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nutrition, which may result in coarse hair but not puffiness. Cretinism arises from severe congenital hypothyroidism and is associated with dwarfism and mental retardation.

5. The correct answer is (C) Damage to cranial nerve V (trigeminal nerve)

Facial sensations of pain or touch are mediated by cranial nerve V.

Facial paralysis can be central or peripheral. Bells palsy results from a peripheral lesion of cranial nerve VIIthe patient cannot wrinkle the forehead on the affected side nor make a smile, so both the upper and lower facial muscles are involved. In central lesions of cranial nerve VII from cerebrovascular accidents, the patient can wrinkle both sides of the forehead but cannot make a smile.

6. The correct answer is (C) Area proximal to the enlarged node

When nodes are abnormal, check the area from which they drain.

Chapter 6 The Thorax and Lungs

Case Study: Shortness of Breath

WHAT PARTS OF THE PHYSICAL EXAM WOULD YOU LIKE TO PERFORM? General survey Vital signs

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HEENT Thorax and lungs Cardiovascular

BASED ON THIS INFORMATION, WHAT IS YOUR DIFFERENTIAL DIAGNOSIS?

Allergic rhinitis Allergic rhinitis is a symptom complex that consists of paroxysms of sneezing; itching of the eyes, nose, and palate; rhinorrhea; and nasal obstruction. It is often associated with post-nasal drip, cough, irritability, and fatigue. This patient clearly has allergic rhinitis; however, this is not a cause of her wheezing and shortness of breath.
Goldman: Cecil Textbook of Medicine, 21 ed.; Chapter 274 Allergic Rhinitis Richard D. deShazo, pp 1445. 2000, W.B. Saunders Company
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Acute bronchitis Symptoms of acute bronchitis include: sputum production, dyspnea, wheezing, chest pain, fever, hoarseness, malaise, rhonchi, and rales. Each of these may be present in varying degrees or may be absent altogether. Sputum may be clear, white, yellow, green, or even tinged with blood. On physical examination, the patient with acute bronchitis may or may not have fever and has tachypnea, as well as pulmonary signs such as wheezing, rhonchi, and prolonged expiration. In this case, the patient has no fever, and the cough is nonproductive. Although an acute bronchitis can result in wheezing, it is less likely in this scenario, especially when the patient also has features of allergic rhinitis.
Diagnosis and Management of Acute Bronchitis. Doug Knutson, M.D.; American Family Physician, Vol. 65, No. 10, May 15,2002

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

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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, 1 Edition Chapter 65 Acute Exacerbations of Asthma, Chakradhar Kotaru, 2002, Elsevier Science, pp. 669-692
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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

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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

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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.

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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.

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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