5.11 Evaluation of Cough, Dyspnea, Hemoptysis & the Solitary Pulmonary Nodule

ABIM Internal Medicine Exam

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2 Chapter 1: Cardiovascular Disease (14% of Exam)

1.1 Ischemic Heart Disease & Acute Coronary Syndromes 1.2 Antithrombotic Therapy, Secondary Prevention & Mechanical Complications of MI 1.3 Atrial Fibrillation, Atrial Flutter & Stroke Prevention 1.4 Supraventricular Tachycardias, Ventricular Arrhythmias & Bradycardias 1.5 Heart Failure: Classification, Staging & Guideline-Directed Medical Therapy 1.6 Device Therapy, HFpEF & the Cardiomyopathies 1.7 Valvular Heart Disease & Endocarditis Prophylaxis 1.8 Pericardial Disease & Acute Aortic Syndromes 1.9 Hypertension: Classification, Diagnosis & Secondary Causes 1.10 Hypertensive Crises & Dyslipidemia 1.11 Adult Congenital Heart Disease & Coarctation of the Aorta 1.12 Syncope: Reflex, Orthostatic & Cardiac Causes 1.13 Cardiac Physical Examination, Murmurs & Antithrombotic Selection

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2.1 Diabetes Mellitus: Diagnosis, Glycemic Targets & Pharmacotherapy 2.2 Insulin Therapy, Hyperglycemic Emergencies & Chronic Complications 2.3 Thyroid Function Testing & Hypothyroidism 2.4 Thyrotoxicosis, Thyroid Storm & Thyroid Nodules 2.5 Adrenal & Pituitary Disorders 2.6 Hypercalcemia, Hypocalcemia & Disorders of Mineral Metabolism 2.7 Osteoporosis & Paget Disease of Bone 2.8 Ovarian, Testicular & Reproductive Endocrine Disorders 2.9 Hypoglycemia, Endocrine Tumors, Polyglandular Syndromes & Severe Hypertriglyceridemia

4 Chapter 3: Gastroenterology & Hepatology (9% of Exam)

3.1 Esophageal Disease 3.2 Stomach & Duodenal Disease and Gastrointestinal Hemorrhage 3.3 Inflammatory Bowel Disease 3.4 Celiac Disease & Irritable Bowel Syndrome 3.5 Diverticular Disease & Colorectal Cancer Screening 3.6 Viral Hepatitis, Steatotic & Alcohol-Associated Liver Disease 3.7 Cirrhosis & the Complications of Portal Hypertension 3.8 Acute Pancreatitis 3.9 Chronic Pancreatitis & Biliary Tract Disease 3.10 Inherited, Autoimmune & Drug-Induced Liver Disease 3.11 Small Intestinal Disease, Ischemia & Gastrointestinal Complications of HIV

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6 Chapter 5: Pulmonary Disease (9% of Exam)

5.1 COPD: Diagnosis, GOLD Classification & Initial Pharmacotherapy 5.2 Interventions That Reduce COPD Mortality & Exacerbation Management 5.3 Asthma: Diagnosis, Stepwise Therapy & Status Asthmaticus 5.4 Interstitial Lung Disease & Idiopathic Pulmonary Fibrosis 5.5 Sarcoidosis, Hypersensitivity Pneumonitis & Occupational Lung Disease 5.6 Pulmonary Embolism: Diagnosis, Risk Stratification & Anticoagulation 5.7 Pulmonary Hypertension & Sleep-Disordered Breathing 5.8 Acute Respiratory Distress Syndrome & Mechanical Ventilation 5.9 Pleural Disease, Empyema & Pneumothorax 5.10 Bronchiectasis, Cystic Fibrosis & Restrictive Lung Disease 5.11 Evaluation of Cough, Dyspnea, Hemoptysis & the Solitary Pulmonary Nodule

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6.1 Rheumatoid Arthritis: Diagnosis & Systemic Manifestations 6.2 Antirheumatic Pharmacotherapy & the Spondyloarthropathies 6.3 Gout: Pathophysiology & Acute Management 6.4 Urate-Lowering Therapy & Calcium Pyrophosphate Deposition Disease 6.5 Osteoarthritis 6.6 Systemic Lupus Erythematosus 6.7 Systemic Sclerosis, Sjogren Syndrome & Inflammatory Myopathies 6.8 The Vasculitides 6.9 Regional Musculoskeletal Syndromes, Back Pain & Sports Injuries 6.10 Other Primary Rheumatic Disorders & Mixed Connective Tissue Disease 6.11 Osteonecrosis & Metabolic Bone Disease

