Cough:stimulationofmechanicalandchemicalafferentreceptorsofbronchialtree

Inquiries:Patientsage,duration,dyspnea(shortofbreathwhenexercisingorat
Impact:Sleepdisturbances,
rest),chestpain,wheezing,productive/dry,bloodinphlegm,smoker?,vitals(HR, worklifedisturbed,
RR,bodytemp),chestexamination,orderradiographyifcoughis>36weeksor
discomfortinthroat.
presentswithabnormalvitalsigns.
AcuteCough(<3weeks)
Persistent(38w)&Chronic(>8weeks)
Symptoms:
Symptoms:
Pertussisseverecough>3weeks(checkbydoingPCRon
Viralfever,nasalcongestion,sorethroat(lasts3
nasopharyngealswabprob.ofdetectingwithtime.
weeks)
COPDseeleft,unlikelyifhavenormalmatchtest
Asthmaadultswithnocturnalcough
COPDpersistentcoughwithphlegmwithtime IfACEinhibitortherapy,acutetractinfection,&chest
abnormalitiesareruledout,consider:
(ofteninpatients>50yrs).
Postnasaldip,asthma,GERD(sinusesare
Pertussisposttussiveemesis(cough>vomiting),
usuallyinflamed
inspiratorywhoop.
Chroniclungdisease,CHF(unlikelyifnormaljugular
Pneumoniacoughaccompaniedbyvitalsign
venouspressureandnohepatojugularreflux),anemiaif
abnormalities(tachycardia,tachypnea,fever).
dyspneais>3weeks.
Acutebronchitiscoughwithwheezingandronchi

Bronchogeniccarcinomacoughaccompaniedby
(likesnoring)
unexplainedweightloss&feversw/nightsweats.
UncommonCHF,hayfever,environment(ex.
workonafarm)
EmpiricTrials:
Usespirometryforpatientswithpersistentcoughandno
improvementwithasthmatreatment.
Examineinducedsputumforincreasedeosinophilcounts(>3%);
measuringincreasedexhalednitricoxidelevels;orprovidingan
empirictrialofprednisone,30mgdailyfor2weeks.
Whenempirictreatmenttrialsarenothelpful,additional
evaluationwithpHmanometry,endoscopy,bariumswallow,
sinusCTorhighresolutionchestCTmayidentifythecause.
Treatment:
Treatment:
Pertussismacrolideantibiotic(azithromycin500
Influenzaamantadine,rimantadine,oseltamivir,or
mgonday1,then250mgoncedailyfordays25;
zanamivirisequallyeffective
H1N1influenzaneuraminidaseinhibitorsarethepreferred clarithromycin500mgtwicedailyfor7days;
erythromycin250mgfourtimesdailyfor14days
treatment
(effectiveonlyifgiven<10daysofonset)
ChlamydiaorMycoplasmadocumentedinfectionor
outbreaksfirstlineantibioticsincludeerythromycin,250
mgorallyfourtimesdailyfor7days,ordoxycycline,100 Refertootolarygologistorpulmonologistifnotable
totreat.
mgorallytwicedailyfor7days.
AcutebronchitisinhaledBeta2agonisttherapy

Acuterespiratorytractinfectiondextromethorphan
Postnasaldripantihistamines,decongestants,ornasal
corticosteroids.
GERDH2blockersorprotonpumpinhibitors

vitaminC(atleast1gdaily)andzinclozengesfor
preventionofcoldsamongpersonswithmajorphysical

