Core Clinical

Problems
Cough

A man presents to
you with coughing
What would you like to know?

Cough

Onset?
Duration?
Character?
Nocturnal?
Precipitating factors?
Relieving factors?
Sputum?
Haemoptysis?
Association?

Cough

Onset?
Duration?
Character?
Nocturnal?
Precipitating factors?
Relieving factors?
Sputum?
Haemoptysis?
Association?

Recent or long standing

(Chronic)

Cough

Onset?
Duration?
Character?
Nocturnal?
Precipitating factors?
Relieving factors?
Sputum?
Haemoptysis?
Association?

Chronicity

Pertussis
TB
Foreign body
Asthma
Drugs
Bronchiectasis
ILD

Cough

Onset?
Duration?
Character?
Nocturnal?
Precipitating factors?
Relieving factors?
Sputum?
Haemoptysis?
Association?

Brassy?
Pressure on the trachea?

Cough

Onset?
Duration?
Character?
Nocturnal?
Precipitating factors?
Relieving factors?
Sputum?
Haemoptysis?
Association?

Hollow/Bovine?
Laryngeal nerve palsy
causing vocal cord
dysfunction

Cough

Onset?
Duration?
Character?
Nocturnal?
Precipitating factors?
Relieving factors?
Sputum?
Haemoptysis?
Association?

Barking?
Acute Epiglottitis

Cough

Onset?
Duration?
Character?
Nocturnal?
Precipitating factors?
Relieving factors?
Sputum?
Haemoptysis?
Association?

Dry?
GORD
Drugs (e.g. ACEI)

Cough

Onset?
Duration?
Character?
Nocturnal?
Precipitating factors?
Relieving factors?
Sputum?
Haemoptysis?
Association?

Change in character of a
chronic cough should
make you consider other
pathology.

Cough

Onset?
Duration?
Character?
Nocturnal?
Precipitating factors?
Relieving factors?
Sputum?
Haemoptysis?
Association?

Asthma
Also Early morning

Cough

Onset?
Duration?
Character?
Nocturnal?
Precipitating factors?
Relieving factors?
Sputum?
Haemoptysis?
Association?

Usually in asthma
Emotion
Weather

Wind
Rain
Cold

Dust
Allergies
Exercise
Drugs

Cough

Onset?
Duration?
Character?
Nocturnal?
Precipitating factors?
Relieving factors?
Sputum?
Haemoptysis?
Association?

Avoidance of
precipitating factors!

Cough

Onset?
Duration?
Character?
Nocturnal?
Precipitating factors?
Relieving factors?
Sputum?
Haemoptysis?
Association?

Presence?

Colour
Volume
Consistency
Pattern

Consider

Infections
COPD
CF
Bronchiectatsis

Cough

Onset?
Duration?
Character?
Nocturnal?
Precipitating factors?
Relieving factors?
Sputum?
Haemoptysis?
Association?

Presence?

Colour
Volume
Consistency
Pattern

Will be covered
elsewhere!

Cough

Onset?
Duration?
Character?
Nocturnal?
Precipitating factors?
Relieving factors?
Sputum?
Haemoptysis?
Association?

Breathlessness
Sputum
Chest pain
Wheeze
Hoarseness
Post nasal drip

Meet
Mr Coughing
61 years old

www.badvertising.org/pages/02%20How%20To%20BA...

Presentation
Cough productive of white sputum most
days over the past 2 years
Life long smoker (30 per day)
Gets breathless going up the stairs

Mr Coughing 61

What do you think he

has?
1.
2.
3.
4.
5.

Asthma
COPD
Lung Cancer
Sarcoid
Rhinitis

What test would you like

next?
1. Spirometry
2. Spirometry with
reversibility
3. Chest x-ray
4. Peak flow diary
5. Sputum cytology

What test would you like

next?
1. Spirometry
2. Spirometry with
reversibility
3. Chest x-ray
4. Peak flow diary
5. Sputum cytology

Confirm obstructive
picture
Assess severity
Lack of reversibility
more often found in
COPD than asthma

Mr Coughing 61

How would you like to

treat him?
1. Smoking cessation
2. Smoking cessation plus
CombiventR 2 puffs
QDS
3. Beclomethasone 200 2
puffs BD
4. Pulmonary
Rehabilitation
5. Salbutamol 2 puffs PRN

Unwell!
He becomes unwell with fevers, sweats,
increasing cough and sputum volume.
Sputum is now green
He also complains of right sided pleuritic
chest pain and had a few crackles at the
right base on chest auscultation

Mr Coughing 61

What do you think has

happened?
1.
2.
3.
4.
5.

Lung carcinoma
Lower respiratory
tract infection
Upper respiratory
tract infection
Pneumothorax
Pulmonary
Embolism

www.meddean.luc.edu/.../pulmonar/cxr/segm.htm

This is his CXR

Mr Coughing 61

How would you like to

treat him?
1.
2.
3.
4.
5.

