Mathew medicine pdf download

Perio Ortho. Pharmacology Toxicology and Forensic Med. Iatrochemistry Charaka Samhita. Surgical Inst. Product was successfully added to your shopping cart. Availability: In stock Regular Price: Rs1, Description Additional Tags Reviews.

Details Description With ever-expanding knowledge and advances in medicine, the sixth edition of this book is significantly revised and presented in new full-colour format. Structured in question-answer format, this book is a must-have for all undergraduate medical students as it prepares them for both theory and viva-voce examinations.

It is also useful for dentistry and nursing students. Product Tags Add Your Tags:. Be the first to review this product. Submit Review. Related Products. Get all the latest information on Events, Sales and Offers. Sign up for newsletter today. Contact Information. Nagar, Pimpri, Pune Phone Email sales pmbhkart. About us Contact us My Account. Order history Advanced search Login. Important Links. The marrow is densely filled with fibrous tissue.

This can control anaemia and splenomegaly in a substantial number of patients. Can lead to myelosuppression that further exacerbates underlying anaemia. It is reserved for patients who cannot undergo splenectomy for any reason, but the efficacy of this therapy is poor, and subsequent cytopenias are often severe. It can be performed only in a limited number of cases as most are above 60 years.

Marrow fibrosis often occurs. Describe the aetiology, classification, clinical features, diagnosis and treatment of myelodysplastic syndrome MDS. The syndrome is characetrised by ineffective haemopoiesis due to increased susceptibility of clonal myeloid progenitors to apoptosis, which leads to cytopenias despite a generally hypercellular marrow. The median age of patients withMDS is 65 years.

Most physicians do not follow the old FAB Classification. Subtype Peripheral blood Bone marrow. Hence, most patients develop anaemia, leucopenia and thrombocytopenia. Some degree of thrombocytopenia is usual. The platelets vary in size and some appear hypogranular. Neutrophils also show variation in size. Morphologic abnormalities are often observed in the granulocytes. Granulation abnormalities vary from an absence of granules to abnormal distribution inside the cytoplasm Doble bodies.

It shows dysplastic features in one or several myeloid series. Myelofibrosis is occasionally present at diagnosis or may develop during the course of MDS. Bone marrow biopsy is useful when marrow is hypocellular as it helps in detecting fibrosis and also helps in differentiating it from aplastic anaemia or acute myeloid leukaemia. Lenalidomide is beneficial in the Sq- syndrome.

Discuss the types, clinical features, investigations, clinical staging and management of chronic lymphocytic leukaemia. Streptococcus pneumoniae, Staphylococcus and Haemophilus influenzae cause most of the infections. Herpes zoster also frequent. Fludarabine is the best studied agent of the three in CLL.

Discuss the clinical features, investigations and management of hairy cell leukaemia. Lymphadenopathy is rare. Pancytopenia, particularly monocytopenia occurs in several patients. These are the malignant B lymphocytes. The hairy structures on the surface of the cell are cytoplasmic projections. They have an eccentrically placed nucleus and foamy cytoplasm. These hairy cells stain positively for tartrate-resistant acid phosphatase TRAP.

The current recommendation is to initiate treatment if patient develops cytopenia, symp- tomatic splenomegaly or constitutional symptoms e. How do you classify splenomegaly? Enumerate the common causes of splenomegaly. Classification and Causes. Nucleated red blood cells may be seen. Total leucocyte count is reduced in the late stages.

Imiglucerase, a recombinant DNA-produced analogue of human glucocerebrosidase has proved highly efficacious in reducing hepatosplenomegaly and improving bone marrow involvement and haematological findings. Other recombinant glucocerebrosidase enzyme replacements include velaglucerase alpha and taliglucerase alfa.

Recently, an oral preparation, eliglustat has been approved for use in adults with type 1 disease. Enumerate the causes, clinical features and treatment of hypersplenism.

What are lymphomas? What are the common types of lymphomas? Majority of lymphoid cells are present in lymph nodes, spleen, bone marrow, thymus and gastrointestinal tract. An uncommon lymphoma is mycosis fungoides. Give a brief account of Read-Sternberg RS cell. Prognosis varies depending upon the histological type. Less commonly, the disease may start in the mediastinal or axillary nodes, and rarely in the abdominal, pelvic or inguinal nodes.

The involved nodes are discrete, non-tender and "rubbery" in consistency. Alcohol-induced discomfort in the lymph nodes is a common feature of Hodgkin's lymphoma. Sites that are rarely involved by Hodgkin's lymphoma include Waldeyer's ring, and mesenteric, epitrochlear and popliteal nodes. This fever occurs in a cyclical pattern, characterised by several days or weeks of fever alternating with afebrile periods.

