EUROPOS SĄJUNGA
Europos Socialinis Fondas
Program of Medicine Studies
MODULE
RESPIRATION
Second Year
Fourth Semester
Faculty of Medicine
Kaunas University of Medicine
1
Table of Contents
1. General information.........................................................................................................................4
2. General content of the module.........................................................................................................5
3. Aim and objectives of the module....................................................................................................8
4. Tutorials............................................................................................................................................9
4.1. Case 1. Dyspnea of an allergic boy...........................................................................................9
4.2. Case 2. Dyspnea and pain in the calfs....................................................................................13
4.3. Case 3. A silicate brick-maker‘s tale.......................................................................................18
4.4. Case 4. A roofer with increasing breathlessness.....................................................................22
4.5. Case 5. An acute illness of a wood-cutter..............................................................................26
4.6. Case 6A. A brick-layer‘s case.................................................................................................30
4.6. Case 6B. Urgent help is required............................................................................................31
5. Lectures..........................................................................................................................................35
5.1. Anatomy of the respiratory system (2 hours)..........................................................................35
5.2. Histology of the respiratory system (2 hours)........................................................................35
5.3. Physiology of the respiratory system (2 hours)......................................................................35
5.4. Pathological physiology of the respiratory system (2 hours).................................................35
5.5. Pathological anatomy of the respiratory system ( 2 hours)................................................36
5.6. Radiology of the respiratory system (2 hours)........................................................................36
5.7. Gas exchange and molecular mechanisms of gas transference (2hours)................................36
5.8. Medicines acting on the respiratory system (2hours)............................................................36
5.9.Thrombolytics and anticoagulants (2 hours)...........................................................................37
5.10. The sources of air pollution, the components of air pollution, their impact on health, the
means of prevention (2hours).......................................................................................................37
5.11. Clinical diagnosis of pathology of the respiratory system (1)(2 hours)................................37
5.12. Clinical diagnosis of pathology of the respiratory system (2)(2 hours)...............................37
5.13. Clinical diagnosis of pathology of the respiratory system (3)(2 hours)...............................37
6. Practicals ........................................................................................................................................38
6.1. Anatomy of the respiratory system (3 hours)..........................................................................38
6.2. Anatomy of pulmonary circulation and the heart (3 hours)...................................................38
6.3. Histology of trachea, bronchi, bronchioles. Histophysiology of blood vessels (2 hours)
.......................................................................................................................................................38
6.4. Histology of pleura and pulmonary parenchyma (2 hours)....................................................39
6.5. Physiology of the respiratory system (3 hours)......................................................................40
6.6. Obstructive airway diseases and tumors (3 hours).................................................................40
Clinic of Pathological Anatomy.........................................................................................................40
6.7. Endoinfections of the respiratory system and pathology of the pleura (3 hours)...................41
6.8. Medicines acting on the respiratory system (2 hours)...........................................................41
6.9. Thrombolytics and anticoagulants (2 hours)..........................................................................42
6.10. Clinical diagnosis of respiratory disorders (1)(4 hours).....................................................42
6.11. Clinical diagnosis of respiratory disorders (2) (4 hours).....................................................42
6.12. Clinical diagnosis of respiratory disorders (3) (4 hours).....................................................43
6.13. Radiology of the respiratory system (1) (3 hours)................................................................43
6.14. Radiology of the respiratory system (2) (3 hours)................................................................43
6.15. Radiology of the respiratory system (3) (3 hours)................................................................44
7. Seminars.........................................................................................................................................45
7.1. Compensatory mechanisms of the maintainance of acid-base balance (2 hours)...................45
7.2. Environmental dust pollution, classification, physical and chemical properties.
Pneumoconioses (2 hours).............................................................................................................45
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8. Module examination questions.......................................................................................................46
8.1. Anatomy..................................................................................................................................46
8.2. Histology and Embryology.....................................................................................................46
8.3. Physiology..............................................................................................................................46
8.4. Pathological physiology.........................................................................................................47
8.5. Pathological anatomy..............................................................................................................47
8.6. Radiology................................................................................................................................47
8.7. Biochemistry...........................................................................................................................48
8.8. Pharmacology.........................................................................................................................49
8.9. Essentials of Medical Diagnosis.............................................................................................49
8.10.Environmental and Occupational Medicine..........................................................................50
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1. General information
Supervisor
of
the
module:
prof.
habil.
dr.
Albinas
Naudžiūnas
(vidausligos@med.kmu.lt)
Coordinator of the module: assoc.prof. dr. Palmira Leišytė (pleisyte@gmail.com)
Departments and number of work days:
Institute of Anatomy (2 days)
Department of Histology and Embryology (2 days)
Department of Physiology (4 days)
Department of Biochemistry (1 day)
Clinic of Pathological Anatomy (2 days)
Clinic of Radiology (2 days)
Department of Basic and Clinical Pharmacology (1 day)
Clinic of Internal Diseases (5 days)
Clinic of General Surgery (2 days)
Subjects and responsible persons:
Human Anatomy (assoc.prof. V. Aželis ; tel. 327238)
Human Histology and Embryology (lect. J. Palubinskienė; tel. 327235)
Physiology (prof. E. Kėvelaitis; tel. 396053)
Pathological Physiology ( prof. A. Kondrotas; tel. 327258)
Biochemistry (prof. L.Ivanovienė; prof.V.Borutaitė; tel. 327321)
Pathological Anatomy (prof.R.Gailys; prof. V. Lesauskaitė; tel. 326879)
Radiology (assoc.prof.S.Lukoševičius; tel. 326154))
Pharmacology (lect.R.Jankūnas;tel. 327242)
Essentials of Medical Diagnosis (assoc.prof.P.Leišytė; tel.306093)
General Surgery (prof. D. Venskutonis; tel. 306066)
Environmental and Occupational Medicine (assoc.prof..R.Ustinavičienė;
tel. 327360)
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2. General content of the module
1. Anatomy of bronchi and lungs:
Embryology.
Bronchial tree.
Topography of lungs, lobes, and pleura.
Bronchial and alveolar vessels.
Pulmonary lymphnodes.
Nerves of the respiratory system.
Respiratory muscles.
2. Histology of bronchi, lungs and pleura:
The structure of trachea and bronchial mucosa, epithelial cells.
Barrier function of respiratory epithelium.
Secretory function of respiratory epithelium.
Submucosa.
Alveoli.
Pleura.
Immunocompetent cells of airways and pulmonary parenchyma: alveolar macrophages,
lymphocytes, neutrophils, eosinophils, mast cells.
Supportive structures of the lungs.
3. Physiology and pathophysiology of the respiratory system:
Mechanics of breathing.
Intrapleural and alveolar pressure.
Pulmonary volumes and capacities.
Pulmonary and alveolar ventilation.
Compliance of the lungs and the chest wall.
Alveolar surface tension; airway resistance.
Pulmonary circulation; ventilation-perfusion ratio.
Autoregulation of pulmonary blood flow distribution.
Composition of inspiratory, expiratory, and alveolar air. Partial pressures of gases.
Gas exchange in the lungs.
Transport of oxygen and carbon dioxide by the blood.
Oxygen-hemoglobin dissociation curve.
Neural and humoral (chemical) regulation of respiration.
Vital pulmonary mechanisms: air filtration in the nose, air warming, moistening, cough,
sneezing.
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Mucociliary clearance.
Complement system.
Lysozyme.
Lactopherin.
Antioxidant systems.
Protease inhibitors.
Immune protective pulmonary mechanisms.
4. Biochemistry of the respiratory system:
Biochemical mechanisms of gas exchange.
Base-acid balance alterations in respiratory failure.
5. Pathology of the respiratory system:
Morphology
of
bronchial
pathology:
emphysema,
chronic
bronchitis,
asthma,
bronchiectases.
Morphology of pulmonary and pleura pathology: pneumonia, pleuritis.
Tumors of lungs and pleura.
6. Medicines acting on the respiratory system:
Bronchodilators.
Antiinflammatory and antiallergic drugs.
Cough and cold medicines (secretolytics, mucolytics, antitusives).
Antihistamines.
Thrombolytics and anticoagulants.
Antibiotics.
7. Radiological investigations of lungs:
Fluoroscopy and radiography of the chest.
Computed tomography (CT) of lungs.
Angiography of pulmonary and bronchial arteries.
Lung ventilation and perfusion scintigraphy.
Ultrasonography of lungs.
Magnetic resonance imaging (MRI) of lungs.
8. Clinical cases :
Syndrome of bronchial obstruction.
Pulmonary embolism (PE).
Respiratory failure.
Syndrome of pulmonary restriction.
Pulmonary consolidation.
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Syndromes of air and fluid accumulation in the pleural cavity.
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3. Aim and objectives of the module
Aim :
To study theory and aquire practical skills on morphology, physiology, biochemistry,
pathology, pathophysiology, pharmacology, clinical examination
of respiratory system,
respiratory syndromes; be able to relate the theory with clinical symptoms and syndromes.
Objectives:
1. To study anatomy and function of respiratory system; to know the mechanisms of pulmonary ventilation, gas exchange; nervous and humoral regulation of breathing, alterations in base-acid balance.
2. To study pathophysiological mechanisms of changes of respiratory system.
3. To know histology and defence mechanisms of respiratory system.
4. To study the medicines acting on the respiratory system.
5. To know pathology of respiratory system, radiological diagnosis.
6. To look into the clinical diagnosis and syndromes of respiratory system; relate clinical
skills and practical knowledge.
