Cough Flashcards
A 2-year-old female is brought in by her father for evaluation of a cough. Her cough started 10 days ago along with a runny nose and a low-grade fever. The runny nose and fever are no longer present but a dry-sounding cough persists.
On examination the patient appears well and has a normal heart rate and respiratory rate. You note no retractions and lung sounds are also normal.
Which one of the following would be an appropriate management option? (check one)
Buckwheat honey
Albuterol (Proventil, Ventolin)
Azithromycin (Zithromax)
Dextromethorphan
Diphenhydramine (Benadryl
Buckwheat honey
This patient’s symptoms are most consistent with a viral upper respiratory infection. There is no curative treatment so management should be focused on symptoms. Most over-the-counter cough and cold preparations, including the ingredients dextromethorphan and diphenhydramine, have no evidence of benefit and carry a risk of harm in children and should not be recommended. Albuterol is only helpful for cough in patients with wheezing. Buckwheat honey has limited evidence of effectiveness but appears to carry no risk of harm and may be recommended for symptom management.
A 28-year-old previously healthy male nonsmoker has a 3-day history of fever and a productive cough. He presents to the urgent care clinic for evaluation after developing pain in the right lower chest when breathing deeply. He has not sought medical care for over 5 years and has never been immunized for influenza.
On examination you note a temperature of 38.6°C (101.4°F), a blood pressure of 136/74 mm Hg, a pulse rate of 90 beats/min, an oxygen saturation of 93% on room air, and a respiratory rate of 20/min. The patient appears uncomfortable but is not in significant distress. The presence of crackles over the right lower anterior chest prompts an order for chest radiography, which reveals an air bronchogram and a patchy alveolar infiltrate involving the medial middle lobe.
Which one of the following treatment options would be most appropriate at this time? (check one)
Outpatient treatment with oral azithromycin (Zithromax)
Outpatient treatment with oral ciprofloxacin (Cipro)
Outpatient treatment with oseltamivir (Tamiflu)
Inpatient treatment with intravenous ceftriaxone (Rocephin) and oral azithromycin
Inpatient treatment with intravenous ceftriaxone and ciprofloxacin
Outpatient treatment with oral azithromycin (Zithromax)
This patient’s presentation is consistent with community-acquired pneumonia (CAP). Pathogens commonly involved include viruses such as influenza, as well as Mycoplasma pneumoniae and Streptococcus pneumoniae. This patient’s history and findings are most consistent with early lobar pneumonia, given the sputum production, presence of rales, and radiographic findings, and empiric antibiotic treatment is most appropriate. His premorbid history of good health and the lack of findings such as confusion, tachypnea, hypotension, or multilobar infiltrates that would indicate severe CAP make outpatient antibiotic treatment the most appropriate option. He is outside of the time frame when anti-influenza treatments would be expected to be effective, even if influenza seemed likely.
For previously healthy individuals who have not taken antibiotics in the previous 3 months the most appropriate treatment for CAP is empiric treatment with an oral macrolide such as azithromycin, clarithromycin, or erythromycin (level I evidence) or doxycycline (level III evidence). In the presence of comorbidities such as diabetes, alcoholism, or chronic heart, lung, liver, or renal diseases, the treatment of CAP should provide broader coverage with dual antibiotic treatment regimens including combinations of fluoroquinolones, p-lactam drugs, and macrolide options, and hospitalization is often indicated.
A 2-year-old male is brought to the urgent care clinic by his parents in February with a low-grade fever that started the night before. His mother awoke early in the morning when she heard his barking cough. He recently started attending preschool and the mother does not know of any sick contacts.
On initial examination the patient is in mild respiratory distress and appears nontoxic. He does not have any rhinorrhea or congestion. He has a temperature of 38.2°C (100.8°F), a respiratory rate of 40/min, a heart rate of 145 beats/min, and an oxygen saturation of 96% on room air. No rashes or petechiae are present.
The most appropriate next step in management would be (check one)
humidified air
albuterol via nebulizer
oral dexamethasone
a viral culture
a chest radiograph
oral dexamethasone
This patient has a classic presentation of croup, which peaks in the fall and winter months. There may not be any particular history of sick contacts and it does not present with a prodrome, in contrast to respiratory syncytial virus. The diagnosis of croup is purely clinical and does not require laboratory studies, viral cultures, or imaging (SOR C). The treatment of croup includes corticosteroids such as dexamethasone in mild cases (SOR A) and the addition of epinephrine in moderate to severe cases (SOR A). The inhalation of humidified air does not improve outcomes (SOR B) nor does nebulized albuterol.
