Note: The book you're referring to is likely Dr. Archith Boloor's Exam Preparatory Manual for Undergraduates: Medicine, which is not in this library. The answer below is compiled from Harrison's 22E, Fishman's Pulmonary Diseases & Disorders, and Murray & Nadel - the same standard references used in that manual - structured in the exam-Q&A format Boloor follows.

HEMOPTYSIS

Definition

• Harrison's 22E, p. 318

Hemoptysis vs Hematemesis (Important Distinction)

Classification by Volume

Causes of Hemoptysis

Airway Causes

• Bronchitis (viral - most common in developed countries, often streak hemoptysis)
• Bronchiectasis (including cystic fibrosis) - recurrent, can be massive; airways dilated, inflamed, highly vascular
• Bronchogenic carcinoma (squamous cell and small cell - central, erode major vessels)
• Carcinoid tumor (vascular, proximal airways)
• Foreign body aspiration

Parenchymal / Infectious Causes

• Pulmonary tuberculosis - most common worldwide (especially developing countries); cavitary disease, Rasmussen's aneurysm (erosion of pulmonary artery aneurysm into TB cavity)
• Lung abscess / Necrotizing pneumonia (S. aureus, Klebsiella, oral anaerobes)
• Pneumonia (Strep. pneumoniae, H. influenzae, Moraxella catarrhalis)
• Aspergilloma (fungus ball in pre-existing cavity, neovascularization - important cause of massive hemoptysis)
• Endemic fungi (Histoplasma, Coccidioides), Nocardia, NTM
• Paragonimiasis (mimics TB; Southeast Asia/China; raw crayfish ingestion)

Vascular Causes

• Mitral stenosis (raised pulmonary venous pressure)
• Pulmonary embolism with infarction
• Left heart failure (pink frothy sputum)
• Arteriovenous malformation (AVM)
• Aortobronchial fistula (aneurysm/pseudoaneurysm - small bleeds then massive)
• Dieulafoy's disease of the bronchus (rare - submucosal fistula between bronchial and pulmonary arteries)

Diffuse Alveolar Hemorrhage (DAH)

• Granulomatosis with polyangiitis (GPA, formerly Wegener's) - "pulmonary-renal syndrome" (hemoptysis + hematuria)
• Anti-GBM disease (Goodpasture syndrome)
• SLE-associated capillaritis
• Cocaine/inhalant toxicity
• Stem cell transplantation
• Vaping-induced lung injury

Miscellaneous

• Coagulopathy / thrombocytopenia / anticoagulants
• Catamenial hemoptysis (pulmonary endometriosis - cyclical bleeding with menstruation)
• Iatrogenic: post-lung biopsy, pulmonary artery catheter rupture, pulmonary vein stenosis post-ablation
• COPD (unexplained, usually non-recurrent)
• Bevacizumab / ramucirumab (anti-VEGF agents) in squamous cell lung cancer

Exam tip: In patients < 40 years - think infection; in patients > 40-45 years or smokers - think bronchogenic carcinoma.

Evaluation

History

• Pattern, severity, frequency, quantity
• Sputum description (streaks vs frank blood vs clots)
• Respiratory symptoms, weight loss, smoking, TB contact, travel history
• Anticoagulant use, menstrual cycle (catamenial)

Physical Examination

• Vital signs, O2 saturation
• Signs of chronic lung disease (clubbing, hyperinflation)
• Cardiovascular: mitral stenosis (opening snap, mid-diastolic murmur)
• ENT: to exclude nasal/oropharyngeal source

Investigations

1. Chest X-ray - first-line; identifies cavities, masses, consolidation, hilar lymphadenopathy
2. CBC - degree of anaemia, thrombocytopenia (contributing factor)
3. Coagulation studies (PT/INR, aPTT)
4. Sputum AFB smear + culture - rule out TB
5. CT chest (HRCT / multidetector CT angiography) - identifies source of bleeding, underlying pathology, bronchial and non-bronchial systemic arteries with high sensitivity
6. Bronchoscopy - direct visualization, localizes bleeding site, allows therapeutic intervention (rigid preferred in massive hemoptysis)
7. Urinalysis / renal function - if pulmonary-renal syndrome suspected (GPA, Goodpasture)
8. Echocardiography - if mitral stenosis suspected