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4. Tutorials
4.1. Case 1. Dyspnea of an allergic boy.
A 18-year-old student of Kaunas University of Medicine visited his general practitioner‘s office
because of attacks of dyspnea, nonproductive cough, and sneezing early in the morning. He has
been suffering from these complaints for three weeks. One month ago he was ill with allergic
conjunctivitis, attended ophthalmologist‘s office, and antiallergic eye drops were prescribed. In
childhood he suffered from frequent bronchitis and pneumonia, allergic reactions to fish products,
chocolate, penicillin.
On examination he looked fair; his respiratory rate was 22 breaths per minute; pulmonary
auscultation revealed diffuse sibilant wheezes over the chest of both sides. His heart rate was 92
beats per minute, and a blood pressure was 140/80 mmHg. The findings of examination of other
systems were normal.
What syndrome do you suppose?
Explain the findings of clinical examination.
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Concept of the problem: bronchial obstruction.
Clinical signs: paroxysmal dyspnea, sibilant wheezes.
Aim
To learn anatomy and histology of bronchi; mechanisms of bronchial obstruction, functional and
clinical diagnosis, principles of pharmacotherapy.
Learning objectives and contents
To complete an analysis of this problem the students must know:

Anatomy and innervation of bronchi.
Subject – Human anatomy
Institute of Anatomy
References:
Gray‘s anatomy for students, 2005, p. 140-146, 149

Functioning of respiratory muscles (definitions of main and accesssory muscles), physiology of
bronchi.

Mechanics of breathing, functioning of main and accessory respiratory muscles during
breathing.

Compliance of the lungs and the chest wall. Alveolar surface tension. Airway resistance. Work
of breathing.
Subject - Physiology
Department of Physiology
References:
W.F.Ganong. Review of Medical Physiology. 22nd ed. Lange Medical Books / McGraw-Hill, 2005,
Ch. 34, p. 649-658.
•
Explanation of bronchial spasm according to static and dynamic volumes, and resistance of
airways; recognition the changes of lung function parameters characteristic to the syndrome of
bronchial obstruction.
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•
Respiratory failure: ventilatory failure, gas exchange failure. Disturbances in nasal breathing,
narrowing of larynx and trachea. Mechanisms of cough and sneezing. Mechanism of bronchial
spasm. Disturbances of functioning of bronchi. Expiratory dyspnea.
Subject- Pathological Physiology
Department of Physiology
References:
Porth CM. Pathophysiology : Concepts of Altered Health States. Lippincott Williams & Wilkins, 7th
ed, 2005. p. 694-705
Supplementary readings
Robbins and Cotran. Pathologic Basis of Disease. Elseivier Inc, 7th ed, 2005. p. 713-728
Ado A.D. Patologičeskaja fiziologija, Moskva, 2002. p. 427-453.
•
Histological structure of the bronchial wall, mucociliary clearance.
Subject- Human Histology and Embryology
Department of Human Histology and Embryology
References:
1. Basic Histology. L.C.Junqueira, J.Carneiro 11th ed. McGraw-Hill, 2005, p.340-349
2. Concise Histology. Don W. Fawcett, Ronald P. Jensh, 2nd ed. Oxford University Press,
2002, p. 228-230.
3. Histologie. R. Lullmann-Rauch. Thieme 2003, p. 285-289.
4. Color Textbook of Histology. Leslie P. Gartner, James L. Hiatt, 2nd ed. Saunders. p. 349355.
•
Morphological changes of lung and heart vessels in asthma.
Subject- Pathological Anatomy
Clinic of Pathological Anatomy
References:
Robbins and Cotran. Pathologic Basis of Disease. Elseivier Inc, 7th ed, 2005. p. 717-728
•
Action of bronchodilators and inhaled steroids in patients with asthma.
Subject - Pharmacology
Department of Basic and Clinical Pharmacology
References:
1. Katzung BG, editor. Basic & Clinical Pharmacology. 10th ed. Boston 2007:121-135,315-327.
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2. Harvey RA, Champe PC, editors. Lippincott’s Illustrated Reviews: Pharmacology. 3rd ed.
Philadelphia 2006:65-80,315-322.
Supplementary readings:
Hardman JG, Limbird LE, editors. Goodman and Gilman’s The Pharmacological Basis of
Therapeutics. 11th ed. New York 2006.
•
Clinical and functional diagnosis of bronchial obstruction syndrome.
Subject– Essentials of Medical Diagnosis
Clinic of Internal Diseases
References:
1. Munro J., Campbell J.W. Macleods‘ Clinical Examination. 10th ed., Churchill Livingstone,
2001, p.136-141.
2. Medicine at a Glance. 2nd ed. Ed. by Patrick Davey. Blackwell publishing, 2006, p.188-189.
3. Davidson‘s Principles and Practice of Medicine. 19th ed., Elsevier Science Limited, 2002,
p.513-520.
Supplementary readings:
Kasper D., Braunwald E., Fauci A., Hauser S., Longo D., Jameson J. Harrison’s Principles of
Internal Medicine (single volume), 17th edition, 2008, p.1596-1606.
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4.2. Case 2. Dyspnea and pain in the calfs.
A 19-year-old man complained having severe breathlessness in the rest, which increased on
slight exertion, and episodes of recurrent chest pain with increasing breathlessness.
He felt ill three months ago during his service in the Soviet Army in Leningrad (SanktPetersburg). After “marching“ the pain in his legs occured with running temperature to 380 C . He
was admitted to the military hospital, pneumonia was diagnosed, antibiotics were given. When he
became better he was discharged from the hospital, and returned to the military subunit. Two weeks
later the pain in his calfs occurred again, there was an episode of dyspnea, and after some days fever
was detected. The soldier was hospitalized again in the military hospital. The diagnosis of chronic
pneumonia and cor pulmonale was made. The youth was demobilized. He went back to Šilutė.
During his way home he suffered from dyspnea, weakness, palpitation. As soon as his parents saw
him, they took him to the hospital.
He suffered from measles and pneumonia in his childhood. The patient was recruited to
military service just after finishing his secondary school. His brother died from seminoma at the age
of 16.
The patient‘s apparent state of health was serious. The height 180 cm, weight 70 kg. His
breath rate was 28 breaths per minute, accessory respiratory muscles took part in the breathing.
Dilated and overfilled jugular veins were seen. On auscultation, vesicular breath sound was audible,
adventitious sounds were absent. He had a pulse rate of 105 beats per minute, S2 accentuated, and
an arterial blood pressure 130/80 mmHg. The liver size determined by percussion along the right
midclavicular line was 10 cm. The left calf was thicker as compared to the right one, the palpation
of the left calf revealed tenderness. The Homans‘ sign was positive.
ECG: the strain pattern of right atrium and right ventricle. The chest X-ray examination
(standard posteroanterior view): the branches of pulmonary artery were broad, shortened due to
hypertension, the right branch – 25 mm. V.cava superior and conus pulmonalis were dilated.
The diagnosis was confirmed by pulmoangiography. Systolic blood pressure in pulmonary artery
was 80/40 mmHg. A lot of contrast medium filling defects were detected in lobar, segmental,
subsegmental branches of pulmonary artery.
During venocavagraphy the floating thrombus was detected in v.cava inferior.
During general anesthesia v.cava inferior was tied up (caval filters in the hospital were
absent). After operation, six hours later, heparin therapy was continued. Retroperitoneal hematoma
complicated the postoperative period. Despite the anticoagulant therapy the patient’s state became
worse, pulmonary hypertension was increasing, respiratory failure was progressing and 8 weeks
later after hospitalization the patient died.
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The findings of autopsy: v.cava inferior, v.iliaca and deep veins of left leg were obstructed
by thrombi. Thrombi were detected in most of segmental and subsegmental pulmonary arteries.
What is your opinion of this clinical case?
How do you estimate the clinical signs?
How do you interprete the laboratory and instrumental examinations?
How do you estimate the treatment given to this patient?
14
Concept of the problem: pulmonary embolism (PE)
Clincal signs: breathlessness, tachycardia, asymmetric edema in legs.
Aim
To study etiopathogenesis of pulmonary embolism, Virchov‘s triad, to know clinical signs of
acute massive pulmonary embolism, to have comprehension of the treatment of pulmonary
embolism.
Learning objectives and contents
To complete an analysis of this problem the students must know:

Anatomy of pulmonary circulation.
Subject - Anatomy
Department – Institute of Anatomy
References:
Gray‘s anatomy for students, 2005, p. 146, 194.
•Histology of vessels.
Subject – Human Histology
Department of Histology and Embryology
References:
Basic Histology. L.C.Junqueira, J.Carneiro 11th ed. McGraw-Hill, 2005, p. 213-217
Supplementary readings:
Concise Histology. Don W. Fawcett, Ronald P. Jensh, 2nd ed. Oxford University Press, 2002, p.
143-144.
•
Peculiarities of pulmonary circulation, blood gas transference, dissociation of oxyhemoglobin,
compounds of carbon dioxide in blood.
Subject - Physiology
Department of Physiology
References:
W.F.Ganong. Review of Medical Physiology. 22nd ed. Lange Medical Books / McGraw-Hill, 2005.
Ch. 34, p. 661-664, Ch. 35. p. 666-670.
15

Pathogenesis of pulmonary hypertension. Mechanisms and alterations of pulmonary perfusion.
Mismatching of ventilation to perfusion. The role of pathological reflexes.
Subject – Pathological Physiology
Department of Physiology
References:
Robbins and Cotran. Pathologic Basis of Disease. Elseivier Inc, 7th ed, 2005. p. 713-728
Supplementary readings:
Porth C.M. Pathophysiology : Concepts of Altered Health States. Lippincott Williams & Wilkins, 7th
ed, 2005. p. 638-649
Ado A.D. Patologičeskaja fiziologija, Maskva, 2002. p. 427-453
•
Alterations of right heart and lungs in pulmonary hypertension, morphology of pulmonary
embolism, Virchov‘s triad.
