Pulmonary Symptoms

The patient complains of dyspnea or cough. Determine the following factors relating to the patient's history.

Recent History

Onset and duration of symptoms: rapid (hours to days), subacute, chronic Progression or stability of symptoms Dyspnea at rest or with exertion? Cough: productive (character of sputum), hemoptysis? Associated symptoms (chest pain, pleuritic pain, etc) Constitutional symptoms: fever, night sweats, unintentional weight loss Sinus congestion, facial tenderness, postnasal discharge, sore throat Orthopnea, paroxysmal nocturnal dyspnea (PND), peripheral edema Wheezing

Past History

CD4 nadir (lowest documented CD4 cell count), current CD4 count If the CD4 count is <200 cells/µL, ask whether the patient is taking Pneumocystis jiroveci pneumonia (PCP) prophylaxis (primary or secondary); if taking PCP prophylaxis and adhering to the regimen, the diagnosis of PCP is less likely. Tuberculosis (TB): date and result of tuberculin skin test (purified protein derivative, or PPD), risk factors for Mycobacterium TB PCP, bacterial or other pneumonia, bronchitis Smoking Cardiovascular diseases, including congestive heart failure, coronary heart disease, arrhythmia, pulmonary hypertension Asthma, emphysema Pollen, dander, or dust allergies Drug allergies, specifically to penicillins and sulfa drugs Medications (eg, ACE inhibitors) Use of inhaled stimulants, injection drugs

Check vital signs, oxygen saturation (resting and after exercise), weight.

Conduct a thorough physical examination, to include evaluation of the following:

	Ears, nose, oropharynx
	Neck
	Lungs
	Heart
	Extremities

Note: If patients are coughing, strongly consider having them wear a surgical mask in the clinic or office until TB or other transmissible infection is ruled out. Covering both the nose and the mouth should prevent the discharge of large infectious droplets into the environment.

The differential diagnosis of pulmonary symptoms is broad (Table 1). Both HIV-related and HIV-unrelated causes should be considered; the patient's risk of HIV-related causes is strongly influenced by the CD4 count. More than 1 cause of symptoms may be present.

Table 1. Partial Differential Diagnosis of Pulmonary Symptoms

CD4 Cell Count	Possible Cause
Adapted from: Huang L. Pulmonary Manifestations of HIV (Table 4). In: Peiperl L, Coffey S, Volberding PA, eds. HIV InSite Knowledge Base [textbook online]; San Francisco: UCSF Center for HIV Information; May 1998.
Any Count	Upper respiratory tract illness Upper respiratory tract infection (URI) Sinusitis Pharyngitis Acute or chronic bronchitis Bacterial pneumonia TB Influenza Chronic obstructive pulmonary disease Reactive airway disease, asthma Non-Hodgkin lymphoma Pulmonary embolus Congestive heart failure Pulmonary hypertension Pneumothorax Bronchogenic carcinoma Anemia Gastroesophageal reflux (may cause cough) Lactic acidosis Medication adverse effect
≤500 cells/µL	Bacterial pneumonia (recurrent) Pulmonary Mycobacterium pneumonia (nontuberculous)
≤200 cells/µL	PCP Cryptococcus neoformans pneumonia or pneumonitis Bacterial pneumonia (associated with bacteremia or sepsis) Disseminated or extrapulmonary TB
≤100 cells/µL	Pulmonary Kaposi sarcoma Bacterial pneumonia (risk of gram-negative bacilli and Staphylococcus aureus is increased) Toxoplasma pneumonitis
≤50 cells/µL	Disseminated histoplasmosis Disseminated coccidioidomycosis Cytomegalovirus pneumonitis Disseminated Mycobacterium avium complex Disseminated Mycobacterium (nontuberculous) Aspergillus pneumonia Candida pneumonia