Dyspnea Overview and Conditions
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Questions and Answers

Which of the following is NOT a major risk factor for pulmonary embolism (PE)?

  • Oral contraceptives
  • Recent surgery
  • Upper airway disease (correct)
  • Prolonged immobilization

    • Which of the following conditions is considered a chronic cause of dyspnea?

  • Pulmonary embolism
  • Acute bronchial asthma
  • Pneumonia
  • Chronic obstructive pulmonary disease (correct)

    • What percentage of pulmonary embolism cases result in sudden death?

  • 75%
  • 10%
  • 50%
  • 25% (correct)

    • What is the primary symptom that occurs in the majority of pulmonary embolism cases?

    <p>Dyspnea</p> Signup and view all the answers

    Which diagnostic test is considered highly sensitive and specific for detecting proximal pulmonary emboli?

    <p>Helical/spiral chest CT</p> Signup and view all the answers

    Among the following, which neuromuscular disease is associated with dyspnea?

    <p>Amyotrophic lateral sclerosis (ALS)</p> Signup and view all the answers

    Which of the following is a consequence of a pulmonary embolism?

    <p>Acute respiratory distress syndrome (ARDS)</p> Signup and view all the answers

    Regarding inherited coagulopathies, which of the following is correctly paired with a condition?

    <p>Prothrombin gene defects - Deep vein thrombosis</p> Signup and view all the answers

    Which incorrect statement about dyspnea causes can be made?

    <p>Restrictive lung diseases are not linked to dyspnea.</p> Signup and view all the answers

    Which of the following best summarizes the role of D-dimer in diagnosing pulmonary embolism?

    <p>A normal D-dimer level essentially rules out PE.</p> Signup and view all the answers

    Which diagnostic test is least accurate for identifying peripheral emboli?

    <p>Chest X-ray</p> Signup and view all the answers

    In which type of spontaneous pneumothorax does a person typically have no prior lung disease?

    <p>Primary pneumothorax</p> Signup and view all the answers

    What defines chronic bronchitis as a subtype of COPD?

    <p>Chronic productive cough lasting over 3 months in 2 consecutive years</p> Signup and view all the answers

    Which symptom is NOT commonly associated with emphysema?

    <p>Cough with copious sputum</p> Signup and view all the answers

    What is a common risk factor for the development of emphysema?

    <p>Smoking</p> Signup and view all the answers

    Which finding would NOT typically appear on a chest X-ray for chronic bronchitis?

    <p>Hyperinflation</p> Signup and view all the answers

    What characterizes the COPD classification for Stage 3 severity?

    <p>FEV1 30-50% predicted</p> Signup and view all the answers

    What is a characteristic symptom of chronic obstructive pulmonary disease?

    <p>Wheezing and rhonchi</p> Signup and view all the answers

    Which of the following conditions is associated with secondary spontaneous pneumothorax?

    <p>Emphysema</p> Signup and view all the answers

    The ABG findings in a patient with severe chronic bronchitis would most likely show what?

    <p>Hypercapnia, hypoxemia, and acidosis</p> Signup and view all the answers

    Choking is categorized under pulmonary issues causing dyspnea.

    <p>True</p> Signup and view all the answers

    Congestive Heart Failure (CHF) is classified as a primary pulmonary cause of dyspnea.

    <p>False</p> Signup and view all the answers

    Anemia is considered a risk factor for developing pulmonary embolism (PE).

    <p>True</p> Signup and view all the answers

    A positive Homan's sign is not a sign associated with pulmonary embolism.

    <p>False</p> Signup and view all the answers

    Oral contraceptives are considered a risk factor for hypercoagulable states.

    <p>True</p> Signup and view all the answers

    The majority of people who survive a pulmonary embolism will experience another within 5 years.

    <p>False</p> Signup and view all the answers

    Pneumonia is classified as a chronic condition causing dyspnea.

    <p>False</p> Signup and view all the answers

    Tachypnea occurs in over 50% of cases of pulmonary embolism.

    <p>True</p> Signup and view all the answers

    Factor V Leiden mutation is an inherited coagulopathy risk factor for pulmonary embolism.

    <p>True</p> Signup and view all the answers

    High altitude pulmonary edema is classified as a chronic condition causing dyspnea.

    <p>False</p> Signup and view all the answers

    Smoking is the only risk factor for chronic bronchitis.

    <p>False</p> Signup and view all the answers

    Hypercapnia is a key finding on ABG testing for a patient with emphysema.

    <p>False</p> Signup and view all the answers

    The chest X-ray of a patient with chronic obstructive pulmonary disease usually shows a normal heart size.

    <p>False</p> Signup and view all the answers

    The typical lung exam findings in emphysema include decreased breath sounds and prolonged expiratory phase.

    <p>True</p> Signup and view all the answers

    Chest X-rays can sometimes show the Westermark sign in cases of pulmonary embolism.

    <p>True</p> Signup and view all the answers

    Secondary spontaneous pneumothorax occurs without any prior lung disease.

    <p>False</p> Signup and view all the answers

    A significant characteristic of chronic bronchitis is a chronic productive cough lasting for less than 2 months.

    <p>False</p> Signup and view all the answers

    Young, tall, thin males are considered at greater risk for primary spontaneous pneumothorax.

    <p>True</p> Signup and view all the answers

    Pulmonary function tests in emphysema usually show an increased FEV1/FVC ratio.

    <p>False</p> Signup and view all the answers

    Westermark sign on chest X-ray indicates an area of increased blood flow.

    <p>False</p> Signup and view all the answers

    What is the primary symptom of chronic bronchitis?

    <p>Chronic productive cough</p> Signup and view all the answers

    Emphysema is solely caused by genetic factors.

    <p>False</p> Signup and view all the answers

    What might a chest X-ray show in a patient with emphysema?

    <p>Bleb formation</p> Signup and view all the answers

    In chronic obstructive pulmonary disease (COPD), the FEV1/FVC ratio is generally less than _____%.

    <p>80</p> Signup and view all the answers

    Match each type of pneumothorax with its description:

    <p>Primary = Occurs without prior lung disease Secondary = Results from pre-existing lung disease</p> Signup and view all the answers

    Which of the following is a common symptom of COPD?

    <p>Progressive dyspnea</p> Signup and view all the answers

    Chest X-ray findings in chronic bronchitis typically show an enlarged heart regardless of other factors.

    <p>False</p> Signup and view all the answers

    What is a known risk factor for developing primary spontaneous pneumothorax?

    <p>Young, tall, thin males</p> Signup and view all the answers

    Chronic bronchitis is primarily associated with _____ as the most common risk factor.

    <p>smoking</p> Signup and view all the answers

    Which of the following diagnostic tests is least accurate for identifying peripheral emboli?

    <p>Chest X-ray</p> Signup and view all the answers

    Which of the following is a typical symptom of pulmonary embolism?

    <p>Dyspnea</p> Signup and view all the answers

    Congestive Heart Failure (CHF) is classified purely as a pulmonary cause of dyspnea.

    <p>False</p> Signup and view all the answers

    Name one major risk factor for pulmonary embolism?

    <p>Prolonged immobilization</p> Signup and view all the answers

    Dyspnea can occur due to dysfunction in the ___ system.

    <p>cardiovascular</p> Signup and view all the answers

    Match the following conditions with their classifications:

    <p>Pneumonia = Acute condition Chronic Bronchitis = Chronic condition Congestive Heart Failure = Non-pulmonary condition Spontaneous Pneumothorax = Acute condition</p> Signup and view all the answers

    What is a common characteristic of chronic obstructive pulmonary disease (COPD)?

    <p>Persistent cough with sputum</p> Signup and view all the answers

    A D-dimer test returning normal results can rule out pulmonary embolism.

    <p>True</p> Signup and view all the answers

    List one acute condition that can cause dyspnea.

    <p>Pneumonia</p> Signup and view all the answers

    Dyspnea rates increase in conditions like ___ and obesity.

    <p>anemia</p> Signup and view all the answers

    Which of the following diseases is a neuromuscular cause of dyspnea?

    <p>Amyotrophic Lateral Sclerosis (ALS)</p> Signup and view all the answers

    Which statement correctly identifies a risk factor related to pulmonary embolism (PE)?

    <p>Prolonged immobilization</p> Signup and view all the answers

    What symptom is least likely to be associated with a pulmonary embolism?

    <p>Persistent cough</p> Signup and view all the answers

    Which of the following conditions does NOT contribute to dyspnea through pulmonary issues?

    <p>Obesity</p> Signup and view all the answers

    Which of the following identifies a common non-pulmonary cause of dyspnea?

    <p>Congestive Heart Failure (CHF)</p> Signup and view all the answers

    What is the role of the D-dimer test in the context of diagnosing pulmonary embolism?

    <p>A normal result definitively rules out PE.</p> Signup and view all the answers

    Which condition is NOT classified as an acute cause of dyspnea?

    <p>Chronic Bronchitis</p> Signup and view all the answers

    What characterizes the major risk factor groups for pulmonary embolism?

    <p>They cover a range of medical and lifestyle conditions.</p> Signup and view all the answers

    Which inherited coagulopathy is associated with an increased risk for developing pulmonary embolism?

    <p>Protein C deficiency</p> Signup and view all the answers

    Which symptom is often regarded as a key indicator of a massive pulmonary embolism?

    <p>Coughing up blood</p> Signup and view all the answers

    What is a typical finding on a chest CT when evaluating for pulmonary embolism?

    <p>Proximal PEs in main arteries</p> Signup and view all the answers

    What is a defining feature of emphysema compared to other forms of COPD?

    <p>Permanent enlargement of air spaces distal to terminal bronchioles</p> Signup and view all the answers

    Which of the following is a key diagnostic feature for chronic bronchitis?

    <p>History of chronic productive cough for at least 3 months in consecutive years</p> Signup and view all the answers

    What finding might a chest X-ray reveal in a patient with chronic obstructive pulmonary disease (COPD)?

    <p>Enlarged heart with rounded hemidiaphragms</p> Signup and view all the answers

    Which condition is most likely to show hypocapnia on arterial blood gas (ABG) analysis?

    <p>Primary spontaneous pneumothorax</p> Signup and view all the answers

    What is a common symptom associated with emphysema?

    <p>Progressive dyspnea with possible weight loss</p> Signup and view all the answers

    Which of the following factors is least likely to contribute to the risk of developing emphysema?

    <p>Long-term usage of inhaled corticosteroids</p> Signup and view all the answers

    What might the pulmonary function tests indicate in a patient with advanced emphysema?

    <p>Decreased FEV1/FVC ratio indicating airflow obstruction</p> Signup and view all the answers

    Which of the following is an important diagnostic test for assessing pulmonary embolism?

    <p>Spiral CT scan</p> Signup and view all the answers

    Which demographic is most at risk for primary spontaneous pneumothorax?

    <p>Young, tall, thin males</p> Signup and view all the answers

    Which ABG finding is most commonly associated with severe chronic bronchitis?

    <p>Hypercapnia, hypoxemia, and acidosis</p> Signup and view all the answers

    Which of the following is a non-pulmonary condition that can lead to dyspnea?

    <p>Congestive heart failure</p> Signup and view all the answers

    Which acute condition is NOT associated with causing dyspnea?

    <p>Congestive heart failure</p> Signup and view all the answers

    Which of the following statements correctly describes a risk factor for pulmonary embolism (PE)?

    <p>Surgery longer than 30 minutes</p> Signup and view all the answers

    What percentage of patients who experience a pulmonary embolism are at risk for another PE within the next ten years?

    <p>33%</p> Signup and view all the answers

    In which scenario would a person's risk for venous thromboemboli increase the most?

    <p>Sitting on a long bus trip</p> Signup and view all the answers

    What is a consequence of prolonged immobilization?

    <p>Increased risk of pulmonary embolism</p> Signup and view all the answers

    Which of the following factors is linked to hypercoagulable states?

    <p>History of malignancy</p> Signup and view all the answers

    Which of the following lung conditions is considered chronic and can lead to dyspnea?

    <p>Emphysema</p> Signup and view all the answers

    Which of the following symptoms is NOT commonly associated with a pulmonary embolism?

    <p>Abdominal pain</p> Signup and view all the answers

    What is a primary risk factor for spontaneous pneumothorax?

    <p>Tall, thin males under 40</p> Signup and view all the answers

    Which diagnostic test is traditionally used to rule out a pulmonary embolism?

    <p>D-dimer test</p> Signup and view all the answers

    What characterizes primary spontaneous pneumothorax?

    <p>Acute onset of dyspnea</p> Signup and view all the answers

    What is the heart function indicator that denotes heart failure when it is less than 35%?

    <p>Ejection fraction</p> Signup and view all the answers

    Which condition is mainly diagnosed using a chest X-ray to show visceral and pleural lines?

    <p>Spontaneous pneumothorax</p> Signup and view all the answers

    Which of the following indicates the presence of a significant pulmonary embolism?

    <p>Hemoptysis</p> Signup and view all the answers

    Which class of the New York Heart Association classification indicates no limitations during normal activities?

    <p>Class one</p> Signup and view all the answers

    During the diagnostic evaluation for pulmonary embolism, which finding on a chest CT is most relevant?

    <p>Pulmonary artery obstruction</p> Signup and view all the answers

    What type of anemia is characterized by low mean corpuscular volume and low mean corpuscular hemoglobin concentration?

    <p>Microcytic anemia</p> Signup and view all the answers

    What is a common finding in patients with foreign body aspiration during examination?

    <p>Localized wheezing</p> Signup and view all the answers

    What symptom indicates stage D heart failure?

    <p>Requires specialized care to survive</p> Signup and view all the answers

    Which finding is typically NOT associated with chronic bronchitis?

    <p>Significant weight loss</p> Signup and view all the answers

    Which finding on a chest X-ray might suggest pulmonary venous hypertension in heart failure patients?

    <p>Cardiomegaly</p> Signup and view all the answers

    An increased cardio-thoracic ratio greater than 0.5 on a chest X-ray indicates what condition?

    <p>Heart failure</p> Signup and view all the answers

    Which symptom would most likely occur immediately during a foreign body aspiration event?

    <p>Acute onset of dyspnea</p> Signup and view all the answers

    What does prolonged expiratory phase indicate in a patient with a respiratory condition?

    <p>Emphysema</p> Signup and view all the answers

    Which laboratory test is specifically a marker for heart failure that indicates heart muscle stretching?

    <p>B-type natriuretic peptide (BNP)</p> Signup and view all the answers

    Hemoglobin primarily serves which function in the body?

    <p>Transport oxygen to tissues</p> Signup and view all the answers

    Which of these conditions is most likely associated with a positive Homan sign?

    <p>Pulmonary embolism</p> Signup and view all the answers

    What is a potential complication of foreign body aspiration?

    <p>Pneumonia</p> Signup and view all the answers

    Which abnormal heart sound may indicate fluid overload in heart failure patients?

    <p>S3</p> Signup and view all the answers

    What is the lifespan of a red blood cell before it is broken down?

    <p>3 months</p> Signup and view all the answers

    What vital sign change is primarily associated with hyperventilation in younger individuals?

    <p>Tachycardia</p> Signup and view all the answers

    What primary component of hemoglobin is essential for oxygen transport?

    <p>Iron</p> Signup and view all the answers

    What is a possible consequence of untreated iron deficiency anemia?

    <p>Impaired oxygen delivery to tissues</p> Signup and view all the answers

    What type of anemia has a normal mean corpuscular hemoglobin concentration but increased size of red blood cells?

    <p>Macrocytic normochromic</p> Signup and view all the answers

    What clinical finding is typically observed in patients with chronic bronchitis?

    <p>Cyanosis with a normal AP diameter</p> Signup and view all the answers

    Which symptom is most characteristic of emphysema compared to chronic bronchitis?

    <p>Progressive shortness of breath</p> Signup and view all the answers

    In chronic bronchitis, what might the ABGs indicate as the disease progresses?

    <p>Mild hypoxemia</p> Signup and view all the answers

    What do pulmonary function tests typically show in a patient with emphysema?

    <p>Increased total lung capacity</p> Signup and view all the answers

    What are potential causes of emphysema?

    <p>Exposure to air pollution and chemicals</p> Signup and view all the answers

    Which finding on a chest X-ray is more characteristic of emphysema than chronic bronchitis?

    <p>Darkened lung fields with decreased markings</p> Signup and view all the answers

    When considering its clinical syndrome, what symptom is associated with congestive heart failure?

    <p>Fluid retention</p> Signup and view all the answers

    What characterizes Stage 1 COPD according to the classification system?

    <p>Normal spirometry with chronic cough</p> Signup and view all the answers

    What finding associated with advanced COPD is often seen on an EKG?

    <p>Right ventricular hypertrophy</p> Signup and view all the answers

    Which of the following is a recognized indicator of air trapping in emphysema?

    <p>Elevated residual volume</p> Signup and view all the answers

    What is a common complaint among patients with chronic bronchitis?

    <p>Intermittent mild to moderate dyspnea</p> Signup and view all the answers

    What presence on an ABG test is often notable in emphysema patients?

    <p>Mild hypoxemia less than a normal range</p> Signup and view all the answers

    What secondary pathophysiological change can occur in the advanced stages of chronic bronchitis?

