Pulmonary Pulmonary PathologyPathology

Situational AnalysisSituational Analysis

Part IPart I

Rosella L. Montano, MDRosella L. Montano, MD

Emmanuel R. Dela Fuente, MDEmmanuel R. Dela Fuente, MD

Alejandro E. Arevalo, MDAlejandro E. Arevalo, MD

Situation no. 1 (Case I-A)Situation no. 1 (Case I-A)

FJ, a 36 year old male, a market vendor, FJ, a 36 year old male, a market vendor, had moderate to high grade fever, had moderate to high grade fever, cough productive of yellowish and cough productive of yellowish and occasionally rusty colored phlegm, and occasionally rusty colored phlegm, and progressive dyspnea of 1 week progressive dyspnea of 1 week duration. He is a known diabetic and duration. He is a known diabetic and takes medications irregularly. takes medications irregularly.

Situation no. 1 (Case 1-A)Situation no. 1 (Case 1-A)

On PE, FJ was awake, BP 110/70, PR was On PE, FJ was awake, BP 110/70, PR was 129/min, RR was 29/min, T 38.9 C. She 129/min, RR was 29/min, T 38.9 C. She preferred the upright position. There were preferred the upright position. There were intercostal and subcostal retractions. There intercostal and subcostal retractions. There was symmetrical chest expansion, increase was symmetrical chest expansion, increase fremiti, dullness and bronchial breath fremiti, dullness and bronchial breath sounds on the left lower lung fields. There sounds on the left lower lung fields. There were also scattered crackles over both lung were also scattered crackles over both lung fields.fields.

1. Interpret the CXR.1. Interpret the CXR.

2. Shown below are 2 gross specimens of the 2. Shown below are 2 gross specimens of the lungs. Which of the following is more lungs. Which of the following is more characteristic for this particular patient?characteristic for this particular patient?

A B

3. Based on the microscopic section of the 3. Based on the microscopic section of the bronchus and bronchiole, explain the bronchus and bronchiole, explain the mechanism of productive cough.mechanism of productive cough.

4. Which of the following histologic pictures is 4. Which of the following histologic pictures is more compatible with the physical finding more compatible with the physical finding of crackles / rales ?of crackles / rales ?

A B

5. Based on the microscopic section of the 5. Based on the microscopic section of the alveolus, explain the mechanism of alveolus, explain the mechanism of dyspnea, increased fremiti and lung dyspnea, increased fremiti and lung dullness on percussion.dullness on percussion.

Situation no. 1 (Case I-B)Situation no. 1 (Case I-B)

His son, mikey, 2 year old, also His son, mikey, 2 year old, also developed cough and cold 4 days ago. developed cough and cold 4 days ago. This was accompanied by moderate This was accompanied by moderate grade fever temporarily relieved by grade fever temporarily relieved by Paracetamol. One day prior to Paracetamol. One day prior to admission, he was noted to refuse to admission, he was noted to refuse to eat his food, and to have rapid eat his food, and to have rapid breathing. Mikey was restless, and was breathing. Mikey was restless, and was noted to have alar flaring. noted to have alar flaring.

Situation no. 1 (Case I-B)Situation no. 1 (Case I-B)

His CR was 108 beats/min, RR 47/min His CR was 108 beats/min, RR 47/min and temperature was 39.4 C. PE of and temperature was 39.4 C. PE of the chest revealed intercostals and the chest revealed intercostals and subcostal retractions, equal tactile subcostal retractions, equal tactile and vocal fremiti, resonance on and vocal fremiti, resonance on percussion with scattered fine percussion with scattered fine crackles over both lung fields.crackles over both lung fields.

1. With this particular patient, which of the 1. With this particular patient, which of the following gross pictures of the lungs is following gross pictures of the lungs is more characteristic?more characteristic?

A B

2. Based on the microscopic section of the 2. Based on the microscopic section of the lung parenchyma, explain the mechanism lung parenchyma, explain the mechanism of dyspnea, equal tactile and vocal fremiti of dyspnea, equal tactile and vocal fremiti and resonance on percussion.and resonance on percussion.

3. Give the Pathophysiology of this 3. Give the Pathophysiology of this complicationcomplication

Low Power High Power

4. Summarize the main histologic 4. Summarize the main histologic differences between bacterial differences between bacterial pneumonia and viral pneumonia and pneumonia and viral pneumonia and its complications its complications

Situation no. 2Situation no. 2

Mina, a 47 year old laundry woman Mina, a 47 year old laundry woman complained of afternoon rises in complained of afternoon rises in temperature accompanied by cough, back temperature accompanied by cough, back pains, and “unquantifiable” weight loss. A pains, and “unquantifiable” weight loss. A consult and a subsequent CXR showed a consult and a subsequent CXR showed a “spot” in the LUL. “spot” in the LUL.

1. Interpret the CXR 1. Interpret the CXR

2. With the signs and symptoms, which of 2. With the signs and symptoms, which of the following pictures is more the following pictures is more compatible with the patient’s history? compatible with the patient’s history? Explain.Explain.