Subject – Pathological Anatomy
Clinic of Pathological Anatomy
References:
Robbins and Cotran. Pathologic Basis of Disease. Elseivier Inc, 7th ed, 2005. p. 742-745
•
Radiological signs in case of PE and pulmonary hypertension – evaluation of filling defects of
contrast enhancement in CT and MRI.
•
Evaluation criteria of PE comparing lung perfusion scintigrams to lung ventilation scintigrams
and chest radiographs.
Subject - Radiology
Clinic of Radiology
References:
1. D. P. Naidich, N.L.Muller, E.A.Zerhouni, W.R.Webb and al. Computed tomography and
magnetic resonance of the thorax, 1998. p.168-241.
2. H.N. Wagner, Zszabo, J Buchanan Principles of Nuclear Medicine, 1995.p.881-906
Supplementary readings:
www. radiologyeducation.com - teaching files
•
Clinical diagnosis of pulmonary embolism.
Subject – Essentials of Medical Diagnosis
Clinic of Internal Diseases
16
References:
1. Medicine at a Glance. Ed. by Patrick Davey. 2nd ed., Blackwell publishing, 2006, p.164165.
2. Davidson‘s Principles and Practice of Medicine. 19th ed. 2002, Elsevier Science Limited,
2002, p.562-566.
Supplementary readings:
Kasper D., Braunwald E., Fauci A., Hauser S., Longo D., Jameson J. Harrison’s Principles of
Internal Medicine (single volume), 17th ed., 2008, p1651-1657.
•
Medicines affecting blood clotting. Oral and parenteral anticoagulants: mechanism of action,
pharmacokinetics, adverse effects, overdose, and antidotes. Anticoagulants: mechanism of
action, therapeutic indications, dosage.
Subject - Pharmacology
Department of Pharmacology
References:
1. Katzung BG, editor. Basic & Clinical Pharmacology. 10th ed. Boston 2007:542-555.
2. Harvey RA, Champe PC, editors. Lippincott’s Illustrated Reviews: Pharmacology. 3rd ed.
Philadelphia 2006:227-244.
Supplementary readings:
Hardman JG, Limbird LE, editors. Goodman and Gilman’s The Pharmacological Basis of
Therapeutics. 11th ed. New York 2006:1443-1489.
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4.3. Case 3. A silicate brick-maker‘s tale.
A 73-year-old man presented to the emergency department with a complain of worsening
breathlessness. He also suffered from cough with mucous sputum production, palpitation, swelling
of legs at the end of the day, persistent boring pain in the right hypochondrium.
He has been ill for 20 years. In the beginning he suffered from cough and sputum production, later
increasing beathlessness on moderate exertion occured. During the last two years breathlessness
became very strong, increased on slight exertion (during walking in the room); palpitation, boring
pain in the right hypohondrium, swelling of legs occured. During the last two weeks he suffered
from breathlessness at rest, edema in legs was also increasing.
He was ill with children infectious diseases, chronic bronchitis (later chronic obstructive pulmonary
disease was diagnosed), pneumonia, three years ago he experienced intermittent paroxysmal
ischemia of brain. He was a smoker for 40 years: he smoked 20 cigarettes per day. During the last
two years he was ex-smoker. He worked as a silicate brick-maker for 30 years. Now he is a
pensioner. He has no allergy, he is married and has two children. His father died of lung cancer,
mother – of cerebrovascular stroke.
The patient‘s apparent state of health is serious. He is conscious, but his answers to questions are
slow. He is in the active forced sitting position. Cyanosis of the face and lips, accessory respiratory
muscles are seen. His chest is of barrel shape, intercostal spaces are increased. His breath rate is 26
breaths per minute, epigastrium pulsation is seen. The chest palpation revealed reduced elasticity.
Tactile fremitus is normal. Cardiac beat is palpable. On percussion, hyperresonance note is audible
over both sides of the chest, his heart borders are shifted to both sides, especially right border. His
heart rate (HR) is 100 beats per minute. On auscultation of the heart, II-III0 diastolic murmur over
the pulmonary artery is audible. He has a blood pressure of 90/60 mmHg. An abdomen is soft, with
small tenderness in the right hypochondrium. Kurloff‘s ordinates: 16-12-10 cm, determined by
percussion. Significant edemas in his legs are seen.
Investigations:
Haematology: Hb 180 g/L, RBCs 5,8x1012/L, WBCs 8,5x109/L, differential WBC count segmented neutrophils 72%, lymphocytes 20%, monocytes 8%.
ECG: sinus tachycardia, HR 100 beats/min, P “pulmonale” II-III-aVF leads, biphasic P in V1 and
V2 leads.
Blood gas examination (blood was taken from a radial artery): pH 7,28, PaCO2 70 mmHg, PaO2
60 mmHg.
18
Posteroanterior radiographic view: Lung pattern is increased, fibrosis in the basal areas is seen, on
the right side - pleurodiaphragmatic adhesions. The shadow of the heart is shifted to both sides, but
the enlargement of right chambers of the heart predominates.
Ultrasonography of upper abdomen: Liver is markedly enlarged but homogeneous. Gall-bladder is
normal.
What syndromes do you suppose? Why?
How do you interprete the complaints and the findings of physical examination?
How do you estimate the data of laboratory and instrumental examination?
Would you explain radiographic changes?
How do you treat this patient?
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Concept of the problem: chronic respiratory failure, chronic cor pulmonale.
Clinical signs: breathlessness, tachycardia, cyanosis, hypoxaemia, hypercapnia.
Aim
To study etiopathogenesis, semiotics, arterial blood gas alterations, clinical diagnosis of
chronic respiratory failure, and chronic cor pulmonale.
Learning objectives and contents
To complete an analysis of this problem the students must know:

Anatomy of pulmonary circulation.
Subject - Anatomy
Institute of Anatomy
References:
Gray‘s anatomy for students, 2005, p. 146, 194
•
Nervous and humoral regulation of breathing, rhythmicity of breathing, breathing centers and
their activity.
Subject - Physiology
Department of Physiology
References:
W.F.Ganong. Review of Medical Physiology. 22nd ed. Lange Medical Books / McGraw-Hill, 2005.
Ch. 36, p. 671-678.
•
Pathogenesis of pulmonary hypertension, developement of secondary erythrocytosis.
•
Chronic respiratory failure. Disorders of ventilation, diffusion, perfusion; mechanisms of
these disorders. Hypoxia, types and mechanisms. Alterations of tissue respiration.
Subject – Pathological Physiology
Department of Physiology
References:
Porth C.M. Pathophysiology : Concepts of Altered Health States. Lippincott Williams & Wilkins, 7th
ed, 2005. p. 112-113, 717
Supplementary readings:
1. Robbins and Cotran. Pathologic Basis of Disease. Elseivier Inc, 7th ed, 2005. p. 713-728
20
2. Ado A.D. Patologičeskaja fiziologija, Moskva, 2002. p. 427-453
•
Morphological changes of the heart in pulmonary hypertension.
Subject – Pathological Anatomy
Clinic of Pathological Anatomy
References:
•
Robbins and Cotran. Pathologic Basis of Disease. Elseivier Inc, 7th ed, 2005. p. 717-728
Supplementary readings:
•
Radiological signs of chronic pulmonary hypertension: roentgenosemiotic syndromes of
alterations of lung pattern and hiluses.
Subject - Radiology
Clinic of Radiology
References:
A Global TexBook of Radiology. Editor H.Peterson, The NICER Institute. Oslo,1999. p.547-51.
•
Clinical diagnosis of chronic respiratory failure and chronic cor pulmonale.
Subject – Essentials of Medical Diagnosis
Clinic of Internal Diseases
References:
1. Medicine at a Glance. Ed. by Patrick Davey. 2nd ed. Blackwell publishing, 2006, p.178-179.
2. Kasper D., Braunwald E., Fauci A., Hauser S., Longo D., Jameson J. Harrison’s Principles
of Internal Medicine (single volume), 17th ed., 2008, p. 1586-1592.
Supplementary readings:
1. James Thomas, Tanya Monagham. Oxford Handbook of Clinical Examination and Practicall
Skills. Oxford University Press, 2007.
2. Lynn S., Bickley MD. Bates’ Guide to Physical Examination and History Taking, 9 th
edition. Lippincott, Williams&Wilkins, 2007.
3. Munro J., Campbell J.W. Macleods‘ Clinical Examination. 10th edition. Churchill
Livingstone, 2001.
21
4.4. Case 4. A roofer with increasing breathlessness.
A 52-year-old roofer sought a medical advice: he complained of increasing breathlessness on
exertion, cough, mucous sputum production.
For the whole year he suffered from nonpurulent productive cough accompanied by increasing
breathlessness during moderate physical exercise (going upstairs to the 2nd floor). He suffered from
acute bronchitis and pneumonia in the past, an operation due to appendicitis was performed on him.
He is a roofer for 30 years. He slated roofs for more than 20 years. He has been smoking 10-15
cigarettes per day for 20 years.
The patient‘s apparent state of health is fair. His breath rate is 12 breaths per minute. A barrelshaped chest is seen. Elasticity of the chest is decreased. Percussion of the chest revealed
hyperresonance. Vesicular breath sounds and fine rales in basilar areas were detected during
auscultation of the lungs.
The general practitioner has sent the patient to the pulmonologist.
Laboratory and instrumental investigations:
Peripheral blood examination: Hb 145 g/L; RBCs 5,1x1012/L; WBCs 8,1x109/L, differential white
blood cell count is normal; ESR 35 mm/h.
