in
his retina. You immediately begin the patient on broad
spectrum antibiotics and order blood cultures and an
echocardiogram to confirm the diagnosis.

8
 Fever (most common symptom), new murmur,
 Roth spots (round white spots on retina surrounded by hemorrhage (A)
 Osler nodes tender (painful ) raised lesions on finger or toe pads (B)  due to
immune complex deposition
 Janeway lesions (small, painless, erythematous lesions on palm or sole) C ,
 glomerulonephritis, septic arterial or pulmonary emboli,
 Splinter hemorrhages D on nail bed
 Multiple blood cultures necessary for diagnosis
Tao Le T and Bhushan V. First Aid for the USMLE Step 1 2017. New York, NY: McGraw-Hill ,2017.

9
Acute—S aureus (high virulence)
 Large vegetations on previously normal valves (E)  Rapid onset
Subacute—viridans streptococci (low virulence)
 Smaller vegetations on congenitally abnormal or diseased valves
 Sequela of dental procedures Gradual onset
Tao Le T and Bhushan V. First Aid for the USMLE
Step 1 2017. New York, NY: McGraw-Hill ,2017.

10
 Mitral valve is most frequently involved
 Tricuspid valve endocarditis is assoc. w IV drug abuse (don’t “tri”
drugs) S aureus, Pseudomonas, and Candida
 Culture ⊝; most likely Coxiella burnetii, Bartonella spp., HACEK
(Haemophilus, Aggregatibacter (formerly Actinobacillus),
Cardiobacterium, Eikenella, Kingella)
 Remember: ♥ Bacteria FROM JANE ♥:
Fever
Roth spots
Osler nodes
Murmur
Janeway lesions
Anemia
Nail-bed hemorrhage
Emboli

11
A10-year-old girl presents to the clinic with fever, malaise,
migratory polyarthritis, and a blanching erythematous
ring-shaped rash over her proximal extremities. On further
questioning, you find out that she suffered from a severe
sore throat 2 to 3 weeks ago. Serum studies demonstrate
an ESR of 100 and a positive anti–streptolysin O titer. You
worry that she may suffer from valvular heart disease
during her adult years as a result of her current condition.

12
 A consequence of pharyngeal infection
with group A β-hemolytic streptococci
 Late sequelae include rheumatic
heart disease, which affects heart
valves—mitral > aortic >> tricuspid
(high-pressure valves affected most)
Early lesion  mitral valve regurgitation
Late lesion mitral stenosis
 Assoc. w
 Aschoff bodies (granuloma w giant
cells [blue arrows in A ])
 Anitschkow cells (enlarged
macrophages with ovoid, wavy, rod-
like nucleus [red arrow in A ])
 ↑antistreptolysin O (ASO) titers
J♥NES (Major Dx Criteria):
Joint (migratory polyarthritis)
♥ (carditis)
Nodules in skin (subcutaneous)
Erythema marginatum
Sydenham chorea
Tao Le T and Bhushan V. First Aid for the USMLE
Step 1 2017. New York, NY: McGraw-Hill ,2017.

13
 Immune mediated (type II hypersensitivity)
 Not a direct effect of bacteria antibodies to M
protein cross-react with self antigens (molecular
mimicry)
 Treatment/prophylaxis: penicillin

14
Lung volumes
 Inspiratory reserve volume
Air that can still be breathed in after normal inspiration
 Tidal volume
Air that moves into lung with each quiet inspiration,
typically 500 mL
 Expiratory reserve volume
Air that can still be breathed out after normal expiration
 Residual volume
Air in lung after maximal expiration; RV and any lung
capacity that includes RV cannot be measured by spirometry

15
Lung Capacities
 Inspiratory capacity IRV + TV
Air that can be breathed in after normal exhalation
 Functional residual capacity RV + ERV
Volume of gas in lungs after normal expiration
 Vital capacity TV + IRV + ERV
Maximum volume of gas that can be expired after a
maximal inspiration
 Total lung capacity IRV + TV + ERV + RV
Volume of gas present in lungs after a maximal inspiration