A B

3. Interpret the Sputum exam3. Interpret the Sputum exam

4. This is a microscopic section from the lung 4. This is a microscopic section from the lung parenchyma. Discuss the evolution parenchyma. Discuss the evolution (formation) of this characteristic lesion, as (formation) of this characteristic lesion, as well as the predisposing factors that would well as the predisposing factors that would favor these lesions to develop.favor these lesions to develop.

Two weeks after, she experienced at least Two weeks after, she experienced at least 2-4 episodes of coughing out blood 2-4 episodes of coughing out blood streaked sputum per day. This was streaked sputum per day. This was accompanied by progressive dyspnea accompanied by progressive dyspnea and a sharp pain along the left subcostal and a sharp pain along the left subcostal region, which is worsened by coughing. region, which is worsened by coughing. During the past few days, she also During the past few days, she also needed to prop herself up on 3 pillows needed to prop herself up on 3 pillows so as to sleep without feeling dyspneic.so as to sleep without feeling dyspneic.

5. Explain the pathophysiology of hemoptysis.5. Explain the pathophysiology of hemoptysis.

6. The 26. The 2ndnd CXR revealed this changes. Explain CXR revealed this changes. Explain the pathoophysiology of dyspnea and the pathoophysiology of dyspnea and pleuritic chest pain.pleuritic chest pain.

Pulmonary Pulmonary PathologyPathology

Situational AnalysisSituational Analysis

Part IIPart II

Rosella L. Montano, MDRosella L. Montano, MD

Emmanuel R. Dela Fuente, MDEmmanuel R. Dela Fuente, MD

Alejandro E. Arevalo, MDAlejandro E. Arevalo, MD

Situation no. 1-1Situation no. 1-1

Albert, a 59 year old businessman Albert, a 59 year old businessman complained of chronic cough and complained of chronic cough and exertional dyspnea for 3 years. He exertional dyspnea for 3 years. He has a 70 pack-year smoking history.has a 70 pack-year smoking history.

1-A. Interpret the following CXR. 1-A. Interpret the following CXR. Which is more compatible with the Which is more compatible with the patient symptoms?patient symptoms?

A B

1-B. These are two gross specimens of 1-B. These are two gross specimens of the lung in relation to the CXRs shown the lung in relation to the CXRs shown earlier. Describe the pathology and earlier. Describe the pathology and explain the etiopathogenesis of each.explain the etiopathogenesis of each.

A B

1-C. These are the microscopic findings of 1-C. These are the microscopic findings of the lungs shown previously. Discussion the lungs shown previously. Discussion should include the following:should include the following:

i.i. morphological changes in the lungs morphological changes in the lungs

ii.ii. Clinical manifestions of the patient Clinical manifestions of the patient

iii.iii. Outcome and Complications Outcome and Complications

A B

Situation no. 1-2Situation no. 1-2

He claims that he used to have blood He claims that he used to have blood streaks in his sputum 2 months ago, streaks in his sputum 2 months ago, but in the past week, he has been but in the past week, he has been coughing up to 1-2 tsps of blood daily.coughing up to 1-2 tsps of blood daily.

2. Arrange the sequence of events from 2. Arrange the sequence of events from normal to dysplasia to carcinoma. normal to dysplasia to carcinoma. Explain the etiopathogenesis as well as Explain the etiopathogenesis as well as the predisposing factors/risk factors.the predisposing factors/risk factors.

41

3

2

Situation no. 1-3Situation no. 1-3

Albert also has a 1 x 1 cm hard, fixed Albert also has a 1 x 1 cm hard, fixed lymph node on the right lymph node on the right supraclavicular area. supraclavicular area.

3-A. Shown are sections from the right 3-A. Shown are sections from the right supraclavicular node. Which of the supraclavicular node. Which of the following is more compatible with following is more compatible with this patient? Describe the gross this patient? Describe the gross findings in the lymph nodes.findings in the lymph nodes.

A

B

3-B. The following are the respective 3-B. The following are the respective histologic findings in the nodes. Discuss histologic findings in the nodes. Discuss according to:according to:

i. Morphologyi. Morphology

ii. Etiopathogenesisii. Etiopathogenesis

iii. Outcomeiii. Outcome

A B

4. Chest X-ray and CT scan were 4. Chest X-ray and CT scan were done. Interpret the results.done. Interpret the results.

CXR

CT

5. This is a section from the right hilar 5. This is a section from the right hilar mass. Describe the gross findings and mass. Describe the gross findings and explain the pathogenesis of explain the pathogenesis of hemoptysis.hemoptysis.

6. This is the histologic section. Classify the 6. This is the histologic section. Classify the tumor according to its behaviour (Benign tumor according to its behaviour (Benign or Malignant), origin (Epithelial, or Malignant), origin (Epithelial, Mesenchymal or Lymphoid) and Mesenchymal or Lymphoid) and differentiation ( Well-, mod.- or poorly differentiation ( Well-, mod.- or poorly differentiated).differentiated).