Act as Internalist 👨🏻‍⚕️🫀🩺

#Interstitial_Occupational_LD@Clinicalinternalmedicine

#HAP@Clinicalinternalmedicine

#Pneumonia@Clinicalinternalmedicine

🔴Interstitial & Occupational Lung Diseases ▪︎Group Of Diseases Share A Similar Presentation & Radiological Features That Causing Interstitial (Parenchymal) Or Alveolar Lumen Damage 🔹Clinical Features & Dx 📍1. Chronic Dry Cough 📍2. Gradual (Insidious) SOB 📍3. Bilateral Basal Fine Inspiratory Crackles 📍4. Finger Clubbing (Mostly in IPF) 📍5. Restrictive Lung Pattern : ▪︎Decrease FVC & Lung Volumes ▪︎impair Gas Transfer ▪︎FEV1:FVC >0.7 (>70%) اكبر من 📍6. Radiological Features : ▪︎Reticulonodular Shadows ▪︎Ground Glass Opacity ▪︎Honeycomb Cysts ▪︎Tractional Bronchiectasis ▪︎Small Lungs 📍7. Central Cyanosis With RHF & Pulmonary HT In Advanced Cases 🔰Idiopathic Pulmonary Fibrosis (IPF) ▪︎Most Common Interstitial Lung Disease ▪︎Causes Progressive Interstitial Lung Fibrosis ▪︎Unknown Cause ▪︎Usually Seen in Older Adults ▪︎Smoking is Strong Risk Factor 🔹Mx Of IPF 📍1. Pirfenidone/Nintedanib (Reduce Decline in Lung Function) ➡️ Useful When Vital Capacity 50-80% 📍2. Stop Smoking 📍3. Control GERD 📍4. Vaccination (Pneumococcal & Influenza) 📍5. Domiciliary Oxygen (Oxygen At Home) 📍6. Lung Transplantation 🔰Non Specific Interstitial Pneumonia ▪︎More in Young Women ▪︎Better Prognosis 🔰Eosinophilic Pneumonia 🔹Clinical Features Of EosinoPhilic Pneumonia 📍1. Acute Presentation : ▪︎Acute Diffuse Alveolar Damage & Pulmonary Infiltration & Hypoxic (Type I) Respiratory Failure (in <5 Days) ▪︎Eosinophils >25% ▪︎Good Response To Steroids 📍2. Chronic Presentation : ▪︎Gradual (Insidious) Onset Of Fever/Dry Cough/SOB/Weight Loss/Malaise ▪︎Present in Middle Age Female ▪︎Increase ESR/IgE/Eosinophils (>10%) ▪︎Good Response To Steroids (Also Need Low Dose Maintenance) 🔰Hypersensitivity Pneumonitis (Extrinsic Allergic Alveolitis) ▪︎Type III & IV Immune Reaction To Organic Antigens Inhalation Causing Diffuse inflammation in Walls Of Bronchioles & Alveoli ▪︎Non Caseating Granulomas Present 🔹Dx Of Hypersensitivity Pneumonitis 📍1. Symptoms Develop Within 4-8h After Exposure To Specific Antigens 📍2. Cough/SOB/Wheeze/Diffuse Inspiratory Crackles/Weight Loss 📍3. +Ve Antibody To That Specific Antigen 📍4. Recurrent Episodes 📍5. Elevated CD8 Lymphocytes 🔰Sarcoidosis ▪︎Multi Systemic Granulomarous Disease Of Unknown Cause ▪︎Mostly In Colder Parts Of Northern Europe 🔹Clinical Features Of Sarcoidosis 📍1. Asymptomatic (Only Xray Changes) : ▪︎Stage1 ➡️ Symmetrical Bilateral Hilar Lympahdenopathy (BHL) ▪︎Stage2 ➡️ BHL + Parenchymal Infiltration ▪︎Stage3 ➡️ Only Parenchymal Infiltration ▪︎Stage4 ➡️ Pulmonary Fibrosis 📍2. Lofgren Syndrome (More in Women) ➡️ Erythema Nodosum/Arthropathy/Uveitis/BHL/Lethargy/Fever 📍3. Cough/Exertional SOB/Lung Fibrosis 🔹Dx Of Sarcoidosis 📍1. LymphoPenia & Increase ACE (Angiotensin Converting Enzyme) 📍2. Abnormal Liver Function Test 📍3. Hypercalcemia & Nephrocalcinosis 📍4. Non Caseating Granuloma 📍5. Erythema Nodosum + BHL (Confirm Dx) 🔹Mx Of Sarcoidosis 📍1. Acute Exacerbations ➡️ NASIDS/Steroids 📍2. Severe Disease ➡️ Methotrexate/Azathioprine/TNF a Inhibitors 📍3. Cutaneous Sarcoid ➡️ Chloroquine & Hydroxychloroquine/Thalidomide * Asbestos ➡️ Risk Of Lung Cancer (Mesothelioma) & Pleural Plaques

