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Toronto Notes 2019 Approach to the Respiratory Patient
Differential Diagnoses of Common Presentations
Respirology R3
Table 1. Differential Diagnosis of Dyspnea
ACUTE DYSPNEA (MINUTES-DAYS) Cardiac
Acute myocardial infarction CHF exacerbation
Cardiac tamponade Coronary artery disease Arrhythmia
Pulmonary
Upper airway obstruction (anaphylaxis, aspiration, croup, EBV) Airway disease (asthma, COPD exacerbation, bronchitis) Parenchymal lung disease (ARDS, pneumonia)
Pulmonary vascular disease (PE, vasculitis)
Pleural disease (pneumothorax, tension pneumothorax)
Neurologic/Psychogenic
Respiratory control (metabolic acidosis, trauma) Anxiety
Panic attack
CHRONIC DYSPNEA (+4 WEEKS) Cardiac
Valvular heart disease
Myocardial dysfunction (decreased CO)
Pulmonary
Airway disease (asthma, COPD)
Parenchymal lung disease (interstitial disease) Pulmonary vascular disease (pulmonary HTN, vasculitis) Pleural disease (effusion)
Metabolic
Medication Severe anemia Hyperthyroidism
Neuromuscular and chest wall disorders
Deconditioning, obesity, pregnancy, neuromuscular disease
Psychogenic
Anxiety
Table 3. Differential Diagnosis of Hemoptysis
AIRWAY DISEASE
Acute or chronic bronchitis*
Bronchiectasis Bronchogenic CA Bronchial carcinoid tumour CF Cystic Fibrosis
Parenchymal Disease
Pneumonia
TB
Lung abscess
Fungal infection Primary lung cancer Pulmonary metastasis
Vascular Disease
PE
Elevated pulmonary venous pressure:
LVF Left ventricular dysfunction/failure
Mitral stenosis Vascular malformation Vasculitis
Goodpasture’s syndrome
Idiopathic pulmonary hemosiderosis
Miscellaneous
Impaired coagulation
Table 2. Differential Diagnosis of Chest Pain
NONPLEURITIC Pulmonary
Pneumonia PE Neoplasm
Cardiac
MI
Myocarditis/pericarditis
Esophageal
GERD
Spasm Esophagitis Ulceration Achalasia Neoplasm Esophageal rupture
Mediastinal
Lymphoma
Thymoma
Subdiaphragmatic
PUD Gastritis Biliary colic Pancreatitis
Vascular
Aortic aneurysm Aortic dissection Aortic injury/rupture
MSK
Costochondritis Skin
Breast
Ribs
Rheumatic disease
Psych
Anxiety
PLEURITIC Pulmonary
Pneumonia PE
Neoplasm Pneumothorax Pleurisy Hemothorax TB
Empyema
Cardiac
Pericarditis
Dressler’s syndrome
GI
Normal Clubbed
160o >180o
IPD>DPD DPD>IPD
Schamroth’s window
Schamroth’s sign
Figure 3. Signs of nail clubbing
Signs of Respiratory Distress
• Tachypnea
• Central/peripheral cyanosis
• Tachycardia
• Inability to speak
• Nasal flaring
• Tracheal tug
• Intercostal indrawing
• Tripoding
• Abdominal breathing (paradoxical
breathing)
Common Causes of Clubbing
• Pulmonary: Lung CA, bronchiectasis, pulmonary fibrosis, abscess, CF, TB, empyema, A-V fistula/malformation (NOT COPD)
• Cardiac: Cyanotic congenital heart disease, endocarditis
• GI: IBD, celiac, cirrhosis, neoplasm
• Endocrine: Graves’ disease
• Other: Other malignancy, primary
hypertrophic osteoarthropathy
Clubbing is not seen in COPD – if present, think malignancy
Hemoptysis
• Most common cause is bronchitis
• 90% of massive hemoptysis is from the
bronchial arteries
• Considered “massive” if >600 mL/24 h or
bleeding rate of >100 mL/h
Most Common Causes of Chronic Cough in the Non-smoking Patient (cough >3 mo with normal CXR)
• GERD
• Asthma
• Postnasal drip
• ACEI
Subphrenic abscess
MSK
Costochondritis Fractured rib/flail chest Myositis
Herpes zoster
Psych
Anxiety
Panic attack/disorder
Panic attack/disorder
(see Cardiology and Cardiac Surgery C4 and Emergency Medicine ER21)
Table 4. Differential Diagnosis of Cough AIRWAY IRRITANTS
Inhaled smoke, dusts, fumes
Postnasal drip (upper airway cough syndrome) Aspiration
Gastric contents (GERD)*
Oral secretions
Foreign body
Airway Disease
URTI including postnasal drip and sinusitis* Acute or chronic bronchitis
Bronchiectasis
Neoplasm
External compression by node or mass lesion Asthma*
COPD
Parenchymal Disease
Pneumonia
Lung abscess Interstitial lung disease
PE
CHF
Drug-induced (e.g. ACEI) Smoking
Pulmonary endometriosis
*Most common cause of hemoptysis
Adapted from: Weinberger SE. Principles of pulmonary medicine, 5th ed. 2008. With permission from Elsevier
*”Big Three” causes of chronic cough
© Andrew Q. Tran 2015