Cough

Question 1

Describe the timescales of acute and chronic coughs.

Answer 1

Acute - < 3 weeks Chronic - > 8 weeks

Question 2

List some other key features of the history of presenting complaint (cough)

Answer 2

• Acute or chronic
• Constant or intermittent
• Productive or dry
• Blood
• Timing
• Character

Question 3

Why is it important to ascertain whether the cough is constant or intermittent?

Answer 3

Constant – suggests intrinsic pathology

Intermittent – suggests that there may be an exogenous trigger

Question 4

Describe the typical appearance of the sputum in: COPD Infection Bronchiectasis/lung abscess

Answer 4

• COPD White or clear
• Infection Yellow or green
• Bronchiectasis/Lung Abscess Large volumes of purulent sputum that is green or rusty

Question 5

List diseases that can cause the following patterns of blood in the sputum:

Blood-streaked sputum

Pink, frothy sputum

Frank blood

Answer 5

• Blood-streaked sputum: Infection (e.g. atypical pneumonia – Klebsiella pneumonia) Bronchiectasis
• Pink, frothy sputum: Pulmonary oedema
• Frank blood: TB, Lung cancer, PE, Rare disease (e.g. Wegner’s granulomatosis, Goodpasture’s syndrome)

Question 6

List some diseases that cause cough that is worse at night.

Answer 6

• Asthma
• GORD
• Pulmonary oedema

Question 7

What do the following types of cough indicate:

• Wheezy cough
• Bovine cough
• Dry cough
• Gurgling/wet cough
• Whooping cough

Answer 7

• Wheezy cough: Airway obstruction due to asthma or COPD
• Bovine cough: Due to vocal cord paralysis (left recurrent laryngeal nerve) usually due to a Pancoast lung tumour
• Dry cough: Bronchitis, Interstitial lung disease
• Gurgling/Wet cough: Bronchiectasis
• Whooping cough: Infection caused by Bordatella pertussis

Question 8

List some common environmental triggers of cough that you should ask the patient about.

Answer 8

• Smoking
• Occupation
• Pets
• Change in house/office
• Cold
• Exercise
• worsening in spring/summer

Question 9

List some significant features of the past medical history in a patient presenting with cough.

Answer 9

• Asthma
• GORD
• Rhinitis/sinusitis
• Heart failure
• Recent chest infection

Question 10

Which drug is commonly associated with causing cough?

Answer 10

ACE inhibitors

Question 11

Why is it important to ask about the patient’s travel history?

Answer 11

Consider TB-endemic regions (e.g. South-East asia)

Question 12

What important detail in the history may increase the likelihood of an infectious cause to the cough?

Answer 12

Close contact with others with cough

Question 13

List some key symptoms that are associated with diseases that cause cough. Include the diseases that they are associated with in your answer.

Answer 13

• Fevers, night sweats, weight loss: Malignancy, TB
• Breathlessness: Asthma, COPD, pneumonia, pulmonary oedema
• Chest pain (pleuritic): Pneumonia, pneumothorax, PE, pleurisy
• Wheeze: COPD, asthma, other airway obstruction

Question 14

List some causes of: Acute dry cough

Answer 14

• Asthma
• Rhinitis/sinusitis with post-nasal drip
• Upper respiratory tract infection
• Drug-induced

Question 15

List some causes of: Acute productive cough

Answer 15

• Lower respiratory tract infection
• COPD
• TB

Question 16

List some causes of: Chronic dry cough

Answer 16

• Asthma
• GORD
• Post-nasal drip
• Smoking
• Lung cancer

Question 17

List some causes of: Chronic productive cough

Answer 17

• Bronchiectasis
• TB
• Lung cancer

Question 18

List some signs of respiratory distress on physical examination.

Answer 18

• High resp rate
• Use of accessory muscles
• Difficulty competing sentences
• Peripheral cyanosis
• Confusion

Question 19

What might tender cervical lymphadenopathy suggest?

Answer 19

Upper respiratory tract infection

Question 20

List some features of COPD that can be found on examination.

Answer 20

• Chest wall deformity (e.g. hyperexpansion, barrel chest)
• Intercostal recession
• Signs of right heart failure (peripheral oedema, raised JVP, parasternal heave, tricuspid regurgitation)
• Asterixis

Question 21

List some blood tests that may be useful in a patient with cough.

Answer 21

• ABG – assess progression towards respiratory falure
• FBC – signs of infection (high WCC)
• CRP
• U&Es – check dehydration, urea is a useful way of gaging severity of pneumonia
• Blood cultures

Question 22

Why might you perform an ECG in a patient with a cough?

Answer 22

• To rule out AF +ischaemia which can occur secondary to pneumonia
• Check for signs of right heart strain

Question 23

Which pathogens that cause pneumonia produce antigens that can be detected in the urine?

Answer 23

• Streptococcus pneumoniae
• Legionella pneumophila

Question 24

Why are sputum cultures rarely useful?

Answer 24

They are often contaminated by commensal bacteria

Question 25

Which scoring system is used to assess the severity of pneumonia?

Answer 25

CURB-65

Question 26

What are the different components of CURB-65?

Answer 26

• Confusion (AMTS <8/10)
• Urea >7mM
• Respiratory rate >30/min
• Blood pressure <90SBP and/or <60 DBP
• 65+ yrs old

Question 27

Which antibiotics are commonly given to patients with CAP and HAP pneumonia and why?

Answer 27

• CAP:
  
  • Amoxicillin
  • Clarithromycin: Atypical mycoplasma (legionella)
• HAP:
  
  • Metronidazole: anaerobes- HAP is often caused by gastric aspiration due to ineffective swallow/ post-op

Question 28

List some complications of pneumonia.

Answer 28

• Pleural effusion
• Empyema
• Abscess
• Septicaemia
• If with COPD- could get burst of bullae –> pneumothorax like symptoms

Question 29

What are the three most common causes of a chronic cough in non-smokers?

Answer 29

• Asthma
• GORD
• Post-nasal drip

Question 30

Why shouldn’t you give 100% oxygen to patients with COPD? Therefore which masks are used to administer O2?

Answer 30

It diminishes the hypoxic drive to breathe – this results in the patient becoming very hypercapnic It also diminishes hypoxic vasoconstriction leading to VQ mismatch

Venturi mask used instead