Coughs in adults

Question 1

Probability diagnosis

Answer 1

Upper respiratory infection

Postnasal drip/ sinusitis/rhinitis

Smoking

Inhaled irritants

Acute bronchitis

Chronic bronchitis/COPD

Question 2

Serious disorders not to be missed

Answer 2

Cardiovascular:

• left ventricular failure
• Cancer:
• lung cancer
• larynx

Infection:

• tuberculosis
• pneumonia
• influenza
• lung abscess
• HIV infection
• SARS (coronavirus)

Other:

• asthma
• cystic fibrosis
• foreign body
• pneumothorax

Question 3

Pitfalls (often missed)

Answer 3

Atypical pneumonias

Gastro-oesophageal reflux (nocturnal)

Smoking (children/adolescents)

Bronchiectasis

Whooping cough (pertussis)

Interstitial lung disorders (e.g. idiopathic pulmonary fibrosis)

Sarcoidosis

Question 4

General pitfalls

Answer 4

Attributing cough due to bronchial carcinoma in a smoker to ‘smoker’s cough’

Overlooking TB, esp. in the elderly, by equating symptoms to old age, bronchitis or even smoking

Overlooking the fact that bronchial carcinoma can develop in a patient with other pulmonary conditions such as chronic bronchitis

Being slow to order a chest X-ray

Question 5

Masquerades checklist

Answer 5

Drugs e.g.

1. ACE inhibitors
2. beta blockers
3. inhaled steroids
4. sulfasalazine

Question 6

Is the patient trying to tell me something?

Answer 6

Anxiety and habit.

Question 7

Key history

Answer 7

Determine the nature of the cough & associated symptoms such as;

• the nature of the sputum, breathlessness
• wheezing
• constitutional symptoms.

Haemoptysis

Hx of smoking habits, past and present

Occupational history

PMHx esp respiratory and drug intake.

Question 8

Key examination

Answer 8

General exam including enlarged cervical or axillary glands

Careful exam of lungs and CVS with inspection of sputum

Question 9

Key investigations

Answer 9

More applicable if haemoptysis

• FBE/ESR/CRP
• Sputum cytology and culture
• Respiratory function tests
• Plain CXR

Other tests as appropriate according to clinical findings e.g.

• CT
• bronchoscopy
• ECG
• echocardiogram
• ventilation/perfusion scan
• CT pulmonary angiogram

Question 10

Diagnostic tips

Answer 10

Postnasal drip is the commonest cause of a persistent or chronic cough esp at night.

Cough may persist for many weeks following a URTI.

Cough is the cardinal feature of chronic bronchitis.

Unexplained cough >50 years is bronchial carcinoma until proved otherwise (esp. if a hx of smoking).

Question 11

Red flag pointers for cough

Answer 11

• age >50 yrs
• smoking history
• history of asbestos exposure
• persistent cough
• overseas travel
• TB exposure
• haemoptysis
• unexplained weight loss
• dyspnoea
• fever