Chest X-ray examination: small reticulonodular changes in both lungs with predominating changes
over the right lung. Here and there pulmonary tissue resembles″honeycomb″.
Spirometry:
1. Vital capacity (VC) 3,8 L (64 % of predicted)
2. The forced expiratory volume in 1 second (FEV1) 2,4 L (88% of predicted)
3. FEV1/VC
(Tiffeneau index 63%, 89% of predicted).
Arterial blood gas analysis: PaO2 60 mmHg, PaCO2 45 mmHg, pH 7,35
Examination of bronchoalveolar lavage:
Cellularity 30x104/ml (Norm 10-20x104/ml)
Macrophages 67% (Norm 80-90%)
Neutrophils 10% (Norm < 2%)
Lymphocytes 23% (Norm 7-15%).
Transbronchial biopsy of pulmonary tissue: Pulmonary fibrosis. Asbestos bodies were revealed
after dyeing it by Prusse.
Which syndrome do you suppose?
Interprete the findings of clinical and laboratory examination.
Explain the detected disorders.
22
Concept of the problem: pulmonary restriction.
Clinical signs: exertional dyspnea, dry cough.
Aim
To learn pathophysiology, functional and clinical diagnosis of restriction syndrome, gas
diffusion mechanisms, pathology of alveolitis, mechanisms of developement of fibrosis.
Learning objectives and contents
To complete analysis of this problem the students must know:
•
gas diffusion and gas exchange mechanisms, acid-base balance regulation.
Suject - Biochemistry
Department of Biochemistry
References:
1. C. Smith, AD Marks, DB. M Lieberman. Marks basic medical biohemistry: a clinical
approach, 2nd ed, Lippincott Williams & Wilkins, 2005, p. 41-53,102-106.
2. J. Baggot. Gas transport and pH regulation in book MD. Devlin Textbook of biochemistry
with clinical correlations. Wiley-Liss; 4th ed, 1997, p. 1025 – 1052.
Supplementary readings:
WJ Marshal, SK Bangert. Clinical chemistry, 5th ed Mosby, 2004, p. 41-61.
•
Histological structure of alveoli, relationship to pulmonary volumes, ventilation mechanisms
in norm and in pulmonary fibrosis (syndrome of restriction).
Subject - Human Histology
Department of Histology and Embryology
References:
1. Basic Histology. Y. L.C.Junqueira, J.Carneiro 11th ed. McGraw-Hill, 2005, p.349-357.
2. Concise Histology. Don W. Fawcett, Ronald P. Jensh, 2nd ed. Oxford University Press,
2002, p. 230-234.
Supplementary readings:
1. Histologie. R. Lullmann-Rauch. Thieme 2003, p. 289-294.
2. Color Textbook of Histology. Leslie P. Gartner, James L. Hiatt, 2nd ed. Saunders. p. 356-36
•
Gas exchange in the lungs; inspiratory, expiratory and alveolar air composition (partial
presures of gases), pulmonary ventilation parameters, pulmonary volumes and capacities.
•
Dead space and alveolar ventilation. Ventilation and blood flow (ventilation/perfusion ratio).
23
Subject - Physiology
Department of Physiology
References:
W.F.Ganong. Review of Medical Physiology. 22nd ed. Lange Medical Books / McGraw-Hill, 2005.
Ch. 34, p. 651-652, 658-661.
•
Pathophysiology of hypoxia and hypercapnia in pulmonary fibrosis.
•
Mechanisms of cough and sputum production. Alterations of lung function. Restrictive
ventilatory pattern. Alveolar ventilation disorder, asphyxia.
Subject – Pathological Physiology
Department of Physiology
References:
Porth CM. Pathophysiology : Concepts of Altered Health States. Lippincott Williams & Wilkins, 7th
ed, 2005. p. 647-657
Supplementary readings:
1. Robbins and Cotran. Pathologic Basis of Disease. Elseivier Inc, 7th ed, 2005. p. 676-682
2. Ado A.D. Patologičeskaja fiziologija, Moskva, 2002. p. 427-453
•
Etiology, pathology of interstitial lung diseases, the role of alveolar macrophages, the genesis
of pulmonary fibrosis.
Subject – Pathological Anatomy
Department of Pathological Anatomy
References:
Robbins and Cotran. Pathologic Basis of Disease. Elsevier Inc, 7th ed, 2005. p. 728-741.
•
Sources of the atmosphere pollution, components of air pollution, the impact on health, the
means of prevention.
Subject – Environmental Medicine
Department of Environmental and Occupational Medicine
References:
Yassi A., Kjellstrom T., de Kok T., Guidotti T. Basic Environmental Health, Oxford university
press, 2001. p. 180-201.
Supplementary readings:
24
1. Aw T.C., Gardiner K., Harrington J.M. Pocket consultant Occupational health, Blackwell
Publishing, 2007, p. 249- 270.
2. WHO Air quality and health website: http://www.euro.who.int/air
•
Radiological signs of alveolitis and pulmonary fibrosis: roentgenosemiotic syndromes of
alterations of lung pattern, hiluses and dissemination.
Subject - Radiology
Clinic of Radiology
References:
A Global TexBook of Radiology. Editor H.Peterson, The NICER Institute. Oslo,1995. p.547-51.
•
Clinical and functional diagnosis of pulmonary restriction syndrome.
Subject – Essentials of Medical Diagnosis
Clinic of Internal Diseases
References:
1. Davidson‘s Principles and Practice of Medicine. 19th ed. Elsevier Science Limited, 2002,
p.492-494.
2. The Merck Manual of Diagnosis and Therapy, 18th edition. Merck Publications, 2006, 364373, 469-480.
3. Medicine at a Glance. Ed. by Patrick Davey. 2nd ed., 2006, Blackwell publishing, 2006,
p.208-209.
Supplementary readings:
1. Munro J., Campbell J.W. Macleods‘ Clinical Examination. 10th ed. Churchill Livingstone,
2001, p.117-144.
2. Kasper D., Braunwald E., Fauci A., Hauser S., Longo D., Jameson J. Harrison’s Principles
of Internal Medicine (single volume), 17th ed., 2008, p. 1611-1618.
25
4.5. Case 5. An acute illness of a wood-cutter
A 48-year-old wood-cutter complains of fever up to 39,50C, sweating, right-sided chest pain, cough
with rusty sputum, moderate breathlessness.
Three days ago he suddenly got ill after lieing for some hours on a cold and wet ground (after
abundant alcohol consumption). He thought that he had caught a cold, and that is why he didn‘t
visit his general practitioner. An ambulance was called when breathlessness and rusty sputum
production occured.
In the past he suffered from children infections, grippe, pneumonia, prostatitis. He is a smoker: he
smokes 20 cigarettes daily. He uses alcohol 2-3 times per week. He is married, and has two
children.
The patient‘s apparent state of health is serious. Flushed face. He is in the forced active right lateral
decubitus position, broken into a sweat, with a herpetic rash around his lips. His body temperature
is 39,50C. His breath rate is 25 breaths per minute. Asymmetric respiration is seen: the right side of
the chest follows the left one. Elasticity of the chest is normal, tactile fremitus is stronger on the
right side of the chest. Percussion along l.axillaris anterior, media, posterior and l.scapularis in the
right side of the chest – below 4th rib - revealed dullness. On auscultation of right chest, bronchial
breath sound is audible, bronchophony is present. He has a regular pulse of 120 beats per minute
and a blood pressure of 90/50 mmHg. Palpation of the abdomen revealed tenderness below the
right hypochondrium.
Investigations were performed urgently:
Haematology: Hb 130 g/L, RBCs 4,1x1012/L, platelets 180x109/L, WBCs 22,5x109/L; differential
WBC count: segmented neutrophils 80%, lymphocytes 12%, monocytes 8%; ESR 60 mm/h; CRP
95 mg/L.
Cytologic examination of sputum: a lot of RBCs, WBCs.
Gram stain of sputum: Gram+ diplococci.
Chest radiograph: On the right inferior area the confluent infiltration is evident, slight right-sided
pleural effusion is possible.
What syndrome do you suppose? Indicate the diagnostic criteria.
How do you interprete the complaints and the findings of physical examination?
What is the cause of tachycardia and reduced blood pressure?
How do you interprete the examinations of peripheral blood and sputum?
How would you explain the radiographic changes?
What treatments do you consider?
26
Concept of the problem: pulmonary consolidation.
Clinical signs: breathlessness, cough, fever, sputum production.
Aim
To study etiopathogenesis, semiotics, morphological, clinical, radiographic signs of pulmonary
consolidation.
Learning objectives and contents
To complete an analysis of this problem the students must know:

Anatomy of the lung lobes.
Subject - Anatomy
Institute of Anatomy
References:
Gray‘s anatomy for students, 2005, p. 140-146
•Histological structure of the lung tissue.
Subject – Human Histology
Department of Histology and Embryology
References:
1. Basic Histology. L.C.Junqueira, J.Carneiro 11th ed. McGraw-Hill, 2005, p. 345-358.
2. Concise Histology. Don W. Fawcett, Ronald P. Jensh, 2nd ed. Oxford University Press,
2002, p. 228-233.
•
Formation of intrapleural pressure, the physiological role.
Subject - Physiology
Department of Physiology
References:
W.F.Ganong. Review of Medical Physiology. 22nd ed. Lange Medical Books / McGraw-Hill, 2005.
Ch. 34, p. 650-651.

Pathogenesis of pneumonia, changes of peripheral blood in inflammation. Disorder of alveolar
function. Disorders of ventilation, diffusion, perfusion, mechanisms of those disorders.
Dyspnea, mechanism of dyspnea.
