Cough Flashcards
What questions should be asked when a patient presents with cough
Acute or chronic? Consistent or intermittent? Productive or dry Any blood Timing Character
What is classified as an acute or chronic cough
Acute <3 weeks
Chronic >8 weeks
3-8 weeks = recovering acute illness or developing chronic illkness
What does blood in the sputum suggest (different appearances)
Blood-streaked - Infection or bronchiectasis
Pink and frothy - pulmonary oedema
Frank blood - TB, lung cancer, pulmonary embolus, bronchectasis
What does character of the cough suggest
Wheezy - obstruction e.g. asthma, COPD
Bovine (breathy) - characteristic of vocal cord paralysis
Dry cough - bronchitis (usually viral) or interstitial lung disease
Gurgling/wet - bronchiectasis
Whooping cough - pertussis
What questions should be asked about what triggers the cough
Environmental irritants- smoking. occupation, pets
Past medical history - asthma, GORD, rhinitis, HF, RTI
Drug history - ACEi
Travel - Asian subcontinent, central Asia and sub-saharan Africa
Close contacts - same as travel
What questions should be asked about factors that are associated with cough
Fever, night sweat, rigors, weight loss Breathlessness Chest pains, pleuritic Wheeze Frequent throat cleaning/and or rhinorrhoea
What are the differentials for an acute dry cough
Asthma Rhinitis/sinusitis + post-nasal drip URTI - pharyg,laryng, tracheitis Drug induced e.g. ACEi Smoke.toxin inhalation Inhaled foreign body Lung cancer Pulmonary oedema
What are the differentials for a chronic dry cough
Asthma GORD Post-nasal drip Smoking Lung cancer Drug induced COPD Pulmonary oedema Recurrent aspiration Psychogenic Non-asthmatic eosinophillic bronchitis
What are the differentials for an acute productive cough
LRTI (pneumonia, bronchitis)
COPD
TB
What are the differentials for a chronic productive cough
Bronchiectasis TB Lung cancer Recurrent aspiration CF/priamry ciliary dyskinesia
What signs on physical examination for a cough would suggest an infective cause
Temperature Sweating Tachycardic Respiratory distress Tender cervical lymphadenopathy Reduced chest expansion Reduced breath sounds Increased vocal resonance in consolidation
What signs on physical examination would suggest COPD
Hyperexpanded/barrel chest
Intercostal recession
Signs of right heart failure (ascites, organomegaly, oedema, raised JVP, parasternal heave, tricusp regurg) - due to cor pulmonale
Asterixis
What signs would suggest someone is in respiratory distress
RR raised Dyspnoea Difficulty completing sentences Use of accessory muscles Peripheral cyanosis Confusion
What blood investigations should be called for coughs with suspected infective cause
ABG - monitor gas exchange, ensure no resp failure
FBC - infection
CRP - infection
U&Es - check for dehydration (sign of severe pneumonia)
Blood cultures - before antibiotics given, check for infections
What imaging would be done for a cough with suspected infective cause
CXR
ECG - rule out ischaemia or AF secondary, may see RHF
What microbiology investigations would be done for a cough with suspected infective cause
Urinary antigens - pneumococcal and legionella antigens
Sputum culture - induced sputum or non-bronchoscopic bronchoalveolar lavage (NBAL)
What is the CURB-65 score and how is it calculated
Used to calculate severity of pneumonia and determine need for hospitalisation
Presence of any 1 scores 1 point, max 5. Patients with 2 or more should be admitted
Confusion - AMTS <8/10
Urea high >6mM
RR > 30 minutes
BP <90 S, <60 D
>65
What are the considerations for which broad-spectrum antibiotic you should give for patients who have an exacerbation of COPD due to pneumonia
Severity (CURB65)
Comorbidity with COPD
HAP vs CAP
Suspicion of unusual organisms
Any pneumonia treated by antibiotics in the past few weeks
Whether the antibiotic is deemed to predispose to C. difficile colitis
What organisms are more likely to be causative in a)HIV patients and b)CF patients
a) Pneumocystis jirovecii
b) pseudomonas
What are the complications of pneumonia
Spread of infection - pleural effusion, empyema, abscess, septicaemia
Damage to local structure - bronchiectasis, pneumothorax
How will a pneumothorax present on examination
Breathless, RR high
Apyrexial
tachycardic, BP slightly elevated
Unilateral decreased expansion, hyperresonant percussion, reduced breath sounds
What are the 3 most common causes of a chronic cough in a non-smoker
Asthma
GORD
post-nasal drip
What investigations should be done for suspected asthma
Peak flow
Spirometry (FEV1/FVC ratio <0.7 shows obstructive disease)
Asthma is a clinical diagnosis
Which features are suggestive of asthma
Breathlessness, chest tightness, cough (particularly worse at night/early morning or triggered by exercise, allergen exposure, cold air or after aspirin/beta blocker admin)
History or family of atopic disorders
Wheeze on auscultation
Otherwise unexplained low FEV, PEF or serum eosinophilia
How is postnasal drip diagnosed
Largely on exclusion and confirmed by trial of treatment
Try antihistamines and/or nasal decongestants
How is GORD diagnosed
Therapeutic trial with PPI and arrange follow up to see if it has worked
Where will a squamous cell carcinoma of the lung most likely present
Hilar regions
What are the treatments for a acute-chronic cough due to recovery from infection
Inhaled corticosteroids or oral antihistamines
Inhale ipratropium bromide
Antitussives e.g. codeine (opiates), dextromorphan, benzocaine (LA) - little evidence
What class of drug is ipratropium bromide
Anticholinergic
Blocks the efferent limb of the cough reflex
What factors / history are suggestive of TB
Cough, producing blood-streaked sputum
Weight loss and night sweats
Travel to high risk country e.g. Pakistan
How should oxygen be administered to COPD patients
Venturi masks
Smaller fixed ratios (24-40%)
Acute resuscitation, high flow should be given regardless
What is a bovine cough
Due to recurrent laryngeal nerve palsy, more common in left than right (as left branch loops around the aorta )
Most commonly due to malignancy e.g. Pancoast’s tumour or surgery e.g. neck
What is required for interpretation of the PaO2 onABG
FiO2 - inspired oxygen
A patient who has a normal O2 may have severely impaired ventilation if they are getting 15 L/min of oxygen
How does Streptococcus pneumoniae present on CXR
Lobar pneumonia - localised rather than patchy infiltrates
How does adenovirus infection present on CXR
Interstitial pneumonia, shadowing is interstitial rather than alveolar
Bronchograms would not be visible
How does mycoplasma pneumoniae present on CXR
Bronchopneumonia with rare abscess
What are the existing treatments for GORD
PPIs H2 receptor antagonists e.g. ranitidine Magnesium carbonate Aluminium hydroxide Alginates