In advanced disease, microcytic anaemia usually develops due to defective iron utilisation. A fine needle aspiration is not recommended for diagnosis. Liver biopsy may provide the diagnosis in those with hepatomegaly. The investigations required for clinical staging include chest radiographs, liver function tests, renal function tests, abdominal ultrasound, bone marrow trephine and aspirate, and CT scan neck, chest, abdomen and pelvis.

It is also very useful at the completion of therapy to document remission. The presence of RS cells in histology specimen differentiates Hodgkin's lymphoma from non-Hodgkin's lymphoma. Sometimes periaortic lymph nodes and spleen spade field are also included. In such case, radiotherapy involves mantle field as well as inverted Y field periaortic iliac, hypogastric and inguinal lymph nodes, and spleen.

The regimens COllll1lonly used are given in the box. If a complete response occurs, 2 to 4 additional cycles are administered followed by involved-field radiotherapy. Acute leukaemia generally occurs within 10 years of use of alkylating agents in combination with radiotherapy. Solid organ cancers usually occur more than 10 years after treatment and are associated with use of radiotherapy. Discuss the pathological classification, clinical staging, clinical features, investigations and management of non-Hodgkin's lymphoma.

Small-cell disease mature lymphocytes is associated with low-grade and large-cell disease immature lymphoid cells with high-grade disease. A lymphoma that originates in the lymphatic tissue in the marrow is designated as lymphocytic leukaemia or lymphoblastic leukaemia. CLL now belongs to the NHL group together with its non-leukaemic counterpart, and small lymphocytic lymphoma. The disease is usually widespread at the time of diagnosis. Waldeyer's ring and epitrochlear lymph nodes are frequently involved.

Gastrointestinal tract stomach , thyroid, skin, sinuses and central nervous system are frequently involved. Paraplegia can occur from compression of spinal cord by an extradural lymphoma. Other pressure effects are dysphagia, breathlessness, vomiting, intestinal obstruction, ascites and limb oedema. However, it is more useful in Hodgkin's lymphoma rather than in non-Hodgkin's lymphoma. Further, "B" symptoms are not included as they are not useful in predicting prognosis. A leukaemic.

High-grade lymphomas may frequently be leukaemic. Immunobistochemical study is essential for differentiating various subtypes of NHL and also to determine prognosis as these will influence the choice of therapy. It is also indicated in the case of HIV-associated lymphoma and highly aggressive lymphoma. How do you differentiate Hodgkin's lymphoma from non-Hodgkin's lymphoma? Some may develop sudden paraplegia. One-fourth has ileocaecal disease and present with either a right lower quadrant mass or pain from intussusception.

It again presents with abdominal involvement. CNS involvement is common in adults. The rate of proliferation and rate of death apoptosis are high, with the dead cells being taken up by pale histiocytic cells within the tumour that punctuate the low-power view, giving a "starry sky" appearance.

In these patients, median survival is 6 months. Opportunistic infections are commonly seen. Peripheral smear usually reveals characteristic, pleomorphic abnormal CD4-positive cells with indented nuclei called "flower" or "cloverleaf' cells.

Bone marrow involvement is usually not prominent. There is no lymphadenopathy, hepatosplenomegaly or hypercalcaernia. Median survival is more than 2 years, but less than 10 years. Explain what is mucosa-associated lymphoid tissue MALT lymphoma or primary gastric lymphoma. Distant metastasis can also occur.

Multiple biopsies are required for establishing diagnosis. Write a short note on mycosis fungoides and Sezary syndrome. The skin rash is usually itchy. The circulating cells are malignant T cells with serpentine nuclei.

Topical nitrogen mustard and phototherapy have similar efficacy. What are plasma cell disorders? Discuss the immunopathology, pathology, clinical features, investigations and treatment of multiple myeloma. Individual plasma cells produce immunoglobulins with only one type of light chain kappa or lambda. So, all the malignant cells produce the same immunoglobulin. It appears on electrophoretic strip as a clear-cut band M-band or M-component.

These excess light chains appear in the urine as Bence-Jones proteinuria. In non-secretory myeloma, there is no M-protein in the blood or urine but has bone marrow plasmacytosis and organ or tissue impairment. Autologous peripheral blood stem cell transplantation is the treatment of choice for younger patients. In older patients, melphalan and dexamethasone are considered. In localised disease without clonal plasma cells in bone marrow biopsy, local radiation is recommended. Gradual replacement of the marrow by plasma cells results in anaemia, leucopenia and thrombocytopenia.

