A 33-year-old healthy nonsmoking man presents to you for evaluation of his cough.

Hesays the cough has been present for about 8 weeks. After a few days, he went to an
urgent care where he received antitussives and a bronchodilator. Those did not help, and
he returned 2 weeks later and was given a course of azithromycin. His cough has
persisted. He complains of an associated sore throat, but no fever. He reports worsening
nighttime symptoms, and drinking coffee seems to precipitate the cough. Which of the
following treatments is most likely to help??

A proton pump inhibitor

An antihistamine
An angiotensin-converting enzyme (ACE)-inhibitor
A steroid inhaler

The most common causes of a chronic cough are asthma, postnasal drainage, smoking, and GERD.
Given that he did not respond to a bronchodilator, asthma is an unlikely diagnosis. Sore throat,
combined with symptoms that are worse when lying down or with ingestion of caffeine or alcohol
make GERD a likely diagnosis. Therefore, treatment with a proton-pump inhibitor would be most
likely to help his symptoms. Antihistamines could treat asthma or post-nasal drip due to allergies. A
steroid inhaler would help with asthma, and an antibiotic might be helpful if an infection were the
underlying cause. ACE- inhibitors have cough as a side effect, and would not be used in this case. If
the cough were acute, the differential diagnosis would include asthma exacerbation, acute
bronchitis, aspiration, exposure to irritants (cigarette smoke, pollutants), allergic rhinitis,
uncomplicated pneumonia, sinusitis with postnasal drip, and viral upper respiratory infection. Of
these usual causes, viral upper respiratory infection is by far the most common cause. Viral upper
respiratory infection is the most frequent illness in humans with a prevalence of up to 35%.

2) You are treating a 52-year-old woman with a 40-pack-year history of smoking. She
reports a productive cough that has been present for the last 3 to 4 months, beginning
in the fall. She remembers having the same symptoms last year in the fall, and
attributed it to a "cold that she just couldn't kick." She does not have fevers, reports
mild dyspnea when walking up stairs, and denies hemoptysis. Which of the following
is the most likely diagnosis?

Irritation of airways from cigarette smoke

Chronic bronchitis
Postnasal drainage due to seasonal allergies
Lung cancer

because the patient reports a productive cough for at least 3 months of the year for at least 2
consecutive years, she meets the criteria for chronic bronchitis. This is acommon cause of chronic
cough in smokers. Chronic bronchitis is a useful clinical designation, but falls under the broad
category of chronic obstructive pulmonary disease (COPD). While it is true that her smoking may
cause irritation of her airways, it wouldn’t explain why the cough isn’t present year-round (since she
continues to smoke throughout the year). The most common cause of chronic cough in nonsmokers
is postnasal drainage, but since this patient has a significant smoking history, chronic bronchitis is
more likely. Lung cancers rarely present solely with cough. Associated signs and symptoms include
weight loss and hemoptysis. Asthma is less likely to present with a productive cough.
 3) You are seeing a 23-year-old man for shortness of breath. He has no history of
asthma or wheezing and is otherwise healthy. His lung examination does reveal
significant wheezing bilaterally. Which of the following tests is necessary?

Observation and treatment

Chest x-ray
Peak ow testing
Pulmonary function tests

Patients with a first episode of wheezing require a chest x-ray. Peak flow testing may be helpful in
monitoring control of asthma, but are not useful in evaluating a first episode. Pulmonary function
testing and a CBC may be needed, but a chest x-ray is an absolute necessity.

4) You are caring for a 32-year-old female smoker with a history of allergic rhinitis
who presents to discuss upper respiratory symptoms. She reports congestion, facial
pressure, nasal discharge, tooth pain, and headache. Her symptoms have been present
for 5 days and they have not improved with decongestants. Sinus palpation causes
significant pain. Which of the following is true regarding the criteria for diagnosing
acute bacterial rhinosinusitis in this adult?