Subject – Pathological Physiology
27
Department of Physiology
References:
Porth CM. Pathophysiology : Concepts of Altered Health States. Lippincott Williams & Wilkins, 7th
ed, 2005. p. 647-655
Supplementary readings:
1. Robbins and Cotran. Pathologic Basis of Disease. Elseivier Inc, 7th ed, 2005. p. 713-728
2. Ado A.D. Patologičeskaja fiziologija, Moskva, 2002. p. 427-453
•
Pathology of pulmonary consolidation.
Subject – Pathological Anatomy
Department - Clinic of Pathological Anatomy
References:
Robbins and Cotran. Pathologic Basis of Disease. Elsevier Inc, 7th ed, 2005.
•
Radiological signs of lung infiltration: syndromes of local opacity of lung field, round opacity,
ring-shaped opacity and dissemination.
Subject - Radiology
Department – The Clinic of Radiology
References:
A Global TexBook of Radiology. Editor H.Peterson, The NICER Institute. Oslo,1999. p.535-52.
•
The changes of sound transmission in consolidation. Clinical signs of pulmonary
consolidation, semiotics.
Subject – Essentials of Medical Diagnosis
Clinic of Internal Diseases
References:
1. Davidson‘s Principles and Practice of Medicine. 19th ed., Elsevier Science Limited, 2002,
p.527-530.
2. Medicine at a Glance. Ed. by Patrick Davey. 2nd ed. Blackwell publishing, 2006, p.184-185.
3. Munro J., Campbell J.W. Macleods‘ Clinical Examination. 10th edition. Churchill
Livingstone, 2001, p.117-144.
Supplementary readings:
1. Bacevicius E. Propedeutics to Internal Medicine. Kaunas, 1998, p. 52-53.
28
2. James Thomas, Tanya Monagham. Oxford Handbook of Clinical Examination and Practicall
Skills. Oxford University Press, 2007.
3. Lynn S., Bickley MD. Bates’ Guide to Physical Examination and History Taking, 9 th
edition. Lippincott, Williams&Wilkins, 2007.
•
Antibiotics, cough and cold medicines (secretolytics, mucolytics, antitusives).
Subject - Pharmacology
Department of Pharmacology
References:
1. Katzung BG, editor. Basic & Clinical Pharmacology. 10th ed. Boston 2007.
2. Harvey RA, Champe PC, editors. Lippincott’s Illustrated Reviews: Pharmacology. 3rd ed.
Philadelphia 2006:353-380.
Supplementary readings:
Hardman JG, Limbird LE, editors. Goodman and Gilman’s The Pharmacological Basis of
Therapeutics. 11th ed. New York 2006:725-737.
29
4.6. Case 6A. A brick-layer‘s case.
A 46-year-old brick-layer with previously good health complains of fever up to 38 0C, right–sided
chest pain, that is increasing during the deep inspiration.
Two weeks ago he fell down to the right side in the building site. Some days later the pain in the
right side occurred. This pain increased during the deep inspiration. He was running a temperature
up to 380C, exertional dyspnea developed. He used analgetics. His health state became worse and he
refered his doctor for medical advice.
In the past he suffered from pneumonia, prostatitis. He is a smoker. He smokes 20 cigerettes per
day. His father died of lung cancer at the age of 58. His mother is still alive.
The patient‘s apparent state of health is fair. Active forced lateral decubitus position is seen: he lies
on the right side. During breathing the right side of the chest follows the left one. His breath rate is
20 breaths per minute. The findings of palpation: elasticity of the chest is normal, tactile fremitus is
weaker on the right side. Percussion along l. medioclavicularis, l.axillaris anterior, media, posterior,
and l. scapularis revealed dullness below right fourth rib. Auscultation of this place detected the
absence of breath sounds. His heart rate is 90 beats per minute, a blood pressure is 120/80 mmHg.
Kurloff ordinates: 10 x 9 x 7 cm. The abdomen on palpation is soft, without tenderness. The liver
and the spleen are nonpalpable. Edema in legs is absent.
Laboratory and instrumental investigations:
Haematology: Hb 140 g/L; RBCs 4,2x1012/L; WBCs 8,2x109/L; differential WBC count –
neutrophils 72%, lymphocytes - 20%, monocytes - 8%.
The chest radiographs (anteroposterior and lateral views): On the right side, below the 4th rib a
dense uniform opacification with oblique fluid line is evident, mediastinum is displaced to the left.
Which syndrome and why do you suspect?
How do you interpret the complaints and the findings of physical examination?
How do you interpret the findings of peripheral blood examination?
How do you explain the radiographic changes?
How can you help the patient?
What findings of pleural fluid examination do you expect?
30
4.6. Case 6B. Urgent help is required.
A 74-year-age retired man complains of acute dyspnea and the pain in the right chest that occurred
suddenly on getting up after endoscopic procedure.
The patient was treated in the department of gastroenterology because of peptic ulcer in the
duodenum. After the treatment the controlling fibroesophagogastroduodenoscopy procedure was
performed. The conclusion of fibroesophagogastroduodenoscopy was made: the ulcer was healed
up, the procedure passed without complications.
Past medical history: pneumonia, chronic bronchitis, five years ago – myocardial infarction. He is a
smoker for 40 years: he smokes 20 cigarettes per day. He is married and has two children. His
parents are dead: his mother died of brain stroke, and his father – of myocardial infarction.
The patient‘s apparent state of health is serious. Active forced sitting position. Cyanosis of the face
and lips is seen. His breath rate is 30 breaths per minute. During breathing the right chest follows
the left one. Tactile fremitus is absent over the right chest. There is tympany to percussion over the
right chest wall. Breath sounds and voice sounds are absent over the same area on auscultation. His
heart rate is 120 beats per minute, and a blood pressure is 80/40 mmHg.
The following investigations were performed urgently:
The posteroanterior radiographic view of the chest: Air in the right pleural cavity, the mediastinum
is displaced to the left.
What syndrome is it? Why?
What are the pathogenesis and semiotics of this syndrome?
Is the complication associated with the performed procedure? Do you consider it a jatrogenic
one?
How do you interpret the findings of physical and radiographic examination?
What help are you going to give urgently?
Concept of the problem: fluid in pleural cavity, air in pleural cavity.
Clinical signs: pain in the chest, dullness to percussion, tympany to percussion.
Aim
To study etiopathogenesis, morphology, clinical signs of fluid and air accumulation in pleural
cavity.
Learning objectives and contents
To complete analysis of this problem the students must know:

Anatomy of pleura.
Subject – Human Anatomy
Institute of Anatomy
References:
Gray‘s anatomy for students, 2005, p. 136-140

Histology of pleura.
Subject - Histology
Department of Histology and Embryology
References:
1. Basic Histology. L.C.Junqueira, J.Carneiro 11th ed. McGraw-Hill, 2005, p.358
2. Concise Histology. Don W. Fawcett, Ronald P. Jensh, 2nd ed. Oxford University Press,
2002, p. 234.
Supplementary readings:
Histologie. R. Lullmann-Rauch. Thieme 2003, p. 294.
•
Mechanisms of pneumothorax, their role in the development of pneumothorax.
Subject – Pathological Physiology
Department of Physiology
References:
Robbins and Cotran. Pathologic Basis of Disease. Elseivier Inc, 7th ed, 2005. p. 713-728
Supplementary readings:
Ado AD. Patologičeskaja fiziologija, Moskva, 2002. p. 427-453.
•
Pathogenesis of air accumulation in pleural cavity.
32
•
Pathogenesis of fluid accumulation in pleural cavity.
•
Disorders of function of pleura.
•
Pneumothorax: etiology, pathogenesis, alterations of organism functions.
•
Hydrothorax: etiology, pathogenesis, alterations of organism functions.
Subject – Pathological Physiology
Department of Physiology
References:
Robbins and Cotran. Pathologic Basis of Disease. Elseivier Inc, 7th ed, 2005. p. 766-770.
•
Fluid accumulation in pleural cavity: etiology, morphological changes, cytological
examination of pleural fluid.
Subject – Pathological Anatomy
Clinic of Pathological Anatomy
References:
Robbins and Cotran. Pathologic Basis of Disease. Elsevier Inc, 7th ed, 2005.
•
Radiological signs of pleural effusion:
roentgenosemiotic syndromes of total and local
opacification.
•
Ultrasonography of pleural effusion and evaluation of fluid volume.
•
Radiological signs of air in pleural cavity: roentgenosemiotic syndrome of brightening of lung
field.
Subject - Radiology
Clinic of Radiology
References:
A Global TexBook of Radiology. Editor H.Peterson, The NICER Institute. Oslo,1999. p.547-51.
•
The clinical diagnosis of fluid accumulation in pleural cavity.
•
The clinical diagnosis of air accumulation in pleural cavity; the changes of sound
transmission; the principles of treatment.
Subject – Essentials of Medical Diagnosis
Clinic of Internal Diseases
References:
1. Medicine at a Glance. Ed. by Patrick Davey. 2nd ed. Blackwell publishing, 2006, p.27-28.
2. Davidson‘s Principles and Practice of Medicine. 19th ed. Elsevier Science Limited, 2002,
p.502-503, 569-573.
33
Supplementary readings:
1. Munro J., Campbell J.W. Macleods‘ Clinical Examination. 10th edition. Churchill
Livingstone, 2001, p.117-144.
2. Bacevicius E. Propedeutics to Internal Medicine. Kaunas, 1998, p. 54-55.
3. Kasper D., Braunwald E., Fauci A., Hauser S., Longo D., Jameson J. Harrison’s Principles
of Internal Medicine (single volume), 17th ed., 2008, p.1651-1657.
34
5. Lectures
5.1. Anatomy of the respiratory system (2 hours)
Institute of Anatomy
In charge – assoc.prof. V. Giedrimas, assoc. prof. V.Aželis.
