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49 Cards in this Set

  • Front
  • Back
My father had pancreatic cancer. Could I have it too?”
It’s highly unlikely; your symptoms are very unusual for pancreatic cancer. Regardless, some routine blood
and x-ray tests should help us exclude that as a possibility.”
Exam components for old person abdominal pain
CV exam Auscultation
Pulmonary exam Auscultation
Abdominal exam Inspection, auscultation, palpation (including Murphy’s sign),
percussion
Closure:
old person abdominal pain
Mr. Smith, there are a number of disorders that can cause pain similar to what you have described. Pain of this type is most commonly due to an ulcer, abdominal infection, or a gallstone. We will have to run some tests to confirm the diagnosis and to rule out more serious illness. These test will include rectal exam, U/S examination of the abdomen, blood tests, and possible upper endoscopy which involves examining your stomach by means of an optical instrument passed through your mouth. Once we have the dx, we will be able to treat your condition and help alleviate the pain. Do you have any questions for me?
DDx
Old person abdominal pain
• Peptic ulcer disease:
• Cholecystitis:
• Gastritis:
• Functional or nonulcer dyspepsia:
• Perforated ulcer:
• Gastric cancer
• Other etiologies: Less likely possibilities include pancreatitis, atypical GERD, choledocholithiasis, mesenteric ischemia,
and extra-abdominal causes.
Diagnostic workup
Old person abdominal pain
• Rectal exam, stool for occult blood
• AST/ALT/bilirubin/alkaline phosphatase, lipase:
• U/S—abdomen:
• Upper endoscopy:
• HIDA (hepatobiliary) scan:
• Noninvasive H. pylori testing:
• “My child is in the house alone. I must leave now.”
• “I can’t afford to stay in the hospital. Please give me a prescription for antibiotics so that I can leave.”
“First we have to make sure that your illness isn’t life-threatening. Our social worker can help us make sure
that your child is safe.”
Exam components for young person abdominal pain
□ CV exam Auscultation
□ Pulmonary exam Auscultation
□ Abdominal exam Inspection, auscultation, palpation, percussion, psoas sign,
obturator sign, Rovsing’s sign, CVA tenderness
DDX
young person abdominal pain
• PID:
• Appendicitis
• Ruptured ectopic pregnancy:
• Ruptured ovarian cyst:
• Adnexal torsion:
• Gastroenteritis:
• Abortion:
• Endometriosis:
Diagnostic workup
young person abdominal pain
Rectal exam:
• Pelvic exam:
• Urine hCG: Positive in pregnancy.
• Cervical cultures:
• UA: To rule out UTI.
• CBC:
• U/S—abdomen/pelvis:
• CT—abdomen/pelvis:
• Laparoscopy:.
Closure:
Young person abdominal pain
Ms. Anderson your symptoms may be due to a problem w/ your reproductive organs, such as an infection in your fallopian tubes or a cyst on your ovaries. This might also result from a complicated pregnancy, as may be indicated if your pregnancy test comes back positive. Another possibility might be an infection in your appendix, which could require surgery. In order to ensure an accurate diagnosis, we will need to run some tests including a blood test, urinalysis, pregnancy test, and possibly CT scan of your abdomen and pelvis. I will also need to perform a rectal and pelvic exam. Do you have any questions for me?
smoking patient
Since cigarette smoking is associated with a variety of diseases, I would advise you to quit smoking; we have many ways to help if you are interested
sexually active patient
I would also recommend that you use a condom every time yo have intercourse in order to prevent STDs, including HIV, and to avoid pregnancy
Social issues
We can have you meet with our social worker to discuss your social situation, and she can offer you a variety of resources.
Physical exam Note for Abdomen
VS: WNL except for temperature of 100.5°F.
Chest: No tenderness, clear breath sounds bilaterally.
Heart: RRR; normal S1/S2; no murmurs, rubs, or gallops.
Abdomen: Soft, nondistended, BS, no hepatosplenomegaly. Direct and rebound RLQ tenderness, RLQ guarding,
psoas sign, Rovsing’s sign, obturator sign, no CVA tenderness.
“Doctor, do you think I will be able to move my arm again like before?”
“I hope so, but first we need to confirm whether it’s broken or dislocated and whether there is any nerve or muscle damage.”
