Asthma exacerbation most likely diagnosis

Most people with acute asthma present with a constellation of symptoms consisting of cough, dyspnea, and wheezing. These typically occur simultaneously. Acute attacks are set of by some type of stimulant, and the patient has been exposed to some type of stimulant, which has produced an allergic response. An asthma exacerbation may or may not be accompanied by fever, depending on the initiating trigger. This patient is most likely having an acute asthma exacerbation, given her symptoms of shortness of breath, acute allergic symptoms, and the findings of wheezing on physical examination.

Barnes: Asthma and COPD Basic Mechanisms and Clinical Management, 1s Edition Chapter 65 - Acute Exacerbations of Asthma, Chakradhar Kotaru, 2002, Elsevier Science, pp. 669-692

Multiple Choice

1. The correct answer is (A) Dullness to percussion over left base

When alveoli are filled with purulent material, as in pneumonia, there is consolidation in the alveoli causing dullness to percussion. Breath sounds in that area may be bronchial, or harsh, or even absent. Tactile fremitis is increased, but only in the area of consolidation and not throughout the lungfields. Inspiratory and expiratory wheezes suggest narrowed airways as in asthma.

2. The correct answer is (C) Standing behind the patient, palpate deeply behind the clavicles as he takes a deep breath

When the patient inspires, the supraclavicular lymph nodes may be more easily palpable, especially from a posterior position.

3. The correct answer is (A) The patient may have a pleural effusion

In pleural effusions, fluid accumulates in the pleural space, separating air-filled lung from the chest wall, blocking transmission of sound from underlying lung tissue. This reduces detection of movement of the diaphragm on percussion.

A right middle lobe pneumonia would not affect descent of the diaphragm. A pneumothorax is air leakage into the pleural space, causing loss of aerated lung tissue but not necessarily impairing descent of the diaphragm. Normal lung findings are usually symmetrical in healthy adults. The right lung has three lobes compared to two on the left but is not significantly larger.

4. The correct answer is (A) Malodorous breath

Lung abscesses are usually anaerobic, causing an unpleasant odor.

The clavicle is not affected by a lung abscess. Clubbing is seen in chronic lung or liver disease and in congenital heart disease. Kussmaul breathing, or rapid deep breathing, is seen in anxiety, exercise, and metabolic acidosis.

5. The correct answer is (C) Diminished or absent breath sounds in the right middle lobe

Atelectasis occurs when air flow is obstructed by a tumor, a mucous plug, or a foreign object; the alveoli of affected lung tissue collapse into an airless state. Percussion reveals dullness over the airless area, and breath sounds are absent. Odor and hyperresonance are not consistent with atelectasis.

6. The correct answer is (B) Softer and more distant

Fat and muscle can muffle heart sounds, making them more distant.

7. The correct answer is (C) Under the right axilla

Only the right lung had a middle lobe. You must also examine the remaining areas of both lung fields to compare the quality of breath sounds at several locations.

8. The correct answer is (A) Resonance

Resonance is the expected finding in normally aerated lung tissue.

9. The correct answer is (C) Muffled voice sounds and symmetrical tactile fremitus

Normal lung findings include: symmetric chest expansion, resonance on percussion, vesicular breath sounds over the lung fields, no adventitious sounds, and muffled voice sounds.

10. The correct answer is (A) Consolidation

A dull percussion note indicates loss of aerated lung tissue (alveoli), or consolidation, as in pneumonia, pleural effusion, atelectasis, or tumor. In asthma and COPD, there is often hyperresonance from air trapping due to narrowing of the airways on expiration. Adipose tissue is more likely to muffle breath sounds than to change the percussion note over normally aerated lung tissue.

11. The correct answer is (B) Side to side comparison

Side to side comparison, the "ladder" technique, helps pinpoint any asymmetries in the quality of the breath sounds. Listen to at least one full respiration in each location.

12. The correct answer is (B) Use the diaphragm of the stethoscope held firmly against the chest

The diaphragm of the stethoscope held firmly on the chest is the correct way to auscultate breath sounds. The patient should be instructed to open the mouth and breathe in and out more deeply than usual, but not to hyperventilate.

13. The correct answer is (A) When the bronchial tree is obstructed

Decreased or absent breath sounds occur when the bronchial tree is obstructed as in pneumonia or pleural effusion. Adventitious sounds are extra sounds such as rales, wheezes, or rhonchi, heard in congestive heart failure, asthma, and bronchitis, respectively. In COPD, there is often delayed expiration, but breath sounds are still heard. Whispered pectoriloquy pertains to the quality of transmitted spoken words, not breath sounds.

14. The correct answer is (C) Pleural effusion

In pneumothorax and COPD, there is hyperresonance and decreased-to-absent breath sounds. In asthma, there is resonance or hyperresonance from air trapping, but breath sounds are often obscured by wheezing.

See Chapter 6, The Thorax and Lungs, in Bates Physical Examination and History Taking, Table 6--7.