    <p>Right axis deviation on EKG</p> Signup and view all the answers

    Which of the following conditions is categorized as a normocytic normochromic anemia?

    <p>Hypopituitarism</p> Signup and view all the answers

    What is a significant diagnostic feature of hemolytic anemias?

    <p>High reticulocyte count</p> Signup and view all the answers

    In cases of iron deficiency anemia, what would you expect regarding total iron binding capacity (TIBC)?

    <p>Elevated TIBC</p> Signup and view all the answers

    What condition is associated with the sign of 'spoon nails'?

    <p>Iron deficiency anemia</p> Signup and view all the answers

    Which physical examination finding might indicate severe anemia?

    <p>Pallor and lethargy</p> Signup and view all the answers

    Which laboratory test is most critical for diagnosing anemia?

    <p>Complete blood count (CBC)</p> Signup and view all the answers

    What symptom may be observed in a patient with vitamin B12 deficiency?

    <p>Burning tongue</p> Signup and view all the answers

    Which condition may result from accelerated red blood cell destruction?

    <p>Hemolytic anemia</p> Signup and view all the answers

    What is an expected reticulocyte count in a patient experiencing bone marrow suppression?

    <p>Decreased reticulocyte count</p> Signup and view all the answers

    Which of the following is NOT a common cause of normocytic normochromic anemia?

    <p>Vitamin A deficiency</p> Signup and view all the answers

    Which clinical manifestation might indicate severe anemia?

    <p>Postural hypotension</p> Signup and view all the answers

    What specific symptom may indicate an iron deficiency in a patient?

    <p>Pica</p> Signup and view all the answers

    Which condition should warrant referral to a hematologist?

    <p>Hemolytic anemia</p> Signup and view all the answers

    Which of the following is a sign of bone marrow suppression?

    <p>Decreased reticulocyte count</p> Signup and view all the answers

    What is the primary pathogen associated with community-acquired pneumonia that causes significant morbidity and mortality?

    <p>Streptococcus pneumoniae</p> Signup and view all the answers

    Which risk factor is NOT commonly associated with pneumonia mortality?

    <p>Young age</p> Signup and view all the answers

    In which situation is hospitalization always required for pneumonia patients?

    <p>CURB score of 4</p> Signup and view all the answers

    Which of the following is a common trigger for asthma?

    <p>Dust mites</p> Signup and view all the answers

    What percentage of adult patients is affected by asthma?

    <p>7.6%</p> Signup and view all the answers

    What diagnostic test might be performed if a patient with pneumonia is high risk for tuberculosis?

    <p>Sputum culture</p> Signup and view all the answers

    What is a defining characteristic of hospital-acquired pneumonia?

    <p>Developing after 48 hours of hospital admission</p> Signup and view all the answers

    Which symptom is commonly associated with a severe asthma attack?

    <p>Nasal flaring</p> Signup and view all the answers

    Which of the following is a common causative pathogen associated with hospital-acquired pneumonia?

    <p>Pseudomonas aeruginosa</p> Signup and view all the answers

    The gold standard diagnostic test for asthma is:

    <p>Spirometry</p> Signup and view all the answers

    What is the typical duration a cough would last in a patient with tuberculosis?

    <p>Three weeks or longer</p> Signup and view all the answers

    Which sign is NOT commonly associated with acute pneumonia?

    <p>Hypercapnia</p> Signup and view all the answers

    What is the most common chronic cough cause related to lifestyle choices?

    <p>Smoking</p> Signup and view all the answers

    Which diagnostic test would NOT be appropriate for a patient with a BCG vaccine?

    <p>Tuberculin skin test</p> Signup and view all the answers

    Which factor can contribute to the worsening of gastroesophageal reflux disease (GERD)?

    <p>Obesity</p> Signup and view all the answers

    Which of the following is NOT a common symptom of tuberculosis?

    <p>Wheezing</p> Signup and view all the answers

    What indicates a positive tuberculin skin test for the general population?

    <p>Greater than 15 mm</p> Signup and view all the answers

    Which symptom is NOT typical of GERD?

    <p>Fatigue</p> Signup and view all the answers

    What is a common result of chronic cough in smokers after quitting smoking?

    <p>Resolution in 30 days</p> Signup and view all the answers

    Which condition could mimic asthma symptoms?

    <p>Gastroesophageal reflux disease (GERD)</p> Signup and view all the answers

    What might a healthcare professional observe in a physical exam of a patient with acute pneumonia?

    <p>Leukocytosis</p> Signup and view all the answers

    Which of the following is a common sign associated with respiratory distress in asthma?

    <p>Cyanosis</p> Signup and view all the answers

    Which condition commonly leads to chronic cough in the non-smoking population?

    <p>Asthma</p> Signup and view all the answers

    What is a characteristic symptom of a patient presenting with pancreatitis?

    <p>Severe abdominal pain radiating to the back</p> Signup and view all the answers

    Which of the following is a common characteristic of lobar pneumonia observed on examination?

    <p>Dullness on percussion</p> Signup and view all the answers

    In cases of extra pulmonary tuberculosis, which of the following sites is most commonly affected?

    <p>Lymph nodes</p> Signup and view all the answers

    What may you find in a chest X-ray of a patient with tuberculosis?

    <p>All of the above</p> Signup and view all the answers

    What is the triad sign of advanced renal disease commonly associated with?

    <p>Hematuria, pain, and a palpable flank mass</p> Signup and view all the answers

    Which imaging tool is considered the most valuable for staging renal tumors?

    <p>CT scan</p> Signup and view all the answers

    What percentage of patients will present with gross or microscopic hematuria related to renal disease?

    <p>60%</p> Signup and view all the answers

    Which of the following symptoms is least likely to be associated with renal tumors?

    <p>Seasonal allergies</p> Signup and view all the answers

    What range of percentage of renal tumor patients may present with metastatic disease symptoms such as cough or bone pain?

    <p>20-30%</p> Signup and view all the answers

    What condition should be considered as a differential in a young child presenting with abdominal pain?

    <p>Appendicitis</p> Signup and view all the answers

    In elderly patients with pelvic pain, which condition should be prioritized for screening?

    <p>Diverticulitis</p> Signup and view all the answers

    Which of the following factors increases the risk of appendicitis in a patient?

    <p>Family history of appendicitis</p> Signup and view all the answers

    Which symptom is a red flag indicating a potential need for surgical intervention in adults with abdominal pain?

    <p>Vomiting after the onset of pain</p> Signup and view all the answers

    What is a common physical exam maneuver used to assess for gallbladder inflammation?

    <p>Murphy's sign</p> Signup and view all the answers

    What condition is characterized by severe left shoulder pain and may indicate splenic rupture?

    <p>Kehr's sign</p> Signup and view all the answers

    Which diagnostic test is preferred for ruling out free or contained abscess in abdominal pain cases?

    <p>CT scan</p> Signup and view all the answers

    What is a key symptom of diverticulitis in patients over 50?

    <p>Acute left lower quadrant pain</p> Signup and view all the answers

    Which test is least ideal for quickly assessing acute abdominal pain when avoiding radiation exposure is a priority?

    <p>MRI</p> Signup and view all the answers

    What is a common gastrointestinal issue associated with chronic pancreatitis?

    <p>Bulky, foul-smelling clay-colored stool</p> Signup and view all the answers

    What distinguishes Crohn's disease from ulcerative colitis?

    <p>Transmural inflammation and skip lesions</p> Signup and view all the answers

    Which laboratory finding is most indicative of diverticulitis during an examination?

    <p>Elevated white blood cell count</p> Signup and view all the answers

    Which of the following symptoms in children would warrant immediate concern for serious abdominal conditions?

    <p>Projectile vomiting</p> Signup and view all the answers

    Which age range is most typical for the onset of inflammatory bowel disease?

    <p>15 to 35</p> Signup and view all the answers

    What is a common symptom that may indicate Crohn's disease?

    <p>Right lower quadrant pain after meals</p> Signup and view all the answers

    Which demographic group has a higher incidence of Crohn's disease?

    <p>Jewish individuals</p> Signup and view all the answers

    What might endoscopic examination reveal in a patient with Crohn's disease?

    <p>Skip lesions</p> Signup and view all the answers

    Which symptom is specifically associated with ulcerative colitis?

    <p>Bloody diarrhea with mucus and pus</p> Signup and view all the answers

    Which diagnostic test is important for evaluating potential appendicitis?

    <p>CBC, particularly looking for an increase in white blood cells</p> Signup and view all the answers

    Which symptom is least commonly associated with appendicitis?

    <p>High fever</p> Signup and view all the answers

    What is the male to female ratio of appendicitis occurrence before age 30?

    <p>3:2</p> Signup and view all the answers

    Which dietary factor is associated with an increased risk of developing appendicitis?

    <p>Fatty diet</p> Signup and view all the answers

    During the physical exam for appendicitis, which sign is typically tested?

    <p>Rovsing's sign</p> Signup and view all the answers

    What does tenesmus refer to in the context of inflammatory bowel disease?

    <p>Painful straining during bowel movements</p> Signup and view all the answers

    Which nutrient deficiencies are common in patients with malabsorption due to inflammatory bowel disease?

    <p>Vitamin B12, Vitamin D, and folic acid</p> Signup and view all the answers

    Which of the following best describes the inflammation pattern in Crohn's disease?

    <p>Segmented with normal areas in between</p> Signup and view all the answers

    What is the negative predictive value associated with an absolute neutrophil count below 7,500, procalcitonin below 0.1, and coal protectin below 0.5?

    <p>100%</p> Signup and view all the answers

    Which imaging test has a sensitivity of greater than 90% for detecting acute appendicitis?

    <p>Spiral CT</p> Signup and view all the answers

    What are common symptoms associated with irritable bowel syndrome?

    <p>Intermittent abdominal pain</p> Signup and view all the answers

    Which of the following is NOT one of the four criteria for diagnosing irritable bowel syndrome?

    <p>Weight gain</p> Signup and view all the answers

    What is the primary cause of cystitis?

    <p>E. Coli</p> Signup and view all the answers

    What is a common symptom of pyelonephritis?

    <p>Flank pain</p> Signup and view all the answers

    Which diagnostic test is best for detecting complications in patients with pyelonephritis?

    <p>CT Scan</p> Signup and view all the answers

    Which symptom is typically NOT associated with cholecystitis?

    <p>Weight loss</p> Signup and view all the answers

    What is the sensitivity range of ultrasound for ruling out appendicitis?

    <p>75-90%</p> Signup and view all the answers

    What lab finding would be expected in a patient with pyelonephritis?

    <p>Leukocyte casts</p> Signup and view all the answers

    Which fact about gallbladder inflammation should be noted?

    <p>It typically has a gradual onset.</p> Signup and view all the answers

    What is the most common cause of community-acquired pneumonia in pyelonephritis cases?

    <p>E. Coli</p> Signup and view all the answers

    How is the pain typically described in patients with gallstones?

    <p>Steady, severe pain</p> Signup and view all the answers

    What condition is associated with a gradual aspect of food intolerance and flatulence?

    <p>Cholecystitis</p> Signup and view all the answers

    What is the main characteristic of interstitial cystitis?

    <p>Recurrent cystitis and urinary frequency</p> Signup and view all the answers

    Which condition is associated with azotemia and oliguria?

    <p>Acute kidney injury</p> Signup and view all the answers

    What is the most common presenting symptom of bladder cancer?

    <p>Painless hematuria</p> Signup and view all the answers

    What is a cause of prerenal azotemia?

    <p>Renal artery stenosis</p> Signup and view all the answers

    Which of the following conditions is classified as postrenal azotemia?

    <p>Obstructive nephropathy</p> Signup and view all the answers

    Which factor is a major risk for chronic kidney disease?

    <p>Uncontrolled hypertension</p> Signup and view all the answers

    What might patients with chronic kidney disease experience as a symptom?

    <p>Chronic itching</p> Signup and view all the answers

    Which imaging technique is preferred for assessing the kidneys with low radiation?

    <p>Low radiation CT of abdomen and pelvis</p> Signup and view all the answers

    What is the definition of chronic kidney disease?

    <p>Kidney damage for over three months</p> Signup and view all the answers

    What can untreated prerenal azotemia lead to?

    <p>Irreversible tubular interstitial fibrosis</p> Signup and view all the answers

    Which of the following is a common sign of renal stones?

    <p>Severe flank pain</p> Signup and view all the answers

    Which demographic is at higher risk for chronic kidney disease?

    <p>Individuals over 60 years old</p> Signup and view all the answers

    What is a common complication of chronic kidney disease when GFR is less than 30?

    <p>Referral to a nephrologist</p> Signup and view all the answers

    Which of the following acute conditions is least likely to cause dyspnea?

    <p>Chronic bronchitis</p> Signup and view all the answers

    Which risk factor is specifically associated with the development of deep vein thrombosis (DVT)?

    <p>Prolonged bed rest</p> Signup and view all the answers

    Which of the following chronic conditions can lead to dyspnea due to neuromuscular dysfunction?

    <p>Amyotrophic lateral sclerosis</p> Signup and view all the answers

    Which mechanism can most directly lead to a pulmonary embolism?

    <p>Venous stasis</p> Signup and view all the answers

    Which statement about pulmonary embolism is incorrect?

    <p>It is solely caused by major trauma.</p> Signup and view all the answers

    Which of the following scenarios poses the highest risk for pulmonary embolism?

    <p>Prolonged immobilization due to illness</p> Signup and view all the answers

    Which non-pulmonary condition is commonly linked to causing dyspnea?

    <p>Anemia</p> Signup and view all the answers

    Which of the following symptoms is typical for patients experiencing dyspnea from restrictive lung disease?

    <p>Decreased lung capacity</p> Signup and view all the answers

    What characterizes Stage D heart failure?

    <p>Requires specialized care to survive</p> Signup and view all the answers

    Which ejection fraction value indicates heart failure?

    <p>35% or lower</p> Signup and view all the answers

    What does a BNP test specifically indicate?

    <p>Heart muscle stretching</p> Signup and view all the answers

    What is a common finding on a chest X-ray for a patient with heart failure?

    <p>Cardiomegaly</p> Signup and view all the answers

    Which of the following describes microcytic anemias?

    <p>Low mean corpuscular volume and low MCHC</p> Signup and view all the answers

    What might you observe in patients with chronic heart failure concerning jugular venous distention?

    <p>Positive jugular venous distention</p> Signup and view all the answers

    What condition commonly leads to macrocytic normochromic anemia?

    <p>Vitamin B12 deficiency</p> Signup and view all the answers

    In the context of heart failure, what does an enlarged heart indicate on a chest X-ray?

    <p>Cardiac width larger than half the transthoracic diameter</p> Signup and view all the answers

    Which of the following is a feature of Class 3 severity heart failure according to the New York Heart Association classification?

    <p>Comfortable only at rest</p> Signup and view all the answers

    Which of the following conditions can present as normocytic normochromic anemia?

    <p>Chronic renal insufficiency</p> Signup and view all the answers

    What does the presence of S3 or S4 heart sounds typically indicate?

    <p>Heart failure or volume overload</p> Signup and view all the answers

    What laboratory finding is indicative of hemolytic anemia?

    <p>Low hemoglobin and elevated reticulocyte count</p> Signup and view all the answers

    Which laboratory test would be most indicative of renal failure in the context of heart failure evaluation?

    <p>Blood urea nitrogen (BUN) and creatinine</p> Signup and view all the answers

    How are red blood cells primarily involved in gas exchange?

    <p>Carry oxygen from lungs to tissues</p> Signup and view all the answers

    In cases of iron deficiency anemia, what is expected regarding total iron binding capacity?

    <p>It is elevated due to available binding sites</p> Signup and view all the answers

    What distinguishes macrocytic anemias from microcytic anemias?

    <p>High mean corpuscular volume</p> Signup and view all the answers

    What might you observe during a physical exam of a patient with severe anemia?

    <p>Pallor and tachycardia</p> Signup and view all the answers

    Which question is pertinent in assessing a patient suspected of anemia?

    <p>Is the patient still bleeding?</p> Signup and view all the answers

    What is a common cause of hemolytic anemia?

    <p>Autoimmune disorders</p> Signup and view all the answers

    Which symptom is typically associated with anemia?

    <p>Easy fatigue ability</p> Signup and view all the answers

    What does a high RDW indicate in the context of anemia?

    <p>Increased variation in red blood cell size</p> Signup and view all the answers

    Which condition could potentially lead to bone marrow suppression?

    <p>Hypopituitarism</p> Signup and view all the answers

    Which diagnosis is not typically associated with hemolytic anemia?

    <p>Chronic inflammation</p> Signup and view all the answers

    What does a CBC with differential primarily evaluate?

    <p>Hemoglobin, hematocrit, and indices</p> Signup and view all the answers

    What is one symptom of severe anemia?

    <p>Postural dizziness</p> Signup and view all the answers

    How are hemolytic anemias typically classified in terms of onset?

    <p>Acute or chronic onset</p> Signup and view all the answers

    What clinical indicator is NOT typically associated with the assessment of pneumonia severity?

    <p>Cough presence with clear sputum</p> Signup and view all the answers

    What is the common pathogen responsible for the majority of community-acquired pneumonia cases?

    <p>Streptococcus pneumoniae</p> Signup and view all the answers

    Which of the following conditions is a characteristic symptom of gastroesophageal reflux disease (GERD)?