🔰Hospital Acquired Pneumonia (HAP)

▪︎More In Elderly & ICU (Intensive Care Unit) & Mechanically Ventilated Patients 🔹Dx Of HAP 📍1. Symptoms Develop At Least 2 Days After Hospitalization Or Ventilated 📍2. Purulent Sputum 📍3. New Chest Xray Changes 📍4. Increase Oxygen Requirements 📍5. Increase Temperature (>38.3°C) 📍6. Leucocytosis Or Leucopenia 📍7. Culture Required (To Determine Type Of Organism) 🔹DDX Of HAP 1. Pulmonary Embolism (PE) 2. Drug Toxicity 3. ARDS 4. Pulmonary Edema & Pulmonary Hemorrhage 🔹Mx Of HAP 📍1. Early Onset HAP (Within 4-5 Days) : ▪︎Give Co Amoxiclav Or Cefuroxime (If No AB Given Before) ▪︎Give Piperacillin-Tazobactam Or 3rd Cephalosporins (If AB Given Before) 📍2. Late Onset (HAP) : ▪︎Usually Caused By Staph.Aureus Or Anaerobes Or Gram -Ve Organisms (E.coli/Psedomonas/Klebsella/Acinetobacter) ▪︎For Psedomonas ➡️ Give Carbapenem (Meropenem)/Cephalosporin/Piperacillin-Tazobactam ▪︎For Staph.Aureus (MRSA) ➡️ Give Vancomycin/Linezolid ▪︎For Acinetobacter ➡️ Give Carbapenem (Meropenem)/IV Colistin

🔰Suppurativa Pneumonia

▪︎Pneumonia Associated With Destruction Of Lung Parenchyma That Leads To Abscess Formation & Accumulation ▪︎Mostly Due To Mixture Of Anaerobic & Aerobic Bacteria & Normal Flora Of Mouth & Upper Respiratory Tract ▪︎In Previously Healthy Lung ➡️ Infection Mostly Due To Staph.Aureus/Klebsella ▪︎With Poor Dental Hygiene ➡️ Mostly Due To Actinomyces Israelii ▪︎With Suppurativa Skin Infection ➡️ Mostly Due To Staph.Aureus (CA MRSA) ▪︎Endocarditis With Suppurativa Pneumonia ➡️ Occur in IV Drug Abusers 🔹Risk Factors For Suppurativa Pneumonia 📍1. Inhalation Of Septic Material During Operations (On Nose/Mouth/Throat) 📍2. Inhaled Foreign Body 📍3. Aspiration (Due To Anesthesia Or Coma Or Neurological Dysfunction Or GERD) 📍4. Immunocompromised 🔹Clinical Features Of Supportive Pneumonia 📍1. Cough With Large Amounts Of Sputum That is Fetid (Bad Odour) & Blood Stained 📍2. High Remitting Pyrexia تبقى فوك الطبيعي طول الوقت 📍3. Finger Clubbing (Within 10-14 Days) 📍4. Marked Weight Loss 📍5. Pleural Pain & Systemic Upset 🔹Dx Of Supportive Pneumonia 📍1. Homogeneous Opacity 📍2. Cavitation 📍3. Air Fluid Level 🔹Mx Of Supportive Pneumonia 📍1. Amoxicillin + Metronidazole ➡️ For Aspiration Pneumonia 📍2. Trimethoprim-Sulfamethoxazole/Clindamycin/Tetracycline/Linezolid ➡️ For Staph.Aureus (CA MRSA) 📍3. 6-12m Tx With Penicillin Or Tetracycline ➡️ For Actinomycosis