Pain with sinus palpation is one of the minor criterion

Purulent nasal drainage is one of the minor criterion
Facial pain is one of the minor criterion
There are no agreed upon criteria for the diagnosis of acute bacterial rhinosinusitis
in an adult

Despite the fact that acute bacterial rhinosinusitis affects more than 20 million Americans per year,
there are no agreed-upon criteria for the diagnosis of acute bacterial rhinosinusitis in adults. This is
because so many of the symptoms mimic other diseases ranging from a common cold to allergic
rhinitis. Some feel that the presence of two major criteria or one major and two minor criteria allow
a clinician to diagnosis sinusitis in adults. Major criteria are: • Purulent anterior nasal discharge or
postnasal discharge • Nasal congestion or obstruction • Facial congestion or fullness • Facial pain
or pressure • Hyposmia/anosmia and fever Minor criteria include: • Headache • Ear pain/pressure
• Halitosis • Dental pain • Cough • Fatigue Bacterial rhinosinusitis can sometimes be distinguished
from viral rhinitis by persistence of symptoms for more than 10 days after onset, or worsening
symptoms within 10 days after an initial improvement. This bimodal presentation can be helpful in
diagnosis.

5. You are seeing a 21-year-old college student who complains of congestion, headache,
sinus pressure, and tooth pain for more than 2 weeks. She is otherwise healthy, but feels
like she's "having trouble shaking this cold." She has used over-the-counter decongestants
with limited relief. A CT scan of her sinuses demonstrates acute sinusitis. Which of the
following is the most common organism causing her symptoms?

Moraxella catarrhalis
S aureus
Group A 3-hemolytic streptococcal species
Streptococcus pneumonia
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 S pneumoniae is the most common bacterial pathogen in bacterial sinusitis. Other causes include H
influenzae, M catarrhalis, and group A β-hemolytic streptococci. Pathogens vary regionally in both
prevalence and drug resistance. Complicating the situation further is that if the sinus aspirates of
healthy adults are cultured, bacteria colonization will be found in around one quarter of them.

6) You are caring for a 42-year-old woman with a 10 days of congestion, purulent
nasal discharge, headache, and tooth pain. Based on clinical grounds, you diagnose her
with uncomplicated rhinosinusitis. According to studies, which of the following
statements regarding treatment of this condition is true?

Treatment with amoxicillin is superior to placebo

Treatment with erythromycin is superior to placebo
Treatment with cipro oxacin is superior to placebo
No signi cant difference has been demonstrated between any antibiotic and
placebo

Between 40% and 70% of patients with acute bacterial rhinosinusitis improve symptomatically
within 2 weeks without antibiotic therapy. Antibiotic treatment is controversial in uncomplicated
cases of clinically diagnosed sinusitis because only around 5% of patients will note a shorter
duration of symptoms with treatment, and antibiotics have nearly twice the number of adverse
events as compared with placebo. Antibiotics should be considered when symptoms are severe, or
when cases are complicated. In these cases, antibiotics reduce the incidence of clinical failure by
50%.

7) You are caring for a patient with recurrent bouts of acute sinusitis. She has had multiple
courses of analgesics, decongestants, and occasional rounds of antibiotics. Among other
remedies, she has tried nasal steroids without relief from her acute symptoms. Which of
the following statement is true regarding imaging in this case?

No imaging will be helpful in this case

Sinus lms may be helpful in this case
CT of the sinuses is only helpful for chronic sinusitis
MRI is the most sensitive in the evaluation of sinusitis

In general, most patients with acute sinusitis do not benefit from imaging studies. However, imaging
may be helpful in uncertain or recurrent cases, as in this question. Sinus films, though not helpful
for initial evaluation, may be abnormal in acute rhinosinusitis, but are actually most helpful when
negative. A normal series has a negative predictive value of 90% to 100%. The positive predictive
value is around 80%, but its sensitivity is only around 60%. CT scans have superior sensitivity (95%
to 98%) when compared with sinus films, so can be valuable in acute settings. That said, they are
particularly valuable in establishing the diagnosis of chronic sinusitis or in equivocal cases before
starting long-term antibiotic therapy. MRI is used when fungal sinusitis or tumors are suspected, but
are not used for routine evaluation. US is not helpful.

8) A 34-year-old man with a past history of asthma presents to an acute care clinic
with an asthma exacerbation. Treatment with nebulized albuterol and ipratropium does
not offer significant improvement, and he is then admitted to the hospital. He is
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 afebrile, has a respiratory rate of 24 breaths/ min, pulse rate is 96 beats/min, and
oxygen saturation is 93% on room air. On examination, he has diffuse bilateral
inspiratory and expiratory wheezes, mild inter costal retractions, and a clear
productive cough. Which one of the following should be the next step in the
management of this patient?

