H&P -- Pulmonology I

chest pain, SOB, cough, wheezing, hemoptysis

what are some common/concerning symptoms to consider when taking a thorax/lungs history

life-threatening

all chest pain is _________ until proven otherwise

acute myocardial infarction (MI), unstable angina, thoracic aortic dissection

life threatening CV causes of chest pain

tension pneumothorax, pulmonary embolus (PE)

life threatening pulmonary causes of chest pain

esophageal rupture (Boerhaave syndrome)

life threatening GI causes of chest pain

stable angina/pericarditis

non-life threatening CV causes of chest pain

bronchitis, pneumonia, simple pneumothorax, lung cancer

non-life threatening pulmonary causes of chest pain

esophageal spasm, esophagitis, GERD, gastritis, PUD, biliary disease, pancreatitis

non-life threatening GI causes of chest pain

Herpes zoster

non-life threatening derm causes of chest pain

costochondritis/muscle strain/contusion

non-life threatening musculoskeletal causes of chest pain

anxiety and panic attacks

non-life threatening psychiatric causes of chest pain

sudden onset, exertional/relieved with rest, new onset > 55 years of age, associated symptoms (unintentional weight loss, extremity swelling, severe dyspnea, hemoptysis, syncope, associated neurologic symptoms), immobility, hyper coagulability

chest pain red flags

fevers, chills, night sweats, unintentional weight loss, diaphoresis

general associated symptoms with chest pain

painful rash

skin associated symptoms with chest pain

URI symptoms (cough, congestion, runny nose, sore throat)

HEENT associated symptoms with chest pain

palpitations, syncope/lightheadedness

Heart associated symptoms with chest pain

extremity pain, swelling, or redness; symmetric asymmetric

PV associated symptoms with chest pain

SOB, cough, sputum production, hemoptysis

lungs associated symptoms with chest pain

abdominal pain, N/V/D, bloody stools, dysphagia, odynophagia

abdominal associated symptoms with chest pain

changes in vision/speech, focal weakness, focal decreased sensation, changes in coordination/gait

neurologic associated symptoms with chest pain

thoracic aortic dissection

if one is having chest pain and neurological symptoms, what should be on your differential?

ACS- hypertension, diabetes mellitus, dyslipidemia

Thoracic dissection- hypertension

PE- DVT, cancer, other hypercoagulable states

Pericarditis- recent MI, chest irradiation, autoimmune disease

chest pain PMH

ACS- CABG or angioplasty

PE- recent surgery (2-3 months); inferior vena cava (IVC) filter

chest pain PSH

Tobacco abuse: ACS, lung cancer

Illicit drugs: (cocaine abuse- ACS; especially in younger patients)

Alcohol abuse: esophageal rupture, GERD, gastritis, pancreatitis

chest pain SH

heart disease

thoracic dissection

clotting disorders

cancer

chest pain FH

distressed, diaphoretic, anxious

general appearance of those with CP

palpitations, lightheadedness, SOB, N/V; HTN, DM, HLD; FH; tobacco, cocaine

ACS signs, symptoms, and risk factors

tearing, interscapular, neuro symptoms, underlying HTN

symptoms/risk factors for aortic dissection

improved leaning forward, pleuritic, preceding viral illness, recent MI

signs, symptoms, and risk factors for pericarditis

prior similar but less severe; syncope; SOB

signs/symptoms/risk factors for tension pneumothorax

pleuritic CP; SOB; leg swelling; Virchow's triad (cancer/OCP use/recent surgery/immobility/pregnant/postpartum)

symptoms of pulmonary embolism

URI symptoms, illness exposure

signs/symptoms/risk factors for bronchitis

fever, productive cough, illness exposure

signs/symptoms/risk factors for pneumonia

unintentional weight loss, night sweats, tobacco abuse

signs/symptoms/risk factors for lung cancer

abdominal pain, dysphagia, odynophagia, N/V, alcohol abuse

signs/symptoms/risk factors for GI causes of CP

painful dermatomal rash

signs of herpes-zoster

recent trauma/overexertion; bony tenderness (worse with movement/palpation)

risk factors/signs of a musculoskeletal cause of CP

recent violent emesis, excess alcohol/food intake; severe distress

risk factors/signs of esophageal rupture

pleuritic CP, short of breath

symptoms of simple pneumothorax

upper abdominal pain

what is an example of an atypical presentation of CP?

lower lobe pneumonia, inferior wall MI, thoracic aortic dissection

what are some conditions that have an atypical presentation of CP?

Shortness of breath

uncomfortable awareness of breathing inappropriate for the level of exertion

based on its affect on the patient's lifestyle and their ability to complete their activities of daily living

how do you determine the severity of SOB?