16
Spirometry

17
 Obstructive lung volumes > normal (↑ TLC, ↑ FRC, ↑RV)
 Restrictive lung volumes < normal (↓ TLC, ↓ FRC, ↓ RV)
 In obstructive, FEV1 is more dramatically reduced compared with
FVC  decreased FEV1/FVC ratio
 In restrictive, FVC is more reduced or close to same compared
with FEV1  increased or normal FEV1/FVC ratio

18
1.Obstructive Pulmonary Diseases (OPDs)
2.Restrictive Lung Diseases (RLDs)
3.Vascular Lung Diseases
4.Pulmonary Infectious Diseases
5.Tumors of the Lung and Pleura

19
Baron SJ and Lee CI. Lange Pathology Flash Cards. New York: McGraw-Hill, 2009.

20
Obstruction of air flow air trapping in lungs
Airways close prematurely at high lung volumes  ↑RV
and ↑ FRC, ↑ TLC
PFTs: ↓↓FEV1, ↓ FVC  ↓FEV1/FVC ratio (hallmark),
V˙/Q˙ mismatch
Chronic, hypoxic pulmonary vasoconstriction can lead to
cor pulmonale
Chronic obstructive pulmonary disease (COPD) includes
chronic bronchitis and emphysema

21
The Netter Collection of Medical Illustrations, 2E. Vol 3- Respiratory System

22
Kumar V and Abbas AK. Robbins and Cotran Pathologic Basis of
Disease 8th ed. Saunders, Elsevier , 2014.
Schematic representation of overlap between
chronic obstructive lung diseases:

23
INTERRELATIONSHIPS OF CHRONIC
BRONCHITIS AND EMPHYSEMA
The Netter Collection of Medical Illustrations, 2E. Vol 3- Respiratory System

24
A 44-year-old man presents to your office complaining of a
persistent cough, which is productive of copious sputum.
He admits that he is a heavy smoker and has suffered from
similar coughs for several years. Physical examination
reveals diffuse wheezing and crackles. You suspect that
this patient will have a decreased FEV1/FVC ratio and
strongly suggest that he stop smoking.

B
B B
25
PRESENTATION
 Findings: wheezing, crackles, cyanosis
(hypoxemia due to shunting), dyspnea,
CO2 retention, 2° polycythemia
PATHOLOGY
 Hypertrophy and hyperplasia of mucus-
secreting glands in bronchi Reid index
(thickness of mucosal gland layer to
thickness of wall between epithelium
and cartilage) > 50%
OTHER
 Diagnostic criteria: productive cough for
> 3 months in a year for > 2 consecutive
years
The Netter Collection of Medical
Illustrations, 2E. Vol 3- Respiratory System

P P P
26
PRESENTATION
 Centriacinar=associated with smoking (A ,B) Frequently in upper
lobes (smoke rises up)
 Panacinar=assoc. w α1-antitrypsin deficiency Frequently in lower
lobes
PATHOLOGY
 Enlargement of air spaces ↓ recoil,↑ compliance, ↓ DLCO from destruction
of alveolar walls (arrow in C )
 ↑ elastase activity  ↑ loss of elastic fibers  ↑ lung compliance

27
A63-year-old man presents to your office complaining of
worsening shortness of breath over the past year. You know
that this patient has smoked two packs of cigarettes a day
for the past 45 years. As you are talking to the patient, you
notice that he is using his accessory muscles of respiration
to breathe, that his chest is barrel shaped and that he is
breathing carefully through pursed lips. Using a spirometer,
you determine that he has a decreased FEV1/FVC ratio and
an increased TLC. You tell the patient that it is imperative
that he stop smoking and prescribe him a tiotropium
inhaler.