A 2-year-old male is brought to your office by his mother. The child has a 2-day history of a runny nose and mild cough associated with a subjective fever. The cough worsened last night. The patient has had a reduced appetite but a good intake of fluids.
On examination the child has an axillary temperature of 37.4°C (99.3°F), a heart rate of 120 beats/min, a respiratory rate of 26/min, a weight of 16 kg (35 lb), and an oxygen saturation of 96% on room air. He appears mildly ill but is alert and does not show any signs of distress, and has a prominent high-pitched barking cough. You note that he has clear rhinorrhea, the tympanic membranes are normal, and the oropharynx is moist and clear. Auscultation reveals inspiratory stridor, but there are no signs of respiratory distress. The patient’s skin has good turgor with no rash.
Which one of the following would be the most appropriate next step in the management of this child? (check one)
Administration of dexamethasone, 0.6 mg/kg orally in a single dose
Initiation of oral amoxicillin, 40 mg/kg twice daily
Administration of albuterol, 2.5 mg/3 mL via nebulizer
Administration of racemic epinephrine 2.25% solution (Asthmanefrin), 0.5 mL via nebulizer
Transfer to a hospital emergency department for stabilization and hospital admission
Administration of dexamethasone, 0.6 mg/kg orally in a single dose
This patient has mild croup based on the clinical findings. A single dose of dexamethasone is recommended
in all cases of croup (SOR A). Hospitalization is not necessary if the child is stable. Racemic epinephrine,
which has been shown to reduce symptoms at 30 minutes but not at 2 hours or 6 hours, is recommended
for the treatment of moderate to severe croup when patients are being observed in a medical setting such
as the emergency department or hospital (SOR A). Amoxicillin and albuterol are not indicated in the
management of croup.
A 2-year-old female is brought to the urgent care center with a fever and cough. Her symptoms started suddenly a few hours ago with a runny nose and fever to 101°F. On examination the child is crying and has a persistent barking cough but has no stridor or significant respiratory distress. Her lungs are clear to auscultation. Her skin is warm, pink, and well perfused, and her oxygen saturation is 99% on room air. A chest radiograph is normal.
Which one of the following treatments has been shown to improve outcomes for this problem? (check one)
Humidified air
Nebulized albuterol (Proventil, Ventolin)
Oral azithromycin (Zithromax)
Oral dexamethasone
Oxygen therapy
Oral dexamethasone
This patient presents with a typical case of mild to moderate croup. This is a viral infection that results in swelling in the larynx. It rarely is severe enough to cause respiratory collapse or require intubation and must be differentiated from more severe conditions such as epiglottitis, retropharyngeal abscess, or pneumonia. There is no reason to treat this viral infection with an antibiotic. The condition is usually benign and self-limiting, with the worst symptoms occurring at night. Cool and/or humidified air has traditionally been recommended, but studies have not confirmed any significant benefit from these interventions. Since this child is not in respiratory distress and oxygenation is normal, supplemental oxygen therapy is not indicated. Studies have confirmed the benefits of treating croup with a single dose of either an oral or intramuscular corticosteroid. Specifically, dexamethasone is recommended due to its 72-hour length of effect. Inhaled racemic epinephrine has been shown to reduce the need for intubation in cases of moderate to severe croup. Albuterol, however, is not indicated.
You see a 50-year-old male in your office with a 2-week history of cough that began as mild and intermittent, but now occurs as paroxysms that frequently cause him to vomit. He feels very tired after these coughing fits. He also reports rhinorrhea throughout the course of his symptoms. He has been feeling overheated but does not report documented fevers. He notes that he does not typically receive routine vaccinations. His vital signs include a temperature of 37.4°C (99.3°F), a pulse rate of 85 beats/min, a respiratory rate of 20/min, and an oxygen saturation of 93% on room air. He has no medication allergies. A test for COVID-19 is negative.