    <p>Sour taste in the mouth</p> Signup and view all the answers

    Which factor is a risk associated with hospital-acquired pneumonia?

    <p>Mechanical ventilation</p> Signup and view all the answers

    What is the characteristic pattern of cough typically seen in patients with chronic bronchitis?

    <p>Productive cough lasting more than three months</p> Signup and view all the answers

    Which of the following is considered a significant risk factor for the development of gastroesophageal reflux disease (GERD)?

    <p>Obesity</p> Signup and view all the answers

    In which patient group is Legionella pneumonia more likely to occur?

    <p>Immunocompromised individuals</p> Signup and view all the answers

    How long can transient airway hyperresponsiveness last following an upper respiratory infection?

    <p>7-8 weeks</p> Signup and view all the answers

    Which of the following findings is least likely to be present in a patient diagnosed with a bacterial pneumonia?

    <p>Normal white blood cell count</p> Signup and view all the answers

    Which type of pneumonia typically occurs more than 48 hours after hospital admission?

    <p>Hospital-acquired pneumonia</p> Signup and view all the answers

    What is the primary cause of chronic cough in smokers?

    <p>Cigarette smoking</p> Signup and view all the answers

    Which diagnostic test may be considered if a patient is suspected to have tuberculosis (TB) along with pneumonia?

    <p>Sputum culture</p> Signup and view all the answers

    What physical exam finding might indicate a consolidation in the lung due to pneumonia?

    <p>Dullness on percussion</p> Signup and view all the answers

    Which of the following is an atypical pathogen that can be responsible for pneumonia primarily in younger adults?

    <p>Mycoplasma pneumoniae</p> Signup and view all the answers

    What is the most common clinical presentation of renal tumors upon diagnosis?

    <p>Gross hematuria</p> Signup and view all the answers

    Which combination of symptoms is known as the triad sign of advanced renal disease?

    <p>Hematuria, pain, and a palpable flank mass</p> Signup and view all the answers

    Which imaging technique is considered the most valuable for staging renal tumors?

    <p>CT scan</p> Signup and view all the answers

    What percentage of patients with renal tumors present with metastatic disease?

    <p>20 to 30%</p> Signup and view all the answers

    Which symptom is most commonly associated with renal tumors when they are advanced?

    <p>Palpable abdominal mass</p> Signup and view all the answers

    What condition should be considered as a differential diagnosis for a young child presenting with abdominal pain?

    <p>Appendicitis</p> Signup and view all the answers

    Which of the following is a common sign associated with diverticulitis?

    <p>Rebound tenderness</p> Signup and view all the answers

    What key physical exam maneuver assesses for gallbladder issues?

    <p>Murphy's sign</p> Signup and view all the answers

    Which age group should be referred urgently for abdominal pain due to a higher risk of requiring surgery?

    <p>Adults over 65</p> Signup and view all the answers

    What specific symptom is indicative of a potential surgical abdomen in adults?

    <p>Pain that migrates from the umbilicus to the right lower quadrant</p> Signup and view all the answers

    Which of the following can mask the symptoms of peritonitis due to its anti-inflammatory effects?

    <p>Corticosteroids</p> Signup and view all the answers

    A high-resolution diagnostic test with comparable sensitivity and specificity to a CT scan is:

    <p>Abdominal ultrasound</p> Signup and view all the answers

    Which of the following is a characteristic finding in Crohn's disease?

    <p>Transmural inflammation affecting the entire GI tract</p> Signup and view all the answers

    Which sign indicates potential splenic rupture during a physical exam?

    <p>C sign</p> Signup and view all the answers

    Which symptoms are most commonly associated with asthma?

    <p>Cough and chest tightness</p> Signup and view all the answers

    Which of the following is NOT a red flag for requiring urgent attention in abdominal pain cases?

    <p>Pain persisting less than 2 hours</p> Signup and view all the answers

    What is considered the gold standard diagnostic test for asthma?

    <p>Spirometry</p> Signup and view all the answers

    In cases of diverticulitis, which symptom may indicate a more severe complication rather than the condition itself?

    <p>Bloody stools</p> Signup and view all the answers

    Which of the following is a typical finding in patients with pulmonary tuberculosis?

    <p>Calcifications in the apical lung region</p> Signup and view all the answers

    What is a common clinical feature of ulcerative colitis?

    <p>Mucosal layer inflammation only</p> Signup and view all the answers

    Which of the following indicates a possible gastrointestinal issue that may require further testing in children?

    <p>Current jelly stools</p> Signup and view all the answers

    Which demographic group is most likely to have a positive tuberculin skin test?

    <p>Non-white individuals with chronic illnesses</p> Signup and view all the answers

    What complication could arise from poorly managed asthma?

    <p>Airway remodeling and constriction</p> Signup and view all the answers

    Which of these conditions can both mimic and trigger asthma?

    <p>Gastroesophageal reflux disease</p> Signup and view all the answers

    What is a common characteristic of a cough in asthma patients?

    <p>May worsen at night</p> Signup and view all the answers

    What is a notable feature in diagnosing latent tuberculosis infection?

    <p>The patient is usually non-infectious</p> Signup and view all the answers

    Which of the following is NOT a common trigger for asthma?

    <p>High fiber diet</p> Signup and view all the answers

    In what situation would a positive tuberculin skin test be interpreted cautiously?

    <p>In individuals with HIV</p> Signup and view all the answers

    What is the minimum size of induration for a positive tuberculin skin test in high-risk individuals?

    <p>10 millimeters</p> Signup and view all the answers

    Which of the following differentials would be least likely for right lower quadrant pain?

    <p>Hepatitis</p> Signup and view all the answers

    Which condition is commonly associated with cough lasting more than three weeks?

    <p>Tuberculosis</p> Signup and view all the answers

    What is a characteristic presentation of cough in asthma during exacerbation?

    <p>Accompanied by wheezing</p> Signup and view all the answers

    What is a distinguishing symptom of emphysema compared to chronic bronchitis?

    <p>Progressive and constant dyspnea</p> Signup and view all the answers

    Which of the following findings on a chest X-ray is most characteristic of emphysema?

    <p>Bleb formation</p> Signup and view all the answers

    In a patient with chronic bronchitis, which pulmonary function test result is expected?

    <p>Normal compliance</p> Signup and view all the answers

    Which of the following reflects the severity classification of COPD in stage two?

    <p>FEV1 greater than 80% predicted</p> Signup and view all the answers

    What symptom differentiates congestive heart failure from COPD?

    <p>Chronic nonproductive cough</p> Signup and view all the answers

    Which of the following are common ABG findings in emphysema patients?

    <p>Mild hypoxemia with absent hypercapnia</p> Signup and view all the answers

    Which examination finding is typical for patients with emphysema?

    <p>Increased AP diameter and accessory muscle use</p> Signup and view all the answers

    What is the primary risk factor for developing chronic bronchitis?

    <p>Long-term smoking</p> Signup and view all the answers

    Which of the following reflects appropriate treatment expectations for Stage 4 COPD?

    <p>Symptom relief may still be achieved</p> Signup and view all the answers

    Which characteristic is least likely to be observed in a patient with advanced emphysema?

    <p>Clear mucoid sputum</p> Signup and view all the answers

    What does right axis deviation indicate in advanced COPD patients?

    <p>Right ventricular hypertrophy</p> Signup and view all the answers

    Which body type is typical for a patient with chronic bronchitis?

    <p>Obese and stocky</p> Signup and view all the answers

    What is an expected finding on pulmonary function tests for severe COPD?

    <p>Reduced FEV1 below 50% predicted</p> Signup and view all the answers

    Which of the following symptoms is indicative of transition from exertional dyspnea to resting dyspnea in congestive heart failure?

    <p>Proxysmal nocturnal dyspnea</p> Signup and view all the answers

    What is the typical age range for the onset of Crohn's disease?

    <p>15 to 35 years</p> Signup and view all the answers

    Which diagnostic feature is characteristic of Crohn's disease during endoscopy?

    <p>Skip lesions with normal intestine in between</p> Signup and view all the answers

    What is a common symptom of ulcerative colitis?

    <p>Recurrent rectal urgency and tenesmus</p> Signup and view all the answers

    Which group has a higher incidence of developing Crohn's disease?

    <p>Jewish individuals</p> Signup and view all the answers

    What finding may indicate Crohn's disease during laboratory testing?

    <p>Increased white blood cell count</p> Signup and view all the answers

    What is a potential complication of ulcerative colitis?

    <p>Colonic adenocarcinoma</p> Signup and view all the answers

    What symptom is typical in appendicitis and often precedes localized pain?

    <p>Initial diffuse abdominal pain</p> Signup and view all the answers

    What laboratory finding is most prominently associated with appendicitis?

    <p>Moderate leukocytosis with neutrophilia</p> Signup and view all the answers

    Which symptom may indicate iron deficiency anemia in inflammatory bowel disease?

    <p>Unintentional weight loss</p> Signup and view all the answers

    Which of the following signs is commonly associated with appendicitis?

    <p>Positive McBurney's point tenderness</p> Signup and view all the answers

    What is a characteristic feature of the abdominal exam in a patient with ulcerative colitis?

    <p>Hyperactive bowel sounds</p> Signup and view all the answers

    What dietary component is thought to contribute to the risk of developing inflammatory bowel disease?

    <p>Processed fried foods</p> Signup and view all the answers

    What risk factor is associated with a decreased likelihood of developing ulcerative colitis?

    <p>Smoking</p> Signup and view all the answers

    What symptom may be indicative of an appendicitis in children?

    <p>Fever 20-48 hours after onset of pain</p> Signup and view all the answers

    What combination of lab results indicates a 100% negative predictive value for acute appendicitis?

    <p>Neutrophil count less than 7,500 with pro calcitonin less than 0.1 and coal protectin less than 0.5</p> Signup and view all the answers

    Which diagnostic tool has a sensitivity of 75 to 90% for ruling out appendicitis?

    <p>Ultrasound</p> Signup and view all the answers

    In patients with irritable bowel syndrome, which symptom is NOT typically associated?

    <p>Weight loss</p> Signup and view all the answers

    What is a key sign of cholecystitis consistent with gallbladder inflammation?

    <p>Positive Murphy sign</p> Signup and view all the answers

    Which of the following is NOT a common symptom of cystitis?

    <p>Flank pain</p> Signup and view all the answers

    What laboratory findings would you expect in a patient with pyelonephritis?

    <p>Pyuria and hematuria</p> Signup and view all the answers

    What characterizes the pain associated with cholecystitis?

    <p>Steady, severe pain worst with movement</p> Signup and view all the answers

    Which of the following is the most common cause of bacterial cystitis?

    <p>E. coli</p> Signup and view all the answers

    Which of the following statements is true regarding the criteria for diagnosing irritable bowel syndrome?

    <p>Symptoms must have been present for at least six months</p> Signup and view all the answers

    What is the primary characteristic of the pain associated with ectopic pregnancy?

    <p>Acute and unilateral</p> Signup and view all the answers

    Which imaging modality is less sensitive for detecting gallbladder wall thickening?

    <p>MRI</p> Signup and view all the answers

    What is the typical response of abdominal pain related to irritable bowel syndrome?

    <p>Relieved by defecation</p> Signup and view all the answers

    Which are the components of the four criteria for diagnosing irritable bowel syndrome?

    <p>Recurrent abdominal pain related to defecation or altered stool consistency and frequency</p> Signup and view all the answers

    What is the main characteristic of prerenal azotemia?

    <p>Renal hypoperfusion due to volume depletion</p> Signup and view all the answers

    Which of the following symptoms is most commonly associated with bladder cancer?

    <p>Painless hematuria</p> Signup and view all the answers

    What does chronic kidney disease (CKD) require for its definition?

    <p>Kidney damage for over three months with or without decreased GFR</p> Signup and view all the answers

    What is a potential complication associated with a GFR of less than 30 in CKD patients?

    <p>Referral to a nephrologist</p> Signup and view all the answers

    What causes postrenal azotemia?

    <p>Obstruction of renal flow from both kidneys</p> Signup and view all the answers

    Which factor is considered a primary risk for chronic kidney disease?

    <p>Hypertension</p> Signup and view all the answers

    What is the most common cause of postrenal azotemia?

    <p>Benign prostatic hypertrophy</p> Signup and view all the answers

    What differentiates intrinsic azotemia from other types?

    <p>It results from intrinsic renal tissue damage</p> Signup and view all the answers

    Which of the following markers would indicate chronic kidney disease?

    <p>GFR less than 60 for more than three months</p> Signup and view all the answers

    Which condition is least likely to cause prerenal azotemia?

    <p>Chronic glomerulonephritis</p> Signup and view all the answers

    What is a common indicator of acute kidney injury?

    <p>Elevation of serum BUN and creatinine</p> Signup and view all the answers

    Which of the following is a clinical feature of intrinsic renal failure?

    <p>Acute tubular necrosis</p> Signup and view all the answers

    Which diagnostic imaging method is considered most sensitive for detecting obstruction in kidneys?

    <p>Intravenous pyelogram</p> Signup and view all the answers

    What is the typical urine output classification for oliguria in adults?

    <p>Less than 500 mL in 24 hours</p> Signup and view all the answers

    What distinguishes primary spontaneous pneumothorax from secondary spontaneous pneumothorax?

    <p>It occurs without prior lung disease.</p> Signup and view all the answers

    Which symptom is most strongly associated with pulmonary embolism?

    <p>Pleuritic chest pain</p> Signup and view all the answers

    What effect does a normal D-dimer test have on the diagnosis of pulmonary embolism?

    <p>It rules out pulmonary embolism with 97% specificity.</p> Signup and view all the answers

    Which diagnostic test is least invasive for suspected cases of pulmonary embolism?

    <p>D-dimer test</p> Signup and view all the answers

    What is a significant risk factor for developing foreign body aspiration?

    <p>Elderly people with dentures</p> Signup and view all the answers

    Which of the following findings is unlikely in a patient with chronic bronchitis?

    <p>Increased resonance on percussion</p> Signup and view all the answers

    Which sign may indicate the presence of a significant pulmonary embolism?

    <p>Unilateral leg swelling</p> Signup and view all the answers

    What is the pathophysiological change in chronic bronchitis?

    <p>Increased bronchial smooth muscle inflammation</p> Signup and view all the answers

    Which of the following findings on a chest X-ray is associated with a pneumothorax?

    <p>Demarcation of the lung with surrounding air</p> Signup and view all the answers

    Which population is at the highest risk for spontaneous pneumothorax?

    <p>Tall, thin males under 40</p> Signup and view all the answers

    In patients with foreign body aspiration, what symptom is most indicative?

    <p>Localized wheezing</p> Signup and view all the answers

    Which underlying condition may lead to secondary spontaneous pneumothorax?

    <p>Marfan syndrome</p> Signup and view all the answers

    What might be observed in a chest X-ray of a patient with emphysema?

    <p>Increased lung volume and flattened diaphragm</p> Signup and view all the answers

    In cases of hyperventilation syndrome, what physiological change is commonly observed?

    <p>Hypocapnia</p> Signup and view all the answers

    Study Notes

    Dyspnea

    • Occurs due to dysfunction in the pulmonary, cardiovascular, neuromuscular, and mental health systems.

    Pulmonary System Breakdown

    • Airway Issues: Choking, obstruction, inflammation.
    • Parenchyma Issues: Tumors, chronic diseases.
    • Pleura Issues: Pneumothorax.
    • Chest Wall Issues: Pectus excavatum.
    • Blood Vessels Issues: Pulmonary embolism (PE).

    Acute Conditions Causing Dyspnea

    • Pneumonia
    • Pulmonary Embolism (PE)
    • Spontaneous Pneumothorax
    • Acute Bronchial Asthma
    • Foreign Body Aspiration
    • Non-Cardiogenic Pulmonary Edema
    • Adult Respiratory Distress Syndrome (ARDS)
    • Noxious Gas Inhalation
    • High Altitude Pulmonary Edema
    • Cardiogenic Pulmonary Edema
    • Hyperventilation

    Chronic Conditions Causing Dyspnea

    • Chronic Obstructive Pulmonary Disease (COPD)
    • Chronic Bronchitis
    • Emphysema
    • Chronic Bronchial Asthma
    • Restrictive Lung Disease
    • Interstitial Lung Disease (sarcoidosis, scleroderma)
    • Pleural Fibrosis
    • Neuromuscular Diseases: Amyotrophic Lateral Sclerosis (ALS), Myasthenia Gravis
    • Chest Wall Deformities

    Non-Pulmonary Causes of Dyspnea

    • Congestive Heart Failure (CHF)
    • Anemia
    • Hyperthyroidism
    • Upper Airway Disease
    • Obesity
    • Neurosis

    Pulmonary Embolism (PE)

    • U.S. Stats:

      • 100,000 venous thromboemboli deaths/year.
      • 25% of PE cases result in sudden death.
      • 1/3 of those who survive a PE will have another within 10 years.

