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Oxford clinical cases > Cough > Flashcards

Cough Flashcards

1
Q

What are the 7 open questions you should ask?

A
  1. Acute or chronic?
  2. Constant or intermittent?
  3. Productive or dry?
  4. Blood?
  5. Timing?
  6. Character?
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2
Q

What is defined as an acute and chronic cough?

A

Acute: <3 weeks
Chronic: >8 weeks
Between 3 and 8 weeks the cough may be due to recovering acute illness or developing chronic illness.

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3
Q

What does an intermittent cough suggest and what does a constant one suggest?

A

Intermittent cough: extrinsic trigger

Constant: intrinsic cause

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4
Q

What does the presence of sputum indicate? What does white or clear, yellow and green sputum suggest?

A

Sputum indicates inflammation and/or infection. COPD: white or clear sputum. Yellow/green: infection. Particularly large volumes of sputum, often green or rusty coloured, may be coughed up in bronchiectasis and lung abscesses.

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5
Q

Blood-streaked sputum?
Pink and frothy sputum?
Frank blood (haemoptysis)?

A

Blood streaked: infection or bronchiectasis
Pink and frothy: pulmonary oedema
frank: TB, lung cancer, pulmonary embolism, bronchiectasis, or other rarer causes

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6
Q

What times of day is asthma worst?

A

Day and early morning, patients often sleep propped up with a few pillows.

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7
Q

When is GORD and pulmonary oedema worse?

A

At night i.e. when lying flat

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8
Q

What is a wheezy cough suggestive of?

A

Asthma, COPD (airway obstruction)

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9
Q

What is a dry cough suggestive of?

A

Bronchitis (usually viral) or interstitial lung disease

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10
Q

What is a wet cough suggestive of?

A

Bronchiectasis

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11
Q

In history of patient with cough, what drug in particular do we ask about?

A

ACE inhibitors

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12
Q

What does breathlessness on exertion point to?

A

Asthma, COPD, pneumonia or pulmonary oedema. rarer in lung cancer.

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13
Q

What does pleuritic chest pain indicate?

A 
Pneumonia
Pneumothorax
PE
Viral pleurisy 
Muscle pain after vigorous coughing 
Fractured rib
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14
Q

What are some causes of an acute dry cough?

A 
Asthma
Rhinitis
URT infection 
Drug induced 
Smoke/toxin inhalation
Foreign body
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15
Q

Causes of a chronic dry cough

A

Asthma
GORD
Post-nasal drip
COPD

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16
Q

Causes of an acute productive cough

A

LRT infection (pneumonia, bronchitis)
COPD
TB

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17
Q

Causes of a chronic productive cough

A

Bronchiectasis
TB
lung cancer

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18
Q

In a patient with a cough, what does tender cervical lymphadenopathy suggest?

A

Upper respiratory tract infection

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19
Q

What are signs of right heart failure? (cor pulmonale)

A 
Raised JVP
ankle oedema
Pulmonary oedema 
Parasternal heave
Tricuspid regurgitation
20
Q

What marker in the bloods is an indicator of severity of pneumonia?

A

The patients U&Es may be deranged if dehydrated and consequently hypo-refusing kidneys. Urea is an indicator of severity of pneumonia and influences prognosis.

21
Q

Why must you perform an ECG in patients with chest pain?

A

To rule out ischaemia or AF secondary to pneumonia. It may also show right heart strain in patients with COPD.

22
Q

Why are sputum cultures often unhelpful?

A

they will contain all the commensal flora that is normaly found in the URT. Bronchial washings can be done to avoid this.

23
Q

What is the CURB65 score?

A

It is a score used to calculate the severity of pneumonia.
The presence of any one prognostic factor scores 1 point and a score of 2 or more should be admitted to hospital.

Confusion: AMTS of less than or equal to 8
Urea: >7mM
Respiratory rate: >30/minute
Blood pressure: <90 systolic and or <60 diastolic
>65 years old

24
Q

What are some complications of pneumonia?

A

Spread of infection: pleural effusion, empyema, abscesses and septicaemia
Damage to local structures: bronchiectasis and pneumothorax

25
Q

When checking for a tension pneumothorax, what are the signs you’d see on examination?

A

Tracheal deviation away from the pneumothorax, hypotension, tachycardia, cyanosis, severe respiratory distress, distended neck veins.

26
Q

Why is a patient with COPD more prone to pneumothorax?