Other areas include gut, skin, airways, liver, kidneys, CNS and breast. In a patient with multiple myeloma, presence of plasmacytomas indicate poor prognosis. Palliative radiotherapy is indicated for controlling symptoms related to plasmacytomas.

Lenalidomide and not thalidomide and bortezomib have some role in management of plasmacytomas. A skeletal survey and bone marrow are mandatory at baseline. If the results at months are stable, the studies should be repeated every months for 1 year and, if stable, evaluation can be lengthened to every months. Higher levels indicate poor prognosis. Radiographs of flat bones like skull, vertebral bodies, ribs and pelvis show the characteristic punched-out osteolytic lesions.

Collapse of multiple vertebrae is a common radiological finding. Immunoelectrophoresis and immunofixation can determine the immunoglobulin type, and confirm that the M-component is truly monoclonal. In myeloma, the number of plasma cells is increased, and they are atypical in morphology. With chemotherapy, this can be prolonged to years. There is no cure available till now.

Mithrarnycin is highly effective in controlling hypercalcaemia, but is highly toxic. A better option is to give pamidronate mg as slow infusion. Its side effects include thrombocytopenia, neutropenia, diarrhoea and sensory neuropathy. Reactivation of varicella zoster virus may occur. Bisphosphonates inhibit osteoclast recruitment and maturation, prevent the development of monocytes into osteoclasts, induce osteoclast apoptosis and interrupt their attachment to the bone.

However, they do not have any effect on overall survival, hypercalcaemia or incidence of non-vertebral fractures. An important complication of bisphosphonates is osteonecrosis of jaw. Hence, they should receive aspirin or low molecular weight heparin.

What are the causes of M-component on electrophoresis? Conditions that can have M-Component. What are the causes of renal failure in multiple myeloma? NSAIDs for bone pains. It is separate from the causes of renal failure in multiple myeloma mentioned above.

What is monoclonal gammopathy of undetermined significance MGUS? How do you differentiate between multiple myeloma and monoclonal gammopathy of undetermined significance MGUS? Describe solitary plasmacytoma of bone. What is solitary extramedullary plasmacytoma? However, since most cases occur in head and neck area, surgery may not be a feasible option.

In such cases, local radiotherapy is recommended. What is plasma cell leukaemia? Give a brief account of Waldenstrom macroglobulinaemia. It is most commonly manifested by bleeding epistaxis, gingival bleeding , blurring or loss of vision, dizziness, headache, vertigo, nystagmus, hearing loss, ataxia, paraesthesias, diplopia, somnolence and coma. This is usually a distal, symmetric, chronic, demyelinating neuropathy, sometimes associated with abnormalities of proprioception and ataxia.

Irnmunofixation is required to characterise monoclonal protein. Briefly outline the side effects, precautions and dosage of thalidomide. In more severe cases, complete absence of limbs can occur. Additionally, foetus can develop external ear abnormalities, hypoplastic or completely absent bones, facial palsy, eye abnormalities, and gastrointestinal and genitourinary tract malformations. Therefore, effective contraception must be used at least 4 weeks before beginning thalidomide therapy, during thalidomide therapy, and for 4 weeks following discontinuation of thalidomide therapy.

If menstrual cycles are irregular, the pregnancy testing should occur every 2 weeks. Discuss the mechanism of haemostasis. Write in brief about platelets and their functions. Briefly outline the natural inhibitors of coagulation. Describe fibrinolytic system. The first two components are called primary haemostasis while the last component is called secondary haemostasis.

The defect may be either quantitative deficiency or qualitative functional. These thrombi form under high shear conditions and are primarily composed of platelet aggregates held together by fibrin strands. They are anucleate and have a discoid shape.

The normal lifespan is about 10 days. The enzyme cyclooxygenase then converts arachidonic acid into endoperoxides. These are converted to thromboxane A2 by thromboxane synthetase and prostacyclin by prostacyclin synthetase. Thromboxane A2 is a potent stimulant of platelet activation and aggregation while prostacyclin inhibits activation. Endoperoxidases Prostaglandin G2 and H i. Thromboxane Prostacyclin synthetase synthetase.

This is greatly facilitated by Va. Tissue trauma Extrinsic pathway. VII t VIia. X xa t Xa Common pathway H. Fibrinogen t Fibrin Stabilised monomers cross-linked fibrin. Heparin also increases its action. Impaired activity of protein C occurs in factor V Leiden, produces thrombophilia.