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7.1 Approach to Anemia & the Microcytic Anemias 7.2 Macrocytic, Normocytic & Hemolytic Anemias 7.3 Hemoglobinopathies, Thalassemias & Paroxysmal Nocturnal Hemoglobinuria 7.4 Platelet Disorders, Thrombocytopenia & the Bleeding Patient 7.5 Coagulation Factor Disorders, Thrombophilia & Anticoagulant Reversal 7.6 Acute Leukemias, Chronic Leukemias & Myeloproliferative Neoplasms 7.7 Lymphomas & Plasma Cell Disorders 7.8 Myelodysplastic Syndrome, Myeloproliferative Neoplasms & Porphyria 7.9 Transfusion Medicine & Late Complications of Transplantation

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9.1 Acute Kidney Injury: Staging, Etiology & Urine Microscopy 9.2 Glomerular Disorders & Nephrotic Syndrome 9.3 Nephritic Syndromes, RPGN & Indications for Renal Replacement Therapy 9.4 Chronic Kidney Disease: Staging & Progression Retardation 9.5 Complications of Chronic Kidney Disease: Anemia, CKD-MBD & Acidosis 9.6 Hyponatremia, Hypernatremia & Water Balance 9.7 Potassium Disorders & Systematic Acid-Base Analysis 9.8 Renal Tubular Acidosis & Nephrolithiasis 9.9 Prostate Disorders, Urinary Incontinence & Other Urologic Conditions 9.10 Cystic Kidney Disease, Obstructive Uropathy, Tubulointerstitial Disease & Hematuria

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14 Chapter 13: Obstetrics & Gynecology / Women's Health (3% of Exam)

13.1 Contraception, Preconception Care & Teratogenicity 13.2 Hypertensive Disorders of Pregnancy & Gestational Diabetes 13.3 Thyroid Disease & Venous Thromboembolism in Pregnancy 13.4 Menopause & Menopausal Hormone Therapy 13.5 Abnormal Uterine Bleeding, Endometrial Disease & Gynecologic Cancer Screening 13.6 Breast Disorders & Diseases of the Vulva and Vagina 13.7 Menstrual Disorders, Fibroids, Endometriosis & Early Pregnancy Complications

15 Chapter 14: Geriatric Syndromes (3% of Exam)

14.1 Comprehensive Geriatric Assessment & Frailty 14.2 Falls, Gait Assessment & Polypharmacy 14.3 Urinary Incontinence & Pressure Injuries in Older Adults 14.4 Mild Cognitive Impairment, Dementia & Its Subtypes 14.5 Delirium & the Pharmacotherapy of Cognitive Disorders 14.6 Palliative Care, Hospice & Advance Care Planning 14.7 Chronic Wounds, Nutrition, Swallowing, Constipation & Hip Fracture 14.8 Sensory Impairment, Dizziness, Elder Mistreatment & Care Settings

16 Chapter 15: Allergy & Immunology (2% of Exam)

15.1 Anaphylaxis: Recognition & Emergency Management 15.2 Urticaria & Angioedema 15.3 Drug Allergy, Desensitization & Adult Immunodeficiency 15.4 Food Allergy, Insect Venom Hypersensitivity, Serum Sickness & Contrast Reactions 15.5 Rhinitis, Conjunctivitis, Eosinophilic & Mast Cell Disorders

17 Chapter 16: Preventive Medicine, Immunization & Clinical Epidemiology

16.1 The USPSTF Framework & Evidence-Based Cancer Screening 16.2 Cardiovascular & Metabolic Screening and Primary Prevention 16.3 Adult Immunization & Vaccines in Special Populations 16.4 Clinical Epidemiology, Biostatistics & Study Design

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17.1 Principles of Bioethics & Decisional Capacity 17.2 Informed Consent, Treatment Refusal & Special Scenarios 17.3 Surrogate Decision-Making, Advance Directives & Confidentiality 17.4 Patient Safety Science, Medical Error & Diagnostic Reasoning 17.5 Quality Improvement Methods, Health Disparities & Health Equity

19 Chapter 18: Perioperative Medicine & Medical Consultation

18.1 Preoperative Cardiovascular Risk Assessment 18.2 Preoperative Pulmonary Risk & Perioperative Medication Management 18.3 Perioperative Anticoagulation, Bridging & Postoperative Complications

20 Chapter 19: Ophthalmology (1% of Exam)

19.1 The Acute Red Eye & Ophthalmic Emergencies 19.2 Painless Vision Loss & Chronic Ophthalmic Disease 19.3 Uveitis, Scleritis & Orbital Disease

21 Chapter 20: Otolaryngology & Dental Medicine (1% of Exam)

20.1 Dizziness, Vertigo & Epistaxis 20.2 Ear Disorders, Hearing Loss & Upper Respiratory Infections 20.3 Oral Cavity, Salivary Gland, Laryngeal & Taste and Smell Disorders

5.11 Evaluation of Cough, Dyspnea, Hemoptysis & the Solitary Pulmonary Nodule

Key Takeaways Explain This Topic AI

Evaluation of common pulmonary symptoms is a 2.5% blueprint subsection covering cough, dyspnea, hemoptysis and the solitary pulmonary nodule.