🔰Pneumonia in Immunocompromised

▪︎Pneumonia Here is The Most Common Cause Of Death ▪︎Infection By Multiple Organisms ▪︎Pneumocystis Carinii (Jirovecii/PCC) Usually Infect HIV Patients As Opportunistic Infection ▪︎Present With Fever/Cough/SOB 🔹Mx By Broad Spectrum AB ➡️ 3rd Cephalosporins/Quinolone + Anti Staph/Penicillin + Aminoglycosides * ▪︎Community Pneumonia ➡️ Streptococcus ▪︎Hospital Pneumonia ➡️ Gram -Ve & Staph ▪︎Aspiration Pneumonia ➡️ Anaerobic ▪︎Pediatric Pneumonia ➡️ Mostly Viral (RSV/Parainfluenza/Adenovirus)

🔴Pneumonia ▪︎Acute Lower Respiratory Tract Infection Affects Lung Parenchyma & Alveolar Spaces & Bronchioles ▪︎Characterized By Lung Consolidation On Chest xray 🔹Risk Factors For Pneumonia 1. Old Age 2. Smokers & Alcoholic & Steroids 3. Infections (HIV/Influenza/Upper Respiratory Tract Infection) 4. Preexisting Lung Disease 5. Air Pollution 6. Neurological Dysfunction (Difficult Swallowing/Recurrent Aspiration/GERD) 7. Hospitalization 🔹Classification Of Pneumonia 📍1. Lobar ➡️ Homogeneous Consolidation Of One Or More Lung Lobes + Pleural Inflammation 📍2. BronchoPneumonia ➡️ Patchy Consolidation With Bronchial & Bronchiolar Inflammation (Mostly Affects Lower Lobes) 📍3. Interstitial ➡️ Diffuse Reticular Opacity (Mostly Viral Or Mycoplasma) 📍4. Community Acquired ➡️ Pneumonia Develops In Community Settings 📍5. Hospital Acquired (Nosocomial) ➡️ Pneumonia Develops At Least 2days (48h) After Hospital Admission 📍6. Ventilator Associated Pneumonia ➡️ Pneumonia Develops 48-72h After Endo-Trachial Intubation 📍7. Health Care Associated Pneumonia ➡️ Pneumonia Develops In Person That : ▪︎Spent At Least 2days in Hospital (in last 90days) ▪︎Attend Hemodialysis Unit ▪︎Received IV Antibiotics ▪︎Worked in Nursing Home Or Long Term Care Unit 🔰Community Acquired Pneumonia (CAP) ▪︎Mostly Affect Children & Elderly ▪︎Mostly Due To Streptococcus Pneumonia ▪︎Mostly Spread By Droplet Infection ▪︎Viral Infections More in Children 🔹DDX Of CAP ▪︎Pulmonary Infarction ▪︎Pulmonary Edema ▪︎Pulmonary Eosinophilia ▪︎TB Infection ▪︎Malignancy ▪︎CryptoGenic Organising Pneumonia ▪︎Bronchiolitis Obliterans 🔹Clinical Features Of CAP 📍1. Fever : ▪︎High Grade ➡️ Bacterial ▪︎Low Grade ➡️ Viral/Atypical ▪︎No Fever ➡️ Afebrile Pneumonia 