Cough/Shortness of Breath

Cough/Shortness of Breath

Cough-Shortness of Breath

• Physical Exam:
  • • VS: State (or WNL or WNL except…)
  • • General: Patient is in no acute distress
  • • HEENT: Examine mouth, throat, lymph nodes => Nose, mouth and pharynx WNL
  • • Neck Exam: No JVD, no lympadenopathy
  • • Chest Exam: Palpation, Percussion, Auscultation => Tactile fremitus normal, Clear breath sounds bilaterally/Clear breath sounds bilaterally, no rhonchi, rales, or wheezing; (Increase in tactile fremitus, and decrease in breath sounds on right side. No rhonchi, rales, or wheezing)
  • • Heart Exam: Palpation, Auscultation => Apical impulse not displaced, RRR, S1, S2 wnl, No murmurs, rubs, or gallops heard
  • • Abd Exam: Palpation, Auscultation
  • • Extremities: Inspect => No cyanosis, or edema
•  DDX:
  • – Asthma (especially Exercise-Induced Asthma)
    
  • – Chronic Obstructive Pulmonary Disease (COPD) – Chronic Bronchitis
    
  • – COPD Exacerbation
    
  • – Pneumonia
    
  • – Atypical pneumonia
    
  • – Lung Neoplasm/Cancer
    
  • – Tuberculosis (TB)
    
  • – Congestive Heart Failure (CHF)
    
  • – ACE inhibitors use
    
  • – Paroxysmal Nocturnal Dysnea (PND)
    
  • – Gastroesophageal Reflux Disease (GERD)
    
  • – HIV
• Work-up:
  • – CBC with diff
    
  • – Chest X-ray (CXR)
    
  • – Peak Flow measurement
    
  • – PFT’s
    
  • – Methacholine Challenge Test
    
  • – Sputum Grain Stain, Acid-fast stain, Culture
    
  • – CT—chest
    
  • – Bronchoscopy (Bronchoalveolar lavage (BAL))
    
  • – PPD
    
  • – HIV antibody

ACE Inhibitor Use

• Presentation:
  • – History: Taking ACE Inhibitor
  • – Dry and non-productive cough
    
• Physical Exam:
  • No fever, normal lung exam
• Treatment:
  • Replace with ARBs
    • valsartan (Diovan, Prexxartan)
    • losartan (Cozaar)

Airway Obstruction

• Presentation:
  • – History: Sudden onset, change to voice, choked on food or denture
    
  • – SOB
• Physical Exam:
  • – Stridor, Cyanosis
• Treatment:
  • endotracheal tube
  • tracheostomy or cricothyrotomy

Allergic Rhinitis 

• Presentation:
  • – History: Runny Nose, Itchy watery eyes, recurrent with season
    
• Physical Exam:
  • – Rhinorrhea, Watery eyes, Allergic shiners
• Treatment:
  • Self Care
    • Avoid allergen and Nasal washing
  • Medication 
    • Antihistamine – Loratadine
    • Decongestant – Pseudoephedrine, Oxymetalozine
    • Bronchodilator – Ipratropium
  • Procedure – Desensitization

https://www.myupchar.com/en / CC BY-SA
OsmoseIt / CC BY-SA

Anaphylaxis 

• Presentation:
  • – Acute SOB, Wheezing
  • – Hx of exposure to allergen
    
• – Physical Exam:
  • – Hives, Hypotension, Tachypnea, Tachycardia
• Treatment:
  • Supportive Care
    • Tracheal intubation, Cardiopulmonary resuscitation (CPR), and IV fluids
    • Oxygen
  • Medication:
    • Epinephrine (adrenaline) – to reduce your body’s allergic response.
    • IV antihistamines and cortisone – to reduce inflammation of your air passages and improve breathing.
    • Beta-agonist ( albuterol) – to relieve breathing symptoms.

Mikael Häggström / CC0

Anemia

• Presentation:
  • – History: Fatigue, Generalized Weakness
  • – SOB
    
• Physical Exam:
  • – Pallor

Asthma

• Presentation:
  • – shortness of breath, cough, and wheezing that worsen in cold air. several such episodes over the past 4 months.
  • – Chronic inflammatory disease of the airways characterized by hyper-responsiveness, mucosal edema, and mucus production.
    