P
28
OTHER FINDINGS
 CXR: ↑AP diameter, flattened
diaphragm, ↑ lung field lucency
 Barrel-shaped chest (D)
 Exhalation through pursed lips to
increase airway pressure and prevent
airway collapse
The Netter Collection of Medical
McGraw-Hill ,2017.

29
An 8-year-old girl is brought into an urgent-care clinic
complaining of shortness of breath. Her past medical
history is significant for multiple allergies. Upon physical
examination, you hear expiratory wheezes and you
observe that the patient is using her accessory muscles of
respiration. You decide to administer an inhaled β2-
adrenergic agonist for relief of her symptoms.

30
PRESENTATION
 Findings: cough, wheezing, tachypnea, dyspnea, hypoxemia, ↓ inspiratory/
expiratory ratio, pulsus paradoxus, mucus plugging (E )
 Triggers: viral URIs, allergens, stress
 Diagnosis supported by spirometry and methacholine challenge
PATHOLOGY
 Bronchial hyperresponsiveness reversible bronchoconstriction
 Smooth muscle hypertrophy and hyperplasia,
 Curschmann spirals (F) (shed epithelium forms whorled mucous plugs), and
 Charcot-Leyden crystals (G) (eosinophilic, hexagonal, double-pointed, needle-
like crystals formed from breakdown of eosinophils in sputum)

31
 OTHER RELATIONSHIPS
 Aspirin-induced asthma: COX inhibition leukotriene
overproduction airway constriction
 Associated with nasal polyps
 Obstructive defects by pulmonary function testing
 Patients with mild asthma may have entirely normal
pulmonary function between exacerbations
 During active asthma attacks, all indices of expiratory airflow
are reduced, including FEV 1 , FEV 1 /FVC (FEV 1 %), and
peak expiratory flow rate
 FVC is often also reduced as a result of premature airway
closure before full expiration

32
 Carcinoma that occurs in apex of lung 
may cause Pancoast syndrome by
invading cervical sympathetic chain
 Compression of locoregional structures
may cause array of findings:
 Recurrent laryngeal nerve
hoarseness
 Stellate ganglion  Horner syndrome
(ipsilateral ptosis, miosis, anhidrosis)
 Superior vena cava  SVC syndrome
 Brachiocephalic vein
brachiocephalic syndrome (unilateral
symptoms)
 Brachial plexus  sensorimotor
deficits The Netter Collection of Medical

33
An 82-year-old woman presents to the emergency
department complaining of severe shortness of breath.
She tells you that her right calf has been sore as well.
On directed history, you discover that she suffered a
stroke 6 months ago and has been bedridden ever since.
Further evaluation reveals that she is hypoxic and has
elevated D-dimer levels. You decide to begin empiric
anticoagulant therapy and you order a ventilation-
perfusion scan on this patient.

34
CLINICAL FINDINGS
 V˙/Q˙ mismatch, hypoxemia, respiratory alkalosis
 Sudden-onset dyspnea, pleuritic chest pain, tachypnea, tachycardia
 Large emboli or saddle embolus A may cause sudden death
 Lines of Zahn are interdigitating areas of pink (platelets, fibrin) and red
(RBCs) found only in thrombi formed before death help distinguish pre- and
postmortem thrombi B
 CT pulmonary angiography is imaging test of choice for PE (look for filling
defects) C

35
Types: (An embolus moves like a FAT BAT)
Fat, Air, Thrombus, Bacteria, Amniotic fluid,
Tumor
 Fat emboli—associated with long bone fractures and
liposuction classic triad of hypoxemia, neurologic
abnormalities, petechial rash
 Amniotic fluid emboli—can lead to DIC, especially
postpartum
 Air emboli—nitrogen bubbles precipitate in
ascending divers (decompression sickness) treat
with hyperbaric O2;
o or, can be iatrogenic 2° to invasive procedures (eg, central
line placement)

36
Upper respiratory infection
Most are viral: common cold, pharyngitis, etc.
Lower respiratory infection
Frequently viral
Bronchitis: cough, wheezing, dyspnea
Pneumonia: cough, fever, rapid respiration,
dyspnea, pleuritic CP

37
A 68-year-old man presents to the emergency department
complaining of a fever, dyspnea, and a cough productive of
green sputum. Physical examination reveals an ill-
appearing man, breathing heavily. On lung examination,
you note bronchial breath sounds and dullness to percussion
over the right lower lung lobe. A chest x-ray demonstrates
circumscribed opacity over the region of
his right lower lung lobe. You obtain sputum and blood
cultures and then admit this patient to the hospital for
antibiotic treatment.