Oxygen
Nebulisers
Antibiotics
Prednisolone
All of these

6 months later
After making a good recovery, he presents 6
months later to his GP who asks you to see
him at your out patient chest clinic
You note that he has had at least 3 chest
infections since his discharge from hospital.
He still smokes!
Examining him you note finger clubbing,
bilateral inspiratory coarse crackles at the lung
bases on chest auscultation
Mr Coughing 61

What investigation
would you like next?
1.
2.
3.
4.
5.

CT chest
High Resolution
CT chest (HRCT)
Arterial Blood
Gases
Pulmonary
Function tests
Bronchoscopy

brighamrad.harvard.edu/.../hcache/211/full.html

This is his HRCT

Mr Coughing 61

What is the diagnosis?

1. Pulmonary fibrosis
2. Hypersensitivity
Pneumonitis
3. Lung cancer
4. Lymphangioleiomy
omatosis
5. Bronchiectasis

One year later

Mr coughing notices that his cough has
changed character over the past couple
of weeks
He has also noticed 5kg weight loss over
the past month and had one episode of
haemoptysis a week ago

Mr Coughing 61

This is his CXR

Mr Coughing 61

What should you do

next?
Sputum cytology
Sputum
microscopy
3. Bronchoscopy and
CT chest staging
4. Lateral CXR
5. Give him
Tranexaemic acid
1.
2.

This is his Bronchoscopy

Mr Coughing 61

Where is the tumour?

1. Left Upper Lobe
2. Bronchus
intermedius
3. Right middle lobe
4. Right lower lobe
5. Left Lower lobe

www.lumen.luc.edu/.../mech/cases/case9/list.htm

www.tbalert.org/resources/resources.php

Mrs Coughing 49

History
This 49-years-old lady has had a dry
cough for a few months.
Her BMI is 36
She doesnt smoke
She takes Gaviscon plus a tablet for her
blood pressure which she cant recall

Mrs Coughing 49

Which of the following blood

pressure tablets might be
relevant in her symptoms?
1.
2.
3.
4.
5.

Ramipril
Bendrofluazide
Nifedipine
Atenolol
None of them!

Which of the following

Blood pressure tablets
might be relevant in her
1. Ramipril
symptoms?
2.
3.
4.
5.

Bendrofluazide
Nifedipine
Atenolol
None of them!

Mrs Coughing 49

Which of the following

Blood pressure tablets
might be relevant
in
her
ACE inhibitors are
1. Ramipril
symptoms?
known to cause
2. Bendrofluazide
3.
4.
5.

Nifedipine
Atenolol
None of them!

cough by inhibiting
the breakdown of
Bradykinin

Mrs Coughing 49

Which of the following

Blood pressure tablets
might be relevant
in
her
Beta Blockers can
1. Ramipril
symptoms?
worsen or precipitate
2. Bendrofluazide
3.
4.
5.

Nifedipine
Atenolol
None of them!

underlying asthma

Mrs Coughing 49

More history
She tells you that her cough is quite bad
first thing in the morning and sometimes
wakes her up during the night
She also wheezes whenever she tries to
catch the bus

Mrs Coughing 49

This is her Spirometry

FEV1
FVC
FEV1/FVC

1.6L (76%)
2.4L (83%)
67%

Mrs Coughing 49

How would you treat

her?
1.
2.

3.
4.
5.

Salbutamol 2 puffs
PRN
Salbutamol 2 puffs
PRN + Becotide 200 2
puffs B.D.
Nebulised Salbutamol
Theophylline
Tiotropium

How would you treat

her?
1.
2.

3.
4.
5.

Salbutamol 2 puffs
PRN
Salbutamol 2 puffs
PRN + Becotide 200 2
puffs B.D.
Nebulised Salbutamol
Theophylline
Tiotropium

You need to give her

PEF meter and ask her
to keep a diary
Review her in a week
Advise her to return
promptly if her
symptoms worsen

Mrs Coughing 49

3 months later
Your treatment has been helpful
She has no cough during the night but
still has a dry cough during the day
occasionally
She also complains of quite bad
heartburn and indigestion

Mrs Coughing 49

What would you advise?

1.
2.
3.
4.
5.

Life style measures

Anti reflux treatment
Dietary modification
Exercise
All of the above

Miss Coughing 23

Their daughter!
Usually keeps well
Eczema as a child
Presents with dry cough, lethargy and
generalised aches and pains
She has also developed a painful red
lesion on her left shin

Miss Coughing 23

www.patient.co.uk/showdoc/40001001/

Miss Coughing 23

What is your next step?

1. Dermatology
referral
2. Arrange skin
biopsy
3. Spirometry
4. CXR
5. Peak Flow diary

adam.about.com/encyclopedia/1613.htm

This is her CXR

Miss Coughing 23

adam.about.com/encyclopedia/1613.htm

This is her CXR

Miss Coughing 23

What is the likely

diagnosis?
1. Tuberculosis
2. Non Tuberculous
mycobacterium
3. Breast cancer
4. Lymphoma
5. Sarcoidosis

This is their dog

www.harbourvets.co.uk/notice_board.htm

Just Kidding!