Imaging Examples:

Old tuberculosis cavities in right apex (Fishman's Pulmonary Diseases)

Goodpasture syndrome - bilateral alveolar infiltrates (Fishman's Pulmonary Diseases)

Management

Non-Massive Hemoptysis

• Identify and treat underlying cause
• Suppress cough (antitussives)
• Treat infection (antibiotics as appropriate)
• Correct coagulopathy if present
• Outpatient management often feasible; monitor closely

Massive / Life-Threatening Hemoptysis

1. Airway - maintain patency; intubate if needed (large-bore ETT, preferably 8.0 mm)
2. Oxygenation - supplemental oxygen
3. Hemodynamic stabilization - IV access, fluids, blood products

Special Situations

Rasmussen's Aneurysm (High-Yield)

• Erosion of a pulmonary artery aneurysm into a pre-existing TB cavity
• Rare but important cause of massive hemoptysis in TB
• Source: pulmonary circulation (not bronchial)

Sources

• Harrison's Principles of Internal Medicine, 22E (2025) - pp. 318-319, 635
• Fishman's Pulmonary Diseases and Disorders, 2-Volume Set - pp. 443-444
• Murray & Nadel's Textbook of Respiratory Medicine

PLEURAL EFFUSION

Definition

• Harrison's 22E, p. 2311; Robbins Pathology, p. 676

Physiology of Pleural Fluid Formation

• Fluid enters the pleural space from capillaries in the parietal pleura
• Fluid is removed via lymphatics of the parietal pleura
• Fluid can also enter from: lung interstitial spaces (via visceral pleura) or peritoneal cavity (via small diaphragmatic holes)
• The lymphatics can absorb 20 times more fluid than is normally formed

Mechanisms of Accumulation (Pathophysiology)

Classification: Transudate vs Exudate

Light's Criteria (Exudate - meets >/= 1):

• Transudates meet none of the above criteria
• These criteria misidentify ~25% of transudates as exudates ("pseudoexudates") - often a diuresed transudate
• If pseudoexudate suspected: use Serum-Pleural fluid Protein Gradient (SPPG) > 3.1 g/dL or Serum-Pleural fluid Albumin Gradient (SPAG) > 1.2 g/dL - 100% sensitive for CHF, 99% for hepatic hydrothorax

Causes

TRANSUDATIVE Effusions

1. Congestive heart failure (most common cause overall)
2. Cirrhosis (hepatic hydrothorax)
3. Nephrotic syndrome
4. Peritoneal dialysis
5. Superior vena cava obstruction
6. Myxedema (hypothyroidism)
7. Urinothorax

EXUDATIVE Effusions

• Metastatic disease - lung carcinoma, breast carcinoma, lymphoma (cause 75% of malignant effusions)
• Mesothelioma (asbestos-related)

• Bacterial infections / Parapneumonic effusion (most common exudative cause in US; up to 50% of community-acquired pneumonia)
• Tuberculosis (most common cause in developing countries)
• Fungal, viral, parasitic infections

• Esophageal perforation (amylase-rich, left-sided)
• Pancreatic disease (amylase-rich)
• Intraabdominal abscesses
• Diaphragmatic hernia
• Post-abdominal surgery, endoscopic variceal sclerotherapy, post-liver transplant

• Rheumatoid pleuritis (very low glucose, low pH)
• SLE, drug-induced lupus
• Sjogren syndrome
• Granulomatosis with polyangiitis (Wegener's)
• Churg-Strauss syndrome

• Post-coronary artery bypass surgery (left-sided, bloody early then serous)
• Asbestos exposure
• Sarcoidosis
• Uremia
• Meigs' syndrome (ovarian fibroma + right-sided pleural effusion + ascites - resolves with tumor removal)
• Yellow nail syndrome
• Drug-induced (nitrofurantoin, dantrolene, methysergide, bromocriptine, amiodarone, dasatinib)
• Trapped lung
• Radiation therapy
• Post-cardiac injury syndrome (Dressler's)
• Hemothorax
• Iatrogenic injury
• Ovarian hyperstimulation syndrome
• Chylothorax (triglycerides > 110 mg/dL - disruption of thoracic duct)