Exam components:
Pain in arms
neck exam Checked for bruises, neck movements
□ CV exam Auscultation
□ Pulmonary exam Auscultation
□ Exam of the arms Compared both arms in terms of strength, range of motion (shoulder, elbow, wrist), sensation, DTRs, pulses
DDX
Pain in arms
• Humeral fracture:
• Osteoporosis:
• Shoulder dislocation:
• Elder abuse:.
• Rotator cuff tear:
Workup
Pain in arms
XR—right shoulder and arm: AP and lateral views that include the joints above and below the injury can show frac- ture or dislocation. An axillary view is useful to help diagnose proximal humeral fracture or dislocation.
• MRI—shoulder: Required to diagnose rotator cuff tears, labral disease, and other disorders.
• Bone density scan (DEXA): To diagnose and quantify osteoporosis.
PE note:
Pain in arm
VS: WNL.
HEENT: Normocephalic, atraumatic, no bruises.
Neck: Supple, full range of motion in all directions, no bruises.
Chest: Clear breath sounds bilaterally.
Heart: RRR; normal S1/S2; no murmurs, rubs, or gallops.
Extremities: Tenderness over the middle and upper right arm and the right shoulder; pain and restricted range of motion on flexion, extension, abduction, and external rotation of the right shoulder. Right elbow and wrist are normal. Pulses normal and symmetric in brachial and radial arteries. Unable to assess muscle strength due to pain. DTRs intact and symmetric. Sensation intact to pinprick and soft touch.
Closure:
Pain in arm
Mr. Green you may have a fractured bone, a simple sprain, or a dislocation of the shoulder joint. We will need to obtain an x-ray of your shoulder in order to help us make a dx. Your safety is my primary concern and I am here to offer you help and support whenever you need it. Sometimes living with a family can be stressful for the whole household. Have you ever considered moving to an assisted-living community or to an apartment complex for seniors? If you are interested, I can arrange a meeting with our social worker, who can assess your situation and help you find the resources you need. Do you have any questions for me?
“Do you think I have AIDS?”
“That’s a difficult question; first I need to find out why you are so concerned about AIDS. Have you been ex- posed to HIV infection?”
Exam component:
Sore throat
Examined nose, mouth, throat, lymph nodes; checked for sinus tenderness
□ CV exam Auscultation
□ Pulmonary exam Auscultation
□ Abdominal exam Auscultation, palpation, percussion
DDx
sore throat
• Infectious mononucleosis:
• Group A streptococcal pharyngitis:
• Other common etiologies: Include viruses (including acute HIV infection, which is often associated with a gener- alized maculopapular rash), Neisseria gonorrhoeae, Mycoplasma (although lower respiratory symptoms usually predominate), rubella, and Chlamydia trachomatis.
Workup
sore throat
• CBC:
• Peripheral smear:
• Monospot (heterophil agglutination test):
• Rapid streptococcal antigen:
• Throat culture:
• Anti-EBV antibodies:
• HIV antibody and viral load:
“My father had colon cancer. Could I have it too?”
“It is a possibility. Tell me more about the symptoms you’re having that concern you with regard to cancer.”
PE component blood in stool
□ CV exam Auscultation
□ Pulmonary exam Auscultation
□ Abdominal exam Auscultation, palpation, percussion
DDX
blood in stool
Bright red blood that is mixed with brown stool suggests a distal colonic or anorectal source. Otherwise, this patient’s
presentation is complex, and the differential remains broad. His chronic constipation may simply be due to a
low-fiber diet or to irritable bowel syndrome, but neither of these entities explains hematochezia and weight loss.
• Colorectal cancer: A positive family history coupled with the presence of blood in the stool, a change in bowel
habits, and weight loss makes colorectal cancer a plausible diagnosis. Screening colonoscopy should have been
offered to the patient at age 45 (10 years prior to the age when a first-degree family member was diagnosed).
• Hemorrhoids: Recurrent hemorrhoids may explain the patient’s hematochezia, although more typical findings in
hemorrhoids are fresh blood on the paper or dripped into the toilet bowl.
• Diverticulosis: This is the most common cause of major lower GI bleeding, but it usually presents with largervolume
bleeds occurring in discrete, self-limited episodes.
• Angiodysplasia: This is another common cause of lower GI tract bleeding, but as with diverticular disease, it cannot
explain the other features of this patient’s presentation.