Upper airway cough syndrome, asthma and gastroesophageal reflux account for most chronic cough in non-smokers with a normal chest radiograph.

Angiotensin-converting enzyme inhibitor cough may begin months after starting the drug and resolves within weeks of stopping it.

Solitary pulmonary nodule management depends on size, growth, morphology and the patient smoking and malignancy risk rather than on a single imaging feature.

Massive hemoptysis is managed by positioning the bleeding lung dependent, protecting the airway, and proceeding to bronchial artery embolization.

Last updated: August 2026

1. Chronic Cough

Cough lasting more than eight weeks is chronic. In a non-smoker with a normal chest radiograph who is not taking an ACE inhibitor , three conditions account for the overwhelming majority of cases, and they frequently coexist:

Upper airway cough syndrome (formerly postnasal drip) — the single most common cause. Throat clearing, cobblestoning of the posterior pharynx, a sensation of drainage. Diagnosed by response to an empiric first-generation antihistamine-decongestant.

Asthma, including cough-variant asthma — cough may be the only symptom, without wheeze. Spirometry with bronchodilator response, or bronchoprovocation testing if spirometry is normal.

Gastroesophageal reflux disease — may occur without heartburn . Cough worse when supine or after meals.

Before any of this, do two things:

Stop the ACE inhibitor. Cough occurs in roughly 10 to 20% of users, is not dose-related, and may begin weeks to months after initiation — patients and clinicians often dismiss the drug because it was started long ago. It resolves within one to four weeks of withdrawal, occasionally taking up to three months. Angiotensin receptor blockers do not cause it.

Obtain a chest radiograph. An abnormal film redirects the entire workup.

Red flags requiring imaging and often bronchoscopy: hemoptysis, weight loss, fever, a substantial smoking history, hoarseness, or an abnormal radiograph.

Non-asthmatic eosinophilic bronchitis is worth knowing as the diagnosis in a patient with chronic cough, sputum eosinophilia, and normal spirometry with a negative bronchoprovocation test ; it responds to inhaled corticosteroids.

2. Dyspnea

The exam task is separating cardiac, pulmonary, hematologic, metabolic and deconditioning causes efficiently.

Initial evaluation: history and examination, pulse oximetry at rest and with ambulation, chest radiograph, ECG, complete blood count and, when the cause is unclear, B-type natriuretic peptide and spirometry.

• Finding Points toward
• Orthopnea, paroxysmal nocturnal dyspnea, S3, elevated jugular venous pressure Heart failure

Elevated B-type natriuretic peptide Cardiac cause (though it rises in renal failure, atrial fibrillation, pulmonary embolism; falls with obesity)

Desaturation with ambulation despite a normal resting saturation Interstitial disease, pulmonary vascular disease, shunt

• Obstructive spirometry Asthma, COPD
• Restrictive spirometry with low DLCO Interstitial disease
• Isolated low DLCO with normal spirometry Pulmonary vascular disease, early emphysema, anemia
• Normal cardiopulmonary testing Deconditioning, anxiety, obesity

Ambulatory oximetry is the single highest-yield underused test. A resting saturation of 96% that falls to 87% after walking reframes the entire differential.

Platypnea-orthodeoxia — dyspnea and desaturation that are worse upright and better supine — is the reverse of orthopnea and indicates a right-to-left shunt, classically hepatopulmonary syndrome (an enumerated blueprint topic) or a patent foramen ovale. Hepatopulmonary syndrome is the triad of liver disease, an elevated alveolar-arterial gradient and intrapulmonary vascular dilatation demonstrated by contrast-enhanced echocardiography with delayed left-sided opacification. Liver transplantation is the only definitive therapy.

3. Hemoptysis

First, confirm the source. Hematemesis and nasopharyngeal bleeding are frequent mimics. Blood from the airway is frothy, bright red and alkaline; blood from the stomach is dark, may contain food particles and is acidic.

