Minicase - Cough/SOB

Question 1

Cough/SOB Hx components

Answer 1

OPQRST

• acute v chronic
• worsening
• sputum
• blood
• associated symptoms (post-nasal drip, heartburn, chest pain, etc)
• environmental factors, allergies
• previous episodes
• hx lung disease, HF
• posttussive emesis
• medications

Question 2

Cough SOB exam (7)

Answer 2

1. pulse ox
2. nasal mucosa
3. oropharynx
4. heart
5. lungs
6. lymph nodes
7. extremities (clubbing, cyanosis, edema)

Question 3

Main ddx for Cough/SOB (9)

Answer 3

1. asthma
2. COPD- chronic bronchitis
3. PNA
4. atypical PNA
5. lung cancer
6. COPD exacerbation (bronchitis)
7. TB
8. CHF
9. Pulmonary edema
   (Other: GERD, postnasal drip, URI, GPA)

Question 4

W/u for asthma (4) - SOB, cough, wheezing that worsen with cold air, multiple past episodes

Answer 4

1. CBC
2. CXR
3. Peak flow measurements
4. PFTs

Question 5

W/u for COPD (chronic bronchitis) (6) - SOB and productive cough that lasted for at least 3mo each year over past 2 years, hx of smoking

Answer 5

1. CBC
2. Sputum gram stain/culture
3. CXR
4. PFTs
5. CT chest
6. quantiferon TB-gold

Question 6

W/u for PNA (6) - 1 wk pleuritic CP, fever, hills, cough with purulent yellow sputum, hx of smoking and COPD

Answer 6

1. CBC
2. sputum gram stain and culture
3. CXR
4. CT chest
5. EKG
6. quantiferon TB-gold

Question 7

W/u for atypical PNA (5) - young pt w/ 2 wks nonproductive cough and prior hx of URI

Answer 7

1. CBC
2. induced sputum gram stain and culture
3. CXR
4. IgM detection for mycoplasma penumoniae
5. Urine Legionella Ag

Question 8

W/u for lung cancer (9) - 6 months worsening cough, hemoptysis, dyspnea, weakness and wt loss with smoking hx

Answer 8

1. CBC
2. sputum gram stain, culture, and cytology
3. CXR
4. CT chet
5. quantiferon-TB gold
6. ANCA (GPA)
7. bronchoscopy
8. ECHO (CHF)

Question 9

W/u for COPD exacerbation (7) - increased dyspnea and sputum production for past 3 days after stopping inhalers last week w/ hx of COPD

Answer 9

1. CBC
2. CXR (PNA, lung cancer, URI rule-out)
3. ABG
4. PFTs
5. sputum gram stain and culture
6. CT chest
7. ECHO (CHF)
   (8. respiratory viral panel PCR)

Question 10

W/u for TB (8) - cough, wt loss, fatigue, night sweats, fever, exposure history

Answer 10

1. CBC
2. PPD/Quantiferon-TB Gold
3. Sputum Grain stain, acid fast stain and culture
   4, CXR (PNA, lung abscess)
4. CT chest
5. bronchoscopy
6. HIV antibody
7. Lymph node biopsy (sarcoidosis, metastatic cancer, lymphoma)

Question 11

W/u for CHF (7) - cough exacerbated by lying down at night and improved by sitting up, exertional dyspnea

Answer 11

1. CBC
2. CXR (CHF, COPD)
3. EKG
4. ECHO (CHF, cardiac valvular disease)
5. PFTs
6. BNP
7. CT chest
   (ddx includes GERD - PPI trial, postnasal drip)

Question 12

W/u for pulmonary edema (6) - worsening dyspnea of 6 hours duration and a cough that is accompanied by pink, frothy sputum

Answer 12

1. CXR (PNA_
2. EKG (CHF, arrythmia)
3. CBC (PNA)
4. ABG
5. PFTs
6. BNP (CHF)