Cough: stimulation of mechanical and chemical afferent receptors of bronchial tree

Inquiries: Patients age, duration, dyspnea (short of breath when exercising or at

Impact: Sleep disturbances,
rest), chest pain, wheezing, productive/dry, blood in phlegm, smoker?, vitals (HR,
work life disturbed,
RR, body temp), chest examination, order radiography if cough is >3-6 weeks or
discomfort in throat.
presents with abnormal vital signs.
Acute Cough (< 3 weeks)
Persistent (3-8 w) & Chronic (>8 weeks)
Symptoms:
Symptoms:
Pertussis- severe cough > 3 weeks (check by doing PCR on
Viral- fever, nasal congestion, sore throat (lasts 3
nasopharyngeal swab prob. of detecting with time.
weeks)
COPD- see left, unlikely if have normal match test
Asthma- adults with nocturnal cough
If ACE inhibitor therapy, acute tract infection, & chest
COPD- persistent cough with phlegm with time
abnormalities are ruled out, consider:
(often in patients>50 yrs).
Post-nasal dip, asthma, GERD (sinuses are
Pertussis- post-tussive emesis (cough->vomiting),
usually inflamed
inspiratory whoop.
Chronic lung disease, CHF (unlikely if normal jugular
Pneumonia- cough accompanied by vital sign
venous pressure and no hepatojugular reflux), anemia- if
abnormalities (tachycardia, tachypnea, fever).
dyspnea is >3 weeks.
Acute bronchitis- cough with wheezing and ronchi

Bronchogenic carcinoma- cough accompanied by

(like snoring)
unexplained weight loss & fevers w/ night sweats.
Uncommon- CHF, hay fever, environment (ex.
work on a farm)
Empiric Trials:
Use spirometry for patients with persistent cough and no
improvement with asthma treatment.
Examine induced sputum for increased eosinophil counts (> 3%);
measuring increased exhaled nitric oxide levels; or providing an
empiric trial of prednisone, 30 mg daily for 2 weeks.
When empiric treatment trials are not helpful, additional
evaluation with pH manometry, endoscopy, barium swallow,
sinus CT or high-resolution chest CT may identify the cause.
Treatment:
Treatment:
Pertussis- macrolide antibiotic (azithromycin 500
Influenza- amantadine, rimantadine, oseltamivir, or
mg on day 1, then 250 mg once daily for days 25;
zanamivir is equally effective
H1N1 influenza- neuraminidase inhibitors are the preferred clarithromycin 500 mg twice daily for 7 days;
erythromycin 250 mg four times daily for 14 days
treatment
(effective only if given <10 days of onset)
Chlamydia or Mycoplasma-documented infection or
outbreaks- first-line antibiotics include erythromycin, 250
Refer to otolarygologist or pulmonologist if not able
mg orally four times daily for 7 days, or doxycycline, 100
to treat.
mg orally twice daily for 7 days.
Acute bronchitis- inhaled Beta2-agonist therapy
Acute respiratory tract infection- dextromethorphan
Postnasal drip- antihistamines, decongestants, or nasal
corticosteroids.
GERD - H2-blockers or proton-pump inhibitors

vitamin C (at least 1 g daily) and zinc lozenges- for

prevention of colds among persons with major physical
stressors
Dyspnea: experience or perception of uncomfortable breathing

Inquiries: Fever, Cough, Chest pain, vital signs, pulse oximetry, cardiac and chest Impact: Sleep disturbances,
examination, chest radiography, arterial blood gas measurement
work life disturbed.
Physical Exam: Evaluate head & neck, chest, heart, and lower extremities.
Visual inspection of the patients respiratory pattern:
Obstructive airway disease (pursed-lip breathing, use of extra respiratory muscles, barrel-shaped chest),
Pneumothorax (asymmetric excursion), or metabolic acidosis (Kussmaul respirations).
Patients with impending upper airway obstruction (eg, epiglottitis, foreign body), or severe asthma
exacerbation, sometimes assume a tripod position
Absent breath sounds suggests a pneumothorax. An accentuated pulmonic component of the second heart sound
(loud P2) is a sign of pulmonary hypertension and pulmonary embolism.
Obstructive airway disease is virtually nonexistent when a nonsmoking patient younger than 45 years has a
maximum laryngeal height 4 cm
Arterial blood gas measurement distinguishes increased mechanical effort causes of dyspnea (respiratory acidosis
with or without hypoxemia) from compensatory tachypnea (respiratory alkalosis with or without hypoxemia or
metabolic acidosis) from psychogenic dyspnea (respiratory alkalosis).
Cyanide poisoning should be considered in a patient with profound lactic acidosis following exposure to burning
vinyl (such as a theater fire or industrial accident).
Suspected carbon monoxide poisoning or methemoglobinemia can also be confirmed with venous
carboxyhemoglobin, methemoglobin levels, or percent carboxyhemoglobin.
If chest radiograph is normal- consider pulmonary embolism, Pneumocystis jiroveci infection (initial radiograph
may be normal in up to 25% ), upper airway obstruction, foreign body, anemia, and metabolic acidosis.
If a patient has tachycardia and hypoxemia but a normal chest radiograph and ECG) then further tests to exclude
pulmonary emboli are warranted, provided blood tests exclude significant anemia or metabolic acidosis.
High-resolution chest CT is particularly useful in the evaluation of pulmonary embolism and has the added benefit
of providing information about interstitial and alveolar lung disease.
Pulse Oximetry- Oxygen saturation values above 96% almost always correspond with a Po2 > 70 mm Hg, and
values < 94% almost always represent clinically significant hypoxemia. Important exceptions to this rule include
carbon monoxide toxicity, which leads to a normal oxygen saturation (due to the similar wavelengths of
oxyhemoglobin and carboxyhemoglobin), and methemoglobinemia, which results in an oxygen saturation of about
85% that fails to increase with supplemental oxygen.