📍2. Rigor/Shivering/Delirium/Malaise/Loss Appetite/Headache 📍3. Cough ➡️ Start As Short Painful Dry Then Become With Mucopurulent Sputum 📍4. Haemoptysis 📍5. Pleuritic Chest Pain ➡️ Radiate To Shoulder & Anterior Abdomen 📍6. Upper Abdominal Pain (In Lower Lobe Pneumonia Or Associated Hepatitis) 📍7. Chest Examination : ▪︎Chest Dullness (Consolidation) ▪︎Bronchial Breathing ▪︎+Ve Whispering Pectoriloquy ▪︎Crackles (Fine Then Coarse) ▪︎Increase Vocal Resonant 🔹Dx Of CAP 📍1. Lung Infiltration On Chest Xray : ▪︎One Or More Lobes ➡️ Lobar Bacterial Pneumonia ▪︎Scattered Bilateral Patchy Infiltration ➡️ Bronchopneumonia ▪︎Diffuse Bilateral Interstitial Infiltration With Hyperinflation ➡️ Viral Or Atypical Pneumonia (Mycoplasma/Chlamydia/Legionella) ▪︎Cavity/Air Fluid Level/Effusion/Collapse/Fibrosis/Pneumatocele ➡️ Staph.Aureus Pneumonia 📍2. CBC : ▪︎Lymphocytosis ➡️ Viral ▪︎Neutrophilia & High ESR & CRP ➡️ Bacterial ▪︎Eosinophilia ➡️ Chlamydia Trachomatis (Atypical Pneumonia) 📍3. Blood Culture 🔹Mx Of CAP 📍1. Oxygen (To Maintain Saturation >92%) 📍2. IV Fluids 📍3. Analgesia For Pleural Pain (Paracetamol/Co Codamol/NASIDS/Opioids) 📍4. Antibiotics : 🔻I. Uncomplicated CAP (CURB Score 0-1) : ▪︎Amoxicillin (Oral 500mg 3x Daily For 5 Days) ▪︎If Patient Allergic To Penicillin ➡️ Clarithromycin (500mg 2x Daily Oral) Or Erythromycin (500mg 4x Daily Oral) 🔻II. Moderate CAP (CURB Score 2) ➡️ Amoxicillin + Clarithromycin For 7 Days (Oral Or IV) 🔻III. Severe CAP (CURB Score ≥3) ➡️ Combined 3 IV Drugs : ▪︎[Clarithromycin Or Erythromycin] ▪︎+ [Co Amoxiclav Or Ceftriaxone Or Cefuroxime Or Amoxicillin] ▪︎+ Flucloxacillin 🔹Prognosis Of CAP 1. Fever Persists Days After Tx 2. Radiological Changes Persist Weeks-Months After Tx 3. If No Response ➡️ Wrong Dx Or Complications Develop 🔹Prevention Of CAP 📍1. Stop Smoking 📍2. Vaccination (Influenza/Pneumococcal/Measles/Pertussis/H.influenza) 🔹Complications Of CAP 1. Pus Accumulation inside The Pleura (Embyema) Or Lung (Lung Abscess) 2. Para-Pneumonic Effusion (Effusion in The Pleural Cavity Adjacent To The Affected Lobe) 3. Lobar Collapse (Due To Sputum Retention) 4. DVT & Pulmonary Embolism 5. ARDS & Organs Failure 6. Arrhythmia 7. Drugs Hypersensitivity & Pyrexia 8. Organs Inflammation 9. Pneumothorax

