First Aid for the USMLE Step 2 CS

Section 3. Minicases

Cough/Shortness Of Breath

Key History

Acute/subacute vs. chronic, increased frequency of cough if chronic, timing; presence/description of sputum, presence of hemoptysis; associated symptoms (constitutional, URI, postnasal drip, dyspnea, wheezing, chest pain, heartburn); exacerbating and alleviating factors, exposures; smoking history; history of lung disease, posttussive emesis, or heart failure; allergies; medications (especially ACE inhibitors).

COUGH/SHORTNESS OF BREATH (cant'd)

Key Physical Exam

Vital signs ± pulse oximetry; exam of nasal mucosa, oropharynx, heart, lungs, lymph nodes, and extremities (clubbing, cyanosis, edema).

   

Presentation

Differential

Workup

 

■ 30 yo M presents with shortness of breath, cough, and wheezing that worsen in cold air. He has had several such episodes in the past 4 months.

Asthma

GERD

Bronchitis Pneumonitis

Foreign body

CBC

CXR

Peak flow measurement

PFTs

Methacholine challenge

test

 

■ 56 yo F presents with shortness of breath and a productive cough that has lasted for at least 3 months each year over the past 2 years. She is a heavy smoker.

COPD—chronic bronchitis

Bronchiectasis

Lung cancer Tuberculosis

CBC

Sputum Gram stain and culture

CXR

PFTs

CT—chest

PPD

 

■ 58 yo M presents with 1 week of pleuritic chest pain, fever, chills, and cough with purulent yellow sputum. He is a heavy smoker with COPD.

Pneumonia

COPD exacerbation

(bronchitis)

Lung abscess

Lung cancer

Tuberculosis

Pericarditis

CBC

Sputum Gram stain and culture

CXR

CT—chest

ECG

PPD

 

■ 25 yo F presents with 2 weeks of nonproductive cough. Three weeks ago she had a sore throat and a runny nose.

Atypical pneumonia

Reactive airway disease

URI-associated cough

(“postinfectious”)

Postnasal drip

GERD

CBC

Induced sputum Gram stain and culture

CXR

IgM detection for

Mycoplasma pneumoniae

Urine Legionella antigen

 

■ 65 yo M presents with worsening cough for the past

6 months accompanied by hemoptysis, dyspnea, weakness, and weight loss. He is a heavy smoker.

Lung cancer

Tuberculosis

Lung abscess

COPD

Vasculitis (eg, Wegener’s

granulomatosis)

Interstitial lung disease

CHF

CBC

Sputum Gram stain, culture, and cytology

CXR

CT—chest

PPD

ANCA

Bronchoscopy

Echocardiography

 

COUGH/SHORTNESS OF BREATH (cant'd)

   

Presentation

Differential

Workup

 

■ 55 yo M presents with increased dyspnea and sputum production for the past 3 days. He has COPD and stopped using his inhalers last week. He stopped smoking 2 days ago.

COPD exacerbation

(bronchitis)

Lung cancer

Pneumonia

URI

CHF

CBC

CXR

ABG

PFTs

Sputum Gram stain and culture

CT—chest

Echocardiography

 
 
 
 
 
 

■ 34 yo F nurse presents with worsening cough of 6 weeks’ duration accompanied by weight loss, fatigue, night sweats, and fever. She has a history of contact with tuberculosis patients at work.

Tuberculosis

Pneumonia Lung abscess Vasculitis Lymphoma Metastatic cancer HIV/AIDS Sarcoidosis

CBC

PPD/QuantiFERON Gold

Sputum Gram stain, acidfast stain, and culture

CXR

CT—chest

Bronchoscopy

HIV antibody

Lymph node biopsy

 
 
 
 
 
 
 
 

■ 35 yo M presents with shortness of breath and cough. He has had unprotected sex with multiple sexual partners and was recently exposed to a patient with active tuberculosis.

Tuberculosis

Pneumonia (including

Pneumocystis jiroveci)

Bronchitis

Asthma

Acute HIV infection

CHF (cardiomyopathy)

CBC

PPD/QuantiFERON Gold

Sputum Gram stain, acidfast stain, silver stain, and culture

CXR

HIV antibody

Echocardiography

 
 
 
 
 
 
 

■ 50 yo M presents with a cough that is exacerbated by lying down at night and improved by propping up on 3 pillows. He also reports exertional dyspnea.

CHF

Cardiac valvular disease

GERD

Pulmonary fibrosis

COPD

Postnasal drip

CBC

CXR

ECG

Echocardiography

PFTs

BNP

CT—chest

 
 
 
 
 
 

■ 60 yo M presents with worsening dyspnea of 6 hours’ duration and a cough that is accompanied by pink, frothy sputum.

Pulmonary edema CHF

Mitral valve stenosis Arrhythmia Asthma Pneumonia

ECG

CXR

CBC ABG PFTs BNP

 
 
 
 
 
 


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