Causes: bronchitis (the most common overall), bronchiectasis, lung cancer , tuberculosis and other infection, pulmonary embolism with infarction, mitral stenosis, and diffuse alveolar hemorrhage from vasculitis or anti-glomerular basement membrane disease.

Diffuse alveolar hemorrhage deserves particular attention because the presentation can be deceptively bland: falling hemoglobin, diffuse alveolar infiltrates and hypoxemia — with hemoptysis absent in up to a third of cases. Bronchoalveolar lavage showing progressively bloodier aliquots, or hemosiderin-laden macrophages, establishes it. In this setting an increased DLCO is the counterintuitive clue, because intra-alveolar blood binds carbon monoxide.

Massive hemoptysis is a mechanical emergency — patients asphyxiate rather than exsanguinate, since the anatomic dead space is small. Management:

Position the bleeding side down to protect the unaffected lung.

Secure the airway , using a large-bore endotracheal tube to permit bronchoscopy.

Reverse coagulopathy.

Bronchial artery embolization — the definitive intervention, because roughly 90% of massive hemoptysis arises from the high-pressure bronchial circulation rather than the pulmonary arteries.

Surgery for refractory bleeding.

4. The Solitary Pulmonary Nodule

A solitary pulmonary nodule is a single, well-circumscribed opacity 3 cm or smaller surrounded by aerated lung. A lesion larger than 3 cm is a mass and is presumed malignant until proven otherwise.

Step 1: Find prior imaging

The most valuable next step, and the cheapest, is comparison with old films . Documented stability over two years for a solid nodule strongly suggests benignity and generally ends the workup. Note that this rule does not apply to subsolid and ground-glass nodules, which grow slowly and require longer surveillance.

Step 2: Assess morphology

• Favors benign Favors malignant
• Smooth, well-defined margins Spiculated or lobulated margins
• Central, laminated, popcorn or diffuse calcification Eccentric or stippled calcification
• Size under 6 mm Size over 8 mm; growth
• Intralesional fat (hamartoma) Cavitation with a thick, irregular wall
• Stability over 2 years (solid) Persistent part-solid nodule with a growing solid component

Popcorn calcification indicates a hamartoma. Central or laminated calcification indicates prior granulomatous infection.

Step 3: Assess patient risk

Age, cigarette smoking (current and pack-years), prior malignancy, family history, and exposures such as asbestos, radon or endemic fungi. Upper lobe location modestly increases malignancy risk.

Step 4: Choose a strategy

• Estimated risk Approach
• Very low (< ~5%) CT surveillance at intervals determined by size and nodule type
• Intermediate (~5 to 65%) PET/CT ; consider non-surgical biopsy
• High (> ~65%) Surgical resection after staging

PET/CT limitations are heavily tested. False negatives occur in lesions under about 8 mm (below spatial resolution), in carcinoid tumors , and in adenocarcinoma in situ / lepidic-predominant lesions , all of which are metabolically indolent. False positives occur with active infection, granulomatous disease including sarcoidosis and histoplasmosis, and rheumatoid nodules . PET is therefore not useful for a 5 mm nodule and not reassuring in a ground-glass lesion.

Ground-glass and part-solid nodules behave differently from solid nodules: they are more often malignant when persistent, grow much more slowly, and require longer surveillance . A part-solid nodule whose solid component enlarges is the highest-risk pattern.

Incidental nodules versus screening

Do not confuse the two pathways. Lung cancer screening with annual low-dose CT applies to asymptomatic adults meeting age and smoking-history criteria and uses a structured reporting system. An incidentally discovered nodule is managed by the risk-based algorithm above.

5. Miscellaneous Pulmonary Disorders: Indications for Spirometry

The blueprint explicitly names indications for spirometry . Order it to:

• Diagnose obstructive or restrictive disease in a patient with dyspnea, chronic cough or wheeze
• Confirm COPD — the diagnosis cannot be made without post-bronchodilator spirometry
• Assess severity and monitor progression in asthma, COPD, interstitial and neuromuscular disease
• Evaluate preoperative risk before lung resection
• Monitor occupational exposure and drug toxicity

Screening spirometry in asymptomatic adults is not recommended , even in smokers, because it does not improve outcomes independent of cessation counseling.

Flow-volume loop patterns identify upper airway obstruction, which is otherwise easily missed:

• Pattern Lesion
• Flattened inspiratory limb Variable extrathoracic obstruction (vocal cord dysfunction, paralysis)
• Flattened expiratory limb Variable intrathoracic obstruction (tracheomalacia, intrathoracic tumor)
• Both limbs flattened Fixed obstruction (tracheal stenosis, large goiter)