Description: anatomy of bronchial tree and lungs.
5.2. Histology of the respiratory system (2 hours)
Department of Histology and Embryology
In charge - lect. J. Palubinskienė
Description: Histology of airways (the structure of trachea and bronchial wall, histology of
pulmonary tissue). Defense structures and mechanisms of the respiratory system, mucociliary
clearance. The structure of pleura. The structure of the vessel wall. Developement of lungs,
disorders of developement.
5.3. Physiology of the respiratory system (2 hours)
Department of Physiology
In charge - assoc.prof. R. Miliauskas
Description: Mechanics of external respiration, types of respiration; formation of intrapleural
pressure; alveolar pressure; lung volumes and capacities, pulmonary and alveolar ventilation;
pressure-volume relationship (compliance), alveolar surface tension. Pulmonary circulation;
ventilation/perfusion ratio; composition of inspiratory, expiratory, and alveolar air. Oxygen
transport; carbon dioxide transport. Nervous and humoral (chemical) regulation of respiration.
Rhythmicity of respiration. Respiratory centers and their activity.
5.4. Pathological physiology of the respiratory system (2 hours)
Department of Physiology
In charge – prof. A. Kondrotas
Description: Etiology, pathogenesis of external respiratory failure, alterations of organism
functions. Etiology, pathogenesis of disorders of ventilation, diffusion, perfusion. Etiology,
pathogenesis of alterations of airways and lung functions. Sneezing, cough, sputum production;
causes, alterations of organism functions. Dyspnea, causes and types. Asphyxia, etiology,
pathogenesis, stages. Bronchial spasm, etiology, pathogenesis, alterations of organism functions.
35
Pneumothorax,
hydrothorax,
etiology,
pathogenesis,
alterations
of
organism
functions.
Comprehension of internal respiration, etiology, pathogenesis, alterations of organism functions.
5.5. Pathological anatomy of the respiratory system ( 2 hours)
Clinic of Pathological Anatomy
In charge – prof. R. Gailys, prof. V. Lesauskaitė
Description: The most common dysplasias of the respiratory system. Pulmonary endoinfections:
bronchitis, bronchopneumonia, lobar pneumonia. Morphology of chronic obstructive pulmonary
diseases (chronic bronchitis, pulmonary emphysema, asthma, bronchiectases) and restrictive
diseases (pneumoconioses). Secondary pulmonary hypertension and cor pulmonale syndrome. Lung
tumors. Pathological anatomy of smoking.
5.6. Radiology of the respiratory system (2 hours)
Clinic of Radiology
In charge – assoc.prof.S.Lukoševičius
Description: Radiological methods of the investigation of the respiratory system: fluoroscopy and
radiography of the chest, computed tomography (CT), magnetic resonance imaging (MRI),
ultrasonography, lung ventilation and perfusion scintigraphy. Radiological topographic anatomy of
the chest, methods of investigation, interpretation of pathological symptoms.
5.7. Gas exchange and molecular mechanisms of gas transference (2hours)
Department of Biochemistry
In charge – prof.L.Ivanovienė, prof.V.Borutaitė
Description: Molecular mechanisms of oxygen tranfer in human organism. Oxygen carriers in
blood and tissues. Hemoglobin structure, types, allosteric effects, factors that influence oxygen
transfer.
Molecular
mechanisms
of
carbon
dioxide
transfer.
Types
and
causes
of
hemoglobinopathies.
5.8. Medicines acting on the respiratory system (2hours)
Department of Basic and Clinical Pharmacology
In charge – lect. R. Jankūnas
Description: Studies of medicines acting on the respiratory system.
36
5.9.Thrombolytics and anticoagulants (2 hours)
Department of Basic and Clinical Pharmacology
In charge – lect. R. Jankūnas
Description: Studies of thrombolytics and anticoagulants.
5.10. The sources of air pollution, the components of air pollution, their impact
on health, the means of prevention (2hours)
Department of Environmental and Occupational Medicine
In charge – assoc.prof. R. Ustinavičienė
Description: The assessment of air pollution. The main sources of air pollution: transport, industry
and energetics enterprises, their contribution to the pollution of the environment. The main
components of air pollution (sulphur oxides, nitrogen oxides, dust, hydrocarbons, cancerogenic
substances), their physical and chemical properties, the impact on health. The prevention of
environmental air pollution: organizational and legislation means, air cleaning in industry and
energetics.
5.11. Clinical diagnosis of pathology of the respiratory system (1)(2 hours)
Clinic of Internal Diseases
In charge - assoc.prof. P. Leišytė
Description: Clinical examination of the respiratory system (the main complaints and their
characteristics, findings of inspection, palpation, percussion, auscultation).
5.12. Clinical diagnosis of pathology of the respiratory system (2)(2 hours)
Clinic of Internal Diseases
In charge - assoc.prof. P. Leišytė
Description: Examination of lung functions in clinical practise (the main lung function tests used in
clinical practise, the main functional parameters, normal and pathological values, interpretation).
5.13. Clinical diagnosis of pathology of the respiratory system (3)(2 hours)
Clinic of Internal Diseases
In charge - assoc.prof. P. Leišytė
Description: Clinical-structural, clinical- functional syndromes of the respiratory system affection.
37
6. Practicals
6.1. Anatomy of the respiratory system (3 hours)
Institute of Anatomy
Anatomy of the respiratory system. Trachea, its structure. Main, lobar, and segmental
bronchi. Bronchial tree. Acinus. Lungs: surfaces, lobes, fissures, topography. Vascularisation
of bronchi and lungs, innervation, lymphatic drainage.
References:
Richard L.Drake. Gray‘s anatomy for students, 2005, p. 140-149, 188
6.2. Anatomy of pulmonary circulation and the heart (3 hours)
Institute of Anatomy
Pulmonary circulation. Heart chambers, orificies, valves. Pulmonary artery, branches.
Pulmonary veins. Pleura: parietal and visceral pleura, pleural cavity, sinuses. Innervation,
vascularisation, topography of pleura. Anatomy of muscles involved in respiration.
References:
Richard L.Drake.. Gray‘s anatomy for students, 2005, p. 136-140, 146, 154-180
6.3. Histology of trachea, bronchi, bronchioles. Histophysiology of blood
vessels (2 hours)
Department of Histology and Embryology
Histological structure of trachea, bronchus and bronchioles. Histophysiology of pulmonary blood
vessels and of muscular vein of lower extremity.
Histological micropreparations:
1. Trachea (H-E, azan);
2. Lungs (H-E, azan);
3. Vein of muscular type (H-E).
4. Lungs (azan)
1. Using medium magnification find mucosa, submucosa layer, C-shaped hyaline cartilage and
adventitia in the preparation of cross-sectioned trachea. Find columnar ciliated epithelial cells,
goblet cells, basal cells and intermediate cells using the highest magnification, and
make a
drawing. Pay attention at a rather thick basement membrane. Find and draw serous glands in the
submucosa layer. There is no smooth muscle between the cartilage and the submucosa layer, except
the smooth muscle, connecting the ends of the cartilage, which constitutes the supportive structure.
38
Some of the glands are behind the muscle. The outer layer is adventitia. Pay attention at the rich
vascular network in the lamina propria, which is well defined in the longitudinal section of the
trachea.
2.Find bronchus in the H-E stained preparation of lungs, inspect it under the highest magnification
and draw: mucosa with respiratory epithelium (pseudostratified columnar ciliated epithelium), the
layer of smooth muscle cells, submucosa layer with serous bronchial glands, hyaline cartilage rings
and plates, and tunica adventitia. In some slides bronchus-associated lymphoid tissue may be
observed: lymphatic follicles with multiple lymphocytes just under the epithelium near the
branching points of bronchial tree. The bronchiole’s wall is without glands and cartilage plates, it
has a prominent muscular layer between the mucosa and the submucosa layers, epithelium is
lowering columnar with longitudinal folds due to contraction of muscular layer.
3.Muscular vein. Evaluate the form of the muscular type vein lumen
using the lowest
magnification. Using the highest magnification find endothelial cells in tunica intima, smooth
muscle cells and collagen fibers in the tunica media which runs into tunica adventitia without clear
border. Remember the functional and structural peculiarities of tunica intima and the endothelial
cells.
4.In the azan stained section of lungs find a large bronchus and a blood vessel in its neighbourhood.
It is a branch of pulmonary artery with multiple elastic lamina in the tunica media. Elastic fibers are
unstained, collagen fibers stain blue, smooth muscle cells are red. Branches of the bronchial arteries
are of much smaller diameter and are found in the adventitia of the wall of bronchus. Tributaries of
pulmonary veins are usually away from larger bronchi, somewhere between the lobules. Make a
drawing of pulmonary vessels and remember the peculiarities of pulmonary circulation.
References:
Basic Histology. L.C.Junqueira, J.Carneiro 11th ed. McGraw-Hill, 2005, p.214-216, 345-349.
Supplementary readings:
http://www.usuhs.mil/pat/surg_path/nlhist/lung.html
6.4. Histology of pleura and pulmonary parenchyma (2 hours)
Department of Histology and Embryology
Histological microreparations:
Lungs (H-E, Rezorcin-fuchsin)
1.Find the natural border of the hematoksilin-eosin stained prepatation of the lungs. It is the pleura.
With large objective lens you may see one layer of squamous cells with elongated nuclei. That is
mesothelium. A translucent space just under the epithelium is the layer of elastic fibers, which are
unstained using this staining method. The layer of the collagen fibers is stained in rose-red, there
may be found small tributaries of pulmonary veins.