Of the following treatments, which one would be the most beneficial for this patient’s most likely condition? (check one)
Continued supportive care only
Tdap vaccination
Azithromycin (Zithromax)
Doxycycline
Oseltamivir (Tamiflu)
Azithromycin (Zithromax)
The duration and characterization of this patient’s cough are most suggestive of pertussis. Of the options listed, azithromycin is the most appropriate for management of pertussis. Azithromycin is most effective for treatment and minimizing spread of the disease within 21 days of symptom onset. Sulfamethoxazole/trimethoprim and other macrolides, such as erythromycin and clarithromycin, are also acceptable options.
Continued supportive care only does not provide the advantages of cure and minimization of community spread that are accomplished by initiating azithromycin. Symptomatic treatment with over-the-counter medication is appropriate but such supportive care does not replace the therapeutic advantages of azithromycin.
This patient’s objection to routine vaccination should be explored as priorities allow. He should be vaccinated against pertussis with Tdap as soon as feasible, but the vaccination would not provide immediate treatment of his current episode of pertussis.
Doxycycline has shown benefit in other bacterial infections but does not provide effective treatment of pertussis. Based upon the duration of symptoms, quality of his cough, and lack of documented fevers, this patient is not likely to have influenza, so oseltamivir would not be appropriate.
A 15-year-old male has a 1-week history of a nonproductive cough, a low-grade fever, a sore throat, and hoarseness. His respiratory rate is 22/min but unlabored, his temperature is 38.1°C (100.6°F), and his O2 saturation is 94% on room air. A chest radiograph reveals bilateral interstitial infiltrates.
Which one of the following treatments would be most appropriate for this patient?
(check one)
Ceftriaxone (Rocephin)
Amoxicillin
Cefdinir
Linezolid (Zyvox)
Azithromycin (Zithromax)
Azithromycin (Zithromax)
Community-acquired pneumonia in children over the age of 5 is most commonly due to Mycoplasma pneumoniae, Chlamydophila pneumoniae, and Streptococcus pneumoniae. Less common bacterial infections include Haemophilus influenzae, Staphylococcus aureus, and group A Streptococcus. Initial treatment with antibiotics is empiric, as the pathogen is usually unknown at the time of diagnosis. The choice in children is based on age, severity of illness, and local patterns of resistance. Children age 5–16 years who can be treated as outpatients are usually treated with oral azithromycin. For patients requiring inpatient management, intravenous cefuroxime plus either intravenous erythromycin or azithromycin is recommended
Which one of the following has been shown to have a beneficial effect for symptoms of the common cold in an adult?
(check one)
Diphenhydramine (Benadryl)
Ipratropium (Atrovent) nasal spray
Intranasal zinc
Intranasal corticosteroids
Systemic corticosteroids
Ipratropium (Atrovent) nasal spray
Ipratropium is the only nasally inhaled anticholinergic recommended by the American College of Chest Physicians for a cough caused by the common cold. One study showed that the nasal formulation decreases rhinorrhea and sneezing, and a Cochrane review found that ipratropium bromide nasal spray improved rhinorrhea but did not help nasal stuffiness (SOR B). Antihistamine monotherapy (either sedating or nonsedating) such as diphenhydramine was no more effective than placebo (SOR A). Corticosteroids have not been found to be effective for the symptoms of a common cold. Intranasal zinc should not be used because it may result in the permanent loss of smell.
Three members of the same family present with a high fever and cough that began abruptly yesterday. All three report having fevers over 40° C (104° F), painful coughs, moderate sore throats, and prostration. They have loss of appetite, but no vomiting or diarrhea. Two other family members have similar symptoms. On examination the patients appear ill and flushed. There is no cervical adenopathy, no visible pharyngeal inflammation, and no significant findings on examination of the chest. Which one of the following is the most likely diagnosis? (check one)
Mycoplasma pneumonia
Influenza-like illness
Bacterial bronchitis
Upper respiratory infection
Legionnaires disease
Influenza-like illness
Influenza has a very abrupt onset, and a fever with a nonproductive cough is almost always present. Unconfirmed cases are referred to as influenza-like illness (ILI) or suspected influenza. Patients with confirmed cases tend to say they have never been so ill. Mycoplasma pneumonia can spread among family members, but it is milder and has a more indolent onset and a longer incubation period. Bacterial bronchitis is an overdiagnosed, supposed complication of upper respiratory infections, and is not contagious. While the phrase cold and flu is often used, upper respiratory infections are not so febrile or prostrating, and coryza is the dominant syndrome sooner or later. Legionella can have point-source epidemics, but the incubation period is longer, symptoms vary from mild illness to life-threatening pneumonia, and diarrhea is prominent in many cases.
