Sintomas - Sistema Respiratório

Front 1

A 36-year-old man comes to your office because of a persistentcough that has been bothering him for the past 3 months.His cough is dry and is more frequent during the evenings.He also notes frequent nasal congestion, especially when heis exposed to dusts and cold weather. He reports no hemoptysis,weight loss, wheezing, fever, or changes in his appetite.ADDITIONAL HISTORYThe patient often feels a dripping sensation in the back ofthis throat. Over-the-counter antihistamines provide partialrelief of his symptoms.

Question: What is the most likelydiagnosis?A. A sthma B. UACSC. GERDD. Viral infection

Back 1

Correct answer: BIn this case, upper airway cough syndrome (UACS) is themost likely diagnosis. He reported a dripping sensation inthe back of his throat, and his symptoms responded to anantihistamine medication. UACS, previously known as“postnasal drip syndrome,” includes a wide constellationof rhinosinus disorders. Allergic rhinitis is one of the mostcommon disorders. Although his symptoms may mimica viral infection, the duration of his cough argues against an infectious cause. Asthma and gastroesophageal refluxdisease(GERD) are very common causes of cough, but inthis case, the patient denied any of the characteristic featuresof these conditions.

Front 2

1. A 28-year-old man who recently emigrated from Mexicovisits your clinic with a history of 4 months of cough. Hehas lost 15 to 20 lbs unintentionally and has occasionalfevers and night sweats. The cough is dry, and he hascoughed up a moderate amount of blood on 3 occasions.He has been a smoker for 2 years. There is no history ofwheezing, rhinitis, or reflux symptoms. He currently worksas a security guard in a chemical plant.What are the alarm features in this patient?A. History of smokingB. Duration of the coughC. Hemoptysis and weight lossD. Type of job

Back 2

Correct answer: CThe alarm features in this case are hemoptysis, weight loss,and fever. Although serious causes of cough are not common,the alarm features require immediate action and often additionaltesting. The duration of the cough provides a guidelinefor the differential diagnosis, but it is not an alarm feature.Although smoking and his occupation provide additionalinformation, they are not alarm features.

Front 3

2. In the patient in Question 1, what is the most likely diagnosis?A. Lung cancerB. Acute bronchitisC. TuberculosisD. Chronic obstructive pulmonary disease

Back 3

Correct answer: CThe most likely diagnosis is tuberculosis. Patients typicallyreport chronic cough with/without hemoptysis, fevers, nightsweats, and weight loss. Patients come from endemic areasor are immunosuppressed. Lung cancer can cause similarsymptoms, but typically it affects an older population.Acute bronchitis is of short duration and does not causechronic cough or weight loss. Although the patient is a currentsmoker, he does not have the characteristic features ofCOPD or emphysema.

Front 4

3. A 56-year-old man sees you for a long-standing cough. Hehas had a cough for at least 6 months. On a review of systems,he denies wheezing, nasal congestion, weight loss, fevers, orhemoptysis. He has occasional heartburn characterized bya midline retrosternal burning, especially after heavy mealsor chocolate. He has had frequent hoarseness over the pastmonth. Another physician did a preliminary work-up thatincluded a chest x-ray and blood and urine studies. All ofthese tests were normal.What should you do next?A. Do additional questioning/testing for possible bronchialasthmaB. Do additional questioning/testing for possible GERDC. Do additional questioning/testing for possible infectiouscauses of coughD. Follow his symptoms and schedule a follow-up in 1 month

Back 4

Correct answer: BHis symptoms suggest GERD. Heartburn characterized bya midline retrosternal burning is a characteristic feature ofGERD. Hoarseness may be a sign of severe disease. The patientshould be treated empirically for this diagnosis. Depending onhis response to therapy, additional testing might be required toconfirm the diagnosis. Although asthma remains a possibility,he had no wheezing or other features to suggest this diagnosis.Based on his symptoms, the likelihood of an infectious causeof his cough is low.

Front 5

A 67-year-old man comes to your clinic for his annual appointmentconcerned about increasing shortness of breath. A yearago he was able to walk up the stairs to his apartment withoutdifficulty, but now he has a hard time walking one block.He has a 70 pack-year smoking history, and several previousattempts to stop smoking have been unsuccessful.ADDITIONAL HISTORYThis patient has had slowly progressive dyspnea with exercisebut no symptoms at rest. The chronicity of the patient’ssymptoms and his ability to engage in conversation reassureyou that he does not require urgent intervention. Heexpresses frustration that he is unable to get a full breathwhen simply walking around his home. The dyspnea often worsens when he has a “cold,” but he denies an acuteincrease in symptoms. There are no other triggers. Whenyou ask about related symptoms, he describes a persistentcough productive of thick green sputum. The cough hasbeen an irritating presence for the past several months. Hedenies fevers, chest pain, chest tightness, or orthopnea.