stressors

Dyspnea:experienceorperceptionofuncomfortablebreathing
Inquiries:Fever,Cough,Chestpain,vitalsigns,pulseoximetry,cardiacandchest Impact:Sleepdisturbances,
examination,chestradiography,arterialbloodgasmeasurement
worklifedisturbed.
PhysicalExam:Evaluatehead&neck,chest,heart,andlowerextremities.
Visualinspectionofthepatientsrespiratorypattern:
Obstructiveairwaydisease(pursedlipbreathing,useofextrarespiratorymuscles,barrelshapedchest),
Pneumothorax(asymmetricexcursion),ormetabolicacidosis(Kussmaulrespirations).
Patientswithimpendingupperairwayobstruction(eg,epiglottitis,foreignbody),orsevereasthma
exacerbation,sometimesassumeatripodposition
Absentbreathsoundssuggestsapneumothorax.Anaccentuatedpulmoniccomponentofthesecondheartsound
(loudP2)isasignofpulmonaryhypertensionandpulmonaryembolism.
Obstructiveairwaydiseaseisvirtuallynonexistentwhenanonsmokingpatientyoungerthan45yearshasa
maximumlaryngealheight4cm
Arterialbloodgasmeasurementdistinguishesincreasedmechanicaleffortcausesofdyspnea(respiratoryacidosis
withorwithouthypoxemia)fromcompensatorytachypnea(respiratoryalkalosiswithorwithouthypoxemiaor
metabolicacidosis)frompsychogenicdyspnea(respiratoryalkalosis).
Cyanidepoisoningshouldbeconsideredinapatientwithprofoundlacticacidosisfollowingexposuretoburning
vinyl(suchasatheaterfireorindustrialaccident).
Suspectedcarbonmonoxidepoisoningormethemoglobinemiacanalsobeconfirmedwithvenous
carboxyhemoglobin,methemoglobinlevels,orpercentcarboxyhemoglobin.
Ifchestradiographisnormalconsiderpulmonaryembolism,Pneumocystisjiroveciinfection(initialradiograph
maybenormalinupto25%),upperairwayobstruction,foreignbody,anemia,andmetabolicacidosis.
IfapatienthastachycardiaandhypoxemiabutanormalchestradiographandECG)thenfurtherteststoexclude
pulmonaryemboliarewarranted,providedbloodtestsexcludesignificantanemiaormetabolicacidosis.
HighresolutionchestCTisparticularlyusefulintheevaluationofpulmonaryembolismandhastheaddedbenefit
ofprovidinginformationaboutinterstitialandalveolarlungdisease.
PulseOximetryOxygensaturationvaluesabove96%almostalwayscorrespondwithaPo2>70mmHg,andvalues
<94%almostalwaysrepresentclinicallysignificanthypoxemia.Importantexceptionstothisruleincludecarbon
monoxidetoxicity,whichleadstoanormaloxygensaturation(duetothesimilarwavelengthsofoxyhemoglobin
andcarboxyhemoglobin),andmethemoglobinemia,whichresultsinanoxygensaturationofabout85%thatfailsto
increasewithsupplementaloxygen.

Symptoms:
Rapidonset:
Pneumothoraxifspontaneous,itisaccompaniedwithchestpainandseenofteninthinmalesorthosewith
lungdisease(confirmedwithchestradiography;endexpiratorychestradiographyenhancesdetectionofa
smallpneumothorax)
Pulmonaryembolismshouldbesuspectedwhenapatientwithnewdyspneareportsarecenthistory
(previous4weeks)ofprolongedimmobilization,estrogentherapy,orotherriskfactorsfordeepvenous
thrombosis(DVT)(eg.previoushistoryofthromboembolism, cancer, obesity, lower extremity trauma) and
when the cause of dyspnea is not apparent.
Silent myocardial infarction- occurs frequently in diabetic patients and women.
Increase left ventricular end diastolic pressure (LVEDP)- Accompanied w/ Tachycardia Systolic hypotension,

Jugularvenousdistention(>57cmH2O,),Hepatojugularreflux(>1cm;compressrightupperquadrant>
30sec),Crackles,especiallybibasilar,Thirdheartsound(auscultatepatientat45degreeangleinleftlateral
decubitusposition),Lowerextremityedema,Radiographicpulmonaryvascularredistributionorcardiomegaly
(>2ofthesemakesitverylikelyitisLVEPD).CheckBNPlevelstoconfirmcardiacissues.
Pulmonary disease (infections), myocarditis, pericarditis, and septic emboli- if accompanied with cough and fever
Acute Bronchitis- if accompanied with wheezing. If unlikely consider, new-onset asthma, foreignbody,andvocal
corddysfunction.
Acutedyspneaconsiderpneumonia,COPD,asthma,pneumothorax,pulmonaryembolism,cardiacdiseaseacute
myocardialinfarction,valvulardysfunction,arrhythmia,cardiacshunt),metabolicacidosis,cyanidetoxicity,
methemoglobinemia,andcarbonmonoxidepoisoning.
Whenpatientreportsdyspeneawithmildornoaccompanyingsymptomsconsidernoncardiopulmonarycauses
ofimpairedoxygendelivery(anemia,methemoglobinemia,cyanideingestion,carbonmonoxide),metabolic
acidosis,panicdisorder,andchronicpulmonaryembolism.
Whenpulseoximetryyieldsambiguousresults,assessmentofdesaturationwithambulation(eg,abriskwalk
aroundtheclinic)canbeausefulfinding(eg,whenPneumocystisjirovecipneumoniaissuspected)for
confirmingimpairedgasexchange.
Whenassociatedwithaudiblewheezing,vocalcorddysfunctionshouldbeconsidered,particularlyinayoung
womanwhodoesnotrespondtoasthmatherapy.