Diagnostic Algorithm

FIGURE: Approach to diagnosis of pleural effusion (Harrison's 22E, p. 2311)

Clinical Features

• Dyspnea (most common, often out of proportion to effusion size in malignancy)
• Pleuritic chest pain (dull, heavy, worse with breathing - from pleural inflammation)
• Dry cough

• Tracheal/mediastinal shift away from large effusion
• Stony dull percussion note (dullest of all percussion notes)
• Reduced / absent breath sounds
• Reduced tactile vocal fremitus
• Reduced chest expansion on affected side
• Aegophony (e-to-a change) at upper border of effusion
• Friction rub (if inflammatory, before fluid accumulates)

Radiology

Bilateral pleural effusion - note curvilinear upper margin (meniscus sign) concave to lung, higher laterally than medially (Grainger & Allison's Radiology)

• Meniscus sign - fluid has concave upper margin, higher laterally than medially
• Subpulmonary effusion - appears as "high hemidiaphragm" with peak more laterally than usual
• Lateral decubitus film - detects even small effusions (as little as 50 mL)
• Supine (ICU) film - hazy opacity of lower thorax; costophrenic angles NOT obscured; vascular markings preserved through opacity

Thoracentesis and Pleural Fluid Analysis

• New or undiagnosed effusion
• CHF effusion that is unilateral, unequal in size, febrile patient, or pleuritic chest pain

• Protein, LDH (for Light's criteria)
• Glucose, cell count and differential
• Gram stain and culture
• Cytology

Specific Effusions - High Yield Points

Parapneumonic Effusion and Empyema

• PPE in up to 50% of community-acquired pneumonia
• Complicated PPE / Empyema requires drainage if ANY of:
  1. Loculated pleural fluid
  2. pH < 7.20
  3. Glucose < 3.3 mmol/L (< 60 mg/dL)
  4. Positive Gram stain or culture
  5. Gross pus in pleural space
  6. Pleural fluid LDH > 900 IU/L
• Treatment: chest tube + intrapleural tPA (10 mg) + DNase (5 mg) if loculated; thoracoscopy; surgical decortication if above fail

Malignant Pleural Effusion

• Three tumors cause 75%: lung, breast, lymphoma
• Poor prognosis (< 6-month survival)
• Dyspnea often out of proportion to effusion size
• Usually exudate; rarely transudate
• Low glucose if high tumor burden
• Diagnosis by cytology (positive in ~60%) or pleural biopsy
• Treatment: therapeutic thoracentesis, indwelling pleural catheter (IPC), pleurodesis (talc most effective)

Tuberculous Effusion

• Exudate with high ADA, lymphocyte-predominant
• Low glucose, low pH
• Culture positivity low (~25%); pleural biopsy more sensitive
• Treatment: standard anti-TB drugs; steroids may reduce residual pleural thickening

Hepatic Hydrothorax

• Complicates ~5-10% of cirrhosis patients
• Ascitic fluid passes through small diaphragmatic defects
• Usually right-sided (85%), transudative
• May occur without detectable ascites
• Treatment: sodium restriction + diuretics; TIPS (70-80% response); VATS repair of diaphragmatic defects + pleurodesis; liver transplantation

Chylothorax

• Triglycerides > 110 mg/dL (or chylomicrons on lipoprotein electrophoresis)
• Milky white fluid; lymphocyte-predominant
• Causes: thoracic duct trauma/surgery, lymphoma (most common malignant cause), lymphangioleiomyomatosis
• Treatment: low-fat diet (medium-chain triglycerides), octreotide, thoracic duct ligation

Meigs' Syndrome

• Ovarian fibroma (or other pelvic tumor) + ascites + pleural effusion (usually right-sided)
• Effusion is transudate
• All resolves with removal of the tumor

Rheumatoid Pleuritis

• Characteristically: very low glucose (< 30 mg/dL), very low pH - lower than any other non-infectious cause
• Cholesterol crystals may be seen in chronic effusions

Management Principles

Transudative Effusion

• Treat the underlying cause (heart failure, cirrhosis, nephrotic syndrome)
• Thoracentesis for symptom relief if large
• Do NOT insert a chest tube for a transudative effusion

