Respiratory exam. F Medical

Chest radiography for abnormal vital signs or chest examination, elderly and immunocompromised persons, and unexplained cough lasting more than 3 to 6 weeks

Catheter devices that fragment and extract thrombus have been used on small numbers of patients. • Inferior venal caval (IVC) interruption (IVC filters) may be indicated when a significant contraindication to anticoagulation exists or when recurrence occurs despite adequate anticoagulation. • IVC filters decrease the short-term incidence of PE but increase the long-term rate of recurrent DVT; thus, provision should be made for their removal at the time of insertion.

Removal of tonsils in cases of recurrent abscesses

Pulse oximetry at rest and with ambulation (not to supplant ABG and, when indicated, CO and methemoglobin measurements) • Electrocardiography (ECG) • Spirometry in patients with suspected obstructive or restrictive airway disease

Common disease affecting nearly 20 million Americans annually. • Usually is a result of impaired mucociliary clearance and obstruction of the ostiomeatal complex, or sinus “pore.” • Edematous mucosa causes obstruction of the complex, resulting in the accumulation of mucous secretion in the sinus cavity that becomes secondarily infected by bacteria. • The typical pathogens are S pneumoniae; other streptococci; H influenza; and less commonly, Staph aureus and M catarrhalis. • Discolored nasal discharge and poor response to decongestants suggest sinusitis.

Thoracentesis and cytology of malignant effusions; fine-needle aspiration of lymph nodes (which may be CT guided). • Bronchoscopy with or without electromagnetic navigation, mediastinoscopy, video-assisted thoracoscopic surgery, or thoracotomy, if needed, for tissue diagnosis

Medications • Treatment should be aimed at the underlying cause (eg, transfusion and iron repletion for severe anemia caused by blood loss; inhaled β2-agonist, anticholinergic, and corticosteroid for asthma). • Opioid therapy can relieve dyspnea that occurs in patients nearing the end of life. Therapeutic Procedures • Supplemental oxygen should be given for patients with hypoxemia; such supplementation in severe COPD with hypoxemia confers a mortality benefit. • Pulmonary rehabilitation should be done in patients with COPD or interstitial pulmonary fibrosis.

Predisposition to venous thrombosis, usually of the lower extremities • Usually dyspnea, chest pain, hemoptysis, or syncope • Tachypnea and a widened alveolar-arterial Po2 difference • Elevated rapid D-dimer and characteristic defects on CT arteriogram of the chest, ventilation-perfusion lung scan, or pulmonary angiogram

Chest radiograph findings range from patchy airspace opacities to lobar consolidation with air bronchograms to diffuse alveolar or interstitial opacities. • Clearing of opacities can take 6 weeks or longer.

Lung transplantation greatly improves pulmonary function and exercise tolerance. • Lung volume reduction surgery in highly selected patients results in modest improvements. • Bullectomy is used for palliation of dyspnea in patients with severe bullous emphysema.

Rapid onset, severe dyspnea: suggests pneumothorax, pulmonary embolism, or flash pulmonary edema. • Pleuritic chest pain: suggests pneumothorax, pulmonary embolism, pericarditis, or pleurisy • Immobilization or hospitalization, cancer, or lower extremity trauma: suggest pulmonary embolism. • Cough and fever: suggest pulmonary disease, particularly infections, myocarditis, or pericarditis. • Wheezing: suggests acute bronchitis, chronic obstructive pulmonary disease (COPD), asthma, foreign body, or vocal cord dysfunction. • Prominent dyspnea with no accompanying features: suggests noncardiopulmonary causes such as anemia, metabolic acidosis, panic disorder, neuromuscular disorders, respiratory muscle weakness, chronic pulmonary embolism, or other causes of impaired oxygen delivery (eg, methemoglobinemia, CO poisoning). • Inspection of respiratory pattern can suggest obstructive airway disease (pursed-lip breathing, accessory respiratory muscle use, barrel-shaped chest), asymmetric expansion (pneumothorax), or metabolic acidosis (deep Kussmaul respirations). • Focal wheezing may suggest foreign body or bronchial obstruction. • Accentuated pulmonic second heart sound (loud P2): suggests pulmonary hypertension or pulmonary embolism. • Orthopnea (dyspnea that occurs in recumbency) and paroxysmal nocturnal dyspnea (shortness of breath that occurs abruptly 30 minutes to 4 hours after going to bed and is relieved by sitting or standing up) and other findings suggestive of elevated LV end-diastolic pressure suggest cardiac disease and heart failure.