    • Risk Factors:

      • Major Risk Factors:
        • Prolonged immobilization (e.g., long plane rides, bed rest).
        • Recent surgery (especially with more than 30 minutes of anesthesia).
        • Trauma.
        • Age >40.
        • Central lines.
      • Hypercoagulable States:
        • Oral contraceptives.
        • Estrogen therapy.
        • Pregnancy.
        • Malignancy.
        • History of DVT.
      • Conditions:
        • AFib.
        • Sickle cell anemia.
        • Low cardiac output.
        • Obesity.
      • Inherited Coagulopathies:
        • Protein C/S deficiencies.
        • Factor V Leiden mutation.
        • Prothrombin gene defects.
        • Antiphospholipid Antibody Syndrome.

    • Signs and Symptoms:

      • Typical Symptoms:
        • Pleuritic chest pain (60-75%).
        • Dyspnea (75-85%).
        • Tachypnea (>50%).
      • Other Symptoms:
        • Cough.
        • Hemoptysis.
        • Apprehension ("I just don’t feel right").
        • Syncope (indicates massive PE).
      • Other Signs:
        • Tachycardia.
        • Diaphoresis.
        • Unilateral leg swelling.
        • Positive Homan's sign.
        • Signs of DVT (deep vein thrombosis).

    • Diagnostic Tests:

      • D-dimer: Normal D-dimer essentially rules out PE (97% specificity).
      • Chest CT: Helical/spiral chest CT is 90% sensitive and specific for detecting proximal PEs in the main arteries. Less accurate for peripheral emboli.
      • Pulmonary Angiogram: High sensitivity and specificity, but expensive and invasive.
      • Chest X-ray: May show Westermark sign (focal hypovolemia-reduction in blood volume makes the affected lung area appear hyperlucent (darker)).
      • Other tests: EKG, Echo, ABG (not diagnostic but helps rule out other causes of dyspnea).

    Spontaneous Pneumothorax

    • Types:

      • Primary: Occurs without prior lung disease.
      • Secondary: Results from pre-existing lung disease (e.g., emphysema).

    • Risk Factors:

      • Young, tall, thin males.

    • Diagnostic Tests:

      • Chest X-ray: Normal.
      • ABG: Hypocapnia (CO2 < 40 mmHg).

    Chronic Obstructive Pulmonary Disease (COPD)

    • Chronic Bronchitis (Subtype of COPD)

      • Definition: Enlargement of the tracheobronchial mucus glands, smooth muscle hyperplasia, inflammation, bronchial wall thickening.
      • Diagnosis: Chronic productive cough for 3 months in each of 2 consecutive years, excluding other causes.
      • Risk Factors: Smoking is the most common risk factor.
      • Symptoms: Persistent, severe cough, copious mucopurulent sputum, wheezing.
      • On Exam: Stocky, obese, central cyanosis, wheezes, rhonchi.
      • Diagnostic Tests:
        • Chest X-ray: May show an enlarged heart (rounded hemidiaphragms), but sometimes normal.
        • ABGs: Hypercapnia, hypoxemia, acidosis (in severe cases).

    • Emphysema (Subtype of COPD)

      • Definition: Abnormal permanent enlargement of air spaces distal to the terminal bronchioles, with destruction of their walls and loss of surface area for gas exchange.
      • Risk Factors: Smoking, passive smoke exposure, air pollution, dust, chemical exposure, childhood respiratory infections, alpha-1 antitrypsin deficiency.
      • Symptoms: Progressive dyspnea, mild cough (may produce clear sputum), weight loss, thin body build.
      • On Exam: Barrel chest, hyperresonance, decreased breath sounds, prolonged expiratory phase.
      • Diagnostic Tests:
        • Chest X-ray: Bleb formation, hyperinflation, decreased peripheral lung markings.
        • Pulmonary Function Tests: Increased total lung capacity due to air trapping, reduced FEV1/FVC ratio.
        • ABGs: Mild hypoxemia, sometimes no hypercapnia or acidosis due to compensation.

    • COPD Classification:

      • Stage 1 (Mild): FEV1 80% predicted.
      • Stage 2 (Moderate): FEV1 50-80% predicted.
      • Stage 3 (Severe): FEV1 30-50% predicted.
      • Stage 4 (Very Severe): FEV1 < 30% predicted.

    Dyspnea

    • Dyspnea is difficulty breathing.
    • Dysfunction in the pulmonary, cardiovascular, neuromuscular, and mental health systems can all cause dyspnea.
    • The pulmonary system is composed of the airway, pleura, chest wall, and blood vessels.
    • Airway issues causing dyspnea include choking, obstruction, and inflammation.
    • Parenchyma issues in the lungs lead to dyspnea, including tumors and chronic diseases.
    • Pneumothorax, a condition where air leaks into the space between the lung and the chest wall can also cause dyspnea.
    • Pectus excavatum, a condition where the breastbone is sunken into the chest, is a chest wall issue that can lead to dyspnea.
    • Pulmonary embolism (PE) is a blood vessel issue that can result in dyspnea.

    Common Conditions Causing Dyspnea

    • Acute Conditions
      • Pneumonia
      • Pulmonary Embolism (PE)
      • Spontaneous Pneumothorax
      • Acute Bronchial Asthma
      • Foreign Body Aspiration
      • Non-Cardiogenic Pulmonary Edema
      • Adult Respiratory Distress Syndrome (ARDS)
      • Noxious Gas Inhalation
      • High Altitude Pulmonary Edema
      • Cardiogenic Pulmonary Edema
      • Hyperventilation
    • Chronic Conditions
      • Chronic Obstructive Pulmonary Disease (COPD)
      • Chronic Bronchitis
      • Emphysema
      • Chronic Bronchial Asthma
      • Restrictive Lung Disease
      • Interstitial Lung Disease (sarcoidosis, scleroderma)
      • Pleural Fibrosis

    Neuromuscular Diseases

    • Amyotrophic Lateral Sclerosis (ALS)
    • Myasthenia Gravis

    Non-Pulmonary Causes of Dyspnea

    • Congestive Heart Failure (CHF)
    • Anemia
    • Hyperthyroidism
    • Upper Airway Disease
    • Obesity
    • Neurosis

    Pulmonary Embolism (PE)

    • An estimated 100,000 venous thromboemboli deaths occur per year in the United States.
    • 25% of PE cases result in sudden death.
    • 1/3 of those who survive a PE will have another within 10 years.

    Risk Factors for PE

    • Major Risk Factors:
      • Prolonged immobilization (e.g., long plane rides, bed rest)
      • Recent surgery (especially with more than 30 minutes of anesthesia)
      • Trauma
      • Age >40
      • Central lines
    • Hypercoagulable States:
      • Oral contraceptives
      • Estrogen therapy
      • Pregnancy
      • Malignancy
      • History of DVT (Deep Vein Thrombosis)
    • Conditions Increasing Risk:
      • AFib
      • Sickle cell anemia
      • Low cardiac output
      • Obesity
    • Inherited Coagulopathies:
      • Protein C/S deficiencies
      • Factor V Leiden mutation
      • Prothrombin gene defects
      • Antiphospholipid Antibody Syndrome

    Signs and Symptoms of PE

    • Typical Symptoms:
      • Pleuritic chest pain (60-75%)
      • Dyspnea (75-85%)
      • Tachypnea (>50%)
    • Other Symptoms:
      • Cough
      • Hemoptysis (coughing up blood)
      • Apprehension ("I just don’t feel right")
      • Syncope (indicates massive PE)
    • Other Signs:
      • Tachycardia
      • Diaphoresis (excessive sweating)
      • Unilateral leg swelling
      • Positive Homan's sign (pain in the calf with dorsiflexion of the foot)
      • Signs of DVT (deep vein thrombosis)

    Diagnostic Tests for PE

    • D-dimer:
      • A normal D-dimer essentially rules out PE (97% specificity).
    • Chest CT:
      • Helical/spiral chest CT is 90% sensitive and specific for detecting proximal PEs in the main arteries.
      • Less accurate for peripheral emboli.
    • Pulmonary Angiogram:
      • High sensitivity and specificity
      • Expensive and invasive
    • Chest X-ray:
      • May show Westermark sign (focal hypovolemia - a reduction in blood volume that makes the affected lung area appear hyperlucent)
    • Other Tests:
      • EKG
      • Echo
      • ABG (not diagnostic but helps rule out other causes of dyspnea)

    Spontaneous Pneumothorax

    • Types:
      • Primary: Occurs without prior lung disease
      • Secondary: Results from pre-existing lung disease (e.g., emphysema)

    Risk Factors for Spontaneous Pneumothorax

    • Young, tall, thin males
    • 25 breaths per minute
    • Symmetric thoracic expansion

    Diagnostic Tests for Spontaneous Pneumothorax

    • Chest X-ray: Normal
    • ABG: Hypocapnia (CO2 < 40 mmHg)

    Chronic Obstructive Pulmonary Disease (COPD)

    • Chronic Bronchitis (Subtype of COPD)

      • Definition:
        • Enlargement of the tracheobronchial mucus glands
        • Smooth muscle hyperplasia
        • Inflammation
        • Bronchial wall thickening
      • Diagnosis:
        • Chronic productive cough for 3 months in each of 2 consecutive years, excluding other causes.
      • Risk Factors:
        • Smoking is the most common risk factor.
      • Symptoms:
        • Persistent, severe cough
        • Copious mucopurulent sputum
        • Wheezing
      • On exam:
        • Stocky, obese
        • Central cyanosis (bluish discoloration of the skin due to low blood oxygen)
        • Wheezes
        • Rhonchi (rattling sounds in the chest)
      • Diagnostic Tests:
        • Chest X-ray: May show an enlarged heart (rounded hemidiaphragms), but sometimes normal.
        • ABGs: Hypercapnia, hypoxemia, acidosis (in severe cases).

    • Emphysema (Subtype of COPD)

      • Definition:
        • Abnormal permanent enlargement of air spaces distal to the terminal bronchioles, with destruction of their walls and loss of surface area for gas exchange.
      • Risk Factors:
        • Smoking
        • Passive smoke exposure
        • Air pollution
        • Dust
        • Chemical exposure
        • Childhood respiratory infections
        • Alpha-1 antitrypsin deficiency
      • Symptoms:
        • Progressive dyspnea
        • Mild cough (may produce clear sputum)
        • Weight loss
        • Thin body build
      • On exam:
        • Barrel chest
        • Hyperresonance (abnormally loud sound when percussing the chest)
        • Decreased breath sounds
        • Prolonged expiratory phase
      • Diagnostic Tests:
        • Chest X-ray: Bleb formation, hyperinflation, decreased peripheral lung markings.
        • Pulmonary Function Tests: Increased total lung capacity due to air trapping, reduced FEV1/FVC ratio.
        • ABGs: Mild hypoxemia, sometimes no hypercapnia or acidosis due to compensation.

    COPD Classification

    • Stage 1 (Mild): FEV1/FVC ratio < 80% predicted.
    • Stage 2 (Moderate): FEV1 50-80% predicted.
    • Stage 3 (Severe): FEV1 30-50% predicted.
    • Stage 4 (Very Severe): FEV1 < 30% predicted.

    Dyspnea

    • Dyspnea, or shortness of breath, can result from dysfunction in the pulmonary, cardiovascular, neuromuscular, or mental health systems.

    Pulmonary System Breakdown

    • Airway issues include choking, obstruction, and inflammation.
    • Parenchyma issues include tumors and chronic diseases.
    • Pleura issues include pneumothorax.
    • Chest wall issues include Pectus excavatum.
    • Blood vessel issues include pulmonary embolism (PE).

    Causes of Dyspnea

    Acute

    • Pneumonia
    • Pulmonary embolism (PE)
    • Spontaneous pneumothorax
    • Acute bronchial asthma
    • Foreign body aspiration
    • Non-cardiogenic pulmonary edema
    • Adult respiratory distress syndrome (ARDS)
    • Noxious gas inhalation
    • High altitude pulmonary edema
    • Cardiogenic pulmonary edema
    • Hyperventilation

    Chronic

    • Chronic obstructive pulmonary disease (COPD)
    • Chronic bronchitis
    • Emphysema
    • Chronic bronchial asthma
    • Restrictive lung disease
    • Interstitial lung disease
    • Pleural fibrosis
    • Neuromuscular diseases
    • Chest wall deformities

    Non-Pulmonary Causes of Dyspnea

    • Congestive heart failure (CHF)
    • Anemia
    • Hyperthyroidism
    • Upper airway disease
    • Obesity
    • Neurosis

    Pulmonary Embolism (PE)

    • Estimated 100,000 deaths per year in the US due to venous thromboemboli.
    • 25% of PE cases result in sudden death.
    • PE survivors may have another within 10 years.

    Risk Factors

    • Major Risk Factors: Prolonged immobilization, recent surgery, trauma, age over 40, central lines.
    • Hypercoagulable States: Oral contraceptives, estrogen therapy, pregnancy, malignancy, history of deep vein thrombosis (DVT), atrial fibrillation (AFib), sickle cell anemia, low cardiac output, obesity.
    • Inherited Coagulopathies: Protein C/S deficiencies, Factor V Leiden mutation, Prothrombin gene defects, Antiphospholipid Antibody Syndrome.

    Signs and Symptoms

    • Pleuritic chest pain (60-75%)
    • Dyspnea (75-85%)
    • Tachypnea (over 50%)
    • Cough, hemoptysis, apprehension, syncope
    • Tachycardia, diaphoresis, unilateral leg swelling, positive Homan's sign, signs of DVT.

    Diagnostic Tests

    • D-dimer: Normal D-dimer rules out PE (97% specificity).
    • Chest CT: Helical/spiral chest CT is 90% sensitive and specific for detecting proximal PEs.
    • Pulmonary Angiogram: High sensitivity and specificity but expensive and invasive.
    • Chest X-ray: May show Westermark sign (focal hypovolemia).
    • Other tests: EKG, Echo, ABG (not diagnostic).

    Spontaneous Pneumothorax

    • Primary: Occurs without prior lung disease.
    • Secondary: Results from pre-existing lung disease.

    Risk Factors

    • Young, tall, thin males, rapid breathing (over 25 breaths per minute), symmetric thoracic expansion.

    Diagnostic Tests

    • Chest X-ray: Normal.
    • ABG: Hypocapnia (CO2 < 40 mmHg).

    Chronic Obstructive Pulmonary Disease (COPD)

    Chronic Bronchitis

    • Definition: Enlargement of tracheobronchial mucus glands, smooth muscle hyperplasia, inflammation, bronchial wall thickening.
    • Diagnosis: Chronic productive cough for 3 months in each of 2 consecutive years excluding other causes.
    • Risk Factor: Smoking is the most common risk factor.

    Symptoms

    • Persistent, severe cough
    • Copious mucopurulent sputum
    • Wheezing

    On Examination

    • Stocky, obese, central cyanosis, wheezes, rhonchi.

    Diagnostic Tests

    • Chest X-ray: May show an enlarged heart, but sometimes normal.
    • ABGs: Hypercapnia, hypoxemia, acidosis.

    Emphysema

    • Definition: Abnormal permanent enlargement of air spaces distal to terminal bronchioles with destruction of walls and loss of surface area for gas exchange.
    • Risk Factors: Smoking, passive smoke exposure, air pollution, dust, chemical exposure, childhood respiratory infections, alpha-1 antitrypsin deficiency.

    Symptoms

    • Progressive dyspnea
    • Mild cough with clear sputum
    • Weight loss, thin body build

    On Examination

    • Barrel chest, hyperresonance, decreased breath sounds, prolonged expiratory phase.

    Diagnostic Tests

    • Chest X-ray: Bleb formation, hyperinflation, decreased peripheral lung markings.
    • Pulmonary Function Tests: Increased total lung capacity due to air trapping, reduced FEV1/FVC ratio.
    • ABGs: Mild hypoxemia, sometimes no hypercapnia or acidosis due to compensation.

    COPD Classification

    • Stage 1 (Mild): FEV1 80% predicted or greater.
    • Stage 2 (Moderate): FEV1 50-80% predicted.
    • Stage 3 (Severe): FEV1 30-50% predicted.
    • Stage 4 (Very Severe): FEV1 less than 30% predicted.

    Dyspnea

    • Dyspnea is a symptom that can be caused by problems in the pulmonary, cardiovascular, neuromuscular, or mental health systems.
    • Pulmonary causes of dyspnea include airway obstruction, pleural effusion, chest wall deformities, and blood vessel problems like a pulmonary embolism (PE).
    • Acute dyspnea can be caused by pneumonia, PE, spontaneous pneumothorax, asthma, foreign body aspiration, non-cardiogenic pulmonary edema, adult respiratory distress syndrome, gas inhalation, high altitude pulmonary edema, cardiogenic pulmonary edema, or hyperventilation.
    • Chronic dyspnea can be caused by chronic obstructive pulmonary disease (COPD), chronic bronchitis, emphysema, chronic asthma, restrictive lung disease, interstitial lung disease, chest wall deformities, pleural fibrosis, and neuromuscular diseases.
    • Non-pulmonary causes of dyspnea include congestive heart failure, anemia, hyperthyroidism, upper airway disease, obesity, and neurosis.

    Pulmonary Embolism

    • About 100,000 PE-related deaths occur annually in the United States.
    • Mortality rates for PE are high: 17-48% within one month, 19-30% within six to twelve months, and 25% experience sudden death.
    • One-third of PE survivors are at risk for another PE within ten years.