Treatments:
IfPatientisdeliriouswithobstructivelungdiseaseintubateand
measurebloodarterialgasestoexcludehyperacapnia.
Ifhypoxemiaimmediatelyprovidesupplementaloxygenunless
significanthypercapniaispresentorstronglysuspectedpending
arterialbloodgasmeasurement.
Dyspneafrequentlyoccursinpatientsnearingtheendoflife;
whereasopioidtherapycanprovidesubstantialrelief
PatientswithadvancedCOPDshouldbe
independentoftheseverityofhypoxemia,oxygentherapy
referredtoapulmonologist,andpatientswith
appearstobemostbeneficialtopatientswithsignificant
CHForvalvularheartdiseaseshouldbe
hypoxemia
referredtoacardiologistfollowingacute
InpatientswithsevereCOPDandhypoxemia,oxygentherapy
stabilization.
improvesmortalityandexerciseperformance.Alsoconsider
Cyanidetoxicityshouldbemanagedin
pulmonaryrehabilitationprograms.
conjunctionwithatoxicologist.

Hemoptysis:coughingupbloodthatisfoundbelowthevocalcords(consideredmassive>12cupsofblood/24hr).
Inquiries:Smokinghistory,Fever,cough&othersymptomsoflowerrespiratory Impact:Sleepdisturbances,
tractinfection,durationofsymptoms,nasopharyngealorgastrointestinalbleeding, worklifedisturbed,
chestradiographyandcompletebloodcount.
discomfortinthroat.
Symptoms:
BloodmayarisefromtheairwaysinCOPD,bronchiectasis,and
bronchogeniccarcinoma;fromthepulmonaryvasculatureinleft
Bloodtingedsputuminotherwisehealthy
ventricularfailure,mitralstenosis,pulmonaryembolism,
adultrespiratiorytractinfection
idiopathicpulmonaryarterialhypertension,andarteriovenous
PhysicalExam
malformations;orfromthepulmonaryparenchymain
Elevatedpulse,hypotension,anddecreased
pneumonia,inhalationofcrackcocaine,orgranulomatosiswith
oxygensaturationsuggestlargevolume
polyangiitis(formerlyWegenergranulomatosis).Diffusealveolar
hemorrhagethatwarrantsemergent
hemorrhageisduetosmallvesselbleedingusuallycausedby
evaluationandstabilization.
autoimmuneorhematologicdisordersandresultsinalveolar
Thenaresandoropharynxshouldbe
infiltratesonchestradiography.Mostcasesofhemoptysis
carefullyinspectedtoidentifyapotential
presentingintheoutpatientsettingareduetoinfection(eg,acute
upperairwaysourceofbleeding.
orchronicbronchitis,pneumonia,tuberculosis).Hemoptysisdue
Chestandcardiacexaminationmayreveal
tolungcancerincreaseswithage,accountingforupto20%of
evidenceofCHFormitralstenosis
DoBronchoscopyifpatientissmoker>40yr casesamongtheelderly.Lesscommonly(<10%ofcases),
pulmonaryvenoushypertension(eg,mitralstenosis,pulmonary
andhadsymptoms>1week
embolism)causeshemoptysis.Mostcasesofhemoptysisthat
Hematuriathataccompanieshemoptysismay
havenovisiblecauseonCTscanorbronchoscopywillresolve
beacluetoGoodpasturesyndromeor
within6monthswithouttreatment,withthenotableexceptionof
vasculitis.
patientsathighriskforlungcancer
Flexiblebronchoscopyrevealsendobronchial
cancerin36%ofpatientswithhemoptysis
whohaveanormalchestradiograph.
DiagnosticStudies:

Treatment:
Ifmildidentify&treatthespecificcause.
Chestradiography,bloodcount,kidneyfunction IfmassiveTheairwayshouldbeprotectedwith
test,urineanalysis,coagulationstudies,
endotrachealintubation,ventilationensured,andeffective
circulationmaintained.Ifthelocationofthebleedingsiteis
known,thepatientshouldbeplacedinthelyingdown
positionwiththeinvolvedlungdependent.
Uncontrollablehemorrhagewarrantsrigidbronchoscopyand
surgicalconsultation.
Instablepatients,flexiblebronchoscopymaylocalizethe
siteofbleeding,andangiographycanembolizetheinvolved
bronchialarteries.Embolizationiseffectiveinitiallyin85%
ofcases,althoughrebleedingmayoccurinupto20%of
patientsoverthefollowingyear.Theanteriorspinalartery
arisesfromthebronchialarteryinupto5%ofpeople,and
paraplegiamayresultifitisinadvertentlycannulated

ChestPain:
Inquiries:Patientsage,duration,dyspnea(shortofbreathwhenexercisingorat
Impact:Sleepdisturbances,
rest),chestpain,wheezing,productive/dry,bloodinphlegm,smoker?,vitals(HR, worklifedisturbed,
RR,bodytemp),chestexamination,orderradiographyifcoughis>36weeksor
discomfortinthroat.
presentswithabnormalvitalsigns.
AcuteCough(<3weeks)
Persistent(38w)&Chronic(>8weeks)
Symptoms:
Symptoms:
Pertussisseverecough>3weeks(checkbydoingPCR
Viralfever,nasalcongestion,sorethroat(lasts3
onnasopharyngealswabprob.ofdetectingwithtime.
weeks)
COPDseeleft,unlikelyifhavenormalmatchtest
Asthmaadultswithnocturnalcough
COPDpersistentcoughwithphlegmwithtime IfACEinhibitortherapy,acutetractinfection,&chest
abnormalitiesareruledout,consider:
(ofteninpatients>50yrs).
Postnasaldip,asthma,GERD(sinusesare
Pertussisposttussiveemesis(cough>vomiting),
usuallyinflamed
inspiratorywhoop.
Chroniclungdisease,CHF(unlikelyifnormaljugular
Pneumoniacoughaccompaniedbyvitalsign
venouspressureandnohepatojugularreflux),anemia
abnormalities(tachycardia,tachypnea,fever).
ifdyspneais>3weeks.
Acutebronchitiscoughwithwheezingandronchi

Bronchogeniccarcinomacoughaccompaniedby
(likesnoring)
unexplainedweightloss&feversw/nightsweats.
UncommonCHF,hayfever,environment(ex.
workonafarm)
EmpiricTrials:
Usespirometryforpatientswithpersistentcoughandno
improvementwithasthmatreatment.
Examineinducedsputumforincreasedeosinophilcounts(>
3%);measuringincreasedexhalednitricoxidelevels;or
providinganempirictrialofprednisone,30mgdailyfor2
weeks.
Whenempirictreatmenttrialsarenothelpful,additional
evaluationwithpHmanometry,endoscopy,bariumswallow,
sinusCTorhighresolutionchestCTmayidentifythecause.

Treatment:
Influenzaamantadine,rimantadine,oseltamivir,orzanamiviris
equallyeffective
H1N1influenzaneuraminidaseinhibitorsarethepreferred
treatment
ChlamydiaorMycoplasmadocumentedinfectionoroutbreaks
firstlineantibioticsincludeerythromycin,250mgorallyfour
timesdailyfor7days,ordoxycycline,100mgorallytwice
dailyfor7days.
AcutebronchitisinhaledBeta2agonisttherapy

Acuterespiratorytractinfectiondextromethorphan
Postnasaldripantihistamines,decongestants,ornasal
corticosteroids.
GERDH2blockersorprotonpumpinhibitors

Treatment:
Pertussismacrolideantibiotic(azithromycin
500mgonday1,then250mgoncedailyfor
days25;clarithromycin500mgtwicedaily
for7days;erythromycin250mgfourtimes
dailyfor14days(effectiveonlyifgiven<10
daysofonset)
Refertootolarygologistorpulmonologistif
notabletotreat.