Symptoms:
Rapid onset:
Pneumothorax- if spontaneous, it is accompanied with chest pain and seen often in thin males or those with
lung disease (confirmed with chest radiography; end-expiratory chest radiography enhances detection of a
small pneumothorax)
Pulmonary embolism- should be suspected when a patient with new dyspnea reports a recent history
(previous 4 weeks) of prolonged immobilization, estrogen therapy, or other risk factors for deep venous
thrombosis (DVT) (eg. previous history of thromboembolism, 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 , Jugular venous distention (> 57 cm H2O,), Hepatojugular reflux (> 1 cm; compress right
upper quadrant > 30sec), Crackles, especially bibasilar , Third heart sound (auscultate patient at 45-degree
angle in left lateral decubitus position), Lower extremity edema, Radiographic pulmonary vascular
redistribution or cardiomegaly (>2 of these makes it very likely it is LVEPD). Check BNP levels to confirm
cardiac issues.

 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, foreign body, and vocal
cord dysfunction.
Acute dyspnea- consider pneumonia, COPD, asthma, pneumothorax, pulmonary embolism, cardiac disease acute
myocardial infarction, valvular dysfunction, arrhythmia, cardiac shunt), metabolic acidosis, cyanide toxicity,
methemoglobinemia, and carbon monoxide poisoning.
When patient reports dyspenea with mild or no accompanying symptoms- consider non-cardiopulmonary causes
of impaired oxygen delivery (anemia, methemoglobinemia, cyanide ingestion, carbon monoxide), metabolic
acidosis, panic disorder, and chronic pulmonary embolism.
When pulse oximetry yields ambiguous results, assessment of desaturation with ambulation (eg, a brisk walk
around the clinic) can be a useful finding (eg, when Pneumocystis jiroveci pneumonia is suspected) for
confirming impaired gas exchange.
When associated with audible wheezing, vocal cord dysfunction should be considered, particularly in a young
woman who does not respond to asthma therapy.

Treatments:
If Patient is delirious with obstructive lung disease- intubate and
measure blood arterial gases to exclude hyperacapnia.
If hypoxemia- immediately provide supplemental oxygen unless
significant hypercapnia is present or strongly suspected pending
arterial blood gas measurement.
Dyspnea frequently occurs in patients nearing the end of life;
whereas opioid therapy can provide substantial relief
independent of the severity of hypoxemia, oxygen therapy
Patients with advanced COPD should be
appears to be most beneficial to patients with significant
referred to a pulmonologist, and patients with
hypoxemia
CHF or valvular heart disease should be
In patients with severe COPD and hypoxemia, oxygen therapy
referred to a cardiologist following acute
improves mortality and exercise performance. Also consider
stabilization.
pulmonary rehabilitation programs.
Cyanide toxicity should be managed in
conjunction with a toxicologist.

