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9.00-9.15
9.15-9.30
9.30-9.45
9.45-10.00
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Cell damage,Inflammation, repair I
Cell damage,Inflammation, repair II
Neoplasia I
Neoplasia II
Submitted by Dr.bisho on Mon, 27/04/2009 - 9:37pm.
This Formative OSCE Contains 70 Stations
For 3rd year students please skip the ones you didnt take the sytems for
Enjoy and Good luck.
Bisher
Submitted by Dr.bisho on Fri, 17/04/2009 - 10:59pm.
 The biopsy specimen of a lung from a patient with Wegener granulomatosis showing evidence of vasculitis and inflammation (high-power view). Image courtesy of Z. Xu, MD.
Submitted by Dr.bisho on Fri, 10/04/2009 - 12:42am.
A 62-year-old man presents with a 3-month history of dyspnea, fatigue, and weight loss. He had a heart transplant 26 months ago, with follow-up immunosuppression therapy.
RETRIEVED FROM eMedicine CME Case Study MEDSCAPE:
Authors:
Shahzad G. Raja, MRCS, Gilles D. Dreyfus, MD, PhD, FRCS
General Statement: A 62-year-old man presents with a 3-month history of dyspnea, fatigue, and weight loss. He had a heart transplant 26 months ago, with follow-up immunosuppression therapy. Summary of Clinical Data: Case History:
A 62-year-old man presents to the emergency department (ED) with a 3-month history of progressively increasing shortness of breath, fatigue, anorexia, and weight loss.
The patient underwent orthotopic heart transplantation for ischemic cardiomyopathy 26 months ago. He received the "standard" immunosuppression protocol for heart transplantation (so-called "triple therapy"), which included cyclosporine, azathioprine, and prednisolone.
In the immediate postoperative period, he was administered prednisolone at 1 mg/kg PO daily, which was tapered over a 3-week period to 20 mg daily and then continued for 3 months. This was decreased to 10 mg for the following 3 months and, finally, reduced to 5 mg daily for the last 6 months (which concluded a year-long taper). His maintenance immunosuppression regimen includes cyclosporine and azathioprine.
Upon further enquiry, the patient states that he developed a nonproductive cough and left thigh pain that has lasted for the past 1 month. His past history includes a coronary artery bypass grafting for triple vessel coronary artery disease (which occurred 8 years ago), hypertension, hyperlipidemia, and intermittent claudication. He has a smoking history of more than 80 pack-years, but he quit smoking at the time of his heart transplantation.
Physical Examination:
On physical examination, the patient appears pale and cachetic. His oral temperature is 98.6°F (37.0°C). His pulse has a regular rhythm and a rate of 102 bpm, and his blood pressure is 148/92 mm Hg. He is tachypneic, with a respiratory rate of 30 breaths/min, and his oxygen saturation is 93% while breathing room air.
The examination of his head and neck, including a check for icteric sclerae, is normal. A well-healed median sternotomy scar is noted. The patient has reduced air entry at the right lung base, with bilateral, scattered, coarse crepitations noted on auscultation of the lungs.
His S1 and S2 heart sounds are normal, and the abdominal examination is unremarkable. The peripheral arterial pulses in the lower extremities are palpable but diminished. Tenderness is elicited on deep palpation of the left mid-thigh. The neurologic examination shows a normal cranial nerve inspection, normal gross motor and sensory function, no pronator drift, and normal speech.
LAB TESTS
A laboratory analysis, including a complete blood cell (CBC) count and a basic metabolic panel, is normal, except for a hemoglobin value of 9.8 g/dL (98 g/L).
A posteroanterior (PA) upright chest radiograph (with an arrow showing the main pathology; see
followed by a computed tomography (CT) scan of the chest (Figure 2), is obtained.
Clinical Data Analysis: In this patient, the PA upright chest radiograph showed right pleural effusion, a left upper lobe mass (arrow), and changes consistent with emphysema. The CT scan showed air bronchograms within the left upper lobe mass; areas of low attenuation throughout the lung parenchyma consistent with emphysema and mediastinal lymphadenopathy were seen as well. A transbronchial biopsy revealed poorly differentiated squamous cell carcinoma, with involvement of the lymphatics and submucosal vessels. A bone scan revealed metastatic disease in the left femur. A review of earlier films, however, showed no evidence or suspicion of early bronchogenic cancer.