  • – Recurrent episodes sx = cough, chest tightness, wheezing, and dyspnea
    
  • – History: Recurrent attachs of dyspnea, cough, wheezing, Hx or FH of asthma
    
  • – Physical: Wheezing (Expiratory high-pitched whistling sound made during breathing)
• Classifications:
  • Mild intermittent asthma
    • Sx ≤ 2 days/week
    • Nighttime awakenings: 0
  • Mild persistent asthma
    • Sx > 2 days/week but not daily, 
    • Nighttime awakenings: 1–2x/month
  • Moderate persistent asthma
    • Sx Daily
    • Nighttime awakenings: 3–4x/month
  • Severe persistent asthma
    • Sx Throughout the day
    • Nighttime awakenings: > 1x/week
• DDX:
  • – Asthma
    
  • – GERD
    
  • – Bronchitis
    
  • – Pneumonitis
    
  • – Foreign body
• Work-up:
  • – CBC with diff
    
  • – Chest X-ray (CXR)
    
  • – Peak Flow measurement
    
  • – PFT’s
    
  • – Methacholine Challenge Test
• Treatment:
  • Self Care – Quitting smoking
  • Supportive Care – Oxygen therapy
  • Medication
    1. SABA (albuterol)
    2. Low dose ICS
    3. Low dose ICS + LABA (salmeterol) or Medium dose ICS
    4. Medium dose ICS + LABA
    5. High dose ICS + LABA
    6. High dose ICS + LABA + Oral corticosteroids

Osmosis / CC BY-SA

NIAID / CC BY

Exercise-Induced Asthma

• Presentation:
  • – During normal breathing via nose → warms and moistens air
  • – When exercise breathe via mouth → inhale colder and drier air
  • – Exercise-induced asthma, muscle bands around airways sensitive to these changes in temperature and humidity → contract → airway narrows
  • – Sx begin 5 – 20 min after exercise started and stop 5 – 10 min after exercise stopped → Sx =
  • – Coughing with asthma
  • – Tightening of the chest
  • – Wheezing
  • – Unusual fatigue while exercising
  • – SOB when exercising
• Treatment:
  • Medication – albuterol inhaler

Bronchiectasis

• Presentation:
  • – Localized, irreversible dilatation of part of bronchial tree
  • – Involved bronchi are dilated, inflamed, and easily collapsible, resulting in airflow obstruction and impaired clearance of secretions
  • – Associated with a wide range of disorders, usually from necrotizing bacterial infections, i,e, Staph, Klebsiella sp., or Bordetella pertussis

National Heart Lung and Blood Institute / Public domain

Congestive Heart Failure (CHF)

• Presentation:
  • – cough that is exacerbated by lying down at night and improved by propping up on three pillows. reports exertional dyspnea.
  • – Heart’s function as a pump to deliver oxygen rich blood to the body is inadequate to meet the body’s needs.
  • – Congestive heart failure can be caused by diseases that:
    1) Weaken the heart muscle
    2 Cause stiffening of the hear muscles
    3) ↑ Oxygen demand by body tissue beyond heart’s capability to deliver.
  • – History: Dyspnea on exertion, pedal edema, orthopnea, hx of HTN, smoking, coronary disease
  • – Physical: Rales in lungs, gallop heart rhythm, distended neck vein, distended liver
• DDX: 
  • – Congestive Heart Failure (CHF)
    
  • – Cardiac valvular disease
    
  • – GERD
    
  • – Pulmonary fibrosis
    
  • – COPD
    
  • – Postnasal drip
• Work-up:
  • – CBC with diff
    
  • – Chest X-ray (CXR)
    
  • – ECG
    
  • – Echocardiography
    
  • – PFTs
    
  • – BNP

Mikael Häggström / CC0

COPD-chronic bronchitis

COPD exacerbation (bronchitis)

• Presentation:
  • increased dyspnea and sputum production over the past 3 days. has COPD and stopped using his inhalers last week. also stopped smoking two days ago.
• DDX:
  • – COPD exacerbation (bronchitis)
    
  • – Lung cancer/neoplasm
    
  • – Pneumonia
    
  • – Upper Respiratory Infection (URI)
    
  • – CHF
• Work-up:
  • – CBC with diff
    
  • – Chest X-ray (CXR)
    
  • – PFT’s
    
  • – Sputum Gram stain and culture
    
  • – CT—chest

Lung Abscess

• Presentation:
  • – D/t anaerobic bacteria
    
  • – Usually associated with gradual onset of fatigue, fever, night sweats, cough producing a foul-smelling expectoration, and weight loss
    
