Key History
Acute/subacute vs. chronic, increased frequency of cough if chronic, timing; presence/description of sputum, presence of hemoptysis; associated symptoms (constitutional, URI, postnasal drip, dyspnea, wheezing, chest pain, heartburn); exacerbating and alleviating factors, exposures; smoking history; history of lung disease, posttussive emesis, or heart failure; allergies; medications (especially ACE inhibitors).
COUGH/SHORTNESS OF BREATH (cant'd)
Key Physical Exam
Vital signs ± pulse oximetry; exam of nasal mucosa, oropharynx, heart, lungs, lymph nodes, and extremities (clubbing, cyanosis, edema).
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Presentation |
Differential |
Workup |
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■ 30 yo M presents with shortness of breath, cough, and wheezing that worsen in cold air. He has had several such episodes in the past 4 months. |
Asthma GERD Bronchitis Pneumonitis Foreign body |
CBC CXR Peak flow measurement PFTs Methacholine challenge test |
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■ 56 yo F presents with shortness of breath and a productive cough that has lasted for at least 3 months each year over the past 2 years. She is a heavy smoker. |
COPD—chronic bronchitis Bronchiectasis Lung cancer Tuberculosis |
CBC Sputum Gram stain and culture CXR PFTs CT—chest PPD |
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■ 58 yo M presents with 1 week of pleuritic chest pain, fever, chills, and cough with purulent yellow sputum. He is a heavy smoker with COPD. |
Pneumonia COPD exacerbation (bronchitis) Lung abscess Lung cancer Tuberculosis Pericarditis |
CBC Sputum Gram stain and culture CXR CT—chest ECG PPD |
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■ 25 yo F presents with 2 weeks of nonproductive cough. Three weeks ago she had a sore throat and a runny nose. |
Atypical pneumonia Reactive airway disease URI-associated cough (“postinfectious”) Postnasal drip GERD |
CBC Induced sputum Gram stain and culture CXR IgM detection for Mycoplasma pneumoniae Urine Legionella antigen |
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■ 65 yo M presents with worsening cough for the past 6 months accompanied by hemoptysis, dyspnea, weakness, and weight loss. He is a heavy smoker. |
Lung cancer Tuberculosis Lung abscess COPD Vasculitis (eg, Wegener’s granulomatosis) Interstitial lung disease CHF |
CBC Sputum Gram stain, culture, and cytology CXR CT—chest PPD ANCA Bronchoscopy Echocardiography |
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COUGH/SHORTNESS OF BREATH (cant'd) |
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Presentation |
Differential |
Workup |
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■ 55 yo M presents with increased dyspnea and sputum production for the past 3 days. He has COPD and stopped using his inhalers last week. He stopped smoking 2 days ago. |
COPD exacerbation (bronchitis) Lung cancer Pneumonia URI CHF |
CBC CXR ABG PFTs Sputum Gram stain and culture CT—chest Echocardiography |
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■ 34 yo F nurse presents with worsening cough of 6 weeks’ duration accompanied by weight loss, fatigue, night sweats, and fever. She has a history of contact with tuberculosis patients at work. |
Tuberculosis Pneumonia Lung abscess Vasculitis Lymphoma Metastatic cancer HIV/AIDS Sarcoidosis |
CBC PPD/QuantiFERON Gold Sputum Gram stain, acidfast stain, and culture CXR CT—chest Bronchoscopy HIV antibody Lymph node biopsy |
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■ 35 yo M presents with shortness of breath and cough. He has had unprotected sex with multiple sexual partners and was recently exposed to a patient with active tuberculosis. |
Tuberculosis Pneumonia (including Pneumocystis jiroveci) Bronchitis Asthma Acute HIV infection CHF (cardiomyopathy) |
CBC PPD/QuantiFERON Gold Sputum Gram stain, acidfast stain, silver stain, and culture CXR HIV antibody Echocardiography |
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■ 50 yo M presents with a cough that is exacerbated by lying down at night and improved by propping up on 3 pillows. He also reports exertional dyspnea. |
CHF Cardiac valvular disease GERD Pulmonary fibrosis COPD Postnasal drip |
CBC CXR ECG Echocardiography PFTs BNP CT—chest |
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■ 60 yo M presents with worsening dyspnea of 6 hours’ duration and a cough that is accompanied by pink, frothy sputum. |
Pulmonary edema CHF Mitral valve stenosis Arrhythmia Asthma Pneumonia |
ECG CXR CBC ABG PFTs BNP |
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