The defect in the vessel wall then becomes covered with endothelial cells. It also degrades Va, Villa and GPlb. PAI-1 is inhibited by activated protein C. Other inhibitors of fibrinolysis include arantiplasrnin and armacroglobulin. Tissue plasminogen Fibrinolytic system activator tPA. Stabilised Fibrin degradation cross-linked fibrin products FDPs. Fibrin degradation products FDPs can be measured as an index of fibrinolytic activity.

Discuss the evaluation of a patient with bleeding disorder. Based on the results of these, some additional complex investigations may be necessary in some cases.

Define thrombocytopenia. Enumerate the common causes, clinical manifestations, investigations and management of thrombocytopenia. Describe Tourniquet test capillary resistance test of Hess; Hess test. Enumerate the common conditions inhibiting platelet function or qualitative platelet disorders. The sphygmomanometer cuff applied around the upper arm is inflated to a pressure halfway between systolic and diastolic blood pressures. The cuff is deflated after 5 minutes.

Count the number of petechiae in an area of 3 cm diameter, 1 cm below the cubital fossa. A number exceeding 20 is interpreted as positive Hess test. Positive Hess test indicates increased capillary fragility resulting from thrombocytopenia.

Clinical manifestations roughly correlate with the platelet count. Discuss the pathogenesis, clinical features, investigations and management of immune idiopathic thrombocytopenic purpura ITP. These antibody-bound platelets are removed and prematurely destroyed by macrophages in the spleen. Helper T-ce! More than one-third of remaining patients recover in next few months to years.

Repeat platelet count using sodium citrate as anticoagulant so as to exclude pseudothrombocytopenia caused by platelet aggregation and clumping in the presence of EDTA anticoagulant. However, a negative test does not exclude ITP. Important adverse effects include deep vein thrombosis and embolism, and mild elevation in liver enzymes. Methylprednisolone is repeated daily for another 1 - 2 days. Discuss thrombotic thrombocytopenic purpura. Other conditions include disseminated intravascular coagulation, disseminated malignancy, malignant hypertension and microvascular vasculitis complicating autoimmune disorders such as systemic lupus erythematosus or certain infections such as Rocky Mountain spotted fever.

Ultra-large vWF multimers cause extensive platelet aggregation and depletion of the circulating pool of platelets. Elevated LDH also occurs due to release from ischaemic tissues. Fibrin degradation products may be normal or slightly elevated. It removes antibody-producing cells. Used in patients refractory to plasma exchange and corticosteroids. May also be used along with plasma exchange if CNS or heart are significantly involved.

Discuss the clinical features, investigations and treatment of haemolytic-uraemic syndrome. Shiga toxins-I and 2, produced by enterohaemorrhagic E. Recently new strain of Shiga producing E. This disrupts protein synthesis, causes endothelial cell death and damage, induces inflammatory and procoagulant cascades that promote microvascular thrombosis. Meningococcal vaccination is mandatory, and the patients should take prophylactic antibiotics at least until 2 weeks after vaccination.

What are the common causes of thrombocytosis? Discuss the aetiology, classification, clinical features, diagnosis and management of haemophilia A. Write a short note on acquired haemophilia A. It results from a reduction of factor VIII antihaemophilic factor. Plasma factor VIII has a half-life of 12 hours. In the plasma, it is carried bound to the von Willebrand's factor vWF.

It is more common in elderly patients. Presentation is with acute onset of severe, and life-threatening bleeding. Spontaneous subcutaneous, deep muscle and retroperitoneal bleeds represent the majority of events, but gastrointestinal, pulmonary and intracranial bleeds also occur. Trauma-related muscle bleeds and haemarthroses are uncommon. Virtually, no tissue is exempted from this.

Spontaneous bleeding usually occurs after 6 months of age but in severe cases, it can occur in the first month also. All these gradually subside over a period of days. Often the patient is left with some residual weakness in the leg. Pain is relieved by analgesics like acetaminophen or codeine. Prophylaxis is superior to on-demand therapy in delaying or preventing the development of haemophilic arthropathy.

An individual with a plasma volume of mL would have units of clotting factor in the circulation. Each unit of cryoprecipitate contains about units of factor vm.

This is maintained for days. Volume of distribution for factor VIII is approximately 0. The calculated dose is administered twice a day.

It is given intravenously at a dose is 0. Intranasal route can be used for oral bleeding and before dental procedures. Patients should be advised to limit water intake to reduce chances of hyponatraemia. Regimen is EACA taken orally in a dose of 5 g four times daily for 7 days, starting on the day of extraction. Briefly discuss haemophilia B Christmas disease and its management.