A

Patients with COPD may suffer from emphysema which results in the formation of bullae (destruction and enlargement of alveoli. This results in loss of elastic traction that keeps the small airways open during expiration. Large spaces develop, termed bullae). These bullae may rupture leading to a pneumothorax.

27
Q

What are the 3 most common causes of a chronic dry cough?

A

Asthma
GORD
post-nasal drip

28
Q

In which two age groups is asthma most common?

A

Children and elderly

29
Q

What should you do if a patient has an intermediate probability of asthma?

A

Counsel using the ratio between FEV1 and FVC. The convention is that a ratio of <0.7 argues in favour of an obstructive airway disease such as asthma and COPD.

30
Q

Why do we no longer use PEF values to diagnose asthma?

A

They are notoriously unreliable. The use of FEV1 after administration of a bronchodilator has fallen out of favour as it has a low sensitivity.

31
Q

Why is it often useful to request a CXR in a patient with a cough?

A

To rule out lung cancer., but we would not expect to see any abnormality suggesting asthma.

32
Q

If someone’s spirometry reading do not suggest asthma but their history does, what do you do?

A

You start them on a trial of salbutamol inhalers.

33
Q

What would a dry cough in a patient with a high BMI suggest?

A

GORD - but there would most likely be acid regurgitation and heart burn.

34
Q

State some clinical features suggestive of asthma

A 
>1:
Wheeze
Breathlessness
Chest tightness
Cough 
Particularly if worse at night and early morning, triggered by exercise, allergen exposure, cold air or after taking aspirin or beta blockers. 
History of atopic disorder
Family history of atopy/asthma 
wheeze on auscultation 
otherwise unexplained low FEV1, PEF or serum eosinophilia
35
Q

What are some features suggestive of an alternative diagnosis other than asthma in someone with a dry cough?

A

Normal physical examination and/or FEV1/PEF when symptomatic.
Prominent dizziness, light-headedness, peripheral tingling (possible hyperventilation syndrome)
Chronic productive cough without wheeze or breathlessness
Symptoms present only with colds (possible rhinitis)
Voice disturbance (possible vocal cord dysfunction which would produce a bovine cough)
Significant smoking history (COPD)
Cardiac disease

36
Q

What is your first step in treating suspected GORD?

A

Trial a PPI and suggest weight loss if a patient has a highBMI.

37
Q

A patient with a cough with no positive respiratory symptoms but recently been diagnosed with hypertension and takes enalapril. What is the likely diagnosis?

A

Cough due to ACE inhibitor (enalapril). Inhibition of ACE, which normally breaks down inflammatory bradykinin in the lungs, leads to a build up of bradykinin and hence lung inflammation, triggering a dry cough in 10-20% of patients.

38
Q

What is another side effect of ACEi?

A

They are responsible for 20-40% of cases of facial angioedema.

39
Q

What other drug would you prescribe instead of ACEi to a hypertension patient suffering from a dry cough?

A

You would switch their medication to an angiotensin receptor blocker such as losartan, candestran or valsartan.

40
Q

A cough is not a common symptom of lung cancer, but when can it be?

A

When tumours are situated in the larger, more proximal airways where cough receptors are more widespread.

41
Q

What kind of cancer is most likely if the cancer is in a hilarious location?

A

Squamos cell carcinoma of the lung

42
Q

Why would a patient who recently had pneumonia which was treated, present with a persistent cough and no other respiratory signs?

A

Patients with pneumonia, particularly viral pneumonia can develop a persistent post-infectious cough.

43
Q

How can you treat a post-pneumonia persistent cough?

A

Antitussives
Inhaled corticosteroids or antihistamines
Inhaled ipratropium bromide

44
Q

If a patient had a history of weight loss, night sweats, blood-streaked sputum and had recently returned from Pakistan what would you suspect?

A

Tuberculosis

45
Q

Which patients should not be given 100% O2?

A

COPD patients

46
Q

You see a patient in clinic with lung cancer who has a bovine cough. Can you explain this symptom?

A

It is likely that the patient has recurrent laryngeal nerve palsy (RLN). such a palsy is more common on the left than the right as the left RLN loops around the arch of the aorta thus has longer intra-thoracic course, whereas the right branch loops around the right subclavian artery. Damage to the RLN is most commonly due to malignancy or surgery.

Oxford clinical cases (4 decks)

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