Oral corticosteroids

Hospital management of acute exacerbations of asthma should include

inhaled short-acting bronchodilators and systemic corticosteroids. The
ef cacy of oral versus intravenous corticosteroids has been shown to be
equivalent. Antibiotics are not needed in the treatment of asthma
exacerbations unless there are signs of infection. Inhaled ipratropium is
recommended for treatment in the emergency department, but not in the
hospital. Chest physical therapy and theophylline are not recommended for
acute asthma exacerbations.

9) ) A 13-year-old adolescent boy has a nonproductive cough and mild shortness of

breath on a daily basis. He is awakened by the cough at least five nights per month.
Which one of the following would be the most appropriate treatment f or this patient?

Inhaled corticosteroids daily

This patient has moderate persistent asthma. The most effective treatment is daily inhaled
corticosteroids. A leukotriene inhibitor would be less effective and as a controller should be
used daily. Oral prednisone daily is problematic due to the risk of adrenal insufficiency.
Short- and long-acting β-agonists are not recommended as daily therapy because they are
considered rescue medications rather than asthma controllers.

10) young women presents with progressively worsening dyspnea and cough. She has
never smoked cigarettes, has no known passive smoke expo sure, and does not have
any occupational exposure to chemicals. Pulmonary f unction testing shows
obstructive lung disease that does not respond to bron chodilators. Which of the
following is the most likely etiology?

A. Radon exposure at home

B. COPD
C. α1-Antitrypsin de ciency
D. Asthma
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C. This patient has a fixed airway obstruction consistent with
COPD. The airway obstruction of asthma would be at least partially reversible on testing with a
bronchodilator. α1-Antitrypsin deficiency should be considered in a patient who develops COPD at a
young age, especially if there is no other identifiable risk factor.

11) A 68-year-old patient of your practice with known COPD has pulmonary function
testing showing an FEV1 of 40% predicted has been having frequent exacerbations of
his COPD. His SaO2 by pulse oximetry is 91%. Which of the following medication
regimens is the most appropriate?

A. Inhaled salmeterol BID and albuterol as needed

B. Oral albuterol daily and inhaled uticasone BID
C. Inhaled uticasone BID, inhaled tiotropium BID, and inhaled albuterol as needed
D. Inhaled uticasone BID, inhaled tiotropium BID, inhaled albuterol as needed, and home
oxygen therapy

12. A 68-year-old patient of your practice with known COPD has pulmonary function
testing showing an FEV1 of 40% predicted has been having frequent exacerbations of his
COPD. His SaO2 by pulse oximetry is 91%. Which of the following medication regimens
is the most appropriate?

A. Inhaled salmeterol BID and albuterol as needed

B. Oral albuterol daily and inhaled uticasone BID
C. Inhaled uticasone BID, inhaled tiotropium BID, and inhaled albuterol as needed
D. Inhaled uticasone BID, inhaled tiotropium BID, inhaled albuterol as needed, and home
oxygen therapy

C. This patient has stage III COPD with frequent exacerbations. He is best treated by a long-
acting bronchodilator (eg, tiotropium) and an inhaled steroid (eg, fluticasone) used
regularly, along with an inhaled, short-acting bronchodilator on an as-needed basis.

13) A 59-year-old man with a known history of COPD presents with worsening
dyspnea. On examination, he is afebrile. His breath sounds are decreased bilaterally.
He is noted to have jugular venous distension (JVD) and 2+ pitting edema of the lower
extremities. Which of the following is the most likely cause of his increasing dyspnea?

COPD exacerbation
Pneumonia
cor pulmonale
Pneumothorax
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C. JD and lower extremity edema are suggestive of cor pulmonale, which is right heart
failure due to chronically elevated pressures in the pulmonary circulation. Right heart
failure causes increased right atrial pressures and right ventricular end diastolic pressures,
which then lead to liver congestion, jugular venous distension, and lower extremity
edema.13) A 36-year-old man has had recurrent bouts of sinusitis. He develops at least
three sinus infections per year and wants to discuss prevention. Which of the following
conditions is the most likely precipitating factor for his recurrent sinusitis?