Discuss the aetiology, clinical features, investigations and treatment of von Willebrand's disease. Type 2A and 2M are usually autosomal dominant though a few cases may be autosomal recessive. Type 1 is autosomal dominant. Hence, the deficiency of vWF results in a defect of platelet function. The antibiotic Ristocetin causes vWF to bind to platelets via GPl b, resulting in platelet clumps and their removal from the circulation.

Write briefly on recombinant factor VII activated. Discuss the causes, pathogenesis, clinical features, lab features and management of disseminated intravascular coagulation DIC; defibrination syndrome; consumption coagulopathy.

The cardinal clinical manifestations of DIC are bleeding and organ damage. Triggering mechanism e. I Activation of coagulation cascade ti.

Most cases present with haemorrhage. Migratory venous thrombosis is known as Trousseau sign. However, fibrinogen is an acute phase reactant, and patients with conditions that cause elevation in acute phase reactants e. Further, in chronic DIC, fibrinogen and platelets may be normal. However, it is important to remember that many conditions other than DIC, such as trauma, recent surgery or venous thromboembolism, are associated with elevated FDPs including D-dimer.

Also, because FDPs are metabolised by the liver and secreted by the kidneys, liver and kidney impairment can influence their levels. It is indicated in patients with active bleeding, in those requiring an invasive procedure and those who are otherwise at risk for bleeding complications. Severe hypofibrinogenaemia that persists despite FFP replacement may be treated with fibrinogen concentrate or cryoprecipitate.

However, it is often given in patients with thrombotic manifestations e. It should be given after the correction of bleeding risk. Major indications of heparin are: Platelet counts or coagulation factors do not increase following replacement and patient continues to bleed. Retained dead foetus before induction of labour. Deposition of fibrin resulting in purpura fulrninans or venous thromboembolism. In acute promyelocytic leukaemia, before induction chemotherapy to prevent DIC. Give a brief account of vitamin K.

It is available in injection form for therapeutic use. This is necessary for the functioning of these factors. Warfarin-type anticoagulants inhibit carboxylation by preventing the conversion of vitamin K to its active hydroquinone form. Vitamin K hydroquinone Vitamin K epoxide. Vitamin K may not be effective in the presence of liver cell disease. Give a brief account of antiplatelet drugs.

These are classified below:. Adenosine interacts with the adenosine receptors to cause increased cAMP via cyclic adenylate cyclase. Due to vasodilatory property, it can lower the blood pressure. The end result of ADP signaling through its P2Y 1 2 receptor is an amplification ofstable platelet aggregation and secretion. This side effect is less common with clopidogrel.

In patients with acute coronary syndrome, mg loading dose is recommended in patients who will undergo angiography and possible revascularisation within 24 hours of iliagnosis. If angiography is not planned, loading dose is mg. The usual daily dose is 75 mg. The platelet functions return to normal about 7 days after the last dose. Clopidogrel needs to be discontinued at least 5 days before any major surgery. About one-third of patients on clopidogrel are resistant and show only a low level of platelet inhibition.

It is able to achieve higher degrees of platelet inhibition than clopidogrel. Maintenance dose of prasugrel is 10 mg daily. Risk of bleeding is higher compared to clopidogrel. In patients with ACS with planned revascularisation, aspirin can be combined with clopidogrel mg loading dose , prasugrel 60 mg loading dose or ticagrelor mg loading dose. Eptifibate may also produce hypotension. Classify anticoagulants.

Give a brief account of the commonly used anticoagulants. These are most commonly used. In addition, active heparin fractions may vary considerably in molecular weight.

Overlapping therapy with warfarin should be started along with heparin. Fresh frozen plasma has little effect on bleeding associated with heparin, low-molecular weight heparins and fondaparinux.

It presents days after heparin exposure with thrombotic features HIT and thrombosis syndrome. Can occur with all types of heparin. Vitamin K is recommended if a diagnosis of HIT is made after warfarin has already been started.

Factor Xa inhibition is through binding to antithrombin. Factor VII has a short half life of only hours, and therefore, PT may get prolonged within a day of administration of warfarin. The goal is to inhibit all vitamin K-dependent factors; factor X and prothrombin have half-lives of less than 2 days. Subsequent daily doses are adjusted according to PT, which is maintained at 1.

Usual maintenance dose varies from 2. This should be monitored by checking PT before and after stopping any other drug. The pathogenesis of skin necrosis and venous limb gangrene involves microthrombosis formation due to depletion of protein C in the setting of increased thrombin generation e. In contrast, in venous limb gangrene, acral distal necrosis occurs in the affected limb.