39
2.Using medium magnification find respiratory bronchioles, alveolar ducts, sacs and alveoli. Using
the highest magnification find type I pneumocytes with flattened nuclei and type II pneumocytes
with round nuclei and transparent cytoplasm.
3.Rezorcin-fuchsin stains elastic fibers in dark red or purple. Determine them with the help of the
highest magnification in the pleura and in the interstitium of the alveolar septa. Alveolar
macrophages may be observed in the alveolar spaces. Make a drawing of the air-blood barrier.
References:
Basic Histology. L.C.Junqueira, J.Carneiro 11th ed. McGraw-Hill, 2005, p. 349-358.
Supplementary readings:
http://www.usuhs.mil/pat/surg_path/nlhist/lung.html
6.5. Physiology of the respiratory system (3 hours)
Department of Physiology
Measurement of lung volumes and capacities by spirography and computer spirometry.
References:
Guyton AC, Hall JE. Textbook of medical physiology. 11th ed. Philadelphia: Elsevier Saunders;
2006, p. 475-477.
6.6. Obstructive airway diseases and tumors (3 hours)
Clinic of Pathological Anatomy
Analysis of macro-, histological preparations, and electron micrographs. Students learn the
morphologic changes in chronic bronchitis, pulmonary emphysema, and asthma, their
complications (pulmonary hypertension, cor pulmonale), and causes of death.
Smoking induced morphologic changes; the role of smoking for developement of respiratory
diseases. Morphology of pneumoconiosis. Classification of lung tumors, complications and causes
of death.
Obstructive emphysema and pneumosclerosis. Electron micrograph (x 15000).
Find out obliteration of alveolar capillaries by collagen and elastic fibres.
Regeneratio epithelii bronchi (metaplasii). Histological slide (H+E). Find section of bronchus
where normal ciliated columnar epithelial cells were replaced by metaplastic stratified squamous
epithelium.
Carcinoma epidermoide (planocellulare) – cornescens. Histological slides (H+E). Find the site
where the basement membrane of the stratified squamous epithelium is penetrated by atypical cells
40
with invasion to the underlying connective tissue. At greater depth, the tumor cells are keratinized
forming keratinous pearls. Note the multitude of immune cells.
References:
Pathologic Basis of Disease/Eds I. L. Robbins, R.S. Cotran. 7 th edition 2005, p. 717-728, 743745,757-766.
6.7. Endoinfections of the respiratory system and pathology of the pleura (3
hours)
Analysis of macro-, histological preparations, and electron micrographs. Students learn the
pathogenesis of endoinfections (acute bronchitis, bronchopneumonia, lobar pneumonia), their
morphology, complications, and causes of death
Migration of neutrophil through capillary . Electron micrograph (x20 000, 12 000). Draw three
steps of extravasation of leucocytes: 1. Margination of leucocytes in the lumen of capillary; 2.
Transmigration across the endothelium. 3. Migration in interstitial tissues.
Bronchitis purulenta et bronchopneumonia (seu pneumonia focalis. Histological slide (H+E).
Find the purulent exudate and the desquamated epithelial cells in the lumen of the bronchus. There
are pulmonary alveoli in the vicinity filled with a purulent exudate. Notice that those alveoli free of
exudate are enlarged (a compensatory mechanism). There is hyperaemia in the lung.
Pneumonia lobaris (crouposa). Histological slide (H+E). Pay attention that all alveoli are filled by
fibrinous exudate and neutrophils. There are and some red blood cells in alveoli.
References:
Pathologic Basis of Disease/Eds I. L. Robbins, R.S. Cotran. 7 th edition 2005, p. 747-756, 766769.
6.8. Medicines acting on the respiratory system (2 hours)
Department of Basic and Clinical Pharmacology
Selective, nonselective and indirect-acting adrenergic agonists, methylxanthines, antileukotriene drugs: pharmacodynamics, therapeutic indications, adverse effects, overdose, antidotes.
Medicines that increase the adrenoreceptor sensitivity to adrenergic agonists. Mechanisms of
drug-resistance.
References:
1. Katzung BG, editor. Basic & Clinical Pharmacology. 10th ed. Boston 2007:121-135,315-327.
2. Harvey RA, Champe PC, editors. Lippincott’s Illustrated Reviews: Pharmacology. 3rd ed.
Philadelphia 2006:65-80,315-322.
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6.9. Thrombolytics and anticoagulants (2 hours)
Department of Basic and Clinical Pharmacology
Anti-platelet medicines (acetylsalicylic acid, ticlopidine, eptifibatide, abciximab). Oral and
parenteral anticoagulants: mechanism of action, adverse effects, overdose, and antidotes.
Thrombolytic agents: mechanism of action, pharmacokinetics, use-related issues.
References:
1. Katzung BG, editor. Basic & Clinical Pharmacology. 10th ed. Boston 2007:542-555.
2. Harvey RA, Champe PC, editors. Lippincott’s Illustrated Reviews: Pharmacology. 3rd ed.
Philadelphia 2006:227-244.
6.10. Clinical diagnosis of respiratory disorders (1)(4 hours)
Clinic of Internal Diseases
Clinical examination of the respiratory system.
References:
1. Munro J., Campbell J.W. Macleods‘ Clinical Examination. 10th ed. Churchill Livingstone,
2001, p.117-144.
Supplementary readings:
1. Bacevicius E. Propedeutics to Internal Medicine. Kaunas, 1998, 21-44.
2. James Thomas, Tanya Monagham. Oxford Handbook of Clinical Examination and Practicall
Skills. Oxford University Press, 2007.
3. Lynn S., Bickley MD. Bates’ Guide to Physical Examination and History Taking, 9 th
edition. Lippincott, Williams&Wilkins, 2007.
6.11. Clinical diagnosis of respiratory disorders (2) (4 hours)
Clinic of Internal Diseases
Functional examination of the respiratory system. Sputum and pleural fluid clinicallaboratory assessment. The main clinical-functional syndromes: irritation of the airways,
bronchial obstruction, pulmonary restriction, respiratory failure.
References:
The Merck Manual of Diagnosis and Therapy, 18th ed. Merck Publications, 2006, p.364-373, 378.
Supplementary readings:
Pellegrino R., Viegi G., Brusasco V. et al. Interpretative strategies for lung function tests. Eur Respir
J 2005; 26: 948-968.
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6.12. Clinical diagnosis of respiratory disorders (3) (4 hours)
Clinic of Internal Diseases
The main clinical-structural syndromes of the respiratory system: pulmonary consolidation,
cavity in the lung, increased airiness of the lung, fluid and air accumulation in the pleural
cavity.
References:
Munro J., Campbell J.W. Macleods‘ Clinical Examination. 10th ed. Churchill Livingstone, 2001,
p.117-144.
Bacevicius E. Propedeutics to Internal Medicine. Kaunas, 1998, p.52-55.
6.13. Radiology of the respiratory system (1) (3 hours)
Clinic of Radiology
Topographic anatomy of the chest radiographs. Cross-sectional anatomy of CT and MRI of the
chest. Methods of evaluation. Radiological signs of pulmonary embolism (PE) and pulmonary
hypertension, Evaluation criteria for pulmonary scintigrams. Radiological signs of chronic
pulmonary hypertension – roentgenosemiotic syndromes of alterations of lung pattern and hyluses.
References:
A Global TextBook of radiology. Ed. H.Pettersson.1995
Supplementary readings:
1. Atlas of Radiologic Anatomy. Ed. A. N. Taylor.1994
2. Principles of chest roentgenology. Ed. L.R.Goodman.1999.
3. D. P. Naidich, N.L.Muller, E.A.Zerhouni, W.R.Webb and al. Computed tomography and
magnetic resonance of the thorax.
4. www. radiologyeducation.com- teaching files.
6.14. Radiology of the respiratory system (2) (3 hours)
Clinic of Radiology
Radiological signs of alveolitis and pulmonary fibrosis:
roentgenosemiotic syndromes of
alterations of lung pattern, hiluses and dissemination. Radiological signs of lung infiltration:
syndromes of local opacity of lung field, round opacity, ring-shaped opacity, and dissemination.
References:
A Global TextBook of radiology. Ed. H.Pettersson.1995
Supplementary readings:
1. Atlas of Radiologic Anatomy. Ed. A. N. Taylor.1994
2. Principles of chest roentgenology. Ed. L.R.Goodman.1999.
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3. D. P. Naidich, N.L.Muller, E.A.Zerhouni, W.R.Webb and al. Computed tomography and
magnetic resonance of the thorax.
4. www. radiologyeducation.com- teaching files.
6.15. Radiology of the respiratory system (3) (3 hours)
Clinic of Radiology
Radiological signs of pleural effusion: roentgenosemiotic syndromes of total and local
opacification. Radiological signs of air in pleural cavity: roentgenosemiotic syndrome of
brightening of lung field. Ultrasonography of pleural effusion, evaluation of fluid volume.
References:
A Global TextBook of radiology. Ed. H.Pettersson.1995
Supplementary readings:
1. Atlas of Radiologic Anatomy. Ed. A. N. Taylor.1994
2. Principles of chest roentgenology. Ed. L.R.Goodman.1999.
3. D. P. Naidich, N.L.Muller, E.A.Zerhouni, W.R.Webb and al. Computed tomography and
magnetic resonance of the thorax.
4. www. radiologyeducation.com- teaching files.
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7. Seminars
7.1. Compensatory mechanisms of the maintainance of acid-base balance (2 hours)
In charge – prof.L.Ivanovienė, prof.V.Borutaitė
Analysis of circulatory, extracellular fluid and
cellular buffering systems, compensatory
mechanisms maintainance of acid-base balance: respiratory acidosis and alkalosis, metabolic
acidosis and alkalosis. The role of sodium and chlorine in the acid-base balance. The assessment of
acid-base balance disorders.