Question: What is the most likelydiagnosis?A. AsthmaB. Chronic obstructive pulmonary diseaseC. Congestive heart failureD. Pneumonia

Back 5

Correct answer: BThe most common causes of dyspnea are primary cardiacand pulmonary causes, anemia, deconditioning, and functionaldyspnea. The patient describes a productive coughfor greater than 3 months and an impressive smoking history;both have high likelihood ratios for chronic obstructivepulmonary disease (COPD). The patient’s presentation ishighly suggestive of the chronic bronchitis variant of COPD.

However,congestive heart failure and COPD frequentlyoccur together; thus a diagnosis of one does not excludethe other. Further evaluation for cardiac causes should bepursued because the patient has several coronary artery diseaserisk factors (smoking, male sex, and age over 60) andCHF may be contributing to the patient’s dyspnea. The classicsymptoms of asthma are dyspnea, wheezing, and cough,which overlap with those of COPD, making diagnostic distinctiondifficult. In this case, the patient’s older age of onsetmakes asthma less likely. Pneumonia is unlikely based onthe chronicity of symptoms and lack of systemic symptomsor signs of infection.

Front 6

1. A 67-year-old hospitalized man complains of shortness ofbreath for the past hour. Although lying in the bed, he isbreathing quickly and appears nervous. He was admitted4 days earlier after being hit by a car and was found to have adisplaced tibial fracture, which required immediate operativeintervention. Chest radiograph at admission showed a 5-cmlung mass suspicious for cancer. The patient has a 60 pack-yearsmoking history. He has had a persistent nonproductive coughfor the past several months but denies any other symptoms.What is the most likely cause of his dyspnea?A. Lung massB. Pulmonary embolismC. Rib fractureD. AnxietyE. Deconditioning

Back 6

Correct answer: BPulmonary embolism (PE) is the most likely cause of dyspneain this patient. The significant smoking history andsuspicious mass on chest radiograph are very concerningfor lung cancer. The patient’s acute dyspnea is most likelydue to a venous thromboembolism (deep venous thrombosis)originating in the leg. The modified Wells criteria are clinicalprediction rules that can be used to classify the patient aslikely (score > 4) or unlikely (score ≤ 4) to have a PE (see vanBelle et al reference in Suggested Reading section of Chapter25). This patient has a Wells score of 4.5, placing himin the category of likely to have a PE because he has hadrecent surgery (1.5 points) and does not have an alternativediagnosis that is more likely than PE to explain his symptoms(3 points). If the patient also has lung cancer, leadingto a hypercoagulable state, this would further increase hisWells score (1 point). Smoking has also been associated withan increased risk of PE. Rib fractures are generally highlypainful and lead to shallow, hesitant respirations and, if displaced,can cause pneumothorax. In this case, rib fracture isunlikely given the delay between the patient’s accident andthe onset of dyspnea. Anxiety should not be diagnosed untilother causes have been ruled out. Deconditioning will be aconcern for this patient during his recovery but is unlikely topresent acutely.

Front 7

2. The captain of the high school cheerleading team presents toclinic with a chief complaint of several months of shortnessof breath upon exertion. She is unable to identify any triggeringsymptoms. She denies hormonal contraceptive use.

Which of the following is the most important aspect of thehistory to elicit?A. Recent bee stingB. MenorrhagiaC. Recent immobilizationD. Exposure to asbestos

Back 7

Correct answer: BAfter cardiac and pulmonary causes, anemia is the most commoncause of shortness in breath. In young women, menorrhagiais a common cause of anemia and should be consideredin this case. The prolonged nature of the patient’s symptomsis inconsistent with anaphylaxis. Chronic pulmonary embolismis unlikely in this otherwise healthy teenager. Althoughexposure to asbestos can cause infiltrative lung disease, pleuraldisease, or malignancy, it typically does not develop fordecades.

Front 8

3. A 67-year-old man with a 40 pack-year smoking historycomplains of shortness of breath for the past 6 months andswelling in his legs. He often wakes up at night gasping forbreath and feels most comfortable sleeping on 3 pillows. Hehas no past history of COPD or CHF, but he has diabetes andhypertension.What is the most likely diagnosis?A. Congestive heart failureB. Chronic obstructive pulmonary diseaseC. AsthmaD. Lung cancerE. Pulmonary embolism

Back 8

Correct answer: AThe patient has several coronary artery disease risk factors(male sex, age > 55 years, smoking history, diabetes, and hypertension)and describes paroxysmal nocturnal dyspnea, 3-pilloworthopnea, and lower extremity edema, the classic symptomsof congestive heart failure (CHF). The patient’s significantsmoking history also raises suspicion for chronic obstructivepulmonary disease. Asthma is less likely given the patient’s ageof onset. The patient’s smoking history puts him at increasedrisk of lung cancer. Pulmonary embolism can be difficult todiagnose. Although the other diagnoses cannot be definitivelyexcluded, the clinical picture is most consistent with CHF.