A 42-year-old male presents for evaluation of a persistent cough. Three weeks ago, he developed a runny nose, dry cough, and generalized malaise without fever. One week later, he began to develop persistent fits of coughing followed by bouts of posttussive emesis. You suspect pertussis.
Which one of the following laboratory tests should be used to confirm your diagnostic suspicion? (check one)
Culture
Direct fluorescent antibody assay
Polymerase chain reaction (PCR)
Serology for IgG
Polymerase chain reaction (PCR)
Polymerase chain reaction (PCR) is the most rapid and accurate test to confirm pertussis and is the diagnostic test of choice (evidence rating B). Cultures are challenging to grow and results take 7–10 days. Direct fluorescent antibody assays have low sensitivity and specificity and are no longer used. Serology for IgG does not peak until the paroxysmal and convalescent stages, and is used primarily for epidemiologic purposes.
A 46-year-old male presents with a persistent cough that has been present for several months and was not preceded by an upper respiratory infection. He does not have a history of asthma, does not smoke, and takes no medications. His symptoms consist of short bursts of coughing that produce a small amount of mucoid sputum during the day. He does not have emesis or nausea. The cough sometimes wakes him at night but does not seem to be specific to any particular posture. He does not have a fever, shortness of breath, wheezing, heartburn, or nasal symptoms. A thorough physical examination is normal and a chest radiograph appears normal.
Which one of the following would be the most appropriate next step in the management of this patient? (check one)
Amoxicillin/clavulanate (Augmentin)
An empiric trial of a proton pump inhibitor
CT of the chest
CT of the sinuses
Referral for bronchoscopy
An empiric trial of a proton pump inhibitor
Chronic cough is defined as a cough lasting at least 8 weeks. If a thorough history (with attention to ACE inhibitor use), a physical examination, and a plain-film chest radiograph do not suggest an obvious cause for the cough, experts suggest that the three most common etiologies are gastroesophageal reflux, persistent postnasal drip, and unrecognized asthma. Treating a chronic cough empirically with a high-dose proton pump inhibitor for 2–3 months is considered a reasonable choice before further investigations are attempted. Ordering an esophageal pH probe or esophagogastroduodenoscopy would also be considered appropriate. Postnasal drip is often due to allergic rhinitis or another noninfectious condition and some guidelines recommend empiric nasal corticosteroid sprays and/or first-generation oral antihistamine use.
CT of the chest and bronchoscopy may become necessary if the evaluation and treatment for these three common conditions does not improve the patient’s symptoms. Since there are no symptoms of bacterial sinusitis, the use of a broad-spectrum antibiotic is not justified.
A 72-year-old male presents with a recent history of cough with bloody sputum. For 3 weeks, he produced dark red to brown sputum with his usual morning cough. The last episode was a week ago. He has a chronic, minimally productive cough that he attributes to allergies. He has not had any fever, chest pain, or dyspnea associated with the bloody sputum. He has never smoked and has no known lung disease. His medications include bupropion (Wellbutrin) and fluoxetine (Prozac). His vital signs are unremarkable.
An examination including the nasal fossa and oropharynx reveals no evidence of bleeding. A pulmonary examination is normal. A CBC, comprehensive metabolic panel, and INR are also normal.
Which one of the following would be the most appropriate next step for this patient? (check one)
Reassurance only, with instructions to return if symptoms recur
Azithromycin (Zithromax)
A chest radiograph
CT of the chest with and without contrast
Referral for bronchoscopy
A chest radiograph
The most common causes of mild hemoptysis in developed countries include COPD, bronchiectasis, acute respiratory infections, and malignancy. Physicians should first rule out pseudohemoptysis (bleeding originating from above the glottis) with a careful examination of the nose and oral cavity. Laboratory studies should be performed to evaluate for anemia, thrombocytopenia, renal function, and hepatic function.