    Risk Factors for Pulmonary Embolism

    • Prolonged immobilization or venous stasis, such as long plane or car rides, bed rest, or recent surgery.
    • Surgery lasting over 30 minutes with anesthesia.
    • Major trauma.
    • Age over 40.
    • Central line placement.
    • History of deep vein thrombosis (DVT) or blood clot.
    • Hypercoagulable states, such as those on oral contraceptives, estrogen therapy, or with a history of malignancy, surgery, pregnancy, or recent delivery.
    • Atrial fibrillation, sickle cell anemia, low cardiac output, obesity, and inherited coagulopathies, including protein C or S deficiencies, Factor V Leiden mutation, prothrombin gene defects, and antiphospholipid antibody syndrome.

    Signs and Symptoms of Pulmonary Embolism

    • Pleuritic chest pain (60-75% of cases).
    • Dyspnea (75-85% of cases).
    • Tachycardia (over 50% of cases).
    • Hemoptysis, apprehension, feeling unwell, syncope, cough, diaphoresis, and tachycardia.
    • On exam, patients may be visibly short of breath, have tachycardia, tachypnea, cough, hemoptysis, unilateral leg swelling, positive Homan's sign, signs of DVT, rales, pleural friction rub, decreased breath sounds, S3 heart sound, and low-grade fever.

    Diagnostic Tests for Pulmonary Embolism

    • D-dimer: A normal D-dimer test has 97% specificity for ruling out PE.
    • Chest CT (helical, spiral, or electron beam): About 90% sensitive and specific for detecting proximal PEs in the main pulmonary arteries, but less accurate for detecting peripheral emboli.
    • Ventilation/perfusion lung scan: Not commonly used anymore.
    • Venous ultrasound: Useful for diagnosing DVT.
    • Pulmonary angiogram: Very sensitive and specific, but also invasive and expensive.
    • Chest x-ray: May show a Westermark sign (focused hypovalemia) in the case of PE, but not diagnostic of PE.
    • EKG, echocardiogram, and ABG: Rule out other causes of dyspnea, but not diagnostic of PE.

    Spontaneous Pneumothorax

    • Primary spontaneous pneumothorax occurs in patients without prior lung disease, while secondary spontaneous pneumothorax occurs due to pre-existing lung disease, such as emphysema, trauma, or central line placement.
    • Risk factors for spontaneous pneumothorax include young age (under 40), tall stature, male gender, smoking, family history, Marfan syndrome, and homocystinuria.
    • Signs and symptoms of spontaneous pneumothorax include acute onset of ipsilateral chest pain and dyspnea, often during rest or sleep.
    • On exam, decreased breath sounds, decreased tactile fremitus, increased resonance, mediastinal shift of the trachea and heart, distended neck veins, hypotension, and Hamman's sign (crunching or rasping sound synchronous with the heartbeat heard over the precordium, sometimes at a distance from the chest in spontaneous mediastinal emphysema with a left-sided pneumothorax) may be present.
    • Diagnostic test: ABG showing hypoxia.
    • Chest x-ray: Diagnostic, showing a demarcation of the lung and collects tissue by surrounding air.

    Foreign Body Aspiration

    • Most common in children aged 1-3, but can also occur in the elderly, especially those with dentures.
    • Peanuts are the most common food aspiration, and alcohol use or CNS impairment increases risk.
    • Signs and symptoms include acute onset of dyspnea, pain, and tachycardia.
    • On exam, localized wheezing, decreased breath sounds, air trapping during expiration, and hyperresonance on the affected side may be present.
    • Diagnostic test: Chest x-ray may show air trapping and consolidation distal to the foreign body, but not always, as many ingested objects are not radiopaque.
    • Phases of foreign body aspiration:
      • Initial phase: Choking, gasping, coughing, or airway obstruction at the time of aspiration.
      • Asymptomatic phase: Subsequent lodging of the object and relaxation of reflexes, leading to reduced symptoms. Can last hours to weeks.
      • Complication phase: Foreign body produces erosions or obstructions, leading to pneumonia, atelectasis, or abscess.

    Hyperventilation

    • Occurs typically in younger patients without other cardiopulmonary disease.
    • Often associated with recent emotional upset.
    • Signs and symptoms include rapid, shallow breathing (respiratory rate > 25 breaths per minute), symmetric thoracic expansion, and sudden onset.
    • Diagnostic test: Chest x-ray will be normal.
    • ABG: Hypocapnia (less than 40 mmHg).

    Chronic Obstructive Pulmonary Disease (COPD)

    • Chronic bronchitis:
      • Enlargement of the tracheobronchial mucus glands with variable amounts of smooth muscle hyperplasia, inflammation, and bronchial wall thickening.
      • Characterized by a chronic productive cough for at least three months during two consecutive years, excluding other causes of chronic cough.
      • Typically associated with smoking, age over 35, repeated pulmonary infections, and obesity.
      • Signs and symptoms include intermittent mild to moderate dyspnea, persistent severe cough, copious mucopurulent or purulent sputum, and wheezing.
      • On exam, patients may be stocky, obese, have central cyanosis in advanced disease, a red beefy face, normal AP diameter, resonance to percussion, wheezes, and rhonchi.
      • Diagnostic tests:
        • Chest x-ray may show an enlarged heart, horizontal appearance, and rounded hemidiaphragms. May be normal.
        • Increased hematocrit due to compensation.
        • EKG may show right axis deviation and right ventricular hypertrophy in advanced disease.
        • ABG may show hypercapnia (moderate to severe disease), normal, mild hypoxemia, or acidosis.
        • Pulmonary function tests: Normal total lung capacity and compliance.

    Emphysema

    • Abnormal permanent enlargement of the air spaces distal to the terminal bronchioles, accompanied by destruction of their walls.
    • This leads to enlarged proximal and distal air spaces that form blebs, resulting in loss of surface area for gas exchange.
    • Risk factors include smoking, age over 50, passive smoking exposure, air pollution, occupational dust, chemical exposure, severe childhood respiratory infections, and alpha-1 antitrypsin deficiency.
    • Symptoms include mild cough, clear or mucoid sputum production, history of shortness of breath (increasing severity related to activity), frequent exacerbations, loss of work, hemoptysis, and weight loss.
    • On exam, patients tend to be thinner, wasted, with increased AP diameter, hypertrophy of accessory muscles, hyperresonance to percussion, decreased breath sounds, prolonged expiratory phase, and expiratory wheezes (faint or prominent).
    • Diagnostic tests:
      • Chest x-ray may show bullae (air pockets), hyperinflation, and decreased markings in the periphery.
      • ABG may show mild hypoxemia. Hypercapnia and acidosis may be absent due to compensation.
      • Pulmonary function tests: Increased total lung capacity (air trapping), reduction in FEV1/FVC ratio (indicates obstruction), FEV1 less than 80% (classifies severity), increased residual volume, and elevation of the residual volume/total lung capacity ratio (air trapping).

    COPD Classification

    • Stage 1 (At risk): Normal spirometry, may have chronic cough and sputum production.
    • Stage 2 (Mild): FEV1/FVC ratio < 70%, FEV1 > 80% of predicted, may or may not have symptoms.
    • Stage 3 (Moderate): Reduced FEV1/FVC ratio and FEV1 (50-80% of predicted).
    • Stage 4 (Severe COPD): FEV1 31-49% of predicted.
    • Stage 4 (Very severe COPD): FEV1 < 30% of predicted, with chronic respiratory failure.

    Congestive Heart Failure (CHF)

    • A clinical syndrome characterized by dyspnea, fatigue, activity intolerance, and fluid retention.
    • Caused by injury to the heart muscle (ischemic or non-ischemic) leading to hemodynamic or neurohormonal failure.
    • Signs and symptoms include dyspnea (exertional initially, progressing to paroxysmal nocturnal dyspnea and dyspnea at rest), chronic nonproductive cough, nocturia, fatigue, exercise intolerance, right upper quadrant pain, loss of appetite, nausea, peripheral edema, tachycardia, reduced pulse pressure, cyanosis, and cachexia in advanced stages.
    • Staging:
      • American College of Cardiology/American Heart Association (ACC/AHA):
        • Stage A: High risk for developing CHF, but no structural heart disorder.
        • Stage B: Structural heart disorders, but no symptoms.
        • Stage C: Past or current heart failure symptoms with underlying structural disease.
        • Stage D: End-stage heart failure requiring specialized care.
      • New York Heart Association (NYHA):
        • Class 1: No limitation of activity, essentially normal.
        • Class 2: Slight limitation of activity, comfortable at rest.
        • Class 3: Marked limitation of activity, comfortable only at rest.
        • Class 4: Symptoms at rest, any activity increases discomfort.
    • On exam, patients may have distress with activity, increased dyspnea with activity, tachycardia, variable blood pressure, weight fluctuations, visual changes, extra heart sounds (S3, S4, diminished S1), point of maximal intensity shifted left and downward, crackles, rales, dullness, expiratory wheezes and rhonchi (not clearing after coughing), positive jugular venous distention, hepatic jugular reflux, hepatic enlargement, ascites, peripheral edema, cold or cool extremities, and diaphoresis.

    Diagnostic Tests for CHF

    • Echocardiogram with Doppler flow: Most useful test, showing structure, valves, and blood flow through the heart. Ejection fraction < 35% suggests heart failure.
    • Chest x-ray: May show cardiomegaly (cardiac width > 50% of transthoracic diameter, cardiothoracic ratio > 0.5), pulmonary venous hypertension, interstitial edema, dilation of upper lobe veins, haziness of vessel outlines, alveolar fluid, and pleural effusions.
    • EKG: May show underlying arrhythmias, such as atrial fibrillation, changes associated with myocardial infarction, non-specific changes related to low voltage (larger heart), left ventricular hypertrophy, and non-specific repolarization changes.
    • BNP (beta-type natriuretic peptide): Specific marker for heart failure, changes when the heart muscle stretches.
    • CBC: Check for anemia and infection.
    • Electrolytes: Measure calcium, magnesium, potassium, and glucose.
    • UA (urinalysis): Check for protein or red blood cells in urine.
    • BUN and creatinine: Evaluate renal function.
    • TSH: Rule out thyroid disease.
    • Liver function tests, CRP, cardiac enzymes, iron, and albumin.

    Anemia

    • Definition: Reduction in red blood cell count, hemoglobin, or hematocrit.
    • Red blood cell function:
      • Transport inhaled oxygen from the lungs to tissues.
      • Pick up carbon dioxide waste at tissues and transport it to the lungs.
    • Hemoglobin: A protein in red blood cells, containing iron (heme), which carries oxygen.
    • Normal red blood cell indices are needed to classify types of anemia.

    Types of Anemia Based on Red Blood Cell Size and Color

    • Microcytic (small size, low MCV):
      • Hypochromic (pale color, low MCHC): Iron deficiency anemia, thalassemia, copper deficiency, zinc deficiency, lead poisoning.
      • Normochromic (normal color, normal MCHC): Chronic illnesses, autoimmune/inflammatory conditions.
    • Macrocytic (large size, high MCV):
      • Normochromic (normal color, normal MCHC): Megaloblastic anemias (vitamin B12 deficiency, pernicious anemia, malabsorption, folic acid deficiency), ethanol toxicity, liver disease, myelodysplastic syndrome, hypothyroidism, HIV infection, myeloid leukemia.

    Anemia

    • Medications that can cause anemia include hydroxyurea, methotrexate, fentanyl, and chemotherapy.
    • Normocytic normochromic anemias include early iron deficiency anemia, acute bleeding, chronic disease, inflammation, bone marrow suppression, chronic renal insufficiency, hypothyroidism, and hypopituitarism.
    • Hemolytic anemias can fall into any MCV category.
    • Hemolytic anemias are diagnosed with a low hemoglobin and an elevated reticulocyte count.
    • Hemolytic anemias are not explained by accelerated red blood cell production.
    • Hemolytic anemias are a separate category and always warrant a referral to a hematologist.
    • Hemolytic anemias can be caused by autoimmune disorders, cold agglutinin disease, and congenital causes such as thalassemia and sickle cell.
    • Important questions to ask: Is the patient still bleeding? Is there evidence of increased red blood cell destruction? Is the bone marrow suppressed? Is the patient iron deficient? Is the patient deficient in folate or vitamin B12?
    • Signs and symptoms of anemia include fatigue, irritability, headache, tachycardia, bounding pulses, palpitations, exertional dyspnea, history of blood loss, glossitis, change in stool color or frequency, peripheral neuropathy, restless legs syndrome, pagophagia, pica, pulsatile sound in the ears, hearing loss, lethargy, confusion, postural dizziness, hypotension.
    • Complications of severe anemia include heart failure, angina, arrhythmia, MI, and death.
    • On physical exam, mild to moderate anemia may only show tachycardia or tachypnea.
    • Severe anemia may show sensitivity to cold, weight loss, lethargy, fever, pallor, jaundice, excessive bleeding, bruising, koilonychia, dry, rough skin, tachycardia, murmurs, gallops, angina, postural hypotension, glossitis, angular stomatitis, blue sclera, lid edema, retinal hemorrhage, headache, vertigo, depression, impaired thought processes, hepatosplenomegaly, and bone pain.
    • Diagnostic tests include CBC with differential, hemoglobin screen, MCV, MCHC, RDW, reticulocyte count, ferritin, and total iron binding capacity.
    • Iron deficiency anemia presents with high total iron binding capacity and low ferritin.

    Cough

    • Differential diagnoses for adults with cough include GERD, asthma, postnasal drip, sinusitis, smoker's cough, chronic bronchitis, acute bronchitis, pneumonia, ace inhibitor cough, neoplasm, heart failure, otitis, airway obstruction, and allergy/hypersensitivity.
    • Differential diagnoses for pediatrics include upper respiratory infection, allergic rhinitis, asthma, bronchiolitis, RSV, cough-variant asthma, croup, cystic fibrosis, irritation, exposure, pneumonia, GERD, sinusitis, and psychogenic cough.
    • Acute cough lasts less than 8 weeks.
    • Examples of acute cough causes include the common cold, influenza, upper respiratory infections, acute bronchitis, pneumonia, sinusitis, allergic rhinitis, and pertussis.
    • Presentation, age, and risk factors determine the need for diagnostic testing.
    • Chest x-rays are not necessary for upper respiratory infections but may be indicated for a prolonged or lower respiratory infection, severe systemic symptoms, or signs of consolidation on exam.
    • If asthma is suspected, pulmonary function testing or bronchoprovocation testing may be considered.
    • Pneumonia is the sixth leading cause of death in the US.
    • Risk factors for pneumonia include age, alcohol, comorbidities, and altered level of consciousness.
    • The CURB-65 score provides objective measures of the risk of mortality from pneumonia.
    • Individuals with a CURB-65 score of 4 or 5 require inpatient care.
    • Individuals with a CURB-65 score of 3 require inpatient care if they are unable to comply with treatment or lack support.
    • Individuals with a CURB-65 score of 1 or 2 can typically be managed in the outpatient setting.
    • Hospital-acquired pneumonia (HAP) occurs more than 48 hours after hospital admission.
    • HAP is more common in ICU patients on mechanical ventilation.

    Abdominal Pain

    • Right lower quadrant pain differentials include appendicitis, ectopic pregnancy, ovarian torsion or cyst, salpingitis, and testicular torsion.
    • Left lower quadrant pain differentials include diverticulitis, ectopic pregnancy, colitis, ovarian torsion or cyst, colon cancer, and inflammatory bowel disease.
    • Right upper quadrant pain differentials include hepatitis, cholecystitis, gallstones, biliary colic, hepatomegaly secondary to heart failure, and right lower lobe pneumonia.
    • Left upper quadrant pain differentials include pancreatitis, splenomegaly, splenic rupture, abscess, or infarction, and left lower lobe pneumonia.
    • Epigastric and generalized pain differentials include gastric ulcer, reflux, GERD, gastritis, gastroparesis, pancreatitis, gastroenteritis, ruptured abdominal aortic aneurysm, myocardial infarction, and early appendicitis.
    • Left or right flank pain differentials include nephrolithiasis, pyelonephritis, and colitis.
    • Umbilical pain differentials include abdominal aortic aneurysm, early appendicitis, bowel obstruction, gastroenteritis, inflammatory bowel disease, mesenteric ischemia or infarction, enteritis, and umbilical hernia.
    • Consideration of demographics and patient history help determine pretest probability and risk of disease.
    • Appendicitis is not rare before the age of 15.
    • Intestinal obstruction due to malignancy is more often found in patients over the age of 40.
    • Pelvic pain in a 75-year-old female suggests diverticulitis or carcinoma.
    • Pelvic pain in a 25-year-old female suggests inflammatory disease, ectopic pregnancy, or a ruptured cyst.
    • For women, regardless of age, ask about vaginal bleeding, last menstrual period, menstrual cycle characteristics, sexual history, obstetric history, and risk factors for ectopic pregnancy.
    • For men, ask about hesitancy, nocturia, low urinary volume, lower abdominal distention, sexual history, and medical history.
    • A family history of appendicitis increases the risk for appendicitis.
    • Medications such as NSAIDs, aspirin, anticoagulants, oral contraceptives, and corticosteroids can increase the risk of abdominal problems or mask symptoms.
    • Red flags for abdominal pain that require referral include patients at higher risk of needing surgery or having a surgical abdomen.