International normalised ratio INR is markedly elevated due to depletion of protein C. This product is therefore contraindicated in patients with IDT. Bivalirudin is a synthetic analogue of hirudin. Bivalirudin is one of the preferred drugs for patients with unstable angina undergoing percutaneous intervention. They directly inhibit free and prothrombinase-bound factor Xa. They inhibit both fibrin-bound and free thrombin. Others which have been discussed above include hirudin, lepirudin and bivalirudin.

For bleeding, treatment is largely supportive which includes anticoagulant discontinuation, fluid resuscitation, red blood cell transfusion, diagnostic and therapeutic procedures to identify the source of bleeding, and application of local haemostatic measures.

Give a brief account of fibrinolytic system and fibrinolytic agents. Briefly describe thrombolytics. These agents activate plasminogen adsorbed onto fibrin clots producing plasmin. Plasmin then degrades fibrin polymers into small fragments. They have different half lives, fibrin specificity and infusion strategies.

On complexing with plasminogen, it converts other plasminogen molecules into plasmin. It is not fibrin-selective as it produces lysis of both fibrinogen and fibrin.

It is used in acute ST-elevation myocardial infarction and pulmonary embolism. It activates plasminogen directly. It is useful in patients who received STK in the past 6 months and require a thrombolytic agent for MI or pulmonary embolism. It does not induce allergic reaction. Though it is more fibrin specific compared to STK it preferentially activates plasminogen bound to fibrin , bleeding complications with rtPA are similar with the two agents.

Discuss blood transfusion and blood component transfusion. What are the complications of blood transfusion? At present, almost all transfusions are in the form of transfusion of components.

In bleeding patient, replacement of intravascular volume is the first priority. For example, a recipient with blood group B has anti-A antibodies and therefore can receive platelets from donors with blood group of B. Infusion of ABO non-compatible platelets is an acceptable practice, in particular when platelet concentrates are in short supply. Patients should only receive plasma which does not contain an antibody which could attack their own red cells. For example, a recipient with blood group A has anti-B antibodies and therefore can receive plasma from donors with blood group of either A or AB which has neither anti-A nor anti-B antibodies.

Rh compatibility is not required. Send one sample to the blood bank for evaluation and centrifuge the other sample to look for any free haemoglobin in the supernatant. The antibodies react with IgA present in the donor blood. Such antibodies are found most frequently in females after pregnancy and are not present in plasma of males unless they have been transfused.

The reaction occurs during or soon after transfusion and may be life threatening. Patient has IgG antibodies to the red cell antigens such as Rh, Kidd, Kell, Duffy because of previous pregnancies or transfusions. The antibodies are undetectable during cross-match but further transfusion causes a secondary immune response resulting in delayed haemolysis. Later, only indirect Coombs' test may be positive. Discuss the differential diagnosis of generalised lymphadenopathy in an adult. Associated other systemic abnormalities should be noted.

Such a patient suddenly develops features of acute leukaemiae. Chapter 2 Diseases of the Respiratory System. Define a bronchopulmonary segment. Name the bronchopulmonary segments. Each segment is an independent unit and these units are separated from each other by fibrous septa. Upper3 lobe 2. Middle 2. Right lobe 1 Left. Bronchopulmonary seg ments: Right-Upper lobe. Apical, 2. Anterior, 3. Posterior; Middle lobe.

Medial, 2. Lateral; Lower lobe. Anterior basal, 3. Posterior basal, 4. Medial basal, 5. Lateral basal. Left-Upper lobe. Posterior, 4. Superior lingular , 5. Inferior lingular ; Lower lobe. Discuss the causes, mechanisms, clinical features, investigations and management of hypercapnic encephalopathy [carbon dioxide CO2 narcosis].

It is especially severe on waking up. In a selected group of patients with mild symptoms, non-invasive ventilation NIV may be tried.

Discuss the causes, clinical features and management of hypoxaemia. However, the normal Pa02 falls gradually as the age advances. These terms are not interchangeable. A person can be hypoxaemic without hypoxia and similarly a person can be hypoxic without hypoxaemia.

For example, if a person is hypoxaemic but has polycythemia, he may not have tissue hypoxia. Similarly, a severely anemic patient may have tissue hypoxia without hypoxaemia. Chapter I 2 Diseases of the Respiratory System It is normal in patients with pure hypoventilation and reduced inspired oxygen concentration. Define clubbing. Enumerate the causes and give the mechanism of clubbing.