The most appropriate next step would be posteroanterior and lateral chest radiographs (SOR C). Chest radiographs can demonstrate pneumonia, abscess, masses, and cavitary lesions. Since they are quick, easily accessible, and provide only a low level of radiation, they are preferred for initial imaging. If the chest radiograph is normal, further evaluation is recommended. The preferred follow-up imaging for nonmassive hemoptysis is CT angiography of the chest with contrast or CT of the chest with contrast, according to the American College of Radiology (ACR) appropriateness criteria (SOR C). The ACR also indicates that CT of the chest with and without contrast is “usually not appropriate.”
Deferring further workup unless hemoptysis recurs is not recommended as the underlying cause of bleeding should be identified and treated. The risk of missed diagnoses of potentially fatal conditions makes watchful waiting a poor option. Empiric use of antibiotics is not recommended as the initial step given the lack of infectious symptoms and signs in this patient. Referral for bronchoscopy would be an appropriate step when the initial chest radiographs are normal and the etiology has not been identified. Up to 10% of patients with hemoptysis and a normal chest radiograph have been diagnosed with bronchogenic carcinoma.
A previously healthy 30-year-old male who is a nonsmoker comes to your clinic for an acute visit because of a cough that produces yellowish phlegm. His illness started with a “cold” 10 days ago. He has no fever or chills, chest pain, or shortness of breath. On examination his vital signs are normal, and his lungs are clear bilaterally to the bases. A chest radiograph is normal.
The most appropriate next step is (check one)
reassurance only
amoxicillin
azithromycin (Zithromax)
doxycycline
reassurance only
Antibiotics do not show any benefit in the treatment of acute bronchitis. While patients may report previous success with antibiotics for the same condition, a Cochrane review found no difference in general improvement at follow-up between antibiotics, no treatment, and placebo. Due to the frequency of side effects of antibiotics and the problems of antibiotic resistance, the NNT Group has rated antibiotics for acute bronchitis as red on its rating system, indicating no benefits.
Chronic cough in an adult is defined as a cough that has been present for longer than 8 weeks. Which one of the following is the most common cause of chronic cough in an adult? (check one)
Asthma
Laryngopharyngeal reflux disease
Nonasthmatic eosinophilic bronchitis
Protracted bacterial bronchitis
Upper airway cough syndrome
Upper airway cough syndrome
Chronic cough in adults is a common presenting symptom for primary care visits. The four most common causes of chronic cough in adults include upper airway cough syndrome (UACS), asthma, nonasthmatic eosinophilic bronchitis, and reflux-related disorders. UACS, previously referred to as postnasal drip syndrome, is the most common cause of chronic cough in adults. This syndrome can have multiple etiologies, including chronic rhinosinusitis, allergic rhinitis, and nonallergic rhinitis. The diagnosis may be suggested by symptoms of rhinorrhea such as nasal stuffiness, sneezing, and postnasal drainage, but the absence of these symptoms does not rule out the diagnosis. The most common causes of chronic cough in children 6–14 years of age are asthma, protracted bacterial bronchitis, and UACS.
A 29-year-old male smoker presents with a 10-day history of a cough. He also had a low-grade fever for 2 days that has resolved. He has had some mild rhinorrhea and has noted that the cough has become productive of greenish sputum over the past 3–4 days. He has not tried any medication. An examination reveals some mild rhinorrhea but his lungs are clear.
Which one of the following would be most appropriate at this point? (check one)
Supportive care only
A chest radiograph
Albuterol (Proventil, Ventolin)
Antibiotic therapy
An inhaled corticosteroid
Supportive care only
The defining symptom of acute bronchitis is cough. Even in smokers the etiologic agent is viral at least 90% of the time, so antibiotics are not indicated. Unless wheezing is noted, albuterol is not helpful. Inhaled corticosteroids are used in maintenance therapy for asthma. Indications for an adult patient with acute bronchitis to have a chest radiograph include: bloody sputum, rusty-colored sputum, or dyspnea; a pulse rate >100 beats/min; a respiratory rate >24/min; or a temperature >37.8°C (100.0°F). A chest radiograph is also indicated if there are abnormal findings on a chest examination such as fremitus, egophony, or focal consolidation. Supportive care is made easier by informing the patient that symptoms are likely to last 2–3 weeks. Symptoms may be managed with measures such as dextromethorphan, guaifenesin, or honey.