    Surgical Referral for Abdominal Pain

    • Adults over 65 and children under 2 are at higher risk for conditions requiring surgery and should be referred for abdominal pain.
    • Adults with abdominal pain needing referral:
      • Fever
      • Pain that changes location (migrates)
      • Pain that awakens them from sleep
      • Weight loss
      • Pain lasting over 6 hours or worsening
      • Vomiting after pain
    • Children under 2 with abdominal pain needing referral:
      • Fever
      • Pain distant from the umbilicus
      • Pain that awakens them from sleep
      • Weight loss or deceleration of weight gain
      • Elevated sedimentation rate
      • Projectile vomiting
      • "Current jelly" stool (late sign of intussusception)
      • Bulky, foul-smelling, clay-colored stool (may indicate cystic fibrosis, celiac disease, chronic pancreatitis, or Crohn's disease)

    Physical Exam Maneuvers

    • Murphy's Sign: Assess for potential gallbladder issues (cholecystitis, cholelithiasis)
    • SOS Sign: Assess for peritoneal irritation
    • Rebound tenderness and Roving Sign: Assess for peritoneal irritation, common in appendicitis
    • Markle Sign: Jarring of the heel that elicits abdominal pain, 74% sensitive for appendicitis
    • Jumping in Place: Can also elicit a positive Markle Sign response
    • Cullen Sign: Severe left shoulder pain caused by diaphragm irritation, occurs with splenic rupture or ectopic pregnancy rupture
    • Obturator Muscle Assessment: Identifies peritoneal irritation
    • Costovertebral Angle Tenderness: Assess for kidney issues (UTI, pyelonephritis), indicative of pyelonephritis

    Diverticulitis

    • Acute abdominal pain, usually in the left lower quadrant
    • Over 50% of patients have had a previous episode
    • Pain is constant and present for days before presentation
    • Tenderness, muscle guarding, and rebound tenderness present
    • Left lower quadrant tenderness, sometimes a palpable mass is present
    • Nausea and vomiting are common (20-60% due to bowel obstruction or ileus)
    • Constipation is common (50% of patients)
    • Diarrhea can also occur (25-35% of patients)
    • Fever
    • Tender, palpable mass in over 20% of patients on abdominal exam
    • Blood in the stool
    • Urinary urgency, frequency, and dysuria (1-10% of cases)

    Imaging and Labs for Diverticulitis

    • Abdominal X-ray: Note free air or ileus (30-50% of patients with abdominal pain)
    • Leukocytosis: May support the diagnosis in patients with left lower quadrant pain
    • CRP: May be elevated
    • CMP: Check electrolytes, especially in prolonged vomiting or diarrhea
    • CT Scan: Preferred to rule out free or contained abscess, high sensitivity (99%) and specificity (90%)
    • Abdominal Ultrasound: High resolution with comparable sensitivity and specificity to CT
    • MRI: Avoids radiation exposure but takes longer, not ideal for acute abdominal pain

    Differentials for Diverticulitis

    • Colorectal cancer
    • Acute appendicitis
    • Inflammatory bowel disease
    • Infectious colitis
    • Ischemic colitis

    Inflammatory Bowel Disease (IBD)

    • Crohn's Disease and Ulcerative Colitis are characterized by chronic inflammation of the GI tract
    • Crohn's Disease:
      • Transmural inflammation (affects all layers of the intestinal wall)
      • Skip lesions (affected areas separated by normal areas)
      • Affects the entire GI tract, from mouth to anus
    • Ulcerative Colitis:
      • Limited to the mucosal layer of the colon
      • Affects the rectum and continuous portions of the proximal colon
    • Cause of IBD is unknown, but theories include:
      • Infection
      • Exposure
      • Stress
      • Allergy
      • Autoimmunity
      • Overproduction of certain enzymes

    Crohn's Disease: Epidemiology and Presentation

    • Affects both sexes equally

    • Slightly more prevalent in females

    • Familial tendency (10x increased risk)

    • Can occur at any age, but peaks between ages 15-35 and 50-80

    • Smokers are more likely to develop Crohn's disease

    • Higher incidence in Jewish individuals

    • Lower incidence in Black and Hispanic populations

    • Western diet high in processed, fried, and sugary foods may contribute

    • Crohn's Disease presents with exacerbations and remissions

    • Symptoms can be abrupt or insidious

    • Crampy, right lower quadrant pain after meals

    • Chronic diarrhea (may be bloody, but not typical)

    • Milk products sometimes aggravate symptoms

    • Low-grade fever if abscesses are present

    • Unintentional weight loss

    • Skip lesions and "string sign" visible on upper GI endoscopy (suggests intestinal constriction due to scarring)

    • Cobblestoning and irregular blanket-like appearance of the bowel wall (caused by ulcers and edema)

    Ulcerative Colitis Epidemiology and Presentation

    • Typically diagnosed among young adults, peaks between ages 20-40
    • Affects both sexes equally
    • More prevalent in individuals with Jewish ancestry
    • 10x increased risk with family history
    • Smokers are less likely to develop ulcerative colitis
    • Symptoms:
      • Diarrhea (bloody, pus, mucus)
      • Tenesmus (painful straining during bowel movements)
      • Urgency
      • Cramping
      • Weight loss
      • Fatigue
      • Fever
      • Dehydration
      • Low potassium
      • Anorexia
      • Nausea
      • Vomiting
      • Iron deficiency anemia
      • Abdominal pain
      • Increased bowel sounds
      • Abdomen may be flat or distended
    • Periods of remissions and exacerbations
    • Increased incidence of mucosal dysplasia, which can progress to colon cancer

    Ulcerative Colitis Diagnostic Testing

    • Stool tests for blood, ova, and parasites
    • Routine culture and C. difficile
    • Endoscopy with biopsy to identify chronic inflammation
    • Barium enema
    • Complete blood count (CBC)
    • Electrolytes
    • ESR for inflammation
    • STI testing, especially in men who have sex with men experiencing rectal urgency and tenesmus

    Appendicitis

    • Occurs in 1 in 1,000 people
    • Rises after the age of 3, peaks in teens
    • 69% of cases occur under the age of 30
    • Most common surgical condition
    • Two-thirds of cases occur between May and October (summer months)
    • Family history increases risk
    • Male to female ratio is 3:2 (more prevalent in men until age 30, then equalizes)

    Appendicitis Risk Factors

    • Fatty diet
    • Contaminated food consumption
    • Stress
    • Medications (erythromycin, theophylline, Augmentin)
    • Pathogens: E. coli, Bacteroides, Enterococci, Pseudomonas

    Appendicitis Presentation

    • Anorexia (loss of appetite)
    • Initial pain is diffuse, epigastric or periumbilical, migrating to the right lower quadrant within 24 hours
    • Vomiting usually occurs AFTER the onset of pain
    • Nausea
    • Acute loss of appetite
    • Constipation and diarrhea (inconsistent symptoms)

    Appendicitis Physical Exam Findings

    • Rebound tenderness
    • McBurney's point tenderness
    • Positive Markle Sign (heel jar sign)
    • Positive Rovsing, Obturator, and Psoas signs
    • Pain with movement
    • Right lower quadrant tenderness
    • Fever may be slight or moderate during the first 12 hours (may be absent, especially in adults)
    • In children, fever 20-48 hours after onset is the most useful sign
    • Flat abdomen

    Appendicitis Imaging and Lab Tests

    • X-ray: Upright to evaluate for obstruction or free air
    • HCG (pregnancy test): For females of childbearing age
    • CRP: Inflammatory marker
    • CMP: Particularly if prolonged vomiting or diarrhea
    • White blood cell count (WBC): Moderate leukocytosis with neutrophilia, but a late finding
      • Over 85% of patients with appendicitis have a WBC count greater than 10,500
    • Absolute neutrophil count less than 7,500 combined with procalcitonin less than 0.1 and coprotectin less than 0.5 has a 100% negative predictive value but is not widely available
    • Ultrasound: Can rule out appendicitis, sensitivity is 75-90% but operator dependent and difficult with large body habitus
    • CT Scan: Highly accurate with sensitivity greater than 90% and specificity of 94% for acute appendicitis

    Irritable Bowel Syndrome (IBS)

    • Patients typically have increased stressors, complain of left lower quadrant pain
    • Associated with anxiety and depression
    • No associated weight loss or rectal bleeding
    • Symptoms:
      • Intermittent abdominal pain (at least one day per week for past three months)
      • Generalized abdominal pain
      • Improves with defecation
      • Diarrhea and/or constipation
      • Change in bowel frequency and pattern
      • Change in stool form

    Irritable Bowel Syndrome: Physical Exam and Testing

    • Abnormalities on exam are rare, but patients may have:
      • Mild left lower quadrant tenderness
      • Increased tympany (drum-like sound when percussing the abdomen)
      • Tenderness with digital rectal exam
    • Testing:
      • CBC
      • Sed rate
      • Sigmoidoscopy (if sed rate is greater than 40 and/or diarrhea)
      • Stool for ova and parasites (if diarrhea)

    Irritable Bowel Syndrome: Diagnostic Criteria (Rome IV)

    • Recurrent abdominal pain on average at least one day per week for the last three months
    • Associated with TWO or more of the following:
      • Related to defecation
      • Associated with a change in stool frequency
      • Associated with a change in stool form or appearance
    • Symptoms onset at least six months before diagnosis

    Cholecystitis

    • Inflammation of the gallbladder
    • Typically caused by gallstones (cholelithiasis)
    • Prior history of fatty food intolerance, flatulence, postprandial fullness (fullness after eating)
    • Gradual to acute onset
    • Severe, steady pain in the right upper quadrant or epigastrium (worsens with motion, cough, and sneezing)
    • Pain may refer to the right shoulder
    • Positive Murphy's Sign
    • Anorexia
    • Nausea
    • Vomiting
    • Fever

    Cholecystitis Diagnostic Testing

    • White blood cell count: Will show leukocytosis
    • Electrolytes: May show changes with prolonged vomiting and diarrhea
    • Ultrasound: Shows inflammation and gallstones, high sensitivity (80%) and specificity (90%)
      • May not detect very small stones
    • HIDA (Hepatobiliary Iminodiacetic Acid) Scan: A radioactive isotope scan used if the ultrasound is inconclusive
    • MRI: Better at detecting stones and the cystic duct than ultrasound, but less sensitive at detecting gallbladder wall thickening. Mainly used in clinical trials

    Chronic Kidney Disease

    • Patients can remain asymptomatic until renal failure is far advanced.
    • General complaints include fatigue, weakness, anorexia, nausea, vomiting, metallic taste, hiccups, irritability, difficulty concentrating, insomnia, restless leg syndrome, itching, yellow skin, ecchymosis, vasculitis, decreased libido, menses changes, and numbness and tingling paresthesias.
    • Diagnostic testing shows increased elevations of BUN and creatinine.
    • Mean survival without intervention is about 100-150 days.
    • eGFR is estimated using serum creatinine, age, sex, and race.
    • Normal eGFR in young adults is 125 mL/min.
    • Normal eGFR in men is about 130 mL/min per 1.73 meters squared, and in women is 120 mL/min per 1.73 meters squared.
    • eGFR less than 60 mL/min is considered chronic kidney disease.
    • Complications include volume overload, hyperkalemia, metabolic acidosis, mineral and bone density disorders, hypertriglyceridemia, cardiovascular problems, hypertension, pericarditis, heart failure, hematologic problems including anemia and coagulopathies, sexual dysfunction, malnutrition, and thyroid dysfunction.

    Bladder and Renal Cancer

    • Typically presents with painless hematuria.
    • Patients may experience low back pain on one side, a mass or lump in the abdomen, fatigue, unintentional weight loss, fever, and peripheral edema.
    • 60% of patients will present with gross or microscopic hematuria.
    • 30% may have flank pain or a palpable abdominal mass.
    • The triad sign of advanced disease is hematuria, pain, and a palpable flank mass. This occurs in about 10% upon presentation.
    • 20-30% present with metastatic disease, such as cough or bone pain.
    • Renal tumors are often found incidentally due to widespread use of CT scans, ultrasounds, and other diagnostic imaging.
    • Diagnostic tests include blood in the urine, anemia, X-ray, ultrasound, and CT scan, which is the most valuable imaging tool for staging.
    • MRIs or bone scans may also be used depending on the stage of the disease.

    Dyspnea

    • Dyspnea is difficulty breathing, caused by problems with the pulmonary, cardiovascular, neuromuscular, or mental health.
    • Pulmonary Causes: Airway (choking, obstruction, inflammation), pleura (tumors, chronic disease), chest wall (pectus excavatum), blood vessels (pulmonary embolism).
    • Acute Conditions: Pneumonia, pulmonary embolism (PE), spontaneous pneumothorax, asthma, foreign body aspiration, non-cardiogenic pulmonary edema, adult respiratory distress syndrome (ARDS), gas inhalation, high altitude pulmonary edema, cardiogenic pulmonary edema, hyperventilation.
    • Chronic Conditions: Chronic obstructive pulmonary disease (COPD), chronic bronchitis, emphysema, asthma, restrictive lung disease, interstitial lung disease (sarcoidosis, scleroderma), chest wall deformities, pleural fibrosis, neuromuscular disease (amyotrophic lateral sclerosis, myasthenia gravis).
    • Non-Pulmonary Conditions: Congestive heart failure, anemia, hyperthyroidism, upper airway disease, obesity, neurosis.

    Pulmonary Embolism (PE)

    • PE is a blockage of the pulmonary artery by a blood clot, most commonly from deep vein thrombosis (DVT).
    • PE-related deaths in the US number about 100,000 annually.
    • Mortality rates are high: 17-48% within one month, 19-30% within 6-12 months, and 25% sudden death.
    • 33% of patients with a PE are at risk for another PE within 10 years.

    Risk Factors for PE

    • Prolonged Immobilization/Venous Stasis: Long plane rides/car rides, prolonged bed rest, recent surgery, surgery lasting over 30 minutes with anesthesia, major trauma.
    • Increased Coagulability: Age over 40, central lines, DVT history, hypercoagulable states (oral contraceptives, estrogen therapy, malignancy, pregnancy/delivery).
    • Other Factors: Atrial fibrillation, sickle cell anemia, low cardiac output, obesity, inherited coagulopathies (protein C/S deficiencies, Factor V Leyden mutation, prothrombin gene defects, antiphospholipid antibody syndrome).

    Signs and Symptoms of PE

    • Pleuritic chest pain: 60-75% of cases.
    • Dyspnea: 75-85% of cases.
    • Tachypnea: Over 50% of cases.
    • Other Symptoms: Hemoptysis, apprehension, syncope (massive embolus), cough, diaphoresis, tachycardia.
    • Exam Findings: Shortness of breath, tachycardia, tachypnea, cough, hemoptysis, unilateral leg swelling, positive Homan's sign (DVT), rales, pleural friction rub, decreased breath sounds, S3 gallop, low-grade fever.

    Diagnostic Tests for PE

    • D-dimer: A normal D-dimer rules out PE with 97% specificity.
    • Chest CT Scan (Helical, Spiral, Electron Beam): About 90% sensitive and specific for proximal PEs in the main pulmonary arteries; less accurate for peripheral emboli. Sensitivity and specificity for all vessel PEs: 53% and 75%. Increased diagnosis hasn't significantly impacted mortality.
    • Lung Scan (Ventilation Perfusion Scan): Not as commonly used.
    • Venous Ultrasound: Useful for diagnosing DVT.
    • Pulmonary Angiography: Highly sensitive and specific but expensive and invasive.
    • Chest X-Ray: May show a Westermark sign (focal hypovascularity) in PE.
    • Electrocardiogram (EKG): Used to rule out other causes of dyspnea, not diagnostic for PE.

    Spontaneous Pneumothorax

    • A collection of air in the space between the lung and the chest wall (pleural space).
    • Primary: Occurs in patients without pre-existing lung disease.
    • Secondary: Occurs in patients with pre-existing lung disease, such as emphysema, trauma, or central line placement.

    Risk Factors for Spontaneous Pneumothorax

    • Young patients under 40, especially tall and thin males.
    • Smokers, positive family history, Marfan syndrome, homocystinuria.

    Signs and Symptoms of Spontaneous Pneumothorax

    • Acute onset of ipsilateral (same side) chest pain and dyspnea, often at rest or during sleep.
    • May occur after strenuous coughing or exertion.
    • Exam Findings: Decreased breath sounds, decreased tactile fremitus, increased resonance, mediastinal shift of the trachea and heart, neck vein distension, hypotension, Hamman's sign (crunching sound with heartbeat).

    Diagnostic Tests for Spontaneous Pneumothorax

    • Arterial Blood Gas (ABG): Shows hypoxia.
    • EKG: Left-sided pneumothorax may cause axis deviation and precordial T wave changes.
    • Chest X-Ray: Shows visceral pleural line, clearly seen on expiratory film, which marks the lung border and collects air.

    Foreign Body Aspiration

    • Typically occurs in children aged 1-3, especially those with dentures in the elderly.
    • Peanuts are the most common aspirated food.
    • Alcohol use and central nervous system impairments increase risk.

    Signs and Symptoms of Foreign Body Aspiration

    • Acute onset of dyspnea, pain, and tachycardia.
    • Exam Findings: Localized wheezing, decreased breath sounds, air trapping during expiration, hyperresonance on the affected side.