Hemoptysis: coughing up blood that is found below the vocal cords (considered massive > 1-2 cups of blood/24hr).
Inquiries: Smoking history, Fever, cough & other symptoms of lower respiratory
Impact: Sleep disturbances,
tract infection, duration of symptoms, nasopharyngeal or gastrointestinal bleeding, work life disturbed,
chest radiography and complete blood count.
discomfort in throat.
Symptoms:
Blood may arise from the airways in COPD, bronchiectasis, and
bronchogenic carcinoma; from the pulmonary vasculature in left
Blood tinged sputum in otherwise healthy
ventricular failure, mitral stenosis, pulmonary embolism,
adult- respiratiory tract infection
idiopathic pulmonary arterial hypertension, and arteriovenous
Physical Exam
malformations; or from the pulmonary parenchyma in
Elevated pulse, hypotension, and decreased
pneumonia, inhalation of crack cocaine, or granulomatosis with
oxygen saturation suggest large volume
polyangiitis (formerly Wegener granulomatosis). Diffuse alveolar
hemorrhage that warrants emergent
hemorrhage is due to small vessel bleeding usually caused by
evaluation and stabilization.
autoimmune or hemato- logic disorders and results in alveolar
The nares and oropharynx should be
infiltrates on chest radiography. Most cases of hemoptysis
carefully inspected to identify a potential
presenting in the outpatient setting are due to infection (eg, acute
upper airway source of bleeding.
or chronic bronchitis, pneumonia, tuberculosis). Hemoptysis due
Chest and cardiac examination may reveal
to lung cancer increases with age, accounting for up to 20% of
evidence of CHF or mitral stenosis
Do Bronchoscopy if patient is smoker > 40yr cases among the elderly. Less commonly (< 10% of cases),
pulmonary venous hypertension (eg, mitral stenosis, pulmonary
and had symptoms >1 week
Hematuria that accompanies hemoptysis may embolism) causes hemoptysis. Most cases of hemoptysis that
have no visible cause on CT scan or bronchoscopy will resolve
be a clue to Goodpasture syndrome or
within 6 months without treatment, with the notable exception of
vasculitis.
patients at high risk for lung cancer
Flexible bronchoscopy reveals endobronchial
cancer in 36% of patients with hemoptysis
who have a normal chest radiograph.
Diagnostic Studies:
Treatment:
If mild- identify & treat the specific cause.
Chest radiography, blood count, kidney function
If massive- The airway should be protected with
test, urine-analysis, coagulation studies,
endotracheal intubation, ventilation ensured, and effective
circulation maintained. If the location of the bleeding site is
known, the patient should be placed in the lying down
position with the involved lung dependent.
Uncontrollable hemorrhage warrants rigid bronchoscopy
and surgical consultation.
In stable patients, flexible bronchoscopy may localize the
site of bleeding, and angiography can embolize the involved
bronchial arteries. Embolization is effective initially in 85%
of cases, although rebleeding may occur in up to 20% of
patients over the following year. The anterior spinal artery
arises from the bronchial artery in up to 5% of people, and
paraplegia may result if it is inadvertently cannulated

Chest Pain:
Inquiries: Patients age, duration, dyspnea (short of breath when exercising or at
Impact: Sleep disturbances,
rest), chest pain, wheezing, productive/dry, blood in phlegm, smoker?, vitals (HR,
work life disturbed,
RR, body temp), chest examination, order radiography if cough is >3-6 weeks or
discomfort in throat.
presents with abnormal vital signs.
Acute Cough (< 3 weeks)
Persistent (3-8 w) & Chronic (>8 weeks)
Symptoms:
Symptoms:
Pertussis- severe cough > 3 weeks (check by doing PCR
Viral- fever, nasal congestion, sore throat (lasts 3
on nasopharyngeal swab prob. of detecting with time.
weeks)
COPD- see left, unlikely if have normal match test
Asthma- adults with nocturnal cough
If ACE inhibitor therapy, acute tract infection, & chest
COPD- persistent cough with phlegm with time
abnormalities are ruled out, consider:
(often in patients>50 yrs).
Post-nasal dip, asthma, GERD (sinuses are
Pertussis- post-tussive emesis (cough->vomiting),
usually inflamed
inspiratory whoop.
Chronic lung disease, CHF (unlikely if normal jugular
Pneumonia- cough accompanied by vital sign
venous pressure and no hepatojugular reflux), anemiaabnormalities (tachycardia, tachypnea, fever).
if dyspnea is >3 weeks.
Acute bronchitis- cough with wheezing and ronchi

Bronchogenic carcinoma- cough accompanied by

(like snoring)
unexplained weight loss & fevers w/ night sweats.
Uncommon- CHF, hay fever, environment (ex.
work on a farm)
Empiric Trials:
Use spirometry for patients with persistent cough and no
improvement with asthma treatment.
Examine induced sputum for increased eosinophil counts (>
3%); measuring increased exhaled nitric oxide levels; or
providing an empiric trial of prednisone, 30 mg daily for 2
weeks.
When empiric treatment trials are not helpful, additional
evaluation with pH manometry, endoscopy, barium swallow,
sinus CT or high-resolution chest CT may identify the cause.
Treatment:
Influenza- amantadine, rimantadine, oseltamivir, or zanamivir
is equally effective
H1N1 influenza- neuraminidase inhibitors are the preferred
treatment
Chlamydia or Mycoplasma-documented infection or outbreaksfirst-line antibiotics include erythromycin, 250 mg orally four
times daily for 7 days, or doxycycline, 100 mg orally twice
daily for 7 days.
Acute bronchitis- inhaled Beta2-agonist therapy
Acute respiratory tract infection- dextromethorphan
Postnasal drip- antihistamines, decongestants, or nasal
corticosteroids.
GERD - H2-blockers or proton-pump inhibitors