Long-term control therapies include inhaled corticosteroids, inhaled long-acting β2-agonists (often in combination with inhaled corticosteroids), systemic corticosteroids, leukotriene modifiers, mediator inhibitors, and phosphodiesterase inhibitors. • Relief therapy or “rescue” therapies include short-acting inhaled β2-agonists, inhaled anticholinergics, and systemic corticosteroids. • Acute exacerbations are treated with inhaled short-acting β2-agonists with or without systemic corticosteroids depending on the severity. • Severe exacerbations (PEFR <40% predicted or personal best) may also require oxygen treatment, inhaled ipratropium bromide, and intravenous magnesium sulfate. • Chronic asthma treatment is guided by asthma severity. • Mild intermittent asthma treatment requires inhaled short-acting β2-agonists for rescue. • Mild persistent asthma treatment includes daily use of a long-term control therapy. • Moderate persistent asthma treatment requires increased corticosteroid dose or adding long-acting inhaled β2-agonist. • Severe persistent asthma treatment requires daily high-dose inhaled corticosteroid and long-acting β2-agonist. • Theophylline is a less-preferred alternative to long-acting bronchodilators.

Viral pharyngitis or EBV or infectious mononucleosis • Primary HIV infection • Candidiasis • Necrotizing ulcerative gingivostomatitis (Vincent fusospirochetal disease) • Retropharyngeal abscess • Diphtheria • Other bacterial pharyngitis: Neisseria gonorrhoeae, mycoplasma, anaerobic streptococci, Corynebacterium haemolyticum • Epiglottitis

For hospital-acquired sinusitis, removal of a nasogastric tube, improved nasal hygiene, and endoscopic or transantral cultures (particularly in HIV-infected or other immunocompromised patients) may be helpful.

History of cigarette smoking • Chronic cough, dyspnea, and sputum production • Rhonchi, decreased intensity of breath sounds, and prolonged expiration on physical examination • Airflow limitation on PFT

Serum B-type natriuretic peptide (BNP or NT-proBNP) testing can help distinguish cardiac from noncardiac causes. • ABG analysis. • Hematocrit or hemoglobin, methemoglobin, or CO measurement as indicated.

Noncontrast coronal computed tomography scans are more cost-effective than conventional films; provide a rapid and effective means to assess all of the paranasal sinuses, identify areas of concern, and direct therapy; and are indicated when symptoms persist longer than 4 to 12 weeks. • Routine sinus series radiographs are not cost-effective but may be helpful in difficult-to-evaluate cases, when the patient does not respond to appropriate therapy, or when the patient has symptoms or signs of more serious infection (eg, mucormycosis [infection with Rhizopus, Mucor, Absidia, or Cunninghamella sp]) are noted. • Magnetic resonance imaging with gadolinium is better at distinguishing tumor, fluid, inflammation, and bone destruction; use if malignancy, intracranial extension, or opportunistic infection is suspected.

Nasal endoscopy is indicated when symptoms persist longer than 4 to 12 weeks.

Myocardial infarction (heart attack) • Pneumonia • Pericarditis • Heart failure • Pleuritis (pleurisy) • Pneumothorax • Pericardial tamponade

Aspiration pneumonia or pneumonitis • Pneumocystis jirovecii pneumonia (PCP) • Acute respiratory distress syndrome (ARDS) • Bronchitis • Lung abscess or obstructing neoplasm • Tuberculosis • Pulmonary emboli • Myocardial infarction or heart failure • Sarcoidosis • Interstitial lung disease • Hypersensitivity pneumonitis • Bronchiolitis, cryptogenic organizing pneumonitis (bronchiolitis obliterans with organizing pneumonia [BOOP]) • Drug reactions • Pulmonary hemorrhage • Atelectasis

Centor diagnostic criteria for group Aβ-hemolytic streptococcus infection are (1) fever greater than 38°C, (2) tender anterior cervical adenopathy, (3) lack of cough, and (4) pharyngotonsillar exudate. • Sore throat may be severe, with odynophagia, tender adenopathy, and a scarlatiniform rash. • Hoarseness, cough, and coryza are not suggestive of group A β-hemolytic streptococcus infection. • Marked lymphadenopathy and a shaggy white-purple tonsillar exudate, often extending into the nasopharynx, suggest mononucleosis, especially if present in a young adult.