The risk of malignancy after solid organ transplantation is a well-recognized event in long-term immunosuppressed transplant recipients; in this group, the overall incidence of carcinoma increases by up to 100-fold, and the incidence of non-Hodgkin lymphoma increases by up to 40-fold. The incidence of carcinoma may vary with the type of allograft, however, because of differences in the induction therapy and immunosuppressive regimens. The most frequently observed tumors are squamous cell carcinoma of the skin, adenocarcinoma of the lung and gastrointestinal tract, Kaposi sarcoma, acute leukemia, and lymphoma.
The incidence of bronchogenic carcinoma after solid organ transplantation remains controversial. Although some authors have reported an incidence similar to that of the overall population, others have found an unexpectedly high incidence in the heart transplant population. In the heart transplant population, the incidence of bronchogenic carcinoma ranges from 0.6% to 4%. The increased incidence of lung malignancy has been theorized to be potentially related to the prolonged use of cytotoxic agents for immunosuppression; however, it is believed that the greatest risk factor for the development of lung cancer in the heart transplant population is likely from a concomitant history of prolonged cigarette smoking. In transplant recipients, the effects of inhaled carcinogens found in mainstream smoking products are believed to act in concert with impaired surveillance mechanisms resulting from long-term immunosuppression to promote the development of cancer. As in the nontransplant population, cardiac transplant recipients with lung carcinoma are predominantly in their sixth or seventh decade of life.
The interval from transplantation to the diagnosis of a malignancy is usually around 3-5 years after transplantation. It is not unusual, however, for a neoplasm to be discovered within 6 months of transplantation. The most striking feature is that a majority of patients have advanced disease (stage IIIA or higher) at the time of diagnosis, even though these patients are monitored very closely. The advanced stage of disease is mainly responsible for the dismal prognosis in these patients.
The symptoms at presentation vary widely and include cough, unresolved pneumonia, dyspnea, weight loss, and anorexia. Despite routine radiographic surveillance, almost half of these cancers are discovered incidentally. This observation suggests that these tumors may have rapid doubling times and/or that "routine surveillance" chest radiographs are inadequate for the early diagnosis of lung cancer in this population of patients. In addition, retrospective review of previous radiographs demonstrates that nearly half of these lesions are initially missed by the reviewing radiologists. Data from studies examining missed and potentially curable lung neoplasms indicate that the majority of these lesions are of "low obviousness". Inclusion of the patient's smoking history on the radiographic requisition may help enhance the radiologist's search for possible lung cancer. Immunosuppression further complicates matters because of the likelihood that a new radiographic abnormality, if detected, may first be attributed to an ongoing infectious process rather than a neoplastic one.
ABOUT BRONCHOGENIC CARCINOMA:
On chest radiographs, a nodule or mass is the most common radiologic manifestation of bronchogenic carcinoma and, in the majority of cases, the tumor size at detection is ≥2 cm in diameter. The majority of radiographically apparent cancers are visible a mean of 12 months before the time of diagnosis. Radiographic recognition of lung cancer in patients with fibrotic lung disease can be particularly problematic because of obscuration by adjacent parenchymal disease. Computed tomography (CT) evaluation improves the visibility of cancers associated with pulmonary fibrosis, which most commonly manifest as ill-defined lesions mimicking air-space consolidation.[6,7]
The diagnosis of bronchogenic carcinoma is established by a bronchoscopic biopsy. The histologic subtypes of the tumors include small cell carcinoma, adenocarcinoma, and anaplastic and squamous cell carcinoma.
Final Diagnosis / Differentials : Basic Management: Surgical intervention is, ideally, the treatment of choice and, when it is performed, medium-term survival is achievable. Optimal surgical treatment might not be possible, however, because of impaired respiratory function. Cardiac transplant recipients do not tolerate extensive lung resection in the same manner as nontransplant recipients. As a result of a previous history of smoking that has caused end-stage failure of 1 organ, many patients invariably have a degree of chronic lung damage, even in the presence of normal spirometry. The surgical procedures consist of lobectomy, bilobectomy, lobectomy with combined chest wall resection, and wedge resections. In reality, as the majority of the patients have an advanced (unresectable) stage of disease, treatment is largely limited to chemotherapy and palliative radiation.