Treatment:
Pertussis- macrolide antibiotic (azithromycin
500 mg on day 1, then 250 mg once daily for
days 25; clarithromycin 500 mg twice daily
for 7 days; erythromycin 250 mg four times
daily for 14 days (effective only if given <10
days of onset)
Refer to otolarygologist or pulmonologist if
not able to treat.

vitamin C (at least 1 g daily) and zinc lozenges- for prevention

of colds among persons with major physical stressors
Palpitations: unpleasant awareness of the forceful, rapid, or irregular beating of the heart.

Physical Examination:
The midsystolic click of mitral valve prolapse can suggest the diagnosis of a supraventricular arrhythmia.
The harsh holosystolic murmur of hypertrophic cardiomyopathy, which occurs along the left sternal border and
increases with the Valsalva maneuver, suggests atrial fibrillation or ventricular tachycardia.
The presence of dilated cardiomyopathy, suggested on examination by a displaced and enlarged cardiac pointof-maximal impulse, increases the likelihood of ventricular tachycardia and atrial fibrillation.
In patients with chronic atrial fibrillation, in-office exercise (eg, a brisk walk in the hallway) may reveal an
intermittent accelerated ventricular response as the cause of the palpitations.
The clinician should also look for signs of hyperthyroidism, such as tremulousness, brisk deep tendon reflexes,
fine hand tremor, or signs of stimulant drug use (such as dilated pupils or skin or nasal septal lesions).
The presence of visible neck pulsations (LR, 2.68; 95% CI, 1.255.78) in association with palpitations increases
the likelihood of atrioventricular nodal reentry tachycardia.
Diagnostic Studies:
12-lead ECG ordered for all palpitations to ascertain etiology.
bradyarrhythmias and heart block can be associated with ventricular ectopy or escape beats that may be
experienced as palpitations by the patient.
Evidence of prior myocardial infarction by history or on ECG (eg, Q waves) increases the patients risk for
nonsustained or sustained ventricular tachycardia.
Ventricular preexcitation (Wolff- Parkinson-White syndrome) is suggested by a short PR interval (< 0.20 ms)
and delta waves (upsloping PR segments).
Left ventricular hypertrophy with deep septal Q waves in I, AVL, and V4 through V6 is seen in patients with
hyper- trophic obstructive cardiomyopathy.
The presence of left atrial enlargement as suggested by a terminal P-wave force in V1 more negative than 0.04
msec and notched in lead II reflects a patient at increased risk for atrial fibrillation. A prolonged QT interval and
abnormal T-wave morphology suggests the long-QT syndrome, which puts patients at increased risk for
ventricular tachycardia.
Nonarrhythmic cardiac causes of palpitations include valvular heart diseases, such as aortic insufficiency or
stenosis, atrial or ventricular septal defect, cardiomyopathy, congenital heart disease, and pericarditis.
The most common psychiatric causes of palpitations are anxiety and panic disorder. Asking a single question,
Have you experienced brief periods, for seconds or minutes, of an overwhelming panic or terror that was
accompanied by racing heartbeats, shortness of breath, or dizziness? can help identify patients with panic
disorder.
Treatment:
In patients with structurally normal hearts, these arrhythmias are not asso- ciated with adverse outcomes.
Abstention from caffeine and tobacco may help. Often, reassurance suffices. If not, or in very symptomatic
patients, a trial of a -blocker may be prescribed

Lower extremity Edema: coughing up blood that is found below the vocal cords (considered massive > 1-2 cups of
blood/24hr).
Inquiries: History of venous thromboembolism. Symmetry. Pain. Dependence.
Impact:.
Skin findings.
Symptoms:
Diagnostic Studies:

Treatment:
If mild- identify & treat the specific cause.
If massive- The airway should be protected with
endotracheal intubation, ventilation ensured, and effective
circulation maintained. If the location of the bleeding site is
known, the patient should be placed in the lying down
position with the involved lung dependent.
Uncontrollable hemorrhage warrants rigid bronchoscopy
and surgical consultation.
In stable patients, flexible bronchoscopy may localize the
site of bleeding, and angiography can embolize the involved
bronchial arteries. Embolization is effective initially in 85%
of cases, although rebleeding may occur in up to 20% of
patients over the following year. The anterior spinal artery
arises from the bronchial artery in up to 5% of people, and
paraplegia may result if it is inadvertently cannulated