    Diagnostic Tests for Foreign Body Aspiration

    • Chest X-ray: May show air trapping and consolidation distal to foreign body. Most ingested items are not radiopaque (like peanuts), so foreign body may not be visible on X-ray.

    Phases of Foreign Body Aspiration

    • Initial Phase: Choking, gasping, coughing, or airway obstruction at the time of aspiration.
    • Asymptomatic Phase: Object lodges in the airway and reflexes relax, reducing symptoms. Can last for hours to weeks.
    • Complication Phase: Foreign body causes erosions or obstruction leading to pneumonia, atelectasis, or abscess.

    Hyperventilation

    • Typically seen in younger, healthy patients with no history of cardiopulmonary disease, often after emotional upset.

    Signs and Symptoms of Hyperventilation

    • Tachycardia, sudden onset, rapid shallow breathing (respiratory rate over 25 per minute).
    • Exam Findings: Symmetric thoracic expansion.
    • Diagnostic Tests: Chest x-ray is normal. ABG may show hypocapnia (< 40 mmHg).

    Chronic Obstructive Pulmonary Disease (COPD)

    • COPD refers to chronic bronchitis and emphysema.
    • Chronic Bronchitis: Enlargement of tracheobronchial mucus glands with thickened bronchial walls due to inflammation and smooth muscle hyperplasia.
    • Emphysema: Abnormal permanent enlargement of air spaces distal to terminal bronchioles with wall destruction, leading to air trapping and bleb formation.

    Chronic Bronchitis

    • Diagnosis: A chronic productive cough for at least 3 months in two consecutive years, with no other cause for chronic cough.
    • Risk Factors: Smoking, age over 35.
    • Signs and Symptoms: Intermittent mild to moderate dyspnea, persistent severe cough, copious mucopurulent or purulent sputum, wheezing.
    • Exam Findings: Stocky body type, obesity, central cyanosis (advanced disease), red "beefy" face, normal AP diameter, resonance to percussion, wheezes or rhonchi.
    • Diagnostic Tests: Chest x-ray may show an enlarged heart, horizontal cardiac appearance, rounded hemidiaphragms, or be normal. Increased hematocrit can occur due to compensation. EKG may show right axis deviation and right ventricular hypertrophy in advanced disease. ABGs may show hypercapnia in moderate to severe disease, normal ABGs, and mild hypoxemia or acidosis. Pulmonary function tests show normal total lung capacity and normal compliance.

    Anemia

    • Medications that can cause anemia: hydroxurea, methotrexate, fentonin, and chemotherapy
    • Normocytic normochromic anemias have a normal MCV (mean corpuscular volume) and normal MCHC (mean corpuscular hemoglobin concentration)
      • These include early iron deficiency anemia, acute bleeding, chronic disease, inflammation, bone marrow suppression, chronic renal insufficiency, hypothyroidism, and hypopituitarism
    • Hemolytic anemias can fall in any MCV category
      • They are a distinct category characterized by low hemoglobin and elevated reticulocyte count
      • This is not explained by accelerated red blood cell production
      • Refer cases to a hematologist
      • Causes include autoimmune disorders, cold agglutinin disease, congenital conditions (thalassemia, sickle cell), disseminated intravascular coagulopathies (DIC), drug-induced issues, transfusion-related hemolysis, sepsis, parasitic infections, snake bites, and idiopathic causes
    • Important questions to ask about anemia:
      • Is the patient still bleeding?
      • Is there evidence of increased red blood cell destruction?
      • Is the bone marrow suppressed?
      • Is the patient iron deficient?
      • Is the patient deficient in folate or vitamin B12?
    • Signs and symptoms of anemia include:
      • Easy fatigability
      • Irritability
      • Headache
      • Tachycardia
      • Bounding pulses
      • Palpitations
      • Exertional dyspnea at rest (progressive)
      • History of blood loss (e.g., heavy menses, trauma)
      • Glossitis
      • Change in color, bulk, or frequency of stool
      • Peripheral neuropathy
      • Burning tongue
      • Paresthesia
      • Restless leg syndrome
      • Pagophagia
      • Pica
      • Roaring pulsatile sound in the ears
      • Hearing loss
      • Lethargy (severe anemia)
      • Confusion (severe anemia)
      • Postural dizziness (severe anemia)
      • Hypotension (severe anemia)
      • Complications: heart failure, angina, arrhythmia, MI, death
    • Physical exam findings in mild to moderate anemia (hemoglobin 6-12):
      • Tachycardia
      • Tachypnea
    • Physical exam findings in severe anemia (hemoglobin < 6):
      • Sensitivity to cold
      • Weight loss
      • Lethargy
      • Fever
      • Pallor
      • Jaundice
      • Easy bleeding or bruising
      • Koilonychia (spoon nails)
      • Dry, rough skin
      • Tachycardia
      • Murmur
      • Gallop rhythm
      • Angina
      • Postural hypotension
      • Glossitis
      • Angular stomatitis
      • Blue sclera
      • Lid edema
      • Retinal hemorrhage
      • Headache
      • Vertigo
      • Depression
      • Impaired thought processes
      • Hepatosplenomegaly
      • Bone pain
    • Diagnostic tests for anemia:
      • CBC with differential
        • Evaluate hemoglobin, hematocrit, and indices (MCV, MCHC, RDW)
      • Reticulocyte count
      • Ferritin
      • Total iron binding capacity

    Cough

    • Differential diagnosis for adults with cough:
      • GERD
      • Asthma
      • Postnasal drip
      • Sinusitis
      • Smoker's cough
      • Chronic bronchitis
      • Acute bronchitis
      • Pneumonia
      • ACE inhibitor cough
      • Neoplasm (e.g., lung cancer)
      • Heart failure
      • Outer ear obstruction
      • Airway obstruction
      • Allergy or hypersensitivity
    • Differential diagnosis for pediatrics with cough:
      • Upper respiratory infection
      • Allergic rhinitis
      • Asthma
      • Bronchiolitis
      • RSV
      • Cough-variant asthma
      • Croup
      • Cystic fibrosis
      • Irritant exposure
      • Pneumonia
      • GERD
      • Sinusitis
      • Psychogenic cough
    • Cough classification:
      • Acute cough:
        • Duration less than 8 weeks (most last < 3 weeks)
        • Causes: common cold, influenza, upper respiratory infections (e.g., pharyngitis), COVID-19, acute bronchitis, pneumonia, sinusitis, allergic rhinitis, pertussis (whooping cough)
      • Chronic cough:
        • Duration more than 8 weeks
        • Most common cause: smoking
        • Other causes: postnasal drip, asthma, GERD, chronic bronchitis, ACE inhibitor cough, lung cancer, interstitial lung disease, bronchiectasis, tuberculosis, lung abscess, aspiration, foreign body in the airway, serum and impaction, heart failure, medications, psychogenic cough, eosinophilic bronchitis, and GERD

    Pneumonia

    • Pneumonia is the sixth leading cause of death in the US, with a 14% mortality rate among hospitalized patients
    • Risk factors for pneumonia:
      • Age
      • Alcohol use
      • Comorbidities
      • Altered level of consciousness
    • Pneumonia severity scoring systems:
      • CURB-65 (Confusion, Urea, Respiratory rate, Blood pressure, Age)
      • PORT (Pneumonia Patient Outcomes Research Team Prediction Schema)
    • Management of pneumonia:
      • Level 4 and 5 severity: always inpatient care
      • Level 3 severity: inpatient if unable to comply with treatment or lack adequate support
      • Level 1 and 2 severity: typically managed outpatient
    • Types of pneumonia:
      • Community-acquired pneumonia (CAP):
        • Begins outside of the hospital or diagnosed within 48 hours of admission
        • Most common cause: Streptococcus pneumoniae
      • Hospital-acquired pneumonia (HAP):
        • Occurs more than 48 hours after hospital admission
        • Most common cause: Pseudomonas aeruginosa
      • Ventilator-associated pneumonia (VAP):
        • Occurs in patients on mechanical ventilation
        • Most common cause: Pseudomonas aeruginosa
      • Atypical pneumonia:
        • Caused by Mycoplasma pneumoniae, Chlamydia pneumoniae
        • More common in younger adults
    • Signs and symptoms of pneumonia:
      • Acute onset of fever
      • Cough (with or without purulent sputum)
      • Dyspnea
      • Vague chest discomfort
      • Pleuritic chest pain
      • Rigors
      • Myalgia
      • Anorexia
      • Headache
    • Physical exam findings in pneumonia:
      • Ill-appearing
      • Rapid respirations (tachypnea)
      • Tachycardia
      • Fever
      • Leukocytosis
      • Pulmonary infiltrates
      • Crackles, rales, or decreased breath sounds
      • Positive egophony and bronchophony
      • Increased tactile fremitus
      • Dullness to percussion over areas of consolidation
    • Diagnostic tests for pneumonia:
      • Sputum culture and Gram stain
      • Chest x-ray
      • Pulse oximetry and ABGs (for severe pneumonia)
      • White blood cell count
      • TB testing (for high-risk patients)

    Chronic Cough

    • Transient airway hyperresponsiveness (TAH) can occur after an upper respiratory infection and persist for 7-8 weeks
    • Most common causes of chronic cough:
      • Smoking
      • Postnasal drip
      • Asthma
      • GERD
      • Chronic bronchitis
      • ACE inhibitor cough
    • Other causes of chronic cough:
      • Lung cancer
      • Interstitial lung disease
      • Bronchiectasis
      • Tuberculosis
      • Lung abscess
      • Aspiration
      • Foreign body in the airway
      • Serum and impaction
      • Heart failure
      • Medications
      • Psychogenic cough
      • Eosinophilic bronchitis
      • GERD

    Gastroesophageal Reflux Disease (GERD)

    • GERD risk factors:
      • Foods that lower lower esophageal sphincter tone (e.g., chocolate, caffeine, yellow onions, peppermint)
      • Tobacco, alcohol, coffee
      • Medications (e.g., calcium channel blockers, beta blockers, anticholinergics, theophylline)
      • Obesity
      • Tight-fitting clothing
      • Large meals
      • Pregnancy
      • Hiatal hernia
      • Asthma
      • Diabetes
    • Signs and symptoms of GERD:
      • Nocturnal cough
      • Choking
      • Sour taste on awakening
      • Cough worsens after eating and when lying flat
      • Heartburn
      • Regurgitation
      • Chest pain
      • Early satiety
      • Bloating
      • Abdominal fullness
      • Dental erosions (in children)
    • Physical Exam:
      • Typically normal
    • Diagnostic tests for GERD:
      • Upper GI series or endoscopy (for patients with known Barrett's esophagus)

    Asthma

    • Asthma is characterized by airway hyperresponsiveness to triggers (e.g., allergies, drugs, exercise, cold air, irritants, stress)
    • Asthma triggers lead to airway wall edema, mucosal thickening, and airway remodeling
    • Asthma affects 7.6% of adults and 8.4% of children
    • There is a genetic susceptibility to asthma
    • The "three A's" are associated with asthma: allergic rhinitis, atopic dermatitis, and asthma
    • GERD can mimic and trigger asthma
    • Signs and symptoms of asthma:
      • Cough (60% of patients present with cough only)
      • Wheezing
      • Nocturnal dyspnea
      • Cough that worsens at night
      • Chest tightness that worsens with activity
      • Generalized or end-expiratory wheezing
      • Accessory muscle use (in severe cases)
      • Nasal flaring
      • Cyanosis
    • Diagnostic tests for asthma:
      • Spirometry (gold standard)
        • Improvement in FEV1 after short-acting bronchodilator is diagnostic
      • ImmunoCAP IgE allergy tests
      • Trial bronchodilators or bronchoprovocation testing
      • TB testing (tuberculin skin test, chest x-ray, CBC)
      • Vocal cord dysfunction evaluation

    Tuberculosis (TB)

    • TB has a higher mortality rate than HIV worldwide
    • 90% of TB cases are primary tuberculosis
    • 90% of primary TB remains in the latent or dormant phase and patients are non-infectious
    • TB is associated with other diseases like diabetes, malignancy, renal failure, and immunosuppression
    • In the US, 80% of TB cases are pulmonary and 20% are extrapulmonary
    • Signs and symptoms of TB:
      • Cough (initially dry, progressing to purulent sputum, may have hemoptysis)
      • Fatigue
      • Anorexia
      • Low-grade fever
      • Night sweats
    • Physical exam findings in TB:
      • Fever
      • Weight loss
      • Chest x-ray showing consolidation, infiltrates, and Ghon complexes (calcifications, typically apical or posterior upper lobe nodules or infiltrates)
    • Diagnostic tests for TB:
      • Chest x-ray
      • Sputum smear and culture (3 sputum samples)
      • Tuberculin skin test (TST)
        • Positive TST:

          • 5 mm in patients with HIV, TB contact, previous TB on chest x-ray, organ transplant patients, recent contacts, or those receiving immunosuppressive therapy

          • 10 mm in IV drug users, medically underserved, persons from Asia, Africa, Latin America, institutionalized individuals, and workers from those areas

          • 15 mm in general population

      • QuantiFERON-TB Gold Blood Test
      • T-SPOT.TB Test
    • BCG vaccine is not given in the US due to low TB infection rates

    Abdominal Pain

    • Common causes of abdominal pain based on location:
      • Right lower quadrant (RLQ):
        • Appendicitis
        • Ectopic pregnancy
        • Ovarian torsion or cyst
        • Salpingitis
        • Testicular torsion
      • Left lower quadrant (LLQ):
        • Diverticulitis
        • Ectopic pregnancy
        • Colitis
        • Ovarian torsion or cyst
      • Middle abdomen:
        • Colon cancer
        • Inflammatory bowel disease (Crohn's disease, ulcerative colitis)
      • Right upper quadrant (RUQ):
        • Hepatitis
        • Cholecystitis
        • Gallstones
        • Biliary colic
        • Hepatomegaly secondary to heart failure
        • Right lower lobe pneumonia
      • Left upper quadrant (LUQ):
        • Pancreatitis
        • Splenomegaly
        • Splenic rupture, abscess, or infarction
        • Left lower lobe pneumonia
      • Epigastric and generalized pain:
        • Gastric ulcer
        • Reflux (GERD)
        • Gastritis
        • Gastroparesis
        • Pancreatitis
        • Gastroenteritis
        • Ruptured abdominal aortic aneurysm (AAA)
        • Myocardial infarction (MI)
        • Early appendicitis
      • Left or right flank pain:
        • Nephrolithiasis (kidney stones)
        • Pyelonephritis
        • Colitis
      • Umbilical:
        • Abdominal aortic aneurysm (AAA)
        • Early appendicitis
        • Bowel obstruction
        • Gastroenteritis
        • Inflammatory bowel disease
        • Mesenteric ischemia, infarction
        • Enteritis
        • Umbilical hernia
    • Demographics, history, and risk factors are important in determining the pretest probability of disease:
      • Alcohol, gallstones, high triglycerides, and high calcium increase risk of pancreatitis
      • White male over 60, smoker, positive family history increase risk of AAA
      • Protective factors for AAA: female, non-white, diabetes, moderate alcohol consumption
      • Recent abdominal surgery increases risk of obstruction
      • Duodenal ulcers are rare before age 15 (appendicitis is not)
      • Intestinal obstruction due to malignancy is more common in patients over 40
      • Balsalm is more prevalent in the elderly and those with diabetes
      • Pelvic pain in a 75-year-old suggests diverticulitis or carcinoma, warranting colon cancer screening and fecal occult blood testing
      • Pelvic pain in a 25-year-old female suggests inflammatory disease, ectopic pregnancy, or a ruptured cyst
    • Important questions to ask about abdominal pain:
      • Women:
        • Vaginal bleeding
        • Last menstrual period
        • Menstrual cycle characteristics
        • Sexual history
        • Obstetric history
        • Risk factors for ectopic pregnancy (e.g., pelvic inflammatory disease, IUD, previous ectopic, tubal surgery, infertility, endometriosis)
      • Men:
        • Hesitancy
        • Nocturia
        • Low urinary volume
        • Lower abdominal distention
        • Sexual history
        • Medical history (e.g., kidney stones)
      • Everyone:
        • Family history of appendicitis
        • Medications (e.g., NSAIDs, aspirin, anticoagulants, oral contraceptives, corticosteroids)
      • Red flags for adults:
        • Age
        • High risk of surgical abdomen

    Abdominal Pain

    • Referral Considerations & Risk Factors: Adults over 65 and children under 2 with abdominal pain require careful consideration for referral.

    • Red Flags for Surgery:

      • Adults: Fever, pain shifting location, pain waking them from sleep, weight loss, pain lasting over 6 hours or worsening, vomiting after pain.
      • Children: Fever, pain far from umbilicus, pain waking them from sleep, weight loss or slowed weight gain, elevated sedimentation rate, projectile vomiting, "current jelly" stool, bulky foul-smelling clay-colored stool (potential cystic fibrosis, celiac disease, chronic pancreatitis, or Crohn's disease).

    • Physical Exam Maneuvers:

      • Murphy's Sign: Assesses for potential gallbladder problems.
      • SOS (Shoulder, Oddi, and Sacral) Muscle: Assesses for peritoneal irritation.
      • Rebound Tenderness and Roving Sign: Indicate peritoneal irritation, potentially seen in appendicitis.
      • Markle Sign: Heel jar elicits abdominal pain. 74% sensitive for appendicitis.
      • C-Sign: Severe left shoulder pain, can indicate splenic rupture or ectopic pregnancy rupture.
      • Obturator Muscle Assessment: Helps identify peritoneal irritation.
      • Costovertebral Angle Tenderness: Assesses for kidney issues, urinary tract infection (UTI), or pyelonephritis.