A high rate of severe postoperative infectious complications, occasionally with lethal consequences, is seen in patients undergoing surgical resection. Postoperative complications are probably favored by the use of immunosuppressive drug therapy. Common postoperative complications include septicemia, pneumonia, prolonged air leak, wound infection, respiratory failure, and chronic renal insufficiency. Some authors have proposed measuring the procalcitonin plasma level to specifically detect bacterial infections in transplant recipients. An earlier treatment for infection may help prevent severe postoperative complications observed in heart transplant recipients undergoing surgery for lung cancer. Preoperative and postoperative repeat sputum cultures must be performed, and careful perioperative management of antibiotic therapy must be adopted.
According to long-term survival data available in the literature, the median survival of patients who underwent curative surgical treatment is 23 months, with a range of 12-34 months. Survival in heart transplant recipients depends mainly on the quality of their posttranplantation surveillance. The worst survival rate (median survival of 27 days) is observed when standard chest radiography is performed at 6-month intervals during follow-up. The median survival after diagnosis of lung cancer is 3 months, and the majority of deaths are directly related to metastatic disease.
A careful search for bronchogenic carcinoma in recipients with a history of smoking may help improve survival. Standard radiographs miss lung cancer in 50% of patients. Regular CT scans of the chest are more appropriate for the detection of early-stage lung cancer. The available literature suggests that twice-yearly combined radiographs and CT scans can increase the likelihood of early tumor detection, resection, and improved survival. When a candidate for cardiac transplantation provides a 30 pack-year smoking history, an aggressive search for occult intrathoracic cancer is advisable; in this situation, screening CT scans of the chest may be worth consideration.
In this case, the patient's condition unfortunately worsened after admission. He underwent endotracheal intubation for progressive respiratory distress and, approximately 1 week after transfer to the Intensive Care Unit of the hospital, he suffered a cardiopulmonary arrest likely related to complications from his metastatic bronchogenic carcinoma that resulted in death.
Conclusion And Wrap-up: Which of the following diagnostic imaging techniques or procedures definitively establishes the diagnosis of bronchogenic carcinoma?
Answer: Transbronchial biopsy
While chest radiography and CT scanning of the chest have a role in the recognition of masses that may potentially represent bronchogenic carcinoma, the definitve diagnosis and the histologic subtype are established by a transbronchial biopsy of the mass.
Which of the following is the most likely cause of death in cardiac transplant recipients with lung cancer?
Answer: Metastatic disease
Despite frequent radiologic examinations in the posttransplant period, lung cancers in cardiac transplant recipients are often diagnosed incidentally, are far advanced at the time of diagnosis, are not surgically resectable, and are poorly responsive to adjuvant therapy. The median survival after a diagnosis of lung cancer is 3 months, and the majority of deaths are directly related to metastatic disease.
Submitted by M.R.T. on Sun, 05/04/2009 - 12:13am.
You are asked to evaluate a 4-year-old boy admitted to your local children's hospital with an diagnosis of pneumonia. The parents state that the child has had multiple, intermittent episodes of fever and respiratory difficulty over the past two years, including cyanosis, wheezing, and dyspnea; each episode lasts for about 3 days. During each event he has a small amount of hemoptysis, is diagnosed with a left lower lobe pneumonia, and improves upon treatment. Repeat radiographs done several days after each event are reportedly normal. His examination on the current admission is significant for findings similar to those described above as well as digital clubbing. Which of the following is the most appropriate primary recommendation?
A): Intravenous cephalosporin and oral macrolide therapy
B): Modified barium swallow study to evaluate for aspiration
C): Nasal swab for viral culture
E): BAL-Bronchoalveolar lavage
Explaination: This child likely has idiopathic pulmonary hemosiderosis (IPH). While fever, respiratory distress, and localized chest radiograph findings should point initially toward an acute pneumonia, the history of recurrence, the rapid clearing of radiographic findings, and the hemoptysis suggest pulmonary hemorrhage. The examination finding of digital clubbing suggests a chronic process. Other typical findings would include microcytic and hypochromic anemia, low serum iron levels, and occult blood in the stool (from swallowed pulmonary secretions). Bronchoalveolar lavage will reveal hemosiderin-laden macrophages and would be most likely to make the diagnosis. A distinct subset of patients with pulmonary hemosiderosis have hypersensitivity to cow's milk (the association is called Heiner syndrome) and may improve with a diet free of cow's milk products.