  • – Evolves over weeks to months

Lung abscess on Chest Xray
James Heilman, MD / CC BY-SA

Lung abscess on Chest CT
Yale Rosen from USA / CC BY-SA

Lung cancer/neoplasm

• Presentation: 
  • worsening cough over the past 6 months together with hemoptysis, dyspnea, weakness, and weight loss. a heavy smoker.
  • History: Hx of smoking, Cough, Chest pain, shortness of breath, hemoptysis
    
• Physical exam:
  • Weight loss, wheezing
• DDX: 
  • – Lung cancer/neoplasm
    
  • – Tuberculosis
    
  • – Lung abscess
    
  • – COPD
    
  • – Vasculitis (i.e., Wegener’s)
    
  • – Interstitial lung disease
    
  • – CHF
• Work-up:
  • – CBC with diff
    
  • – Sputum Gram stain and culture
    
  • – Chest X-ray (CXR)
    
  • – CT—chest
    
  • – PPD
    
  • – Bronchoscopy

Lung Cancer on Chest Xray
James Heilman, MD / CC BY-SA
Chest CT small cell lung carcinoma
Healthengine / CC BY-SA

Pleurodynia 

• Presentation:
  • – Uncommon acute illness usually caused by one of the coxsackieviruses
    
  • – Occurs in summer and early fall and presents with acute severe paroxysmal pain of thorax or abdomen that worsens with cough or breathing
    
  • – Most patients recover within 3 days to 1 week

Pneumonia

Atypical pneumonia

• Presentation:
  • – two weeks of a nonproductive cough. Three weeks ago had a sore throat and a runny nose.
  • – Anyone at any age can get walking pneumonia.
  • – Caused by Mycoplasma pneumoniae, Chlamydia pneumoniae, Legionella species
  • – M. pneumoniae is a common cause of mild pneumonia that usually affects people younger than 40
  • – People who live and work in crowded places, i.e. schools, homeless shelters, prisons →↑ risk contracting it
  • – Spread via resp. droplets → sx appear 15 – 25d after exposure to mycoplasma and develop slowly over 2 – 4 days
  • – Symptoms include:
    • – Non-Productive Cough → may come in violent spasms but produce very little mucus
    • – Fever, Malaise Headache, Myalgia → Mild flu-like symptoms such as fever and chills
    • – Sore throat/Hoarseness
    • – Headache
    • – Tiredness
    • – Chest pain
    • – Lingering weakness may persist after other sx gone
    • – Sputum may be blood-streaked
    • – GI sx prominent in Legionella infection
    • – Severe ear pain d/t bullous myringitis may complicate up to 5% of Mycoplasma infections
• DDX:
  • – Atypical pneumonia
    
  • – Reactive airway disease
    
  • – URI-associated (“postinfectious”)
    
  • – Postnasal drip
    
  • – GERD
• Work-up:
  • – CBC with diff
    
  • – Induced Sputum Gram stain and culture
    
  • – IgM detection for Mycoplasma pneumoniae
    
  • – Urine Legionella antigen

Tuberculosis

• Presentation:
  • worsening cough of 6 weeks’ duration together with weight loss, fatigue, night sweats, and fever. a history of contact with tuberculosis patients at work.
  • shortness of breath and cough. had unprotected sex with multiple sexual partners and was recently exposed to a patient with active tuberculosis.
• DDX:
  • – Tuberculosis
  • – Pneumonia (including Pneumocystis jiroveci)
  • – Lung abscess
  • – Vasculitis
  • – Lymphoma
  • – Metastatic cancer
  • – HIV/AIDS, Acute HIV infection
  • – Sarcoidosis
    
• Work-up:
  • – CBC with diff
  • – PPD
  • – Sputum Grain Stain, Acid-fast stain, and Culture
  • – Chest X-ray (CXR)
  • – CT—chest
  • – Bronchoscopy (Bronchoalveolar lavage (BAL))
  • – HIV antibody

URI-Associated Cough

• Presentation:
  • – Acute cough frequently follows URI (“postinfectious”) and can commonly persist for 1-2 weeks (or up to 6-8 weeks in patients with underlying asthma)
    
  • – Causes range form rhinosinusitis to acute bronchitis