• Pseudomembranous (C. difficile) colitis: It is important to ask all patients with acute diarrhea about recent antibiotic
exposure, as symptoms of antibiotic-associated colitis may be delayed for up to 6–8 weeks. Stools rarely contain
gross blood, however. The absence of fever and lower abdominal cramping also makes this diagnosis (and
other infectious colitis) less likely.
• Ulcerative colitis: The absence of abdominal pain and the very recent onset of diarrhea and tenesmus make inflammatory
bowel disease a less likely etiology for this patient’s month-long hematochezia.
Diagnostic workup
Blood in stool
• Rectal exam, stool for occult blood: Useful to detect masses and hemorrhoids. Always test for occult blood in stool.
• Stool for C. difficile toxin: Recall that one negative test does not exclude the diagnosis, as the assays are positive in
only 80% of patients on the first stool sample and in 90% after two stool samples.
• Fecal leukocytes: Usually present in invasive bacterial infection and in inflammatory bowel disease. Variably present
in C. difficile colitis.
• CBC: To investigate anemia. Also, leukocytosis could suggest infection or inflammatory bowel disease.
• Anoscopy: Can identify bleeding internal hemorrhoids, rectal ulcers, and traumatic lesions.
• Flexible proctosigmoidoscopy: If nondiagnostic, follow up with a barium enema or a colonoscopy.
• Colonoscopy: Should be the initial test performed in patients > 40 years of age presenting with hematochezia.
• Double-contrast (air contrast) barium enema: Not as accurate as colonoscopy for the diagnosis of polyps and cancer
(and cannot diagnose angiodysplasia). Used mainly when colonoscopy is unavailable or contraindicated.
• CT—abdomen/pelvis: Contrast-enhanced exams can detect diverticulosis or masses but generally are not useful in
the evaluation of GI bleeding.
“Is this a heart attack? Am I going to die?”
“As you suspect, your symptoms are of considerable concern. We need to learn more about what’s going on to
know if your pain is life-threatening.”
PE components
Chest pain
□ Neck exam Looked for JVD, carotid auscultation
□ CV exam Inspection, palpation, auscultation
□ Pulmonary exam Auscultation, palpation, percussion
□ Abdominal exam Auscultation, palpation, percussion
□ Extremities Checked peripheral pulses, checked blood pressure in both
arms, looked for edema
PE note
Chest pain
Patient is in severe pain.
VS: BP 165/85 (both arms), RR 22.
Neck: No JVD, no bruits.
Chest: No tenderness, clear symmetric breath sounds bilaterally.
Heart: Apical impulse not displaced; RRR; normal S1/S2; no murmurs, rubs, or gallops.
Abdomen: Soft, nondistended, nontender, BS, no hepatosplenomegaly.
Extremities: No edema, peripheral pulses 2+ and symmetric.
DDX
chest pain
Myocardial ischemia or infarction: The patient has multiple cardiac risk factors (including smoking, hypertension,
and hyperlipidemia), and his symptoms are classic for cardiac ischemia.
• Cocaine-induced: Cocaine can predispose to premature atherosclerosis or can induce myocardial ischemia and
infarction by causing coronary artery vasoconstriction or by increasing myocardial energy requirements.
• GERD: Severe chest pain is atypical but not uncommon for GERD and may worsen with recumbency overnight.
Other atypical symptoms may include chronic cough, wheezing, or dysphagia. The classic symptom of GERD
is heartburn, which may be exacerbated by meals.
• Aortic dissection: With the sudden onset of severe chest pain, aortic dissection should be suspected given the
high potential for death if missed (and the potential for harm if mistaken for acute MI and treated with thrombolytic
therapy). However, the patient’s pain is not the classic sudden tearing chest pain that radiates to the
back. In addition, his peripheral pulses and blood pressures are not diminished or unequal, and there is no aortic
regurgitant murmur (although physical exam findings have poor sensitivity and specificity to diagnose aortic
dissection).
• Pericarditis: The absence of pain that changes with position or respiration and the absence of a pericardial friction
rub make pericarditis less likely.
• Pneumothorax: This diagnosis should be entertained in a patient with acute chest pain and difficulty breathing,
but it is less likely in this case given that breath sounds are symmetric.
