GP - Cough Flashcards
What is a cough?
Cough is a reflex response to airway irritation. It’s triggered by stimulation of cough receptors in the airway, either by irritants or by conditions that cause airway distortion
How long is acute cough? (remember that cough tends to last longer than nasal symptoms)
< 3 weeks
How long is sub-acute cough?
3-8 weeks
How long is chronic cough?
> 8 weeks
What are the causes of acute cough?
Viral URTI e.g. cold or flu (most common)
Other causes include:
Acute bronchitis
Pneumonia
Acute exacerbations of asthma
COPD
Bronchiectasis
PE
Pneumothorax
What are the causes of a sub-acute cough?
Post-infectious cough (cough that sticks around long after you have recovered from an infection) e.g. after infection with Mycoplasma pneumonia or Bordetella pertussis (whooping cough/ 100-day cough)
What are the causes of chronic cough?
Smoking (most common)
ACEi
Upper airway cough syndrome (post-nasal drip)
Asthma
GORD
Give 3 complications of cough
Cough syncope
Depression, anxiety
Sleep disturbance
Reduced quality of life
As a GP, what would you ask in the Hx in someone with cough?
- Onset of cough
- Duration of cough
- Frequency of cough
- Type of cough (dry vs productive) - if productive, what colour? Any blood? frothy?
- Diurnal variation - does it get worse at night? (asthma)
- Aggravating and relieving factors
- Associated symptoms - e.g. chest pain, SOB, GI symptoms
- Previous episodes - was what you had before similar to what you are having now?
- PMHx of medical conditions that can cause cough e.g. HF, asthma, COPD, GORD, Bronchiectasis - when was the last chest infection? how often do you have chest infection?
- DHx - medications that cause cough? e.g. ACEi, simvastatin, sitagliptin ,or medications suggestive of a medical condition that may cause cough e.g. HF, COPD, asthma; allergies
- FHx
- SHx - smoking - how many pack years? exercise tolerance; living in urban area vs rurual area; any staircases at home? Occupation e.g. shipyard workers, farmers, pet hairdressers, painters, bakers
- THx - areas at high risk of getting TB (Africa, India, China), pneumonia
Red flag symptoms:
- Haemoptysis
- Hoarseness - lung cancer, laryngeal cancer, thyroid cancer, FB
- Peripheral oedema and weight gain - HF, liver failure, renal failure
- Dyspnoea that is worse at rest or at night - LVF
- Fever, weight loss
- Dysphagia
- Vomiting
- Smokers aged over 45 years with a new cough, change in cough, or coexisting voice disturbance, and smokers aged 55–80 years who have a 30 pack-year smoking history and currently smoke or who have quit within the past 15 years
What red flag symptoms do you have to ask in someone with a cough?
Haemoptysis
Hoarseness
Peripheral oedema and weight gain
Fever, weight loss
SOB esp at night or at rest
Dysphagia
Vomiting
How would you assess the severity of cough or quality of life?
Use a validated tool e.g. Leicester Cough questionnaire
What examinations would you do to a patient with a cough in primary care?
Examinations:
- Respiratory
- Cardiovascular
- GI examination
- Otoscopy examination for acute otitis media
- Throat examination
What investigations would you request in primary care for someone with cough?
(note that the term ‘request’ is different from the term ‘carry out’; ‘request’ means that you can request tests that are done in secondary care e.g. ABG, CXR, MRI, CT, endoscopy, rhinoscopy, but ‘carry out/ do’ means that the GP can do that investigation right away in the GP clinic)
Depends on the cause, but generally the following could be requested:
Pulse oximetry
ABG
Peak flow
Spirometry
CXR
Sputum culture
Blood culture
Blood tests - FBC, U&Es, CRP/ ESR
Pertussis serology - if whooping cough is suspected
ECG
Echo
What investigations can a GP do in primary care to a patient with cough?
Pulse oximetry
Peak flow
Blood tests
Sputum culture
How to manage someone with acute cough?
- Acute cough with URTI or acute bronchitis:
- Advise that acute coughs are usually caused by a viral URTI e.g. cold or flu, they are usually self-limiting but it may take up to 3 weeks to resolve
- Explain why Abx would not work
- Stop smoking
- Self care advice e.g. paracetamol or ibuprofen for pain relief
- Advise to seek medical advice if symptoms deteroriate rapidly or do not improve after 3 weeks
- Acute cough/ bronchitis AND at higher risk of complications:
- Higher risk of complications includes:
- People with pre-existing comorbidity
- Young children born prematurely
- > 65 yrs with 2 or more, OR > 80 yrs with 1 or more of the following:
- Hospitalisation in previous year
- T1DM or T2DM
- Hx of CHF
- Current use of oral corticosteriods
- Offer immediate Abx –> doxycycline
- Higher risk of complications includes:
- Acute cough AND bronchitis AND systemically very unwell at a face to face examination:
- Offer immediate Abx –> doxycycline