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❇️Important DDX of Finger Clubbing

❇️Important Facial Features

#COPD@Clinicalinternalmedicine

🔴 Chronic Obstructive Pulmonary Disease (COPD) ▪︎It's A Preventable & Treatable (Controlled) Group Of Diseases (Chronic Bronchitis & Emphysema) Consist Of AirFlow Limitation & Premature Closure Of Airways That Increasing The Work Of Breathing Due To Chronic Inflammation ▪︎Major Cause Of Death & Disability Worldwide 🔰Types Of COPD 📍1. Chronic Bronchitis (Blue Bloater) ▪︎Bronchial Wall Inflammation & Thickening & Increase Gland Secretions ▪︎Results in Chronic Cough & Sputum For 3m in 2 Years ▪︎Cyanosis & Secondary Polycythemia Due To Hypoxia ▪︎Low Ph (Acidosis) ▪︎More Chest Infection 📍2. Emphysema (Pink Puffer) ▪︎Abnormal Permanent Airspaces (Alveoli) Enlargement & Wall Destruction & Loss Elasticity Causing Air Trapping Inside Alveoli & Hyperinflation ▪︎Severe Dyspnea & Pursed Lips ▪︎Normal Skin Color (Pink) ▪︎Barrel Chest By Hyperinflation ▪︎Near Normal Ph (No Acidosis) 📍3. ExtraPulmonary Features Of COPD : ▪︎Weight Loss ▪︎Skeletal Muscle Dysfunction ▪︎Lung Cancer ▪︎Osteoporosis ▪︎Depression ▪︎Metabolic Syndrome ▪︎Cardiovascular & Cerebrovascular Diseases 🔰Risk Factors For COPD 📍1. Smoking (>10 Pack Years) ➡️ Single Most Important Risk Factor 📍2. Low Birth Weight/Childhood Infections/Maternal Smoking/Cannabis Smoking 📍3. HIV & AdenoVirus Infections/Air Pollution/Low Socioeconomic State 📍4. Genetic Alpha-1 Anti-Trypsin Deficiency ➡️ Emphysema At Young Ages 🔰Dx Of COPD 🔸A. By Spiromerty 📍1. FEV1/FVC <0.7 (<70%) 📍2. Poor Response To Bronchodilators (Confirm Dx) 📍3. Determine Severity By Post Bronchodilators FEV1% : ▪︎Stage 1 (Mild): FEV1 >80% ▪︎Stage 2 (Moderate): FEV1 50–79% ▪︎Stage 3 (Severe): FEV1 30–49% ▪︎Stage 4 (Very severe): FEV1 <30% 🔸B. By Clinical Features 📍1. Chronic Productive Cough & Dyspnea (Smoker Cough 1st Symptoms) 📍2. Onset in Mid Life (40 Years) With Hx Of Smoking 📍3. Persistent (Irreversible) AirFlow Limitation 📍4. Fixed Symptoms (No Symptoms Variation During the Different daytime) 📍5. Fatigue/Anorexia/Weight Loss (In Severe COPD) 📍6. Chest Xray/CT ➡️ To Detect Lung Hyperinflation/Bullae/HF/Lung Cancer 📍7. Peripheral Edema (R HF/Salt & Water Retention) 📍8. Morning Headache (High CO2) 📍9. Quiet Breath Sounds (Hyperinflation) & Crackles (Infection) 🔰Mx Of COPD 📍1. Reduce Exposure To Noxious Particles & Smoking Cessation 📍2. Mild Symptoms ➡️ Short Acting B2 Agonist (SABA) 📍3. Moderate To Severe Symptoms : ▪︎Long Acting B2 Agonist (LABA) ▪︎Inhaled Steroids (ICS) + Long Acting B2 Agonist (LABA) ▪︎Oral Systemic Steroids (Prednisolone) 📍4. Pulmonary Rehabilitation (Exercise) 📍5. Long Term Domicillary Oxygen ➡️ 15h/Day (To Reach 90% Oxygen Saturation) 📍6. Surgical Resection Of Bullae 📍7. Annual Influenza & Pneumococcal Vaccine 🔰Acute Exacerbations Of COPD ▪︎Mostly Due To Infection (Bacterial/Viral) Or Change Air Quality ▪︎Haemophilus influenzae Most Common Infection ▪︎Risk Of Respiratory Failure/Fluid Retention/Death 🔹Mx Of Acute Exacerbations 📍1. Low Concentration Oxygen (24-28%) By Venturi Mask Or Nasal Cannula ➡️ To Reach Oxygen Saturation >90% 📍2. Short Acting B2 Agonist (SABA) + Anticholinergic (Salbutamol + Ipratropium) 📍3. Oral Systemic Steroids (Prednisolone 30mg For 10 Days) 📍4. Antibiotics (Aminopenicillin/Tetracycline/Macrolides) 📍5. Ventilation (Non Invasive Or Mechanical) 📍6. Diuretics For Peripheral Edema 🔰Complications Of COPD 1. Respiratory Failure 2. Recurrent Respiratory Infections 3. Pulmonary Hypertension 4. Pneumothorax 5. Right Side HF 6. Skeletal Muscle Dysfunction 7. Depression & Anxiety

📝Work up of pt suspected PE

📝Modified Wells Score for PE