14) a 52-year-old woman with a 40-pack-year history of smoking. She reports a

productive cough that has been present for the last 3 to 4 months, beginning in the fall.
She remembers having the same symptoms last year in the fall, and attributed it to a
“cold that she just couldn’t kick.” She does not have fevers, reports mild dyspnea
when walking up stairs, and denies hemoptysis. Which of the following is the most
likely diagnosis?

15) Cystic fibrosis therapy?

16) A 56-year-old man is evaluated for chronic cough. It is present most of the time
and is progressively getting worse over the past 3 years. With the cough he usually has
white to yellow sputum that he has to expectorate On examination, his chest is clear.
Which of the following is the most likely diagnosis?
A. chronic obstructive pulmonary disease (COPD)
B. early cor pulmonale
C. chronic bronchitis
D. asthma
E. emphysema

C. chronic bronchitis Chronic bronchitis is a clinical diagnosis defined by the

presence of chronic productive cough for 3 months in each of 2 successive years in a
patient in whom other causes of chronic cough have been excluded. Emphysema is a
pathologic term describing the abnormal permanent enlargement of airspaces distal
to the terminal bronchioles, accompanied by destruction of their walls without
obvious fibrosis. Emphysema may be noted in patients with COPD.

17) You are caring for a man with asthma. He is currently taking an inhaled
corticosteroid twice daily and using his short-acting β-agonist as needed. Over the past
3 months, he has required escalating doses of his inhaled corticosteroid, and now he is
at the maximum dosage, still using his “rescue” inhaler more than he would like.
Which of the following is the best medication to add to his regimen?

a. A burst and rapid taper of oral steroids

b. A long-acting β-agonist
c. Cromolyn (Intal)
d. Ipratropium (Atrovent)
e. Theophylline

18)major signs of sinusitis and Symptoms

19) Assuming no contraindications, which of the following medications is the first-

line pharmacologic agent of choice in treating mild to moderate COPD?

Anticholinergic therapy SABA

20) A 36-year-old man has had recurrent bouts of sinusitis. He develops at least three
sinus infections per year and wants to discuss prevention. Which of the following
conditions is the most likely precipitating factor for his recurrent sinusitis?
 a. Allergic rhinitis
b. GERD
c. Cigarette smoking
d. Environmental pollutants
e. Immunode ciency

Patients complains of cough and weight loss, hemoptysis.

By objective assessment he has di use alopecia, nicotine stains, and
clubbing of his ngers. He has also cervical lymphadenopathy. Chest
examination revealed signs of right upper lobe lung consolidation (can be
collapse or pleural e usion as well).

Diagnosis

lung cancer

Risk factors

Smoking
Previous radiation exposure
Asbestosis exposure
Occupational chemicals
Genetics

Classi cations

Small cell lung cancer - limited

Extensive
Non small cell lung cancer

Diagnosis

CXR
High resolution CT scan
Tissue biopsy

Treatment

Chemotherapy
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 Surgery

Prevention.

Smoking cessation
Routine CT of smokers help to detect cancer at early stages

CASE 1.
In your o ce come 45 years old man, complains of cough and
breathlessness. Examination of the respiratory system showed: s tachypneic
with a respiratory rate of 30 bpm. He is using the accessory muscles of
respiration. He is sitting in a 'tripod position' (leaning forward posture with
his hands on the knees). He has pursed-lip breathing. There is peripheral and
central cyanosis with palmar erythema, There are nicotine stains in his
ngers. The distance between the top of the thyroid cartilage and the
suprasternal notch is reduced and I can see a BIPAP machine near the bed.
There is a tracheal descent with inspiration (positive tracheal tug/Campbell
sign) His chest is barrel-shaped (increased anteroposterior chest diameter)
There is a paradoxical inspiratory indrawing of the costal margins (positive
Hoover's sign). Chest expansion is reduced bilaterally. Percussion note is
hyper-resonant all over the chest with obliteration of cardiac and liver
dullness. There is a marked decrease in breath sound intensity bilaterally.
There are early inspiratory crackles (at the beginning of inspiration) and
bilateral scattered rhonchi. There is also elevated JVP and bilateral pitting
oedema of the legs.