• Pulmonary embolism: As above, this is on the differential for acute chest pain and difficulty breathing, but this patient
has no apparent risk factors for pulmonary embolism.
• Costochondritis (or other musculoskeletal chest pain): This is more typically associated with pain on palpation or
pleuritic pain.
Diagnostic workup
Chest pain
ECG: Acute myocardial ischemia, infarction, and pericarditis have characteristic changes on ECG.
• Cardiac enzymes (CPK, CPK-MB, troponin): Specific tests for myocardial tissue necrosis that can turn positive as
early as 4–6 hours after onset of pain.
• CXR: A widened mediastinum suggests aortic dissection and can also diagnose other causes of chest pain, including
pneumothorax and pneumonia.
• Transthoracic echocardiogram (TTE): Can demonstrate segmental wall motion abnormalities in suspected acute
MIs (infarction is unlikely in the absence of wall motion abnormalities).
• Cardiac catheterization: Can diagnose and treat coronary artery disease.
• Transesophageal echocardiogram (TEE): Highly specific and sensitive for aortic dissection, and can be done rapidly
at the bedside.
• CT—chest with IV contrast: Another rapidly available diagnostic study that can rule out aortic dissection or pulmonary
embolism.
• Upper endoscopy: Can be used to document tissue damage characteristic of GERD. However, it can be normal
in up to one-half of symptomatic patients; esophageal probe (pH and manometry measurements) together with
endoscopic visualization constitutes an effective diagnostic technique.
• Cholesterol panel: Can identify a critical risk factor for cardiovascular disease.
• “Is my child going to be okay?”
• “Do you think I need to bring my child to the hospital?”
“Well, I will need to examine your child first. Although I suspect that he has a viral infection, I still need to
make sure that he does not have anything else.”
DDX
7 mth child with fever
Viral URI: Possible clues suggesting this diagnosis as the source of fever include rhinorrhea and recent exposure
to a sibling with URI. It is probably viral, self-limited, and benign, but lower respiratory tract infection must first
be ruled out in light of the child’s apparent dyspnea and tachypnea.
• Pneumonia: Fever, rhinorrhea, tachypnea, and dyspnea support this diagnosis, although cough is not present. The
physical exam may find retractions, nasal flaring, grunting, dullness on chest percussion, and rales.
• Meningitis: Findings are often subtle and nonspecific and may be limited to fever, irritability, and poor feeding,
as seen in this case. The physical exam may reveal a bulging fontanelle; meningeal signs may not be obvious in
infants (nuchal rigidity and focal neurologic signs are more commonly seen in older children).
• UTI: Infants with UTI may not have symptoms referable to the urinary tract. Those who do may have dribbling
or colic before and during voiding. Patients with high fever and CVA tenderness are presumed to have
pyelonephritis until proven otherwise.
• Otitis media: Otalgia and ear drainage can suggest this diagnosis in an ill, febrile child but are often not present
(as in this case). The physical exam is key and may reveal a hyperemic, bulging TM; loss of TM landmarks; and
decreased TM mobility.
• Gastroenteritis: This patient has fever but no GI symptoms. Viral infection typically causes vomiting and/or watery
diarrhea, whereas bacterial infection may cause fever, tenesmus, bloody diarrhea, and severe abdominal
pain.
• Occult bacteremia: This is an important consideration for children with high fever (> 102°F/38.9°C) and no obvious
source. There is a relatively high proportion of children with no identifiable fever source who will have a
positive blood culture, which can progress to sepsis if untreated. An extensive workup (see below) is not necessarily
indicated in this case, as fever is < 102°F (38.9°C).
Diagnostic workup
7 mth Child with fever
Pneumatic otoscopy: Key to look for the decreased TM mobility seen in otitis media.
• Tympanometry: Useful in infants > 6 months of age; confirms abnormal TM mobility in otitis media.
• CBC with differential, blood culture, UA and urine culture: Constitutes the “septic” or occult bacteremia workup in
children with unexplained high fever. Notably, a WBC count > 15,000/μL is suggestive of occult bacteremia.
UTI may be occult and must be investigated.
• LP—CSF analysis: Should be performed if there is any concern for meningitis. CSF analysis includes cell count
and differential, glucose, protein, Gram stain, culture, latex agglutination for common bacterial antigens, and
occasionally PCR for specific viruses.
