Week 6 - Chronic cough Flashcards
Mr. C.B. is a 73 year old Caucasian male who presents with the following complaint: “It’s my cough. It’s getting worse and I can’t seem to do anything for the last 3-4 months.”
Take a history of this patient.
HPC:
• Had cough all my life - white/clear sputum.
• Gradually getting worse - “not able now”.
• No wheeze, fevers, pain or reflux.
• Bronchodilators not helping now.
• Face flushed, hot (no fever) - 3 weeks.
• Loss of appetite, loss of weight, no energy.
• ? Asbestos exposure
• Ex smoker, 5 years ago (20s/d/50y)
• CT: mass lesion in the left lower lobe apical segment (hilar or peripheral?) with central necrosis. There are at least 2 other intrapulmonary nodules, prominent lymph nodes in the mediastinum. Multiple metastases in the liver right and left lobe (staging/grading of cancer).
HPC:
• Duration
- How long have you had the cough (acute vs. chronic)?
- Transient vs. progressive vs. intermittent?
- Onset?
• Character? i.e. barking, loud and brassy, hollow sound, painful?
• Variation? i.e. diurnal (during day), post prandial (after eating), nocturnal (worse at night).
• Sputum production
- Volume?
- Appearance/smell? i.e. mucoid, purulent.
- Haemoptysis (blood in sputum)?
• Allevating factors?
• Exacerbating factors?
• Associated symptoms? i.e chest pain, fever, dyspnoea, sinus problems.
• Severity?
• Effect on lifestyle?
- Long duration - what made you present now?
- Lung problems in past?
- Smoker?
- Tablets? e.g. ACE inhibitors
- Weight loss, loss of appetite, fatigue, energy?
- Wheeze?
- Fever?
- Pain or reflux?
- Carcinoid syndrome - intermittent diarrhoea, flushing face - dry* (without sweating), palpitations, abdominal cramps and SOB/wheezing.
PMHx:
• Past history of cardiovascular/respiratory disease, cancer, reflux?
PSHx:
• Any past surgeries?
Medications:
• Any regular medications?
Allergies:
• Agent, reaction, treatment?
Immunisations:
• E.g. Fluvax, pneumococcal?
FHx:
• Family history of cancer, cardiovascular/respiratory disease?
SHx: • Background? • Occupation? i.e. exposure to asbestos. • Education? • Religion? • Living arrangements? • Smoking? • Nutrition? • Alcohol/recreational drugs? • Physical activity?
Systems Review:
• General - weight change, fever, chills, night sweats?
• CVS - chest pain, palpitations, orthopnoea/PND?
• RS - dyspnoea, cough, sputum or wheeze?
• GI - vomiting, diarrhoea, indigestion, dysphagia, change in bowel habit, abdominal pain?
• UG - dysuria, polyuria, nocturia, urgency, incontinence, urine output?
• CNS - heachaches, nausea, trouble with hearing or vision?
• ENDO - heat/cold intolerance, swelling in throat/neck, polydipsia or polyphagia?
• HAEM - easy bruising, lumps in axilla, neck or groin?
• MSK - painful or stiff joints, muscle aches or rash?
Perform a physical examination on this patient.
- Introduction, explanation, consent, wash hands. Patient properly positioned, seated, chest exposed.
- General inspection: dyspnoeic, use of accessory muscles, pursed lip breathing, tripod position, cyanosis, cough, wheeze, stridor, hoarseness, body habitus (wasting, cachexia). Check patient surroundings (sputum cup, oxygen mask).
3. Vital signs: • HR - tachycardia • RR - tachypnoeic. • BP - normal. • Temp - may be febrile. • O2 sats, BGL, BMI
- Hands:
• Warm/cool, dry/sweaty.
• Pallor, peripheral cyanosis.
• CRT, clubbing (cancer not COPD).
• Tar staining of fingers.
• Palms - wasting of small muscles of hand, finger weakness with abduction.
• Wrists - flapping tremor, wrist tenderness.
• Pemberton’s sign - flushing, plethora, cyanosis, inspiratory stridor, elevation of JVP when arms in full abduction for 1 minute.
5. Face: • Thick leathery skin. • Eyes - sub-conjunctival haemorrhage, Horner's syndrome (ptosis, miosis, anhydrosis). • Nose - discharge, swelling. • Sinuses - tenderness. • Mouth - cyanosis.
- Neck:
• Trachea - tracheal tug, tracheal deviation. - Chest/back:
• Inspection - shape/symmetry (barrel shaped - COPD), scarring/deformity, chest expansion (may be reduced bilaterally - hyperinflated chest with reduced expansion).
• Palpation - chest expansion (reduced bilaterally, Hoover’s sign anteriorly), tactile fremitus, chest wall tenderness (may be pleuritic chest pain).
• Percussion - hyper-resonance (COPD), dullness to percussion over any masses.
• Auscultation - may be bronchial breath sounds, reduced intensity, crackles. Vocal resonance.
8. Legs: • Temperature. • Oedema. • Clubbing. • CRT. • Peripheral pulses.
- CVS:
• JVP, auscultation.
What is your provisional diagnosis and differential diagnoses?
• Provisional diagnosis: Lung cancer (SCC) - dyspnoea, weight loss, no energy, worsening chronic cough, hyponatraemia. • DDx: - COPD. - Pneumonia. - Asthma. - GORD. - Sinusitis. - Carcinoid syndrome (face flushed).
What investigations would you carry out on this patient?
- FBC - Hb (anaemia), WCC (infection).
- U+Es - liver/renal function.
- CXR - peripheral nodule, hilar enlargement, consolidation, lung collapse, pleural effusion, bony secondaries.
