48. Sputum/cough

Question 1

Cough differentials

a) Acute (< 3 weeks)
b) Subacute (3 - 8 weeks) or chronic

Answer 1

a) - Viral URTI/ common cold
- Asthma exacerbation
- LRTI (pneumonia)
- ACE inhibitors
- Inhaled foreign body
- PE

b) - Resp - postnasal drip, smoke-related, asthma/COPD, bronchiectasis/ CF, infection (TB, pneumonia), pulmonary fibrosis, malignancy, whooping cough
- Non-resp - GORD, psychogenic, heart failure

Question 2

Cough: red flags

Answer 2

• Haemoptysis
• SOB
• Weight loss, anorexia
• Chronic smoking history

Question 3

History.

a) SOCRATES
b) Resp symptoms
c) Other symptoms
d) PMHx
e) DHx
f) FHx
e) Social history - important points

Answer 3

• Site: N/A
• Onset: sudden (foreign body, anaphylaxis), gradual
• Character: dry (asthma, malignancy), productive (infection, malignancy, TB), haemoptysis (infection, PE), copious sputum production (bronchiectasis)
• Radiation: N/A
• Ass Sx
• Time course: diurnal (asthma, GORD), progressive (malignancy)
• Exacerbating factors: exercise, allergens (asthma)
• Relieving factors: salbutamol (asthma, COPD)
  Severity: N/A

b) - Sputum, SOB, chest pain, chest tightness, wheeze

c) - Atopic symptoms - eczema, hayfever (asthma)
- Weight loss, anorexia, fatigue (TB, malignancy)
- Fever, night sweats (infection, TB, malignancy)
- Leg swelling, orthopnoea (heart failure)

d) - Resp disease
- Known reflux
- Cardiac disease (cardiac asthma)
- Vaccination history

e) - ACE inhibitors
- Pro-reflux drugs
- Improve with codeine?

f) - Asthma/ atopy
- Family members unwell

g) - Occupation - asbestos exposure, other fumes, etc.
- Smoking - pack year history
- Close contact illness
- Travel history

Question 4

Examination.

a) A-E
b) Important examinations to perform

Answer 4

• Airway
• Breathing - SpO2, RR, ausculate chest
• Circulation - BP, HR, CRT, pulse, JVP, HS I + II, fluid status
• Disability - glucose, pupils, GCS, confusion (CURB-65)
• Exposure - calves (heart failure, PE), abdomen, temp, examine ENT and lymph nodes

b) - Resp
- Cardiac
- ENT and lymph nodes

Question 5

Investigations.

a) Bedside
b) Bloods
c) Imaging
d) Special tests

Answer 5

a) - Peak flow (if asthmatic - compare with best /predicted PEFR)
- Spirometry
- Sputum culture
- ECG

b) - FBC, CRP, U+Es, clotting,
- ?D-dimer

c) - CXR
- ?CTPA

d) - ?PPI trial/ oesophageal manometry/pH studies
- ?ECHO
- ?Ziehl-Nielsen staining
- ?HRCT
- ?bronchoscopy

Question 6

Management.

a) Lifestyle
b) Medications that may help

Answer 6

a) Smoking cessation

b) - GORD - PPI
- Postnasal drip - antihistamines, nasal steroids
- Asthma/wheeze - salbutamol, steroids
- Antitussives - eg. opiates (codeine)
- Mucolytics - eg. carbocisteine, acetylcisteine, dornase alfa, mannitol, hypertonic saline