• CT—head: Used mainly to rule out brain abscess or hemorrhage.
• CXR: To diagnose pneumonia.
• Bronchoscopy: A diagnostic aid in severe or refractory pneumonia cases.
• Serum antibody titers: To identify causative viruses in pediatric infections (not commonly used).
• U/S—renal: To look for anatomic anomalies that predispose to UTI.
• Voiding cystourethrogram: To look for vesicoureteral reflux in UTI.
• “Do you think that I did the right thing by coming here and telling you about my child’s fever?”
• “Is my child going to be okay?”
“You absolutely did the right thing. Maria may have an infection that needs antibiotics; we need to examine
her here in the office and then decide whether she needs any more testing or treatment.”
DDX
18 mth child with fever
Otitis media: Fever and otalgia suggest this diagnosis but are present in < 50% of patients. Physical exam is key
and may reveal a hyperemic, bulging TM; loss of TM landmarks; and decreased TM mobility.
• Meningococcal meningitis: Fever, lethargy, and a possible petechial rash are worrisome for meningococcemia. Patients
may also have headache, vomiting, photophobia, neck stiffness, and seizures. This is a severe, rapidly progressive,
and sometimes fatal infection; the patient would appear very ill.
• Scarlet fever: This patient has fever, difficulty swallowing (i.e., possible pharyngitis), and a rash that started on
her face and spread to the trunk. However, the description does not allow one to ascertain whether or not the
rash consists of a diffuse erythema with punctate elevations resembling sandpaper that spares the area around
the mouth. Also, scarlet fever is more common in school-age children.
• Fifth disease or other viral exanthem: In children, viruses commonly present with low-grade fever and rash. In
general, viral exanthems are quite nonspecific in their appearance and are usually maculopapular and diffuse.
Parvovirus B19 infection, or fifth disease, usually presents as intense, red facial flushing (“slapped cheek” appearance)
that then spreads over the trunk and becomes more diffuse. Rubeola classically presents as 2–5 days
of high fever followed by a diffuse rash. However, almost any virus can be accompanied by rash in the pediatric
patient, and it is not always necessary to ascertain which virus is causing the illness. If the illness is prolonged or
particularly troublesome, antibody titers can be ordered to determine the exact etiology of the illness.
• Varicella: Fever and rash, along with day care attendance, could be consistent with this infection. However, in
varicella the lesions are present in various stages of development at any given time (i.e., red macules, vesicles,
pustules, crusting), and the rash is intensely pruritic. The incidence of varicella has declined since vaccination
began in the 1990s.
Diagnostic workup
18 mth child with fever
Pneumatic otoscopy: Key to look for the decreased TM mobility seen in otitis media.
• Tympanometry: Useful in infants > 6 months of age; confirms abnormal TM mobility in otitis media.
• LP—CSF analysis: Should be performed if there is any concern for meningitis. CSF analysis includes cell count
and differential, glucose, protein, Gram stain, culture, latex agglutination for common bacterial antigens, and
occasionally PCR for specific viruses.
• Platelets, PT/PTT, D-dimer, fibrin split products, fibrinogen: Evidence of DIC is often seen in meningococcemia.
• CBC with differential, blood culture, UA and urine culture: To isolate Neisseria meningitidis and to screen for occult
bacteremia or UTI.
• Throat culture: To isolate Streptococcus pyogenes (causes scarlet fever). The rash is pathognomonic for this diagnosis.
• Parvovirus B19 IgM antibody: The best marker of acute or recent infection in suspected fifth disease.
• Skin lesion scrapings: Varicella antigens are identified by PCR or direct immunofluorescence (DFA) of skin lesions.
Also, a Tzanck smear may show multinucleated giant cells in varicella infection.
• Varicella antibody titer: May be useful in uncertain cases (look for a fourfold rise in antibody titer following acute
infection).
Pneumatic otoscopy: Key to look for the decreased TM mobility seen in otitis media.
• Tympanometry: Useful in infants > 6 months of age; confirms abnormal TM mobility in otitis media.
• LP—CSF analysis: Should be performed if there is any concern for meningitis. CSF analysis includes cell count
and differential, glucose, protein, Gram stain, culture, latex agglutination for common bacterial antigens, and
occasionally PCR for specific viruses.