Submitted by Dr.bisho on Sun, 05/04/2009 - 12:05am.
A 2-year-old girl is playing in the garage, only partially supervised by her father, who is weed-whacking around the garden gnomes in the front yard. He finds her in the garage, gagging and vomiting. She smells of gasoline. In a few minutes she stops vomiting, but later that day she develops cough, tachypnea, and subcostal retractions. She is brought to your emergency center. Which of the following is the most appropriate first step in management?
D): Perform pulse oximetry and arterial blood gas
E): Administer gasoline binding agent intravenously
Explaination: Hydrocarbons with low viscosity and high volatility are the most likely agents to cause respiratory symptoms. Gasoline, kerosene, and furniture polish (which contain hydrocarbons) are common agents responsible for hydrocarbon aspiration. Hydrocarbon aspiration can produce dyspnea, cyanosis, and respiratory failure. Treatment is symptomatic, sometimes requiring intubation and mechanical ventilation. Induction of emesis is contraindicated, as this may cause further aspiration. Placement of a nasogastric tube is used only in high-volume ingestions or when the hydrocarbon is mixed with another toxin. Charcoal is not useful, and no intravenous binding agent is available.
Submitted by Dr.bisho on Sat, 04/04/2009 - 11:48pm.
A 13-year-old girl with a history of 2 days of cough and fever has the chest x-ray shown below. Which of the following is the most appropriate initial treatment?
ER XRAY SHOWS:
A): N-acetylcysteine chest physiotherapy
B): A penicillinase-resistant antibiotic with anerobic activity
E): Thoracentesis and chest tube placement
Explaination: The x-ray reveals a lung abscess involving the right upper lobe, characterized by the round density, the air-fluid level, and the opaque rim. Lung abscesses are usually caused by anaerobic bacteria such as bacteroides, fusobacteria, anaerobic streptococci, and occasionally by Klebsiella. By the late 1990s an increase in the number of Staphylococcus aureus lung abscesses had also been seen. These organisms were previously sensitive to penicillin, but some organisms (especially bacteroides and staphylococcus) are now resistant due to ß-lactam production. Lung abscesses frequently respond surprisingly well to treatment with antibiotics alone; surgical intervention may be indicated if the abscess is large and loculated or is causing respiratory compromise. Patients who do not improve with antibiotic therapy alone are also surgical candidates.
Submitted by Oral Surgeon on Sat, 07/03/2009 - 3:53pm.
ThIS Is THE laST dRUg List ThAT wAs DisTrEpUted tO tHe STuDEntS 
EnJOy & gOOd LUck 
Submitted by Dreamcatcher on Wed, 04/03/2009 - 7:57pm.
2 questions.. (I'm sorry, bear with me )
1) In Dr. Dilip Das's lecture he says that in secondary (reactivation) TB regional lymph nods are almost always affected
however, in Robbin's "Pathologic Basis of Disease" - its says: "secondary pulmonary TB is classically localized to the apex of the upper lobes of one or both lungs.... As a result of this localization the regional lymph nodes are less prominently involved early in secondary disease than they are in pirmary TB" (page 383)
so does that mean that later on they're involved.. but in comparison with primary they're less??
2) In the pharmacology lecture we were told that Isoniazid & Rifampicin - both sterilizing agents
However, in Dr. Eiman Mokaddas's "practical" entitled: Laboratory Diagnosis of TB
She has a table that states that rifampicin & pyrazinamide as the sterilizing agents..
What did I miss??
P.S. ahead of time, I'd like to thank all that will give up some of their valuable time to answer me .. thank you
Submitted by Alfaddagh on Tue, 03/03/2009 - 8:57pm.
can someone explain:
Most cells in the VRG show a discharge pattern synchronous with either inspiration ("I" neurons) or expiration ("E" neurons), They exhibit reciprocal innervation (mutually inhibitory).??
Submitted by admin on Mon, 02/03/2009 - 4:23pm.
Physiology MCQ's formative sent via email.
Please attempt to solve them as answers where not sent
Submitted by admin on Mon, 02/03/2009 - 4:06pm.