15. The correct answer is (D) A spontaneous pneumothorax

Young men may present with acute shortness of breath from spontaneous pneumothorax of unknown etiology. With a pneumothorax, free air in the pleural space causes partial or complete lung collapse and deviation of the trachea to the nonaffected side. If the pneumothorax is large, tachypnea and cyanosis may occur. See Chapter 6, The Thorax and Lungs, in Bates Physical Examination and History Taking, Table 6--7.

16. The correct answer is (C) Asthma

Asthma arises from hypersensitivity to allergenic inhaled particles, producing inflammation and smooth muscle constriction in the bronchioles and increased airway resistance during expiration. This produces increased work of breathing and use of accessory muscles.

17. The correct answer is (B) Wheezes

Wheezes are high-pitched musical breath sounds caused by air squeezed or compressed through narrowed inflamed small- and middle-caliber airways. Whispered pectoriloquy occurs when whispered voice sounds are transmitted more clearly through collapsed alveoli. Bronchophony results from increased transmission of spoken voice sounds. Usually muffled or absent breath sounds result from collapse, not just narrowing, of the bronchioles.

18. The correct answer is (A) Diaphragm and intercostals

The major muscle of respiration is the diaphragm. The intercostals muscles lift the sternum and elevate the ribs during inspiration, increasing the anteroposterior diameter.

Chapter l

The Cardiovascular System Multiple Choice

1. The correct answer is (A) Anemia

An accentuated S1 occurs in tachycardia, rhythms with a short PR interval, and in high cardiac output states. Anemia is one cause of a high cardiac output state and, along with this patient's fatigue, is the most likely diagnosis.

In mitral regurgitation, the S1 sound is diminished. This occurs because the mitral valve is calcified and relatively immobile. In right bundle branch block, the S1 sound is split. A right bundle branch block means that there is a delay in the interventricular conduction, which will result in two separate S1 sounds. Atrial fibrillation will result in a varying intensity of S1; the mitral valve is in varying positions before being shut by ventricular contraction, so its closure sound varies in loudness.

2. The correct answer is (B) Pulmonic stenosis

Pulmonic stenosis means that the pulmonic valve has delayed closure. This results in a widely split S2, which means that the usual splitting is increased and persists throughout the respiratory cycle (including expiration).

Physiologic splitting of the S2 sound means that it varies with inspiration and expiration; it is usually accentuated with inspiration and disappears with expiration. It is best heard in the 2nd or 3rd left interspace. Atrial septal defect means that there is a fixed splitting of the S2 sound, which does not vary with inspiration and expiration—it is always of the same intensity. The fixed split of S2 can also occur with right ventricular failure. In a left bundle branch block, the split is paradoxical or reversed. This means that the splitting of the S2 sound occurs with expiration and disappears with inspiration—this is the exact opposite of what you would expect physiologically. This is caused by a delayed closure of the aortic valve, the most common cause of which is a left bundle branch block.

3. The correct answer is (C) Mitral valve prolapse

Given the patient scenario and the location and timing of the sound, the most likely diagnosis is mitral valve prolapse. The click is heard best at or medial to the apex.

A bicuspid aortic valve will result in an aortic ejection sound that is heard at both the base and the apex and does not vary with respiration. Pulmonary hypertension causes a pulmonic ejection sound that is heard best in the 2nd and 3rd left interspaces. The intensity often decreases with inspiration. The sound of mitral stenosis is an opening snap that is heard in very early diastole. It is heard best just medial to the apex and along the lower left sternal border.

4. The correct answer is (A) Innocent

This is the most likely cause. There are no associated findings of any pathologic or cardiovascular disease.

Pulmonic stenosis is not a correct response. With pulmonic stenosis, the murmur may radiate toward the left shoulder and neck. The intensity is soft to loud, with a medium pitch and a harsh quality. There are associated findings of a widely split S2 and diminished P2, especially in severe pulmonic stenosis. A physiologic murmur is also incorrect. A physiologic murmur results from a temporary increase in blood flow caused by such pathologic conditions as anemia, hyperthyroidism, and fever. This patient is completely healthy and exhibits no other signs of a systemic disease. Choice (D) likewise in incorrect. A bicuspid aortic valve will result in aortic stenosis, which is characterized by a murmur that is located in the right 2nd interspace and that radiates to the neck, down the left sternal border, and even to the apex. The pitch is medium and it has a harsh quality. It is best heard with the patient sitting and leaning forward. It is unlikely to occur this early in life without any other findings of systemic disease.

5. The correct answer is (C) Aortic stenosis

In aortic stenosis, the murmur is located in the right 2nd interspace and often radiates into the neck and down the left sternal border, even to the apex. It is often loud and has a medium pitch with a harsh quality. It is best heard with the patient sitting up and leaning forward.