• Platelets, PT/PTT, D-dimer, fibrin split products, fibrinogen: Evidence of DIC is often seen in meningococcemia.
• CBC with differential, blood culture, UA and urine culture: To isolate Neisseria meningitidis and to screen for occult
bacteremia or UTI.
• Throat culture: To isolate Streptococcus pyogenes (causes scarlet fever). The rash is pathognomonic for this diagnosis.
• Parvovirus B19 IgM antibody: The best marker of acute or recent infection in suspected fifth disease.
• Skin lesion scrapings: Varicella antigens are identified by PCR or direct immunofluorescence (DFA) of skin lesions.
Also, a Tzanck smear may show multinucleated giant cells in varicella infection.
• Varicella antibody titer: May be useful in uncertain cases (look for a fourfold rise in antibody titer following acute
infection).
“Maybe. Antibiotics don’t help in bronchitis, but they will help if we find pneumonia.”
PE component for
Cough
□ Head and neck exam Examined mouth, throat, lymph nodes
□ CV exam Auscultation, palpation
□ Pulmonary exam Auscultation, palpation, percussion
□ Extremities Inspection
DDX
cough
• URI-associated cough: 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). URIs range from rhinosinusitis to acute bronchitis.
• Acute bronchitis: Cough can also accompany acute URI.
• Pneumonia: Pleuritic pain may signal lower respiratory tract infection. This diagnosis is often confirmed by characteristic
chest exam findings, which may be difficult to elicit in an otherwise healthy SP. Increased tactile
fremitus suggests airspace consolidation, but there are no bronchial breath sounds or rales to help suggest a focal
pneumonia. Also, the absence of dyspnea argues against this diagnosis.
• Pleurodynia: An uncommon acute illness usually caused by one of the coxsackieviruses. It occurs in summer
and early fall and presents with acute severe paroxysmal pain of the thorax or abdomen that worsens with cough
or breathing. Most patients recover within three days to one week.
• Other etiologies: Other causes of acute cough include aspiration (alcoholics, elderly, and neurologically impaired
are at risk), pulmonary embolism (extremely rare in a young patient with no risk factors), and pulmonary
edema (signs and symptoms of heart failure would be present). Given the patient’s history of STD, he should be
screened for HIV infection. Notably, there is no evidence of immunosuppression on exam (e.g., no thrush), and
in PCP pneumonia cough is usually nonproductive and accompanied by dyspnea.
Diagnostic workup
Cough
• CXR: To help diagnose pneumonia (i.e., to see infiltrates, effusion), although a normal film does not necessarily
rule it out.
• CBC: In acute infection, can reveal leukopenia or leukocytosis.
• Sputum Gram stain and culture: Often low yield (due to contamination by oral flora and often discordant results
between Gram stain and culture in pneumococcal pneumonia), but may help identify a microbiologic diagnosis
in pneumonia.
• Urine Legionella antigen, serum Mycoplasma PCR, cold agglutinin measurement: To help diagnose specific causes of
atypical pneumonia. Usually not useful in the initial evaluation of patients with community-acquired pneumonia.
• Bronchoscopy with bronchoalveolar lavage: An invasive test that is rarely necessary to diagnose communityacquired
pneumonia, but a gold standard that is often used early when PCP infection is suspected.
• Pulse oximetry or ABG: May help determine the need for hospitalization.
• HIV antibody: Should be offered to all patients with risk factors for this infection.
PE note
Cough
Patient is in no acute distress.
VS: WNL.
HEENT: Nose, mouth, and pharynx WNL.
Neck: No JVD, no lymphadenopathy.
Chest: Increase in tactile fremitus and decrease in breath sounds on the right side. No rhonchi, rales, or wheezing.
Heart: Apical impulse not displaced; RRR; normal S1/S2; no murmurs, rubs, or gallops.
Extremities: No cyanosis or edema.
“Will I get better if I stop smoking?”
“Well, we still have to sort out exactly what’s making you sick. Stopping smoking should help your chronic
cough, and over the long term it will significantly decrease your cancer risk.”
PE component
Persistent Cough
□ Head and neck exam Inspected mouth, throat, lymph nodes
□ CV exam Auscultation
□ Pulmonary exam Auscultation, palpation, percussion
□ Abdominal exam Auscultation, palpation
□ Extremities Inspection
PE note
Persistent Cough
Patient is in no acute distress.
