Cough/shortness of breath

Question 1

Key history in cough/shortness of breath

Answer 1

Acute/subacute vs. chronic
Progression
Timing
Presence and description of sputum
Hemoptysis
Other symptoms (constitutional, URI, dyspnea, wheezing, chest pain, heartburn)
Exacerbating and alleviating factors
Exposures
Smoking history
History of lung disease, heart failure
Medications (e.g. ACEis)

Question 2

Key physical exam in cough/shortness of breath

Answer 2

Vitals with pulse oximetry
HEENT exam
Heart, lungs, lymph nodes
Extremities (clubbing, cyanosis, edema)

Question 3

30 yo M with SOB, cough, wheezing worse in cold air

+ several such episodes over last four months

Answer 3

Asthma
GERD
Bronchitis

CBC, CXR, peak flow measurement, PFTs, methacholine challenge

Question 4

56 yo F with SOB, productive cough lasting at least three months each year over the last two years
+ heavy smoker

Answer 4

COPD - chronic bronchitis
Bronchiectasis
Lung cancer

Sputum Gram stain and culture, PFTs, CBC, CXR, CT - chest

Question 5

58 yo M with one week of pleuritic chest pain, fever, chills, cough with purulent yellow sputum
+ heavy smoker with COPD

Answer 5

Pneumonia
COPD exacerbation (bronchitis)
Lung abscess

CBC, CXR, Sputum Gram stain and culture, CT - chest, PPD, ECG

Question 6

25 yo F with two weeks of nonproductive cough

+ sore throat and runny nose three weeks ago

Answer 6

Atypical pneumonia
Reactive airway disease
URI-associated cough (“post-infectious”)
Postnasal drip

CBC, induced sputum Gram stain and culture, CXR, IgM detection for Mycoplasma pneumoniae, urine Legionella antigen

Question 7

65 yo M with worsening cough over past six months
\+ hemoptysis
\+ dyspnea
\+ weakness
\+ weight loss
\+ heavy smoker

Answer 7

Lung cancer
Tuberculosis
COPD

CBC, CXR, CT - chest, PPD, PFTs, sputum Gram stain, culture and cytology, bronchoscopy, echocardiography

Question 8

55 yo M with increased dyspnea and sputum production over last 3 days
+ COPD and stopped using inhalers last week
+ stopped smoking two days ago

Answer 8

COPD exacerbation (bronchitis)
Lung cancer
Pneumonia
URI

CBC, CXR, ABG, PFTs, sputum Gram stain and culture, CT - chest, echocardiography

Question 9

34 yo F with worsening cough over last six weeks
+ weight loss, night sweats and fever
+ Hx of contact with tuberculosis patients at work

Answer 9

Tuberculosis
Pneumonia
Lung abscess
Lymphoma

CBC, PPD/QuantiFERON Gold, sputum Gram stain, acid-fast stain and culture, CXR, CT - chest, bronchoscopy, HIV antibody, lymph node biopsy

Question 10

35 yo M with SOB and cough
+ unprotected sex with multiple partners
+ recently exposed to patient with active tuberculosis

Answer 10

Tuberculosis
Pneumonia (including Pneumocystis jiroveci)
Bronchitis
Acute retroviral syndrome
Asthma

CBC, PPD/QuantiFERON Gold, sputum Gram stain, acid-fast stain, silver stain and culture, CXR, CT - chest, HIV antibody, echocardiography

Question 11

50 yo M with cough exacerbated by lying down at night
+ improved by propping head up on three pillows
+ exertional dyspnea

Answer 11

Congestive heart failure
Cardiac valvular disease
GERD
COPD
Postnasal drip

CBC, CXR, echocardiography, ECG, PFTs, BNP, CT - chest

Question 12

60 yo M with worsening dyspnea over last six hours and cough with pink, frothy sputum

Answer 12

Pulmonary edema
Congestive heart failure
Mitral valve stenosis
Arrhythmia

ECG, CXR, CBC, ABG, BNP, PFTs