Presentation usually at 40 to 50 years of age with cough, sputum production, and shortness of breath. • Dyspnea initially occurs only with heavy exertion, progressing to symptoms at rest in severe disease. • Exacerbation of symptoms is beyond normal day-to-day variation, often including increased dyspnea, an increased frequency or severity of cough, increased sputum volume, or a change in sputum character. • Infections (viral more commonly than bacterial) precede exacerbations in most patients. • Late-stage COPD characterized by hypoxemia, pneumonia, pulmonary hypertension, cor pulmonale, and respiratory failure. • Clinical findings may be absent early. • Patients are often dichotomized as “pink puffers” or “blue bloaters” depending on whether emphysema or chronic bronchitis predominates.

Abnormal findings are seen on chest radiograph or CT scan; CT scan determines staging and resectability. • An MRI of the brain is important to stage patients who present with at least stage II disease in order to rule out brain metastases. • PET imaging can help confirm no metastases in NSCLC patients who are candidates for surgical resection. • PET-CT scans are inadequate for evaluating brain metastases due to the high FDG uptake there.

Sore throat, fever, anterior cervical adenopathy, and tonsillar exudate suggest group A β-hemolytic streptococcus infection.

Sputum Gram stain, blood cultures, rapid influenza testing, or urine antigen assays for Legionella pneumophila and S pneumoniae may guide antibiotic treatment. • All hospitalized patients should have complete blood count, chemistry panel, and arterial blood gas analysis. • HIV testing should be done in all adult patients. • Preantibiotic sputum and blood cultures has been standard practice for patients who require hospitalization. • Blood cultures can identify the pathogen, particularly in cases of HAP.

Inquire about Fever, cough, chest pain; onset, duration, severity, and periodicity of symptoms Vital sign measurement and pulse oximetry Cardiac and chest examination findings Chest radiography findings; arterial blood gas (ABG) measurement in selected patients

Episodic or chronic symptoms of airflow obstruction • Reversibility of airflow obstruction, either spontaneously or after bronchodilator therapy • Symptoms frequently worse at night or in the early morning • Prolonged expiration and diffuse wheezes on physical examination • Limitation of airflow on pulmonary function testing or positive bronchoprovocation challenge

Upper respiratory tract infection • Viral rhinitis • Allergic rhinitis • Nasal polyposis • Dental abscess • Rhinocerebral mucormycosis • Otitis media • Pharyngitis • Dacryocystitis • Paranasal sinus cancer

Acute or subacute onset of fever, cough with or without sputum, and dyspnea may be present. • Rigors, sweats, chills, pleurisy, chest discomfort, and hemoptysis are common. • Fatigue, anorexia, headache, myalgias, and abdominal pain may be present. • Physical findings include fever or hypothermia, tachypnea, tachycardia, decreased oxygen saturation, rales or abnormal breath sounds, and dullness to percussion. • Symptoms may be more nonspecific in HAP and VAP; two or more clinical findings (fever, leukocytosis, and purulent sputum) in the setting of a new or progressive pulmonary opacity on chest radiograph are suggestive.

The presence of the four Centor diagnostic criteria strongly suggests group A β-hemolytic streptococcus infection, and some would treat the patient regardless of laboratory results. • When three of the four Centor criteria are present, there is an intermediate likelihood of GABHS. • When two or three Centor criteria are present, throat cultures or rapid antigen detection testing of a throat swab should be obtained. • When zero or one Centor criterion is present, group A β-hemolytic streptococcus infection is unlikely; throat culture or rapid antigen detection testing of a throat swab is not necessary. • A single-swab throat culture is 90% to 95% sensitive and the rapid antigen detection testing (RADT) is 90% to 99% sensitive for GABHS. • With about 90% sensitivity, lymphocyte to white blood cell ratios of greater than 35% suggest EBV infection, not tonsillitis. • Consider HIV antibody or viral load testing for acute HIV infection.