Front 9

A 35-year-old man with history of chronic cough comes toyour office and is very concerned after having 2 episodesof prolonged coughing that produced blood-streaked sputum.He also reports subjective fever for 4 days and coughproductive of yellow sputum. This is the first time he hasexperienced this constellation of symptoms.ADDITIONAL HISTORYThe patient denies dyspnea. He reports no history of smoking,weight loss, travel abroad, or exposure to sick contacts or tuberculosis. He has no other medical problems andtakes no medications.Question: What is the most likelydiagnosis?A. Lung cancerB. Acute bronchitisC. TuberculosisE. Pulmonary embolism

Back 9

Correct answer: BThe patient’s most likely diagnosis is acute bronchitis. Hishemoptysis was mild, and it was followed by a short periodof subjective fever, increased cough, and sputum production.Bronchitis remains the most common cause of hemoptysis.He does not have risk factors for lung cancer such as weightloss, advanced age, or tobacco exposure. He does not have anyfeatures suggestive of tuberculosis including exposure to sickcontacts, weight loss, or prolonged fevers. He does not haveany history of prolonged immobilization or recent surgery tosuggest pulmonary embolism.

Front 10

1. A 65-year-old woman comes to your clinic with a history ofcoughing up 1 to 2 tablespoons of bright blood on 2 occasions.She has smoked heavily for the past 30 years andreports recent weight loss of 25 to 30 lbs. Her past medicalhistory includes diabetes, hypertension, and rheumatoid arthritis.Her medications include insulin, atenolol, and ibuprofen.What are the alarm features present in this patient?A. Quantity of hemoptysisB. Advanced age, weight loss, and history of smokingC. History of diabetes, hypertension. and rheumatoid arthritisD. Current medications

Back 10

Correct answer: BThe history of weight loss, advanced age, and tobacco exposurein the setting of hemoptysis are considered alarm featuresconcerning for malignancy. The quantity of hemoptysis can beconsidered an alarm feature if it is greater than 200 mL in 24hours. She does not have additional risks for hemoptysis. Hermedications cannot explain the hemoptysis, and there was noexposure to any anticoagulants.

Front 11

2. In the patient in Question 1, what is the most likely diagnosis?A. BronchitisB. BronchiectasisC. Lung cancerD. Tuberculosis

Back 11

Correct answer: CWeight loss, tobacco exposure, advanced age, and hemoptysismake lung cancer a likely diagnosis.

Front 12

3. A 50-year-old woman comes to your office with a history of2 episodes of coughing blood. The quantity is estimated tobe 2 to 3 tablespoons of bright blood on each occasion. Shehas mild shortness of breath, but she feels comfortable at rest.She has never smoked, denies weight loss or fever, and has noother medical problems.What would be the next step in her management?A. Referral to a pulmonologist for bronchoscopyB. Return to your clinic in the next several weeks to monitorher symptoms C. Chest x-ray with an admission to the hospital for additionaltestingD. Complete vital signs and physical examination

Back 12

Correct answer: DThe next step is to obtain the vital signs and perform a physicalexamination to obtain more information. The patient willneed a chest x-ray but after she is examined. Depending on the chest imaging, the patient might require additional testingincluding bronchoscopy. It would not be appropriate to justmonitor her symptoms without an intervention.

Front 13

4. A 28-year-old man visits your clinic with complaint of coughingup small amounts of blood over the past 2 to 3 weeks andlow-grade intermittent fevers for the past 2 months. He smokedfor 8 years but stopped 2 to 3 years ago. He reports weight lossof 10 to 15 lbs that he attributes to diet. His laboratory data areunremarkable with the exception of a leukopenia and a positiveHIV test.What is his most likely diagnosis?A. BronchitisB. BronchiectasisC. Lung cancerD. Tuberculosis

Back 13

Correct answer: DThe most likely diagnosis is tuberculosis, because of theimmunocompromised state associated with HIV infection.Bronchitis typically has a shorter and more benign course. Hedoes not have any history of recurrent pulmonary infectionsto suggest bronchiectasis. Although he has weight loss andtobacco exposure, he is younger than most patients with lungcancer.

Front 14

5. A 30-year-old man comes to the emergency room complainingof mild dyspnea and diffuse chest pain that started suddenly3 hours ago and worsens with inspiration. While sittingin the waiting room, he has an episode of prolonged coughingthat produces small amounts of bright red blood. The physicalexamination reveals tachycardia and a testicular mass. He hasno other medical problems and takes no medications. He justreturned from a 12-hour drive to visit his family.What is the most likely diagnosis?A. BronchitisB. Pulmonary embolismC. PneumoniaD. Tuberculosis

Back 14

Correct answer: BThe most likely diagnosis is pulmonary embolism, whichtypically presents with acute chest pain and dyspnea. Prolongedimmobility and hypercoagulability are risk factors forpulmonary embolism. The patient was immobile for a prolongedperiod of time during his recent travel. Furthermore,his testicular mass most likely represents a malignancy, whichincreases his risk for hypercoagulability. Bronchitis andpneumonia are less likely as he did not complain of fevers orincreased sputum production. He does not have risk factorsfor tuberculosis.