Exudative Effusion

• Identify and treat specific cause
• Drainage if complicated PPE/empyema criteria met
• Malignant: IPC or pleurodesis for palliation

Pleurodesis

• Goal: obliterate pleural space to prevent recurrence
• Agents: Talc (most effective), bleomycin, doxycycline, tetracycline
• Method: chemical pleurodesis via chest tube or thoracoscopy (VATS)
• Requires lung re-expansion (will not work in trapped lung)

Indwelling Pleural Catheter (IPC)

• For recurrent malignant effusion or hepatic hydrothorax as bridge to transplant
• Outpatient drainage; can lead to auto-pleurodesis in ~40% of malignant cases

Sources

• Harrison's Principles of Internal Medicine, 22E (2025) - pp. 2311-2313
• Robbins, Cotran & Kumar Pathologic Basis of Disease - p. 676
• Murray & Nadel's Textbook of Respiratory Medicine
• Grainger & Allison's Diagnostic Radiology - p. 62

PLEURAL EFFUSION

Definition

Physiology of Normal Pleural Fluid

• Fluid enters from capillaries of the parietal pleura
• Fluid is removed by lymphatics of the parietal pleura
• Can also enter from lung interstitium (via visceral pleura) or peritoneum (via diaphragmatic holes)
• Lymphatics can absorb 20x more fluid than is normally formed

Mechanisms of Accumulation

Classification: Transudate vs Exudate

Light's Criteria - Exudate meets at least ONE:

• Transudates meet none
• ~25% of transudates misidentified as exudates ("pseudoexudates") - often a diuresed transudate
• If pseudoexudate suspected: SPPG > 3.1 g/dL or SPAG > 1.2 g/dL corrects this (100% sensitive for CHF, 99% for hepatic hydrothorax)

Causes

TRANSUDATES (systemic factors altered)

1. Congestive heart failure - most common cause of pleural effusion overall
2. Cirrhosis / Hepatic hydrothorax
3. Nephrotic syndrome
4. Peritoneal dialysis
5. Superior vena cava obstruction
6. Myxedema (hypothyroidism)
7. Urinothorax

EXUDATES (local factors altered)

• Metastatic disease - lung, breast, lymphoma (cause 75% of malignant pleural effusions)
• Mesothelioma

• Parapneumonic effusion - most common exudative cause in US (up to 50% of community-acquired pneumonia)
• Tuberculosis - most common cause in developing countries
• Fungal, viral, parasitic infections

• Pulmonary embolism (exudate or transudate)

• Esophageal perforation (amylase-rich, left-sided)
• Pancreatic disease (amylase-rich, left-sided)
• Intraabdominal abscesses, diaphragmatic hernia
• Post-abdominal surgery, post-liver transplant, endoscopic variceal sclerotherapy

• Rheumatoid pleuritis (characteristically very low glucose < 30 mg/dL, very low pH)
• SLE, drug-induced lupus
• Sjogren syndrome, GPA (Wegener's), Churg-Strauss

• Post-CABG (left-sided, bloody then serous)
• Asbestos exposure
• Sarcoidosis
• Uremia
• Meigs' syndrome (ovarian fibroma + ascites + right-sided effusion - transudate; resolves with tumor removal)
• Yellow nail syndrome
• Drug-induced: nitrofurantoin, dantrolene, methysergide, bromocriptine, amiodarone, dasatinib
• Trapped lung
• Radiation therapy
• Post-cardiac injury syndrome (Dressler's)
• Hemothorax
• Ovarian hyperstimulation syndrome
• Chylothorax (triglycerides > 110 mg/dL)
• Iatrogenic

Clinical Features

• Dyspnea (most common; often out of proportion to size in malignancy)
• Pleuritic chest pain (dull, heavy, worse on breathing)
• Dry cough

• Tracheal/mediastinal shift away from large effusion
• Reduced chest expansion on affected side
• Stony dull percussion (dullest of all - differentiates from consolidation which is dull)
• Reduced / absent breath sounds
• Reduced tactile vocal fremitus (TVF)
• Aegophony at upper border of effusion
• Pleural friction rub (early, before fluid accumulates)