 vitaminC(atleast1gdaily)andzinclozengesforprevention
ofcoldsamongpersonswithmajorphysicalstressors
Palpitations:unpleasantawarenessoftheforceful,rapid,orirregularbeatingoftheheart.
PhysicalExamination:
Themidsystolicclickofmitralvalveprolapsecansuggestthediagnosisofasupraventriculararrhythmia.
Theharshholosystolicmurmurofhypertrophiccardiomyopathy,whichoccursalongtheleftsternalborderand
increaseswiththeValsalvamaneuver,suggestsatrialfibrillationorventriculartachycardia.
Thepresenceofdilatedcardiomyopathy,suggestedonexaminationbyadisplacedandenlargedcardiacpoint
ofmaximalimpulse,increasesthelikelihoodofventriculartachycardiaandatrialfibrillation.
Inpatientswithchronicatrialfibrillation,inofficeexercise(eg,abriskwalkinthehallway)mayrevealan
intermittentacceleratedventricularresponseasthecauseofthepalpitations.
Theclinicianshouldalsolookforsignsofhyperthyroidism,suchastremulousness,briskdeeptendonreflexes,
finehandtremor,orsignsofstimulantdruguse(suchasdilatedpupilsorskinornasalseptallesions).
Thepresenceofvisibleneckpulsations(LR,2.68;95%CI,1.255.78)inassociationwithpalpitations
increasesthelikelihoodofatrioventricularnodalreentrytachycardia.
DiagnosticStudies:
12leadECGorderedforallpalpitationstoascertainetiology.
bradyarrhythmiasandheartblockcanbeassociatedwithventricularectopyorescapebeatsthatmaybe
experiencedaspalpitationsbythepatient.
EvidenceofpriormyocardialinfarctionbyhistoryoronECG(eg,Qwaves)increasesthepatientsriskfor
nonsustainedorsustainedventriculartachycardia.
Ventricularpreexcitation(WolffParkinsonWhitesyndrome)issuggestedbyashortPRinterval(<0.20ms)and
deltawaves(upslopingPRsegments).
LeftventricularhypertrophywithdeepseptalQwavesinI,AVL,andV4throughV6isseeninpatientswith
hypertrophicobstructivecardiomyopathy.
ThepresenceofleftatrialenlargementassuggestedbyaterminalPwaveforceinV1morenegativethan0.04
msecandnotchedinleadIIreflectsapatientatincreasedriskforatrialfibrillation.AprolongedQTintervaland
abnormalTwavemorphologysuggeststhelongQTsyndrome,whichputspatientsatincreasedriskfor
ventriculartachycardia.
Nonarrhythmiccardiaccausesofpalpitationsincludevalvularheartdiseases,suchasaorticinsufficiencyor
stenosis,atrialorventricularseptaldefect,cardiomyopathy,congenitalheartdisease,andpericarditis.
Themostcommonpsychiatriccausesofpalpitationsareanxietyandpanicdisorder.Askingasinglequestion,
Haveyouexperiencedbriefperiods,forsecondsorminutes,ofanoverwhelmingpanicorterrorthatwas
accompaniedbyracingheartbeats,shortnessofbreath,ordizziness?canhelpidentifypatientswithpanic
disorder.
Treatment:
Inpatientswithstructurallynormalhearts,thesearrhythmiasarenotassociatedwithadverseoutcomes.
Abstentionfromcaffeineandtobaccomayhelp.Often,reassurancesuffices.Ifnot,orinverysymptomatic
patients,atrialofa blockermaybeprescribed

LowerextremityEdema:coughingupbloodthatisfoundbelowthevocalcords(consideredmassive>12cupsof
blood/24hr).
Inquiries:Historyofvenousthromboembolism.Symmetry.Pain.Dependence.
Impact:.
Skinfindings.
Symptoms:
DiagnosticStudies:

Treatment:
Ifmildidentify&treatthespecificcause.
IfmassiveTheairwayshouldbeprotectedwith
endotrachealintubation,ventilationensured,andeffective
circulationmaintained.Ifthelocationofthebleedingsiteis
known,thepatientshouldbeplacedinthelyingdown
positionwiththeinvolvedlungdependent.
Uncontrollablehemorrhagewarrantsrigidbronchoscopyand
surgicalconsultation.
Instablepatients,flexiblebronchoscopymaylocalizethe
siteofbleeding,andangiographycanembolizetheinvolved
bronchialarteries.Embolizationiseffectiveinitiallyin85%
ofcases,althoughrebleedingmayoccurinupto20%of
patientsoverthefollowingyear.Theanteriorspinalartery
arisesfromthebronchialarteryinupto5%ofpeople,and
paraplegiamayresultifitisinadvertentlycannulated