VS: WNL.
HEENT: Mouth and pharynx WNL.
Neck: No JVD, no lymphadenopathy.
Chest: Clear breath sounds bilaterally; no rhonchi, rales, or wheezing; tactile fremitus normal.
Heart: Apical impulse not displaced; RRR; normal S1/S2; no murmurs, rubs, or gallops.
Abdomen: Soft, nontender, BS, no hepatosplenomegaly.
Extremities: No clubbing, cyanosis, or edema.
DDX
Persistent Cough
• Pulmonary tuberculosis: Clinical suspicion is high for this given the constitutional symptoms, hemoptysis, and recent
exposure to active TB. The patient should be placed in respiratory isolation immediately.
• Lung cancer: As noted above, constitutional symptoms and hemoptysis in a long-time smoker are worrisome for
cancer.
• Lung abscess: A lung abscess due to anaerobic bacteria is usually associated with a gradual onset of fatigue, fever,
night sweats, cough producing a foul-smelling expectoration, and weight loss. Symptoms evolve over a period of
weeks or months (the time course in this case favors abscess over uncomplicated pneumonia). Other bacterial
causes of lung abscess typically present more acutely.
• Atypical pneumonia: Refers to infection by Mycoplasma pneumoniae, Chlamydia pneumoniae, and Legionella
species. These can all present similarly with an insidious onset of fever, malaise, headache, myalgia, sore throat,
hoarseness, chest pain, and nonproductive cough. Sputum may be blood-streaked. GI symptoms may be prominent
in Legionella infection, and severe ear pain due to bullous myringitis may complicate up to 5% of Mycoplasma
infections. The presence of weight loss and night sweats makes atypical pneumonia less likely in this
case.
• Typical pneumonia: Classic bacterial pneumonia begins with abrupt onset of fever, chills, pleuritic chest pain,
and productive cough. Remember that signs of pulmonary consolidation on physical exam are absent in up to
two-thirds of documented cases. The more subacute time course seen here makes this diagnosis less likely.
• COPD exacerbation: This patient’s baseline productive cough is due to COPD/chronic bronchitis secondary to tobacco
exposure. Exacerbations of chronic bronchitis are more acute and involve increased sputum production
and/or increased wheezing and dyspnea. Night sweats and weight loss are not typical features of this diagnosis.
• Wegener’s granulomatosis: This rare small-vessel vasculitis usually develops over 4–12 months and classically involves
the triad of upper respiratory tract, lower respiratory tract, and renal disease (which usually does not cause
symptoms before the diagnosis is established). Constitutional symptoms are common. The absence of chronic
upper respiratory complaints (e.g., sinusitis or nasal crusting) makes this diagnosis less likely.
• Other etiologies: Other common, benign causes of chronic cough include postnasal drip, GERD, asthma, and
ACE inhibitors.
Diagnostic workup
Persistent Cough
• CBC: To identify leukocytosis in infection (nonspecific).
• c-ANCA: Highly specific (> 90%) and sensitive for active Wegener’s granulomatosis.
• Blood cultures: May be useful in severe pneumonia to identify causative pathogenic bacteria.
• PPD (tuberculin skin test): Identifies individuals who have been infected with Mycobacterium tuberculosis but
does not distinguish between active and latent infection.
• Sputum Gram stain, AFB smear, routine and mycobacterial sputum cultures, and cytology: To identify a causative
agent of infection or to help detect malignancy.
• CXR—PA and lateral: To look for apical cavitary disease in TB reactivation, noncalcified nodules in lung cancer, a
cavity with an air-fluid level in lung abscess, a patchy infiltrative pattern in atypical pneumonia, lobar consolidation
in typical pneumonia, and infiltrates, nodules, masses, or cavities in Wegener’s granulomatosis.
• CT—chest: May demonstrate lesions unseen on CXR, and aids in characterizing the size, shape, and composition
of lung and mediastinal pathology. Can also guide diagnostic procedures (e.g., percutaneous transthoracic biopsies)
and assist in staging.
• Bronchoscopy: Useful in diagnosing and staging lung cancer and in diagnosing infections.
• Lung biopsy: Can lead to definitive diagnosis. A range of techniques is used depending on the location of the tumor.