    Diverticulitis

    • Affects primarily the left lower quadrant.
    • Over 50% of cases involve prior episodes.
    • Pain is constant and lasts for days before seeking medical attention.
    • Tenderness, muscle guarding, rebound tenderness present.
    • Left lower quadrant tenderness and potentially a palpable mass.
    • Nausea and vomiting common.
    • 20-60% experience bowel obstruction or ileus.
    • Constipation in 50% of patients.
    • Loose stools and diarrhea in 25-35%.
    • Fever and palpable mass in over 20% of patients.
    • Potential blood in the stool.
    • Urinary urgency, frequency, and dysuria in 1-10% of cases.
    • Diagnostic Tests:
      • Abdominal X-ray to assess for free air or obstruction (30-50% of cases).
      • Leukocytosis (elevated white blood cell count) supports diagnosis in patients with left lower quadrant pain.
      • Elevated C-reactive protein (CRP).
      • CMP (Comprehensive Metabolic Profile): Check electrolytes especially if prolonged vomiting and diarrhea.
      • CT Scan: Preferred imaging to rule out free or contained abscess with >99% sensitivity and specificity.
      • Abdominal Ultrasound: High resolution with comparable sensitivity and specificity to CT.
      • MRI: Avoids radiation but takes longer, not ideal for acute abdominal pain.

    Inflammatory Bowel Disease (IBD)

    • Two main types:
      • Crohn's Disease:
        • Characterized by: Transmural inflammation, skip lesions affecting the entire GI tract, can affect the mouth to perianal area.
        • Etiology: Unknown.
        • Prevalence: Equal among sexes, slightly more common in females, familial tendency, higher risk in Jewish individuals, lower in Black and Hispanic populations.
        • Risk Factors: Smoking increases risk, Western diet (processed, fried, and sugary foods).
        • Presentation: Exacerbations and remissions, crampy pain (typically right lower quadrant) after meals, chronic diarrhea (sometimes bloody), milk products sometimes aggravate, low-grade fever (if abscesses present), unintentional weight loss.
        • Endoscopy/Colonoscopy Findings: Skip lesions with normal intestines in between.
        • String Sign: Constriction of a segment of the intestine due to scarring.
        • Cobblestoning: Irregular blanket-like appearance of the bowel wall caused by crisscrossing ulcers with edema.
        • Diagnostic Tests:
          • CBC: Anemia, increased WBCs.
          • ESR and CRP: Increased due to inflammation.
          • Hypoalbuminuria: Reflecting absorption issues.
          • Iron, Vitamin B12, Vitamin D, and Folic Acid deficiencies: Malabsorption.
      • Ulcerative Colitis:
        • Characterized by: Relapsing and remitting episodes of inflammation confined to the mucosal layer of the colon, affecting the rectum and proximal colon.
        • Etiology: Unknown (possible theories include infection, exposure, stress, allergy, autoimmunity, overproduction of enzymes, but no identified pathogen).
        • Prevalence: Equal among sexes, more prevalent with Jewish ancestry, ten times increased risk with family history, smokers are less likely to develop UC (unlike Crohn's).
        • Presentation: Diarrhea (bloody, pus, mucus), tenesmus (painful straining), urgency, cramping, weight loss, fatigue, fever, dehydration, low potassium, anorexia, nausea, vomiting, iron deficiency anemia.
        • Physical Exam: Increased bowel sounds, abdomen flat or distended.
        • Diagnostic Tests:
          • Stool for blood, ova, and parasites, routine cultures, and C. difficile.
          • Endoscopy with biopsy to identify chronic inflammation.
          • Barium enema.
          • Blood count, electrolytes, and ESR (for inflammation).
          • STI testing, especially for men who have sex with men, experiencing urgency and tenesmus.
          • Tenesmus: Continued or recurrent urge to defecate even after bowel movement.

    Appendicitis

    • Affects 1 in 15 people.
    • More common after age 3, peaking in teens; 69% occur under age 30.
    • Most frequent surgical condition.
    • Two-thirds of cases from May to October.
    • Family history increases risk.
    • Male-to-female ratio 3:2 (more common in men until age 30, then equalizes).
    • Risk Factors: Fatty diet, contaminated food, stress, medications (e.g., erythromycin, theophylline, augmentin).
    • Pathogens: E coli, bacteroides, enterococci, and pseudomonas.
    • Presentation:
      • Anorexia (loss of appetite).
      • Initial pain diffuse, epigastric, or periumbilical; migrates to the right lower quadrant within 24 hours.
      • Vomiting, nausea, and loss of appetite are common.
      • Constipation or diarrhea, inconsistent symptoms possible.
    • Physical Exam Findings:
      • Rebound tenderness, pain at McBurney's point, positive Markle sign (heel jar), positive Rovsing, Psoas, and Obturator signs.
      • Pain with movement.
      • Right lower quadrant tenderness.
      • Fever may be slight or moderate in the first 12 hours, absent in adults.
      • Children: Fever between 20-40 hours after the onset is the single most useful sign.
      • Flat abdomen on palpation.
    • Diagnostic Tests:
      • X-ray (upright): Evaluates for obstruction, free air, ileus.
      • HCG (human chorionic gonadotropin) urine test: Females of childbearing age.
      • C-reactive protein: For inflammation.
      • CMP: Especially if prolonged vomiting or diarrhea.
      • WBC: Moderate leukocytosis with neutrophilia (late finding).
      • Absolute neutrophil count < 7,500, procalcitonin < 0.1, and calprotectin < 0.5: 100% negative predictive value for appendicitis, but not widely available.
      • Ultrasound: 75-90% sensitive, operator dependent, difficult in obese patients.
      • Spiral CT (CT scan): Highly accurate with sensitivity >90% and specificity 94% for acute appendicitis.

    Irritable Bowel Syndrome (IBS)

    • Common Characteristics: Stressors often play a role, left lower quadrant pain most common, potential anxiety or depression.
    • Distinguishing Features: No associated weight loss or rectal bleeding.
    • Symptoms:
      • Intermittent abdominal pain, at least one day per week for the past 3 months.
      • Pain related to defecation.
      • Change in stool frequency, pattern, and form.
      • Symptoms present for at least 6 months before diagnosis.
    • Physical Exam: Usually normal, sometimes lower quadrant tenderness, increased tympany, or tenderness with digital rectal exam.
    • Diagnostic Tests:
      • CBC, sedimentation rate, sigmoidoscopy (if ESR > 40 and diarrhea), stool for ova and parasites (if diarrhea).
      • Rome IV Criteria for IBS Diagnosis:
        • Recurrent abdominal pain at least 1 day per week for the past 3 months.
        • Two or more of the following criteria:
          • Pain is related to defecation.
          • Associated with a change in stool frequency.
          • Associated with a change in stool form or appearance.

    Cholecystitis

    • Etiology: Inflammation of the gallbladder, often caused by gallstones.
    • Common Features:
      • History of fatty food intolerance, flatulence, postprandial fullness.
      • Gradual to acute onset.
      • Steady and severe pain in the right upper quadrant or epigastrum
      • Pain worsens with movement, coughing, and sneezing.
      • Pain can radiate to the right shoulder.
      • Positive Murphy's sign.
      • Anorexia, nausea, and vomiting.
      • Fever.
    • Diagnostic Tests:
      • WBC: Leukocytosis.
      • Electrolyte Testing: Monitoring for imbalances due to prolonged vomiting and diarrhea.
      • Ultrasound: Sensitivity 80%, specificity 90% for showing inflammation and gallstones.
      • HIDA (Hepatobiliary Iminodiacetic Acid) Scintigraphy (DA Scan): Helpful if ultrasound unclear.
      • MRCP (Magnetic Resonance Cholangiopancreatography): Detects stones and cystic duct better than ultrasound, but less sensitive for gallbladder wall thickening.

    Genitourinary Conditions

    • Right Flank Pain:
      • Nephrolithiasis (Kidney Stones): Severe flank pain (typically one-sided), sudden onset, progressing to severe and constant; nausea, vomiting, fever, restlessness, hematuria.
      • Pyelonephritis: Acute onset fever, chills, flank pain, painful urination, nausea, vomiting, and diarrhea.
      • Ectopic Pregnancy: Right lower quadrant pain.
      • Salpingitis: Right lower quadrant pain.
      • Testicular Torsion: Right lower quadrant pain.
      • Mittelschmerz: Ovulation pain.
      • Ovarian Torsion or Cyst: Right lower quadrant pain.
      • Inguinal Hernia: Right lower quadrant pain.
      • Ureteral Calculi: Right lower quadrant pain.
    • Left Flank Pain:
      • Nephrolithiasis (Kidney Stones): Severe flank pain (typically one-sided), sudden onset, progressing to severe and constant; nausea, vomiting, fever, restlessness, hematuria.
      • Pyelonephritis: Acute onset fever, chills, flank pain, painful urination, nausea, vomiting, and diarrhea.
      • Ectopic Pregnancy: Left lower quadrant pain.
      • Salpingitis: Left lower quadrant pain.
      • Testicular Torsion: Left lower quadrant pain.
      • Mittelschmerz: Ovulation pain.
      • Ovarian Torsion or Cyst: Left lower quadrant pain.
      • Inguinal Hernia: Left lower quadrant pain.
      • Ureteral Calculi: Left lower quadrant pain.
    • Hypogastric Pain:
      • Cystitis: Localized pain, urinary frequency, urgency, dysuria, suprapubic discomfort; difficulty urinating, potential hematuria.
      • Endometriosis: Hypogastric pain.
    • **Cystitis (Urinary Tract Infection) **
      • Etiology: Most commonly caused by gram-negative bacilli (75-90% by E. coli).
      • Symptoms: Localized pain, frequency, urgency, dysuria, suprapubic discomfort, difficulty urinating, potential hematuria.
      • Systemic Symptoms: Usually afebrile, systemic infection suggests a problem higher in the urinary tract.
      • Physical Exam: Usually unremarkable, may have suprapubic tenderness.
      • Diagnostic Tests: Clean-catch UA, midstream urine sample with culture. Even if negative, still send it for culture. Dipstick positive for leukocytes and nitrites, along with clinical symptoms, has 75% sensitivity and 66% specificity.
    • Pyelonephritis:
      • Etiology: Infectious inflammatory disease of the kidney pelvis and parenchyma. 85% caused by E. coli.
      • Risk Factors: Untreated lower UTI or cystitis, pregnancy, vesicoureteral reflux (in children), anatomical anomalies.
      • Symptoms: Acute onset, fever, chills, flank pain, painful urination, nausea, vomiting, diarrhea.
      • Physical Exam: Fever, tachycardia, costovertebral angle tenderness with unilateral flank pain, nausea, vomiting.
      • Diagnostic Tests:
        • UA: Nitrates, RBCs, potentially WBC casts.
        • CBC: Leukocytosis with left shift.
        • Urine Culture: Identify the organism.
        • Blood Culture: Ordered for systemic infection in compromised patients.
        • Renal Ultrasound: Used in complicated pyelonephritis or if the infection is not responding.

    Interstitial Cystitis/Bladder Pain Syndrome

    • Characterized by: Recurrent cystitis-like symptoms, urinary frequency, dyspareunia (painful intercourse), symptoms worsen before menstruation (associated with PMS).
    • Important Note: It is an inflammatory condition, NOT an infection.

    Bladder Cancer

    • Most Common Symptom: Painless hematuria.

    Renal Cancer

    • Most Common Symptom: Painless hematuria.

    Nephrolithiasis (Kidney Stones)

    • Symptoms: Severe flank pain (typically one-sided), sudden onset progressing to constant, associated with nausea, vomiting, fever, restlessness, hematuria.
    • Diagnostic Tests:
      • UA: Document hematuria and rule out infection.
      • KUB Imaging: Plain X-ray of the kidneys, ureter, and bladder.
      • Low-radiation CT: Preferred imaging for abdomen and pelvis without contrast.
      • Intravenous Pyelogram (IVP): More sensitive for obstruction.
      • Renal Ultrasound:

    Acute Kidney Injury (AKI)

    • Definition: Abrupt decrease in glomerular filtration rate (GFR), manifested by azotemia and oliguria.
    • Azotemia: Increased BUN and creatinine levels.
    • Oliguria: Urine output less than 500 mL in 24 hours for an adult, less than 0.5 mL/kg/hour for adults/children, less than 1 mL/kg/hour for neonates.
    • Types and Causes:
      • Prerenal Azotemia:
        • Etiology: Renal hypoperfusion due to volume depletion (e.g., GI loss, hemorrhage, dehydration).
        • Other Factors: Impaired renal flow (medications, sepsis, anaphylaxis, anesthesia), vascular resistance changes (septic shock, anaphylaxis, medications), low cardiac output states (e.g., shock caused by myocardial infarction).
      • Intrinsic Azotemia: 40-45% of all cases.
        • Causes: Renal vascular disease, glomerular disease (primary or secondary glomerulonephritis), tubulointerstitial disease (e.g., acute tubular necrosis, acute interstitial nephritis). (Investigated after prerenal and postrenal causes are ruled out).
      • Postrenal Azotemia:
        • Etiology: Obstructive nephropathy, least common (about 5%).
        • Occurs When: Renal flow from both kidneys is obstructed. Intraluminal pressure increases within each nephron, reducing GFR.
        • Common Causes: Urethral obstruction, bladder dysfunction, obstruction of ureters or renal pelvis. Benign prostatic hypertrophy (BPH) or prostate cancer are most frequent.
    • Consequences of Untreated Postrenal Azotemia: Leads to irreversible tubulointerstitial fibrosis.

    Chronic Kidney Disease (CKD)

    • Definition: Kidney damage lasting over 3 months, defined by structural or functional abnormalities with decreased GFR.
      • Manifested by: Pathological abnormalities or markers for kidney damage, GFR less than 60 for more than 3 months.
    • Associations: Chronic illnesses.
      • Diabetes: 30% of CKD cases.
      • Hypertension: 25% of CKD cases.
      • Glomerulonephritis: 20-25% of CKD cases.
    • Symptoms: Fatigue, malaise, itching (from toxins), irritability, poor concentration.
    • Glucose Control: Essential to prevent CKD.
    • Risk Factors: Diabetes, hypertension, cardiovascular disease, autoimmune conditions, cancer (past or present), systemic infections (e.g., HIV, herpesvirus), kidney stones or recurrent UTIs, sickle cell trait, indigenous origin, family history of kidney disease, exposure to nephrotoxic drugs, recovery from AKI (over 60 years old).
    • Associated Symptoms: Nausea, vomiting, itching, skin ulcerations.
    • Medications: NSAIDS and lithium can worsen or contribute to CKD.

    Chronic Kidney Disease

    • Develops slowly with non-specific symptoms
    • Patients can remain asymptomatic until renal failure is advanced (GFR 10-15)
    • Common complaints include fatigue, weakness, anorexia, nausea, vomiting, metallic taste, hiccups, irritability, difficulty concentrating, insomnia, restless legs, itching, yellow skin, ecchymosis, vasculitis, decreased libido, menstrual changes, and numbness/tingling
    • Diagnostic testing shows elevated BUN and creatinine (creatinine >10)
    • Mean survival without intervention is 100-150 days
    • eGFR is estimated using serum creatinine, age, sex, and race
    • Normal eGFR in young adults is 125 ml/minute
    • Normal eGFR for men is 130 ml/minute/1.73 m2, and women is 120 ml/minute/1.73 m2
    • eGFR < 60 ml/minute indicates CKD
    • CKD is staged based on eGFR
    • Complications include volume overload, hyperkalemia, metabolic acidosis, mineral and bone disorders, hypertriglyceridemia, cardiovascular problems (hypertension, pericarditis, heart failure), hematologic problems (anemia, coagulopathies), sexual dysfunction, malnutrition, and thyroid dysfunction
    • Referral to a nephrologist is recommended for eGFR < 30 ml/minute

    Bladder and Renal Cancer

    • Common symptoms include painless hematuria, low back pain on one side (not associated with injury), abdominal mass, fatigue, unintentional weight loss, persistent fever (not associated with a cold, flu, or infection), and peripheral edema
    • 60% present with gross or microscopic hematuria
    • 30% may have flank pain or a palpable abdominal mass
    • The triad sign of advanced disease is hematuria, pain, and palpable flank mass (occurs in 10% upon presentation)
    • 20-30% present with metastatic disease (e.g., cough or bone pain)
    • Renal tumors are often found incidentally due to widespread use of CT scans, ultrasounds, and other imaging modalities
    • Diagnostic tests include urinalysis with blood, anemia assessment, x-ray, ultrasound, and CT scan (most valuable for staging)
    • MRI and bone scans may be used depending on the stage of the disease

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    Explore the various causes and classifications of dyspnea, including how it relates to the pulmonary, cardiovascular, and neuromuscular systems. This quiz covers both acute and chronic conditions that can lead to this complex symptom. Test your knowledge on the underlying mechanisms and classifications of dyspnea.

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