38

39
A 21-year-old woman presents to the university health clinic
complaining of general weakness and a low-grade fever of 3
days’ duration. Upon directed history, you learn that she has
had an occasional cough and dyspnea and that her two
roommates have been suffering from similar symptoms.
When a chest x-ray reveals patchy infiltrates, you prescribe
her a course of azithromycin and schedule her for a follow-
up visit to make sure that her symptoms have resolved.

40
Compare diffuse, patchy bilateral infiltrates of “atypical” interstitial
pneumonia (A) with localized, dense lesion of lobar pneumonia (B)
(A)
(B)

41
NEONATES
(< 4 WK)
CHILDREN
(4 WK–18 YR)
ADULTS
(18–40 YR)
ADULTS
(40–65 YR)
ELDERLY
Group B
streptococci
E coli
Viruses (RSV)
Mycoplasma
C trachomatis
(infants–3 yr.)
C pneumoniae
(school-aged
children)
S pneumoniae
Runts May
Cough
Chunky
Sputum
Mycoplasma
C pneumoniae
S pneumoniae
Viruses (eg,
influenza)
S pneumoniae
H influenzae
Anaerobes
Viruses
Mycoplasma
S pneumoniae
Influenza virus
Anaerobes
H influenzae
Gram ⊝ rods

42
 Alcoholic Klebsiella, anaerobes usually due to aspiration
(eg, Peptostreptococcus, Fusobacterium, Prevotella,
Bacteroides)
 IV drug users S pneumoniae, S aureus
 Aspiration Anaerobes
 Atypical Mycoplasma, Legionella, Chlamydia
 Cystic fibrosis Pseudomonas, S aureus, S pneumoniae,
Burkholderia cepacia
 Immunocompromised S aureus, enteric gram ⊝ rods,
fungi, viruses, P jirovecii (with HIV)
 Nosocomial (hospital acquired) S aureus, Pseudomonas,
other enteric gram ⊝ rods
 Postviral S pneumoniae, S aureus, H influenzae

43
 Localized collection of pus within parenchyma
(A)
 Caused by aspiration of oropharyngeal contents
(especially in pts predisposed to loss of
consciousness (LOC) [eg, alcoholics, epileptics])
or bronchial obstruction (eg, cancer)
 Air-fluid levels B often seen on CXR Fluid
levels common in cavities presence suggests
cavitation
 Due to anaerobes (eg, Bacteroides,
Fusobacterium, Peptostreptococcus) or S
aureus.
 Lung abscess 2° to aspiration is most often
found in right lung however, location depends
on patient’s position during aspiration.
Treatment: clindamycin

44
Antimicrobial therapy
TaoLeTandBhushanV.FirstAidfortheUSMLEStep12017.NewYork,NY:McGraw-Hill,2017.

45
THE END
See next slide for hypertext tools and resources for further study.

46
Companion Notes
Make the Diagnosis with Pathophysiology Q&A. pdf
eBooks
Bate’s Guide to the Physical Examination and History
Taking, Lynn Bickley (with Video)
DeGowin’s Diagnostic Examination, 9th Ed. Richard
DeGowin,et al.
Textbook of Physical Diagnosis: History and Examination,
Mark Schwartz. (with Video)
A Practical Guide to Clinical Medicine, Charlie Goldberg
and Jan Thompson.
(A PDF version of the website compiled by this presenter.)

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