Radiology

Chest X-ray (PA erect)

• Meniscus sign - concave upper border, higher laterally than medially
• Subpulmonary effusion - appears as "high hemidiaphragm" peaking more laterally; stomach bubble separated > 2 cm from lung (left-sided)
• Supine film (ICU) - hazy opacity of lower thorax; costophrenic angles NOT obscured; vascular markings visible through opacity (opposite to erect)
• Loculated effusion - lens-shaped, does not shift with position; "pseudotumour/vanishing tumour" in fissures

Bilateral pleural effusion showing meniscus sign - Grainger & Allison's Diagnostic Radiology

Diagnostic Algorithm

Diagnostic approach to pleural effusion - Harrison's 22E, p. 2311

Thoracentesis and Pleural Fluid Analysis

• Protein + LDH (Light's criteria)
• Glucose, cell count + differential
• Gram stain + culture
• Cytology

Specific Effusions - High Yield Points

Parapneumonic Effusion / Empyema

1. Loculated pleural fluid
2. pH < 7.20
3. Glucose < 60 mg/dL (< 3.3 mmol/L)
4. Positive Gram stain or culture
5. Gross pus in pleural space
6. LDH > 900 IU/L

• Chest tube drainage
• Intrapleural tPA 10 mg + DNase 5 mg if loculated
• Thoracoscopy (VATS) with breakdown of adhesions
• Surgical decortication if above fail

Malignant Pleural Effusion

• Lung + breast + lymphoma = 75% of all malignant effusions
• Poor prognosis (< 6-month median survival)
• Dyspnea out of proportion to size
• Low glucose if high tumor burden
• Treatment: therapeutic thoracentesis → indwelling pleural catheter (IPC) or pleurodesis (talc most effective)

Tuberculous Pleural Effusion

• Exudate; lymphocyte-predominant
• High ADA (> 40-45 U/L)
• Low glucose, low pH
• AFB culture positivity low (~25%); pleural biopsy + culture more sensitive
• Treatment: standard 4-drug anti-TB therapy; steroids reduce residual thickening

Hepatic Hydrothorax

• 5-10% of cirrhosis patients
• Ascitic fluid through diaphragmatic defects
• Usually right-sided (85%), transudate
• May occur without detectable ascites
• Treatment: Na restriction + diuretics → TIPS (70-80% response) → VATS pleurodesis → liver transplant

Chylothorax

• Milky white fluid; lymphocyte-predominant; triglycerides > 110 mg/dL
• Causes: thoracic duct trauma/surgery, lymphoma (most common malignant cause), LAM
• Treatment: low-fat diet (MCT oil), octreotide, thoracic duct ligation/embolization

Meigs' Syndrome

• Triad: Ovarian fibroma + ascites + right-sided pleural effusion
• Effusion is a transudate
• Resolves completely after tumor removal
• Must distinguish from Pseudo-Meigs' (other pelvic tumors)

Rheumatoid Pleuritis

• Characteristically: glucose < 30 mg/dL (lowest of all non-infective causes)
• Very low pH, high LDH
• Complement levels very low

Management Summary

Transudative Effusion

• Treat underlying cause (CHF → diuretics/ACEi; cirrhosis → Na restriction, diuretics, TIPS; nephrotic → steroids + treat cause)
• Therapeutic thoracentesis for symptomatic relief
• Do NOT insert chest tube for a simple transudate

Exudative Effusion

• Identify and treat underlying cause
• Drain if complicated PPE/empyema criteria met
• Malignant: IPC or chemical pleurodesis

Pleurodesis

• Talc - most effective agent
• Others: bleomycin, doxycycline, tetracycline
• Method: via chest tube (slurry) or thoracoscopy (poudrage)
• Will NOT work if lung is trapped (cannot re-expand)
• Trapped lung diagnosis: pleural manometry, pneumothorax ex vacuo on imaging post-thoracentesis, rapid recurrence

Sources

• Harrison's Principles of Internal Medicine, 22E (2025) - pp. 2311-2313
• Robbins, Cotran & Kumar Pathologic Basis of Disease - p. 676
• Murray & Nadel's Textbook of Respiratory Medicine
• Grainger & Allison's Diagnostic Radiology - p. 62