Approach to cough Flashcards
What are the differentials for acute cough (<3 weeks)?
1) Infectious: URTI, LRTI
2) Non infectious: allergen e.g. cats, smoke
3) Others (non respiratory): Foreign body aspiration, acute exacerbation of chronic cough
What are the differentials for acute cough (>8 weeks)?
Respiratory
- Infective: TB, Bronchiectasis, Pneumonia, Infectious exacerbations of non infective cause
- Non infective: interstitial lung disease, malignancy, COPD, asthma
Non respiratory
- GERD
- ACE inhibitors
- Cardiac cough i.e. heart failure
- Allergic rhinitis without post nasal discharge
What are the clinical features suggestive of TB?
- Low grade fever, SOB, sputum, haemoptysis
- Chronic IFLASH
- Constitutional sx: LOW, LOA, night sweats
- Travel, contact hx
- Immunocompromised
- Upper lobe consolidation, bilateral hilar lymphadenopathy
What are the clinical features suggestive of bronchiectasis?
- Copious purulent green sputum
- Haemoptysis
- Clubbing, coarse creps, rhonchi
What are the clinical features suggestive of recurrent infections?
- A/W fever, SOB, sputum production
- Bronchial breath sounds, dullness to percussion, fine creps, increased vocal resonance
- Consolidation on CXR
What are the clinical features suggestive of malignancy?
- Dyspnea
- Diminished breath sounds, focal wheezing (obstruction)
- LOW, LOA
- Haemoptysis
- Family hx
- Smoking
What are the clinical features suggestive of COPD?
- Cough + sputum (clear or white) production on most days over a 3-month period in each of 2 years
- Long smoking hx
- Barrel chest, emphysematous changes possible
What are the clinical features suggestive of asthma?
- A/W dyspnea, wheezing, chest tightness
- diurnal variation
- reversibility (normal at baseline)
- Ppt by dust / smoke / exercise / cold
- Ask about severity, treatment compliance, exposures
- Atopic history, family history
- Reversible airway obstruction on spirometry
What are the clinical features suggestive of ILD?
- Dry cough a/w SOB
- Fine end-inspiratory crepitations, clubbing
- Occupation history, Drug Hx
- Autoimmune sx: joint pain, red eyes, alopecia, rash
What are the clinical features suggestive of chronic rhinitis + post nasal drip?
- Frequent throat clearing
- Rhinorrhea, sneezing, itch, anosmia
- Conjunctivitis
- PND: Sensation of liquid dripping into back of throat
- Precipitated by contact with dust mites; or wakes up in the morning w/ stuffy nose
- PMH and FH of Atopy
- Nose exam: polyps, inflammation, secretions
What are the clinical features suggestive of GERD?
- A/W heart burn, sour taste in mouth
- Cough worse at night/on lying down/post prandial
What are the clinical features suggestive of ACE-I?
- Tickling, scratchy or itchy sensation in throat
- Usually 1 week of starting therapy
- Resolves within 4 days of stopping therapy
What are the clinical features suggestive of cardiac cough?
- History of Heart Issues
- PND, Orthopnoea
- LL Swelling, Dyspnoea
- Reduced Effort Tolerance
What are the specific characters of cough to ask for in the history?
- Normal: explosive, percussive in character
- Whooping: Bordetella pertussis
- Bovine: breathy, non-explosive. Suggests vocal cord paralysis
- Wheezy: asthma, COPD
What are the triggers of cough to ask for in the history?
- Nocturnal – asthma; or pulmonary edema/GERD (when lying flat)
- Seasonal cough – atopic asthma
- Cold weather – COPD, bronchitis
- Allergens/occupation – asthma
- Post exercise – asthma
- Eating or drinking – aspiration, GERD
What are the relieving factors of cough to ask for in the history?
- Sitting up
- Nebulisers
- GTN
What is the nature of the sputum to ask for in the history?
Dry – ILD, ACE, GERD, Post nasal drip
Colour
- Clear or white: COPD
- Yellow or green: infection, asthma (caused by eosinophils)
- Pinkish: pulmonary oedema
Consistency
- Firm plugs: asthma
Volume
- Large volumes: bronchiectasis.
- Most days over 3-month period for 2 or more consecutive years – chronic bronchitis
Haemoptysis - First confirm haemoptysis (vs hematemesis)
What to ask about the associated features of cough would you ask the patient if you suspect pulmonary disease?
- SOB
- Pleuritic (sharp, localized, worse on deep inspiration and coughing) – pneumonia, pneumothorax, pulmonary embolus
- Fever (with chills and rigors)
What to ask about the associated features of cough would you ask the patient if you suspect asthma, COPD?
Wheeze, rhonchi
What to ask about the associated features of cough would you ask the patient if you suspect TB
Night sweats, LOA, LOW
What to ask about the associated features of cough would you ask the patient if you suspect malignancy?
LOA, LOW
What to ask about the associated features of cough would you ask the patient if you suspect nasal or sinus disease?
- Rhinitis: nasal blockage, sneezing, runny nose, fever
- Sinusitis: pain in face, headaches, changes in head position affecting cough, fever
What to ask about the associated features of cough would you ask the patient if you suspect reflux?
- After meal, when talking or singing
- Symptoms of choking, heartburn, sour taste in mouth
- Worse when lying down
What is the drug history would you ask about in a patient with cough?
- ACE-I
- PE risk factors: OCP
- NSAIDs, Beta-blockers: may cause bronchospasm
- Methotrexate, amiodarone: Interstitial lung disease
What is the fam history would you ask about in a patient with cough?
- Ischemic heart disease
- Lung Cancer
- Atopic diseases
- Emphysema (alpha1 antitrypsin deficiency)
- Thromboembolic disease
- Connective tissue diseases
What is the social history would you ask about in a patient with cough?
- Smoking/alcohol
- Occupational and home environment
Asbestos – lung fibrosis, pleural cancer, lung cancer
Dust, damp accommodation, occupational exposures (eg. Flour) – asthma
Animals/birds – allergens for asthma, allergic alveolitis
What is the risk factors would you ask about in a patient with cough?
Travel history
Infectious contacts: TB
Thromboembolic risk factors
- Immobility
- Recent surgery
- Oral contraceptives