- Cytology - sputum and pleural fluid.
- Biopsy - peripheral lesions and superficial lymph nodes may be amenable to percutaneous fine needle aspiration or biopsy.
- CT - staging of tumour and to guide bronchoscopy.
- Bronchoscopy - to give histology and assess operability.
- Tumour markers.
- PET - to help in staging.
- Radionucleotide bone scan - if suspected metastases.
- Lung function tests - to help assess suitability for lobectomy.
What treatment does this patient require?
- Chemotherapy.
- Palliative care.
- Consider the results of the CT scan in order to help with treatment options.
- In patients with extensive disease such as this, median survival is 6-12 months with current therapies - chemotherapy.
- Without treatment, the median survival is 2-4 months.
- Radiotherapy is usually indicated for brain or bony pain.
Identify the causes of an acute and chronic cough.
Acute (<3 weeks):
• URTI - common cold, sinusitis.
• LRTI - pneumonia, bronchitis, exacerbation of COPD, irritation (inhalation of bronchial irritant e.g. smoke or fumes).
• Post-nasal drip.
Chronic (months to years):
• COPD/smoking related lung diseases - emphysema.
• Asthma - wheeze, relief with bronchodilators.
• GORD - occurs when lying down, burning central chest pain.
• Upper airway cough syndrome - history of rhinitis, post-nasal drip, sinus headache and congestion.
• Bronchiectasis - chronic, very productive.
• ACE inhibitor medication - drug history.
• Carcinoma of lung - smoking, haemoptysis.
• Congestive cardiac failure - dyspnoea, PND.
• Psychogenic - variable, prolonged symptoms, usually mild.
• Alpha 1 anti-trypsin deficiency.
• Valvular heart disease.
• Arrhythmia.
• Cystic fibrosis.
• Idiopathic pulmonary fibrosis.
• Chest wall deformities.
• Pulmonary hypertension.
• Neuromuscular disorders.
What are the patient’s most relevant risk factors for developing lung cancer?
- Smoking.
* Possible asbestos exposure.
FBC:
• Hb 192g/L (130-170)
• HCT 60%
• FBC otherwise normal.
- Why does the patient have polycythemia?
- What other conditions is the patient at risk of developing due to raised Hb and HCT?
- Increased EPO production.
- At risk of:
• DVT.
• MI.
• CVA.
FBC:
• Hb 192g/L (130-170)
• HCT 60%
• FBC otherwise normal.
- Why does the patient have polycythemia?
- What other conditions is the patient at risk of developing due to raised Hb and HCT?
- Increased EPO production - chronic hypoxia leading to EPO production is the most likely cause.
- At risk of:
• DVT.
• MI.
• CVA.
*Other common causes of polycythemia.
U+Es: • Urea 2.6 mmol/L. • Creatinine 80 micromol/L. • Na 120 mmol/L. • K 4.3 mmol/L. • Chloride 95 mmol/L.
- Why does the patient have hyponatraemia?
- What are the most common symptoms of hyponatraemia?
- SIADH - this patient has symptoms suggestive of lung cancer. ADH may be secreted by lung tumours. ADH prevents water loss by acting on the distal portion of the renal tubule and collecting ducts. Water is retained but not solutes leading to hyponatraemia.
2. Common symptoms of hyponatraemia are: • Nausea. • Vomiting. • Headache. • Irritability. • Muscle weakness. • Other symptoms include short term memory loss, confusion, decreased level of consciousness and cramps.
- Revise endocrine changes, neurological manifestations, haematological manifestations of lung cancers. 10% of all patients develop clinically overt paraneoplastic syndrome.
Describe the cough reflex.
• In healthy people coughing protects the airway from chemical irritants and foreign bodies.
• These stimulate the afferent C fibres located mainly on the posterior wall of trachea, pharynx and the carina.
• When triggered, impulses travel via internal laryngeal nerve → superior laryngeal nerve → vagus nerve (CN X) → medulla of the brain (afferent neural pathway).
• Relevant signals are transmitted back from the cerebral cortex an medulla via the vagus and superior laryngeal nerves to the glottis, external intercostals, diaphragm and other major inspiratory and expiratory muscles (efferent neural pathway).
• The mechanism of the cough is as follows:
- Diaphragm and external intercostals muscles contract, creating a negative pressure around the lung.
- Air rushes into the lungs in order to equalise the pressure.
- The glottis close and the vocal cords contract to shut the larynx.
- The abdominal muscles and other expiratory muscles contract (this increases the pressure of air within the lungs).
- The vocal cords relax and the glottis opens releasing air.
- The bronchi and non-cartilaginous portions of the trachea collapse to form slits through which the air is forced, which clears out any irritants attached to the respiratory lining.
• Tumour tissue in the central airway causes stimulation of the mechanoreceptors via sputum accumulation and physical mass accumulation.
Describe how salbutamol and tiotropium work.
Salbutamol:
• Prescribed for the relief or prevention of bronchospasm. It has a duration of action of 4 hours and is indicated in the treatment of asthma and COPD.
• Direct acting sympathomimetic drug which has a high degree of selectivity for B2 adrenoceptors.
• This has a prominent effect of the bronchodilators leading to relaxation of the smooth muscle of the bronchi.
• Side effects are typical of its mechanism of action and include palpitations, tremor, restlessness, anxiety, headache.
Tiotropium (Spiriva):
• Long acting anticholinergic agent. It inhibits M receptors in the smooth muscle of the bronchus and bronchioles leading to bronchodilation.
• It is indicated in the treatment of COPD. It is not indicated for the immediate relied of acute shortness of breath.
• Side effects include: dry mouth, constipation, urinary retention.