Tachypnea

rapid respirations, over 20 breaths per minute

Bradypnea

slow respiratory rate, usually below 10 respirations per minute

Hyperpnea

increase in depth and rate of breathing

Hypopnea

shallow breathing

Dyspnea on exertion (DOE)

shortness of breath with activity

conversational dyspnea

inability to speak complete sentences without stopping to breathe

orthopnea

inability to lie flat in bed secondary to dyspnea

paroxysmal nocturnal dyspnea

suddenly awaken with the ned to sit up on the edge of the bed due to dyspnea

Cardiac causes- congestive heart failure, pericardial effusion, pericardial tamponade - Pulmonary causes- pneumonia & other respiratory infections; pneumothorax, pleural effusion; asthma or chronic obstructive pulmonary disease (COPD) exacerbation; pulmonary embolus

Metabolic- diabetic ketoacidosis (DKA), salicylate toxicity

Anemia

Anxiety with hyperventilation (diagnosis of exclusion

differential diagnosis for SOB

peripheral edema, increased nocturia, orthopnea, PND

CHF associated symptoms

decreased chest pain when sitting up, fevers, underlying cancer, prior chest irradiation, recent cardiac surgery

pericardial effusion associated symptoms

preceding URI symptoms, cough, sputum production, fever, malaise, pleuritic chest pain, illness exposure, immunosuppressed

pneumonia associated symptoms

sudden onset, prior episodes, pleuritic chest pain, syncopal or near syncopal if tension pneumothorax, underlying COPD

pneumothorax associated symptoms

undelying causes --- infection, cancer, pulmonary embolus, CHF, cirrhosis, nephrotic syndrome (associated symptoms of these conditions)

pleural effusion associated symptoms

cough, sputum production, chest tightness, self-reported wheezing, tobacco abuse

COPD associated symptoms

viral illness or allergen exposure, cough, congestion, chest tightness, self-reported wheezing; FH asthma, eczema, or allergies

asthma associated symptoms

pleuritic chest pain, leg swelling, Virchow's triad (risk factors for blood clots): underlying cancer & recent surgery

pulmonary embolus associated symptoms

polyuria, polydipsia, polyphagia, weight loss, vomiting, diffuse abdominal pain, confusion

DKA associated symptoms

generalized weakness, malaise, black (melena) or bloody (hematochezia) stools

anemia associated symptoms

palpitations, trembling, choking sensation, feeling of detachment from body, generalized tingling, hot flashes

anxiety associated symptoms

Acute inflammatory respiratory disorders

Chronic inflammatory respiratory disorders

Cancer

Cardiovascular disorders

Miscellaneous causes

cough ddx

Upper respiratory infection (URI) Sinusitis

Acute bronchitis

Acute bronchiolitis

Influenza

COVID-19

Viral & bacterial pneumonia

Asthma

acute infectious/inflammatory respiratory processes

Sinusitis

Lung abscess

Tuberculosis (TB)

Asthma

Chronic bronchitis (COPD)

Bronchiectasis

Postnasal drip

Allergies

chronic inflammatory respiratory processes

Congestive heart failure

Pulmonary emboli

what are some cardiovascular/pulmonary causes of cough?

Irritant exposure

GERD

Medication-related

Foreign body aspiration

what are some misc causes of cough?

URI, croup, pertussis, acute bronchitis, bronchiolitis, influenza, COVID, pneumonia, CHF, asthma, foreign body

what conditions are characterized by acute (hours to days) onset of cough?

sinusitis, bronchitis, asthma

what conditions are characterized by subacute (weeks) onset of cough?

asthma, chronic bronchitis, lung cancer, postnasal drip, allergies, GERD

what conditions are characterized by chronic (months) onset of cough

is it productive?

what is the color/consistency of sputum?hemoptysis?

how can one ask about quality of cough?

Wheezing

continuous muscical sound produced by oscillation of opposing walls of a narrowed airway; may be expiratory or both expiratory and inspiratory

distal

wheezing originates from more _____ airways

respiratory tract infections, asthma, COPD, & foreign bodies

what are some causes of wheezing?

Stridor

inspiratory high-pitched sound; indicates obstruction at the trachea or above

obstruction at the trachea or above

what does stridor indicate?

Infections (croup, epiglottitis)

Anaphylaxis (severe systemic allergic reaction)

Vocal cord edema or paralysis

Anatomic- vascular rings, tonsillar hypertrophy (primarily in children), laryngeal stenosis, tracheal tumors, goiter

what are some potential causes of stridor?

Sudden onset cough, dyspnea; (generally asymptomatic between exacerbations)

Preceding URI or allergen exposure

Symptoms more early am & at night

what do acute asthma exacerbations look like?

Recurrent "bronchitis" or "pneumonia" in infants increases the risk of underlying asthma

FH of asthma, allergies, or eczema increases the risk of underlying asthma

one should suspect newly-diagnosed asthma in a pt with...

dyspnea, cough, sputum production, chest tightness -- ALMOST ALWAYS IN THE SETTING OF TOBACCO ABUSE

what are symptoms of chronic COPD?

CHF- AKA "cardiac asthma"

bronchitis, bronchiolitis, pneumonia

bronchiectasis

tumors (focal wheezing)

foreign bodies (focal wheezing)

what are some conditions other than asthma and COPD that cause wheezing?

Hemoptysis

coughing up blood; ranges from blood-streaked sputum to gross blood with clots

Cardiac - CHF

pulmonary - bronchitis (#1), pneumonia, lung abscess, PE, lung cancer

MISC - coagulopathy, iatrogenic

ddx for hemoptysis

> 600 mL of blood in 24 hours

what constitutes massive hemoptysis?

lung cancer, TB, bronchiectasis

consider nasal, oropharyngeal, and GI sources

what are some causes of massive hemoptysis?

always ask about tobacco use

advise to quit

assess willingness to quit

assist in efforts

arrange follow-up

how to discuss smoking cessation with a patient

vaccination

what is the only effective way to prevent influenza?

pneumonia, sepsis, meningitis

what conditions are caused by strep pneumoniae?

vaccination

infections by strep pneumoniae can be prevented via...

smoking cessation

influenza vaccination

pneumococcal vaccination

what are the 3 major components of health promotion when considering pulmonary issues?