Lung Differentials

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Lung Differentials

• Jennifer Renstrom
• Pharm D Candidate

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Healthy Lung
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Common Abnormalities

• Pain
• Cough
• Altered breathing patterns
• Dyspnea
• Wheeze
• Crackles

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Pulmonary Pain

• Insensitive to pain
• Lung tissue
• visceral pleura
• Sensitive to pain
• Parietal pleura
• chest wall
• diaphragm
• major airways
• mediastina
• Often have referred pain

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Pleural Pain

• Intense pain
• Inflammation
• Viral infection
• Localized pain
• catch in side of chest
• Motion makes it worse
• Causes Pneumonia, pulmonary embolism,
  Tuberculosis, cancers

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Lung Cancer
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Intercostal Neuritis

• Similar to pleural pain but not exacerbated by
  movement
• Electric shock sensation
• Hypersensitive or anesthetic areas
• Causes
• Herpes zoster (shingles)
• Spinal cord tumor

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• Muscular Pain
• Usually localized
• Can be mistaken for deeper chest disease

• Costochondral Pain
• Tietzes syndrome
• Dull, gnawing, aching
• Tenderness on pressure
• Palpable enlargement of cartilage between sternum
  and ribs

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Tuberculosis
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Productive Cough

• Loose cough with rattling
• Heavy smoking, chronic bronchitis
• Abundant, frothy, thin sputum
• Bronchioloalveolar carcinoma
• Voluminous, pink, frothy sputum
• Pulmonary edema
• Rust-colored sputum
• Pneumococcal pneumonia
• Copious purulent sputum when changing posture
• Bronchiectasis
• Foul-smelling sputum
• Anaerobic bacterial infection, lung abscess

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Pulmonary Edema
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Pulmonary Embolism
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Hemoptysis

• Small streaks
• Acute respiratory tract infection
• Grossly bloody sputum
• Pneumonia
• Other Causes
• Bronchitis, Bronchiectasis, TB, Cancers
• GI origin

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Bronchiectasis
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Breathing patterns
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Altered Breathing Patterns

• Bradypnea
• O2 toxicity, primary hypoventilation, opiates,
  brain tumor
• Tachypnea
• Fever, pneumonia, metabolic alkalosis, anxiety,
  exercise
• Hyperpnea
• Metabolic acidosis

• Cheyne-Stokes
• Medulla loses sensitivity to nervous stimuli or
  fluctuations CO2
• Stroke, brain tumor, heart disease, kidney
  disease, meningitis, pneumonia
• Biots
• Meningitis, medullary lesions
• Sighing
• Emotional tension

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Pneumonia
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Dyspnea

• Sudden, unprovoked
• Pneumothorax, embolism, MI
• Activity induced
• Short walk, 1 flight of stairs CHF
• Exercise induced with wheezing
• Exercise induced asthma
• Emotional state
• Anxiety attacks

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Pneumothorax
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Wheezes

• Monophonic
• Tumor
• Rigid wheeze throughout breath
• Flexible inspiration or expiration
• Asthma
• Single or multiple
• Asbestosis/interstitial fibrosis
• Lower regions
• Inspiratory
• late inspiratory crackles
• Short late inspiratory wheeze
• many short multiple pitch wheezes throughout
  inspiration

• Polyphonic
• Expiration
• COPD

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Asbestosis
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Crackles

• Early Inspiratory
• Few crackles, transmitted to mouth
• Chronic Bronchitis, asthma, emphysema
• Fine
• Pulmonary fibrosis, asbestosis, CHF, TB

• Late Inspiratory
• More numerous, very with patient position
• Interstitial fibrosis, asbestosis, pneumonia,
  pulmonary congestion, pulmonary sarcoidosis,
  scleroderma, rheumatoid lung
• Coarse
• Chronic Bronchitis, Bronchietasis

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Pulmonary Fibrosis (Sarcoidosis)
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Pleural Friction Rub

• Friction caused by coarseness
• Fibrin deposits
• Thickened pleura
• Nonmusical sounds
• longer and lower pitch than crackles
• Inspiration sounds mirrored on expiration
• Not always distinguishable from crackles

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Other Findings

• Percussion
• Dull Sound
• Pneumonia, TB, cancers, atelectasis, pleural
  effusion
• Hyperresonant
• Emphysema, pneumothorax, acute asthma attack

• Neck Vein Distention
• COPD
• Stridor
• Laryngeal or tracheal obstruction
• Tumors, tracheal stenosis, aspiration
• Hoarseness
• Irregularities on vocal cords, disorder of nerves
  and muscles
• Tumors, stenosis, laryngitis, chronic voice abuse

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Collapsed Lung
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AsthmaAcute Exacerbation
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Emphysema
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Clubbing

• Polished, glistening, loss of wrinkles
  (eventually)
• Note tobacco stains
• Causes
• CHF, subacute endocarditis, bronchiectasis,
  cystic fibrosis, lung abscess, pulmonary
  fibrosis, lung cancer, liver cirrhosis, regional
  enteritis, chronic ulcerative colitis

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Cystic Fibrosis
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Lung Abscess
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Disease Differential
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Disease Differential Cont.