X-ray of fingers show resorption of terminal tufts acro-osteolysis instead of an overgrowth of phalangeal tufts seen in clubbing. Finger involvement is asymmetrical as compared to clubbing.

It is postulated that circulating megakaryocytes and large platelet particles, normally destroyed by the lungs, reach distal extremities and interact with endothelial cells resulting in the liberation of platelet-derived growth factor PDGF and other factors.

These factors cause proliferation of the connective tissue. Normally, an open diamond-shaped window is visible between the opposing nails due to the presence of Lovibond angle. Obliteration of this area indicates the presence of clubbing. This is known as Scharnroth's sign. Clubbing is present when the sum of the individual digit ratio is greater than Normally, the distal phalangeal depth is smaller than the depth of the interphalangeal joint.

To perform this test, calipers should be used. For clubbing to be present, the distal phalangeal depth: interphalangeal joint depth ratio should exceed 1. The index finger is the suggested digit used for measurement. Describe abnormalities in nails due to systemic diseases.

Abnormalities in Nails Due to Systemic Diseases. Enumerate the pulmonary function tests and give their clinical significance. Pulmonary Function Tests. The patient inhales fully and then forcibly exhales as fast as possible into the mouth piece of the spirometer until no more air can be expelled. A chart records the volume exhaled against time.

Obstructive ventilatory defect, where there is narrowing of airways during expiration e. It measures the maximum flow generated during expiration performed with maximal force and started after a full inspiration. Reduced values indicate airflow obstruction. It is of no use in restrictive ventilatory defect. TLC is the amount of air in the lungs at the end of full inspiration. RV is the volume of air in the lungs at the end of full expiration. In extraparenchymal diseases with restriction during both inspiration and expiration ankylosing spondylitis and kyphoscoliosis , RV is increased while TLC is reduced.

This helps in analysing the site of obstruction within the lung. As the lung volume reduces further, the smaller airways are responsible for most of the resistance. It is a sensitive index of small airway function. Oxygen saturation and bicarbonate concentration can be derived from the above values. For any age, this gradient is not more than 20 mmHg. In effect, it gives an estimate of the ability of the lungs to exchange gases. During a 6 minute walk test, healthy subjects can typically walk metres.

Define respiratory failure. Discuss the role of oxygen therapy in chronic type II respiratory failure complicating chronic obstructive pulmonary disease. Treatment is by maintaining upright posture, incentive spirometry, chest physiotherapy, post-operative analgesia and lowering of intra-abdominal pressure. Due to shock, the oxygen delivery to respiratory muscles is reduced. In' addition, the metabolic demand of body is increased.

Hypoventilation can therefore, occur due to low tidal volume, increased dead space or reduced respiratory rate. In hypoventilation, PaC02 increases while Pa02 decreases. Alveolar-arterial oxygen gradient is normal. Alveolar-arterial oxygen gradient is elevated. Due to associated hypoxaemia, patient with chronic respiratory failure may develop polycythaemia, pulmonary hypertension and cor pulmonale.

Correction of hypoxaemia will then cause a further rise in PaC02 resulting in confusion, drowsiness or loss of consciousness. Think carefully before prescribing oxygen to such patients. However, oxygen is indicated in selected cases. However, its role is controversial. Measure alveolar-arterial oxygen gradient Measure alveolar-arterial oxygen gradient.

Hypoventilation alone Reduced Fi02 e. Pneumonia Acute respiratory distress syndrome Collapse of lung Cardiogenic pulmonary oedema. What are sleep apnoea syndromes? Also increases risk of metabolic syndrome, type 2 diabetes mellitus and non-alcoholic fatty liver disease. The combination of the effort and the central hypoxic stimulation wakes the patient from sleep. These awakenings are so brief that the patient remains unaware of them.

Bed partners will report a sudden cessation of snoring followed by a loud snort and the resumption of snoring. Many of these patients also have OSA while a few have sleep hypoventilation an increase of at least 10 mmHg in PaC02 during sleep. There are severe limitations to this technique, especially the inability to detect apnoeas or hypopnoeas not associated with oxygen desaturation.

Furthermore, nocturnal oxygen desaturation may be related to sleep hypoventilation without upper airway obstruction, e. COPD, severe kyphoscoliosis, muscular dystrophy.

Thus, most patients would require objective assessment and diagnosis by a sleep study using polysornnography. This technique is termed as split-night study initial diagnostic polysornnography followed by CPAP titration during polysomnography on the same night.

CPAP is initiated and titrated to the level required to eliminate all disordered breathing, snoring and flow limitation. CPAP maintains upper airway patency by creating a "pneumatic splint".