Shown are some MCQ's of the anatomy of the nose and the larynx, adopted from clijnical anatomy
1)Maxillary sinus drains into:
A- Middle meatus of the nose
B-superior meatus of the nose
C- Sphenoethmoidal recess
D- Inferior meatus of the nose
E- Nasolacrimal duct
2)Frontal sunis drains into:
A- Inferior meatus of the nose
B-lacrimal sac
C- Middle meatus of the nose
D- Sphenoethmoidal recess
E- superior meatus of the nose
3) The following are true of trachea except
A- lies anterior to esophagus
B- left principal bronchi is wider than right
C- sensory of mucosa of trachea are derived from vagi and recurent nerves
D- begins at level of C6
E- measures about 11.25 cm in adults
4)sustained tension of vocal cords/folds achieved best by action of which muscle?
A- Thyroarytenoid
B- Posterior cricoarytnoid
C- cricothyroid
D- lateral cricoarytnoid
E- transverse cricoarytnoid
5) Following form lateral wall of external nose except?
A- ethmoid
B- nasal part of frontal
C- frontal process of maxilla
D- upper lateral nasal cartillage
E- nasal bone
Correct answers:
1)a
2)c
3)b
4)c
5)a
Submitted by M.R.T. on Sun, 01/03/2009 - 10:14am.
You were asked to see Mr.Fahad a 66 year old man presenting with progressive S.O.B. on mild exertion associated with a dry bothersome cough of 2 years duration and increasing dyspnea. Recently he noticed having breathing problems even during short walk to the mosque. Mr.Fahad was refered to the respiratory clinic by an internist who had earlier ruled out non respiratory causes of dyspnea. Mr.Fahad has never smoked. He used to work in a cement factory and in the distant past, he used to breed pigeons as a hobby.
General Statement: A 66 yr old male presenting with progressive exertional dyspnea and a dry cough of 2 years duration, reports of exposure to pigeons and cement. Summary of Clinical Data: Patient History:
- Mr. Fahad’s dyspnea started 2 years ago and got progressively worse. He now gets dyspnic on
walking a few meters at ground level or on climbing one flight of stairs.
- There is no history of wheezing, orthopnea or paroxysmal nocturnal dyspnea (PND). The dyspnea
is also associated with a bothersome dry cough.
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Past medical history & system review:
- The patient’s system review was negative. He had no previous medical or surgical history.
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Medications:
- He tried different cough syrups in the past.
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Family and personal history:
- He had spent most of his working life as a supervisor in a cement factory and retired 5
years ago. His family history is non-contributory.
- He had chickens and pigeons at home but got rid of them 4 years ago.
Physical examination:
- The patient was not dyspneic at rest but upon returning from the bathroom he looked
dyspneic with laboured breathing.
- JVP was normal and there was no lower limb edema.
- He had bilateral finger clubbing.
- CVS examination was normal.
- Chest examination showed normal breath sounds with fine crackles heard at both bases of
the lung.
Investigations
- The patient had a chest radiograph (CXR), which showed bilateral interstitial changes more
prominent in the lower zones.
- High resolution CT of the chest showed sub-pleural bilateral reticular infiltrates mainly in the
lower and sub-pleural areas as well as basal honeycombing.
- Pulmonary function tests showed the following:
Principles of Assessment:
- Chest radiograph and high resolution computed tomography of the chest are the most important
tests to determine the pattern and extent of interstitial lung diseases.
- The lung function tests measure the lung volumes and capacities which determine the degree of
lung impairment.
Final Diagnosis / Differentials : Submitted by Dr.bisho on Sat, 28/02/2009 - 7:43pm.
This is a small summary of the review, questions will be sent via email, then a copy will be uploaded here
Submitted by rizenhazard on Thu, 26/02/2009 - 11:48pm.
Submitted by alias on Wed, 25/02/2009 - 2:25pm.
download attached file
Submitted by alias on Wed, 25/02/2009 - 1:59pm.
 EMPHYSEMA, A - CENTRILOBULAR (UPPER ZONES); AND B - PANACINAR (LOWER ZONES) - In centrilobular emphysema only the central or proximal portions of the respiratory lobule (respiratory bronchial) is involved. The distal alveoli are spared. It usually involves the upper lobe and is the most common type of emphysema. Associated with smoking and coal dust. In panacinar (panlobular) emphysema, there is involvement of the complete respiratory lobule (all alveoli are involved of a respiratory lobule). Typically involves the lower zones and anterior margins of the lung. Associated with alpha 1-antitrypsin deficiency.
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