7. Cough Flashcards
Open questions to ask in persistent cough history?
Acute or chronic? Constant or intermittent? Productive or dry? Blood? Timing? Character?
Acute or chronic?
BTS (British thoracic society) defines acute as <3 weeks and chronic as >8 weeks. Between 3-8 weeks the cough may be due to recovering acute illness or developing chronic illness
Constant or intermittent?
Intermittent - suggests extrinsic trigger eg if pt only coughs at work suggests allergy to something at workplace.
Constant - suggests intrinsic cause
Productive or dry?
Presence of sputum indicates inflammation +/or infection. Pts w/ COPD have chronically inflamed airways and often produce white or clear sputum. Pts with infection have yellow or green sputum. Large volumes of sputum often green or rusty coloured, may he coughed up in bronchiectasis and lung abscesses
Blood?
Blood streaked sputum? Suggests infection or bronchiectasis
Pink & frothy sputum? Suggests pulmonary oedema
Frank blood (haemoptysis)? Suggests TB, lung cancer, PE, bronchiectais or other rarer causes eg granulomatosis with polyangiitis (GPA, formerly known as Wegener’s granulomatosis), or Goodpasture’s syndrome
Timing?
Asthma classically worse at night and early hours of the morning.
Pulmonary Oedema or GORD can also be worse at night due to positional effect of lying flat.
Pts often report sleeping propped up on pillows to mitigate these effects.
Trigger factors eg pets, cold weather or exercise indicate asthma, as does a worsening in spring/summer
Character?
A wheezy cough suggests airway obstruction due to asthma or COPD.
A bovine cough (breathy) is characteristic of vocal cord paralysis
A dry cough is suggestive of bronchitis (usu viral) or interstitial lung disease
A gurgling/ wet cough is suggestive of bronchiectasis
Pertussis infection causes a ‘whooping cough’
Direct q’s to ask about factors triggering cough
Environmental irritants: smoking, occupation, pets, change of house, office etc
PMH: asthma, GORD, rhinitis/sinusitis, HF, recurrent chest infection
DH: ACEi
Travel Hx: pt may have visited area where TB is highly prevalent eg asian subcontinent, central asia, sub-saharan africa
Close contacts: Have household members and work colleagues had a noticeable cough. Particularly relevant for TB, where prolonged, close contact is usu required for transmission meaning TB is most commonly acquired from household members
Ask about factors associated with cough that may give you clues about the underlying cause
Fevers, night sweats, rigors, weight loss? = malignancy, TB, or another severe infection
Breathlessness, particularly on exertion? = asthma, COPD, pneumonia or PO but rarer in Lung cancer
CP, particularly pleuritic CP? = indicate pneumonia, pneumothorax, PE, or viral pleurisy. Equally it may be due to muscle strain secondary to vigorous coughing or a fractured rib if there has been any trauma
Wheeze? Suggests obstruction of airways such as that found in asthma, COPD or tumours compressing an airway
Frequent throat clearing +/or rhinorrhea? Symptoms suggestive of rhinitis
Differential diagnosis of cough–> ACUTE DRY COUGH
ASTHMA RHINTIS/SINUSITIS with post nasal drip UPPER RTI (pharyngitis, laryngitis, tracheitis) DRUG INDUCED eg ACEi Smoke/toxin inhalation Inhaled foreign body Lung cancer (causing obstruction of a major bronchus) PO (secondary to heart failure)
Differential diagnosis of cough –> ACUTE PRODUCTIVE
LOWER RTI (pneumonia, bronchitis)
COPD
TB
Differential diagnosis of cough –> CHRONIC DRY
ASTHMA GORD POST NASAL DRIP Smoking Lung cancer Drug induced COPD PO (secondary to heart failure) Non-asthmatic eosinophilic bronchitis Recurrent aspiration (due to impaired swallow) Psychogenic
Differential diagnosis of cough –> CHRONIC PRODUCTIVE
Bronchiectasis
TB
Lung Cancer
Recurrent aspiration (due to impaired swallow)
(if congenital: CF or primary ciliary dyskinesia)
Signs on physical examination consistent with infection
Systemic feat’s: febrile, sweating, tachycardia?
Resp distress: resp rate incr, difficulty breathing, using accessory muscles, peripherally cyanosed, confused?
Tender cervical lymphadenopathy: in pt with cough, this suggests infection in Upper RT
Lungs: reduced chest expansion, breath sounds (reduced in effusion, bronchial sounding in pneumonia) and vocal resonance (incr in consolidation, reduced in pleural effusion)
Signs of COPD
Chest wall deformities eg hyperexpansion or barrel chest
Intercostal recession: a sign of severe COPD
Signs of RHF due to her COPD: PO, raised JVP, parasternal heave, loud or palpable P2 heart sound, or tricuspid regurgitation
Asterixis: even though some COPD pts are chronic C02 retainers, asterixis can be seen if COPD deteriorates and CO2 levels rise significantly
