1. Pulmonary Pathology Situational Analysis Part I Rosella L. Montano, MD Emmanuel R. Dela Fuente, MD Alejandro E. Arevalo, MD

2. Situation no. 1 (Case I-A) FJ, a 36 year old male, a market vendor, had moderate to high grade fever, cough productive of yellowish and occasionally rusty colored phlegm, and progressive dyspnea of 1 week duration. He is a known diabetic and takes medications irregularly.

3. Situation no. 1 (Case 1-A) On PE, FJ was awake, BP 110/70, PR was 129/min, RR was 29/min, T 38.9 C. She preferred the upright position. There were intercostal and subcostal retractions. There was symmetrical chest expansion, increase fremiti, dullness and bronchial breath sounds on the left lower lung fields. There were also scattered crackles over both lung fields.

4. 1. Interpret the CXR.

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

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

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

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

9. Situation no. 1 (Case I-B) His son, mikey, 2 year old, also developed cough and cold 4 days ago. This was accompanied by moderate grade fever temporarily relieved by Paracetamol. One day prior to admission, he was noted to refuse to eat his food, and to have rapid breathing. Mikey was restless, and was noted to have alar flaring.

10. Situation no. 1 (Case I-B) His CR was 108 beats/min, RR 47/min and temperature was 39.4 C. PE of the chest revealed intercostals and subcostal retractions, equal tactile and vocal fremiti, resonance on percussion with scattered fine crackles over both lung fields.

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

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

13. 3. Give the Pathophysiology of this complication Low Power High Power

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

15. Situation no. 2 Mina, a 47 year old laundry woman complained of afternoon rises in temperature accompanied by cough, back pains, and “unquantifiable” weight loss. A consult and a subsequent CXR showed a “spot” in the LUL.

16. 1. Interpret the CXR

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

18. A B

19. 3. Interpret the Sputum exam

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

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

22. 5. Explain the pathophysiology of hemoptysis.

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

25. Pulmonary Pathology Situational Analysis Part II Rosella L. Montano, MD Emmanuel R. Dela Fuente, MD Alejandro E. Arevalo, MD

26. Situation no. 1-1 Albert, a 59 year old businessman complained of chronic cough and exertional dyspnea for 3 years. He has a 70 pack-year smoking history.

27. 1-A. Interpret the following CXR. Which is more compatible with the patient symptoms? A B

28. 1-B. These are two gross specimens of the lung in relation to the CXRs shown earlier. Describe the pathology and explain the etiopathogenesis of each.

29. A B

30. 1-C. These are the microscopic findings of the lungs shown previously. Discussion should include the following: i. morphological changes in the lungs ii. Clinical manifestions of the patient iii. Outcome and Complications

31. A B

32. Situation no. 1-2 He claims that he used to have blood streaks in his sputum 2 months ago, but in the past week, he has been coughing up to 1-2 tsps of blood daily.

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

34. 4 1 3 2

35. Situation no. 1-3 Albert also has a 1 x 1 cm hard, fixed lymph node on the right supraclavicular area.

36. 3-A. Shown are sections from the right supraclavicular node. Which of the following is more compatible with this patient? Describe the gross findings in the lymph nodes.

37. A B

38. 3-B. The following are the respective histologic findings in the nodes. Discuss according to: i. Morphology i. Morphology ii. Etiopathogenesis ii. Etiopathogenesis iii. Outcome iii. Outcome

39. A B

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

41. CXR CT

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

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