A physiologic murmur results from a temporary increase in blood flow caused by such pathologic conditions as anemia, hyperthyroidism, and fever. This patient is completely healthy and exhibits no other signs of a systemic disease. It is best heard in the 2nd-4th interspaces between the left sternal border and the apex and rarely radiates. Pulmonic stenosis is not a correct choice. With pulmonic stenosis, the murmur is located in the 2nd and 3rd left interspaces and may radiate toward the left shoulder and neck. The intensity is soft-to-loud with a medium pitch and a harsh quality. There are associated findings of a widely split S2 and diminished P2, especially in severe pulmonic stenosis. Likewise hypertrophic cardiomyopathy is not the correct choice. In hypertrophic cardiomyopathy, the mid-systolic murmur is best heard in the 3rd and 4th left interspaces. It can radiate down the left sternal border to the apex and possibly the base, but NOT to the neck. It has a medium pitch and a harsh quality. It decreases with squatting and increases with straining down.

6. The correct answer is (A) Mitral regurgitation

The murmur of mitral regurgitation is best heard at the apex and radiates to the left axilla. It is soft-to-loud in intensity with a medium-to-high pitch and a blowing quality. It does not become louder with inspiration.

The murmur of tricuspid regurgitation is best heard at the lower left sternal border and radiates to the right of the sternum, to the xiphoid area, NOT into the axilla. It has a variable intensity, a medium pitch, and a blowing quality. The intensity of tricuspid regurgitation increases slightly with inspiration. The murmur of a ventricular septal defect is located in the 3rd, 4th, and 5th left interspaces and has a wide range of radiation. It has a very loud intensity and high pitch with a harsh quality. In aortic stenosis, the murmur is mid-systolic and is located in the right 2nd interspace. It often radiates into the neck and down the left sternal border, even to the apex. The sound is often loud and has a medium pitch with a harsh quality. It is best heard with the patient sitting up and leaning forward.

Chapter 8 The Breast

Multiple Choice

1. The correct answer is (A) Fibroadenoma

Fibroadenomas often start during puberty and young adulthood. They may be single or multiple and are often round or disc-like. They can be soft but are usually firm. They are very mobile and delineated from the surrounding tissue. They are generally nontender and show no signs of skin retraction.

The lump is not a cyst. Cysts usually start between the ages of 30 to 50. They are also round and well delineated. An important distinction between cysts and adenomas are that cysts tend to be tender and often change in size and throughout the menstrual cycle. Retraction signs of the skin are also absent. The patient does not have cancer. Breast cancer is very rarely seen under the age of 30 and usually strikes middle-aged and elderly women. There is usually a single lump, and it tends to be irregularly shaped and very hard. It can be fixed to underlying or surrounding tissue. Cancerous masses tend to be nontender, and, in advanced cases, skin retractions are noted.

2. The correct answer is (C) Cancer

Breast cancer can start either before or after the menopause. The masses are usually irregular in shape, hard, and nontender. They can be fixed to underlying tissue.

Fibroadenoma generally starts during adolescence or early adulthood. The lumps are well delineated and tend to be round or disc-like. Cysts appear in the 30-50 age range, and they are generally well delineated and tender. They also change size with the menstrual cycle.

3. The correct answer is (B) Cysts

Cysts often start in women between 30 and 50 years of age. They tend to be round but can be soft or firm. They are mobile and well delineated. Generally they are tender, and they can change in size during the menstrual cycle. They become more pronounced in some women on oral contraceptives. Careful evaluation is still warranted due the rare possibility of breast cancer in this age group.

Fibroadenoma is incorrect. Although fibroadenomas often start during young adulthood, they tend to be nontender. They may be single or multiple and are often round or disc-like. They can be soft but are more likely to be firm. They are very mobile and delineated from the surrounding tissue. Cancer is not a correct response. It is very rarely seen in the early thirties, generally striking middle-aged and elderly women. There is usually a single lump, and it tends to be irregularly shaped and very hard. It can be fixed to underlying or surrounding tissue. Cancerous masses tend to be nontender, and, in advanced cases, skin retractions are noted.

4. The correct answer is (C) Nonpuerperal galactorrhea

Galactorrhea, or milky discharge, when not due to pregnancy or lactation is called nonpuerperal. It is usually has hormonal or pharmacologic associations. In this case, a prolactinoma in the pituitary gland would be at the top of the differential, given the galactorrhea and the amenorrhea.

Nipple discharge in benign breast abnormalities tends to be clear and unilateral. Nipple discharge in breast cancer is usually unilateral and can be clear or bloody.

5. The correct answer is (C) Peau d'orange sign

Peau d'orange, or orange-peel sign, is caused by local lymphatic blockage due to tumor. The involved skin then becomes thickened, and the pores become more prominent. This is usually a late sign of breast cancer.

Choice (A) is incorrect. A retracted nipple is flattened or pulled inward. The surrounding skin is not thickened, nor are there enlarged pores. Paget's disease is also incorrect. This uncommon form of breast cancer starts as an eczema-like scaly skin change around the areola. The lesion may weep, crust, or erode.

Chapter 9 The Abdomen

Case Study: Left Lower Quadrant Abdominal Pain: Adult

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