References:
1. Devlin Textbook of biochemistry with clinical correlations. Wiley-Liss; 4th ed, 1997, p. 1025
– 1052.
2. C Smith, AD Marks, DB. M Lieberman. Marks basic medical biohemistry: a clinical
approach, 2nd ed, Lippincott Williams & Wilkins, 2005, p. 41-53.
Supplementary readings:
WJ Marshal, SK Bangert. Clinical chemistry, 5th ed Mosb
7.2. Environmental dust pollution, classification, physical and chemical properties.
Pneumoconioses (2 hours)
Department of Environmental and Occupational Medicine
In charge – lect.R.Raškevičienė
Classification of dust (organic, inorganic). Factors that influence the effect of inhaled particles: the
size, density, the shape, chemical properties, penetration, fibrogenity, interaction with tissues,
antigenity. Pneumoconioses, classification and etiology. Occupations and works, associated with
the dust exposure. Asbestosis, silicosis, silicatosis, anthracosis, other pneumoconioses. The
prevention of pneumoconioses. The individual preventive measures for protection of airways.
References:
1. Aw T.C., Gardiner K., Harrington J.M. Pocket consultant Occupational health, Blackwell
Publishing, 2007, p. 249- 270.
2. WHO Air quality and health website: http://www.euro.who.int/air
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8. Module examination questions
8.1. Anatomy
1. The structure of the bronchial tree. Acinus.
2. The lungs, surfaces, fissures, lobes. Pulmonary hilus. Pulmonary radix.
3. Skeletotopy of the lungs and their lobes.
4. Pleura, pleural cavity, sinuses, topography.
5. Skeletal muscles involved in respiration.
6. Innervation and vascularisation of bronchi, lungs, and pleura. Lymphatic drainage.
8.2. Histology and Embryology
1. The structure of wall of bronchi and bronchioles.
2. Histophysiology of airway mucosa.
3. Enumerate the epithelium cells of the respiratory mucosa, indicate their functions.
4. Characterize the differences of bronchus and bronchiole wall structure.
5. The structures and cells that take part in defence against foreign substances in airways and
alveoli.
6. The structure of alveolar septum.
7. The structure of air-blood barrier.
8. The structure and function of the pleura.
9. The genesis of the respiratory system development. Most common development defects.
8.3. Physiology
1. The mechanics of pulmonary ventilation. Intrapleural and alveolar pressure changes during the
breathing cycle.
2. Lung volumes and capacities.
3. Pulmonary and alveolar ventilation.
4. Pulmonary circulation and ventilation/perfusion ratio. Autoregulation of pulmonary blood flow.
5. Composition of inspired, expired, and alveolar air. Gas exchange in the lungs.
6. Oxygen transport by the blood. Oxyhemoglobin dissociation curve.
7. Carbon dioxide transport by the blood.
8. Neural regulation of respiration. Respiratory centers and their activity.
9. Central and peripheral chemical regulation of respiration.
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8.4. Pathological physiology
1. Etiology, pathogenesis of external respiratory failure, alterations of organism functions.
2. Etiology, pathogenesis of disorders of ventilation, diffusion, perfusion.
3. Functional disturbances of airways and lungs, their etiology and pathogenesis.
4. Sneezing, cough, sputum production; causes, alterations of organism functions.
5. Dyspnea, causes and types.
6. Asphyxia, etiology, pathogenetical mechanisms, stages.
7. Bronchial spasm, etiology, pathogenesis, alterations of organism functions.
8. Pneumothorax, hydrothorax; etiology, pathogenesis, alterations of organism functions.
9. Comprehension of internal respiration; etiology, pathogenesis, alteration of organism functions.
8.5. Pathological anatomy
1. General characteristics of pulmonary obstructive diseases. Chronic bronchitis and pulmonary
emphysema: morphologic types, complications, causes of deaths.
2. Pulmonary hypertension: causes, pathogenetic mechanisms, causes of deaths (cor pulmonale
syndrome).
3. Causes and mechanisms of pulmonary endoinfections, classification. Bronchopneumonia:
morphology, causes of death.
4. Lobar pneumonia: stages, morphology, complications, causes of death.
5. Lung tumors: localization, morphological and histological forms, complications, causes of
death.
6. Bronchiectases: morphology, complications, causes of death.
7. Morphology of pleural pathology, complications, causes of death.
8. Smoking induced pathology.
8.6. Radiology
1. Radiological diagnostic modalities.
2. Principles of roentgenological investigation, the main elements.
3. Characteristics of an X-ray picture.
4. Harmful effect of roentgenological investigations.
5. Radiation doses from different radiological investigation procedures.
6. Regulations of roentgenological investigations. Groups of radiation-sensitive organs, norms of
radiation protection.
7. The means of radiation protection of patients during roentgenological investigation.
8. Tomography and its types.
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9. Computer tomography (CT) of the chest, cross-sectional anatomy and indications.
10.Ultrasonography of pleural cavity and thoracic wall, method of investigation and application.
11.Magnetic resonance imaging (MRI): the principle of the method, cross-sectional anatomy of the
chest, fields of application.
12.Classification of contrast media, fields, ways and methods of application.
13.Angiographic investigations of pulmonary arteries (patient preparation, an investigation
technique, contraindications, possible complications and prevention).
14.Pulmonary ventilation and perfusion scintigraphy (V/Q scan); radiopharmaceuticals, their dose
calculation, patient preparation, scan procedure, indications and contraindications.
15.The algorithm of radiological diagnosis of the respiratory system. The scheme for evaluation of
radiological images.
16.Roentgenological method for investigation of lungs and pleura.
17.Basics of roentgenoanatomy of lungs: areas, hiluses, lung pattern.
18.Lobes and segments of lungs on radiograph and CT.
19.Anatomic elements of lungs and mediastinum on CT slices.
20.Differential diagnosis of total and subtotal opacity of lung field.
21.CT and roentgenodiagnostics of round opacity of the lung field, alterations of volume of lobe
and segment. Differential diagnosis of lung infiltrations.
22.Free and encapsulated fluid in the pleural cavity.
23.Pneumothorax, hydropneumothorax.
24.Differential roentgenodiagnosis of ring-shaped opacity of lung field.
25.Focal opacities of lungs and their differential CT roentgenodiagnosis.
26.Causes of alterations of lung hiluses and lung pattern, the character and roentgenological view.
27.The value of roentgenography, CT and MRI in diagnosis of chronic heart failure, myocardial
affection and exudative pericarditis.
28.Radiological detection of pulmonary bleeding (due to pulmonary, heart and blood diseases).
29.Radiological investigations in case of sharp chest pain.
30.Evaluation criteria for lung perfusion scintigrams.
31.Evaluation criteria for lung ventilation scintigrams.
32.Evaluation criteria of PE comparing lung perfusion scintigrams with ventilation scintigrams and
chest radiographs.
8.7. Biochemistry
1.Characteristics of molecular structures of hemoglobin and myoglobin. Mechanisms of oxygen
binding and release from hemoglobin and myoglobin.
48
2.Mechanisms of hemoglobin’s oxygen tranfer efficiency alterations in the presence of effectors
(CO2, 2,3-BPG and pH).
3.Bohr effect and its physiological significance.
4.Mechanisms of regulation of acid-base status: bicarbonate and hemoglobin buffer systems,
mechanism of action and disturbances ( metabolic and respiratory acidoses and alkalosis).
5.The role of sodium and chloride ions in acid-base balance.
8.8. Pharmacology
1. Classification of medicines acting on adrenergic synaptic cleft.
2. Selective beta-adrenomimetics: pharmacodynamics, indications, and adverse effects.
3. M-cholinergic antagonists.
4. Pharmacodynamics of cough and cold medicines.
5. Mechanism of action of anti-inflammatory and anti-allergic drugs.
6. Anti-platelet medicines.
7. Comparison of pharmacodynamics of direct and indirect anticoagulants.
8. Medicines acting on fibrinolysis, their pharmacodynamics and pharmacokinetics.
8.9. Essentials of Medical Diagnosis
1.
Complaints of patients with respiratory diseases.
2.
Thoracocentesis, technique of performance. Examination of pleural fluid, pathological
meanings.
3.
Examination of sputum: macroscopic, microscopic, bacteriologic examination, pathological
findings, their clinical meanings.
4.
Spirometry: flow-volume curve (norm and pathology).
5.
Spirometry: time-volume curve (norm and pathology).
6.
Main indices of arterial blood gas analysis: normal and pathological values.
7.
Pulmonary consolidation syndrome, main clinical signs, clinical meanings.
8.
Syndrome of cavity in the lung, main clinical signs, clinical meanings.
9.
Syndrome of increased airiness in the lung, main clinical signs, clinical meanings.
10.
Syndrome of air accumulation in the pleural cavity, main clinical signs, clinical meanings.
11.
Syndrome of fluid accumulation in the pleural cavity, main clinical signs, clinical meanings.
12.
Syndrome of airway irritation, the main clinical signs, clinical meanings.
13.
Syndrome of bronchial obstruction, the main clinical signs, functional changes, clinical
meanings.
49
14.
Syndrome of pulmonary restriction, the main clinical signs, functional changes, clinical
meanings.
15.
Respiratory failure, the clinical sings, functional changes, classification (types and grades),
causes.
8.10. Environmental and Occupational Medicine
1. Sources of environmental air pollution, their characteristics.
2. The main components of environmental air pollution, their impact on health.
3. The prevention of environmental air pollution.
4. Environmental air dust, classification, impact on health, prevention.
5. Pneumoconioses, classification, etiology.
6. Individual protective measures for prevention of airways.
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