Diagnosis

COPD

Ethiology

Smoking
Genetics
Air pollutants
Occupational

Most impo risk factor

Smoking
Alfa 1 anti tripsin de ciency
Indoor kitchen smoke in Many countries

Diagnosis
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 Physical diagnosis ; like ; Hallmark symptom of progressive and persistent
shortness of birth , peripheral or central cyanosis, clubbing
History
Age - midlife onset (age 45 or more )
Screening for alpha 1 antitripsin de ciency
Chest radiography
Spirometry ; Decrease in FEV1/FVC = <70%
Peak ow metre

Treatment

Anti cholinergic bronchodilators - ipratropium

Beta 2 agonist a gents
Laba or lama for high symptoms (long acting bronchodilators)

Case 3-1
A 45-year-old man presents to the clinic with a cough productive of purulent
sputum of 3-week duration. He says that he had just gotten over a cold a
few weeks prior to this episode, He occasionally has fevers and he coughs
so much that he has chest pain. He reports having a mild sore throat and
nasal congestion. He has no history of asthma or of any chronic lung
diseases. He denies nausea, vomiting, diarrhea, and any recent travel. He
denies any smoking history. On examination, his temperature is 98.6°F (37.0°
(), his pulse is 96 beats/min, his blood pressure is 124/82 mm Hg, his
respiratory rate is 18 breaths/min, and his oxygen saturation is 99% on room
air. Head, ears, eyes, nose, and throat (HEENT) examination reveals no
erythema of the posterior oropharynx, tonsillar exudates, uvular deviations,
or signi cant tonsillar swelling. Neck examination is negative. The chest
examination yields occasional wheezes but normal air movement is noted
Likely diagnosis: Acute bronchitis.
➤ Next step: Bronchodilators, analgesics, antitussives; antibiotics have
not
been consistently shown to be bene cial. The illness is usually self-
limited.
➤ Common noninfectious causes of cough: Asthma, chronic
obstructive
pulmonary disease (COPD), malignancy, postnasal drip,
gastroesophageal
re ux disease (GERD), medication side e ect (eg, angiotensin-
converting
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enzyme inhibitors), congestive heart failure.

CASE 4: A 61-year-old woman presents to the emergency room (ER)

complaining of cough for 2 weeks.
The cough is productive of green sputum and is associated with sweating,
shaking chills, and fever up to 102°F (38.8°). She was exposed to her
grandchildren who were told that they had upper respiratory infections 2
weeks ago but now are ne. Her past medical history is signi cant for
diabetes for 10 years, which is under good control using oral hypoglycemics.
She denies tobacco, alcohol, or drug use. On examination, she looks ill and
in distress, with continuous coughing and chills. Her blood pressure is
100/80 mm Hg, her pulse is 110 beats/min, her temperature is 101°F (38.3°),
her respirations are 24 breaths/ min, and her oxygen saturation is 97% on
room air. Examination of the head and neck is unremarkable. Her lungs have
rhonchi and decreased breath sounds, with dullness to percussion in
bilateral bases. Her heart is tachycardic but regular. Her extremities are
without signs of cyanosis or edema. The remainder of her examination is
normal. A complete blood count (CBC) shows a high white blood cell (WBC)
count of 17,000 cells/mm3, with a di erential of 85% neutrophils and 20%
lymphocytes. Her blood sugar is 120 mg/dl.

Most likely diagnosis

Pneumonia

Next diagnostic step

X- ray
CT scan
Sputum gram stain and culture
Invasive procedures(bronchoscopy)
PCR test to nd the pathogen

Next therapeutic step

Antibiotics - 5 days
Pneumococcal pneumonia with bacterimia - beta lactic + antibiotics
Drug resistant - beta lactate + macrolids

Potential complications

S- specticemia
L - lung access
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 A - ARDS
P - para pneumonic e usions

H - Hypotension
E - emphysema
R - respiratory failure

Prevention

In uence vaccine + a one time pneumococcal vaccine

How would you diagnose CF?( Cystic brosis)

CXR
Sweat chloride test
Genetic - CF gene

2) What is the basic abnormality in CF?

Increase in mucus production , infection, lead to cold in children ,

infection, chronic hypoxemia, decrease pancreatic enzymes

3)Can you name some conditions that give false positive high
sweat chloride?

Atopic dermatitis
Glycogen storage disease

4) How would you manage a CF patient?

Gene therapy , mucoltics , antibiotics , bronchodilators , o2

supplements , anti in ammatory .

5) Which bacteria commonly cause infections in CF patients?

Psedomonas aeruginosa
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