These devices are designed to advance the mandible, thereby pulling the tongue structure forward and opening the pharyngeal airway.

None of them has been shown to produce consistent benefit in patients with OSA. Unknown aetiology. Apnoeas are terminated with an abrupt and large breath. Daytime somnolence is less common than that in OSA. Parkinson's disease and multisystem atrophy. What are the common therapeutic indications of oxygen therapy in clinical practice?

Add a note on the hazards of oxygen therapy. Therapeutic Indications. It has a one way valve that does not allow rebreathing of exhaled air. What non-cardiogenic pulmonary oedema? Alveolar spaces become flooded with oedema fluid of high protein content. The term 'acute Jung injury ALI ' is no longer used. ARDS is one form of non-cardiogenic pulmonary oedema.

Others include high altitude pulmonary oedema, salicylate toxicity, neurogenic pulmonary oedema and re-expansion pulmonary oedema.

In practice, terms ARDS and non-cardiogenic pulmonary oedema are used interchangeably. There is a complex inter-relationship between cytokines and pro-inflammatory mediators that initiate and amplify the inflammatory response.

Other responses include release of cytokines, lipid mediators, proteases, oxidants, growth factors, nitric oxide and nuclear factor-KB NF-KB. A few fine inspiratory crepitations may be audible. Crepitations are more prominent and heard throughout both lung fields, especially over basal areas. Tubular breath sounds may be heard. These are located more at the periphery of the lungs. As the disease progresses, hypoxaemia worsens and hypercapnia appears.

A gradual and modest increase in PaC02 mmHg with reasonable degree of acidosis pH of 7. Discuss non-invasive ventilation. During CPAP, pressure greater than atmospheric pressure is applied continuously to the airways. Its use averts airway collapse after expiration, thereby maintaining open alveoli.

With CPAP, there is no inspiratory muscle unloading; in fact, tidal ventilation is completely dependent on the respiratory muscles.

BiPAP, on the other hand, applies a pressure during the inspiratory phase greater than the pressure applied during exhalation. It is also useful in the final stages of weaning when patients are being observed without ventilatory support. It is also used in patients with OSA. Discuss the aetiology, clinical features, investigations, complications and management of seasonal influenza. It is also the main viral target of protective humoral immunity by neutralizing antibody. This phenomenon is called antigenic drift.

This "drift" contributes to yearly seasonal epidemics and is the basis for the yearly change in vaccine formulations. Generally, such shifts occur only every few decades and are the basis for influenza pandemics. At times, these animal strains infect humans and spread from person to person.

The fauces are hyperaemic and chest is usually clear. Both are M2 inhibitors. Both are equally effective in reducing symptoms and duration of illness when taken within 48 hours of the onset of symptoms. Oseltamivir is given in a dose of 75 mg twice a day while zanarnivir is administered by oral inhalation of dry powder at a dose of 10 mg twice a day.

Both vaccines contain three strains of influenza: an H3N2 virus, an HlNl seasonal virus and an influenza B virus. Vaccine composition is adjusted yearly. The inactivated vaccine is approved for use in all persons older than 6 months. Both vaccines are produced in a process that uses chicken eggs and allergy to eggs is a contraindication to either vaccine.

It is also contraindicated in persons with other medical conditions such as diabetes mellitus, renal dysfunction, haemoglobinopathies or immune deficiency. Other contraindications include pregnant women and those receiving antiviral drugs active against influenza. Discuss briefly about swine flu Hl Nl influenza and prevention of human influenza panendemic.

Presently, HlNl influenza is in post-pandemic phase. Subsequently, the influenza activity in the world has declined. It has the genetic structure resulting from reassortment of genes from four influenza viruses, i.

Reassortment is when 2 or more viruses infect the same host cell and then exchange genes during replication. The new virion has gene segments from each of its parent virus.

In the present HlNl pandemic, mortality and morbidity is lower compared to seasonal influenza. Children and younger adults may shed the virus for as long as 10 or more days and immunosuppressed persons may shed the virus for weeks. These patients develop dyspnoea, cyanosis, haemoptysis, chest pain, confusion and hypotension.

Ventilatory support is often required in these patients. However, some persons, especially children, may shed virus for 10 days or longer. In intubated patients, endotracheal aspirates or bronchoalveolar lavage BAL should be obtained. Detect influenza viral nucleoprotein antigen and can provide results within 30 minutes. It can cause nausea and vomiting, rarely confusion, hallucinations and self-injury. It is given intravenously and may be useful for seri- ously ill patients.