Transcript Cough
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 0% 1 0% 2 0% 0% 3 4 0% 5 What test would you like next? 1. Spirometry 2. Spirometry with reversibility 3. Chest x-ray 4. Peak flow diary 5. Sputum cytology 0% 1 0% 2 0% 0% 3 4 0% 5 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 0% 1 0% 2 0% 0% 3 4 0% 5 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. Lung carcinoma 2. Lower respiratory tract infection 3. Upper respiratory tract infection 4. Pneumothorax 5. Pulmonary Embolism 0% 1 0% 2 0% 0% 3 4 0% 5 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 0% 1 0% 2 0% 0% 3 4 0% 5 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. CT chest 2. High Resolution CT chest (HRCT) 3. Arterial Blood Gases 4. Pulmonary Function tests 5. Bronchoscopy 0% 1 0% 2 0% 0% 3 4 0% 5 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. Lymphangioleiom yomatosis 5. Bronchiectasis 0% 1 0% 2 0% 0% 3 4 0% 5 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? 1. Sputum cytology 2. Sputum microscopy 3. Bronchoscopy and CT chest staging 4. Lateral CXR 5. Give him Tranexaemic acid 0% 1 0% 2 0% 0% 3 4 0% 5 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 0% 1 0% 2 0% 0% 3 4 0% 5 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 doesn’t smoke She takes Gaviscon plus a tablet for her blood pressure which she can’t 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! 0% 1 0% 2 0% 0% 3 4 0% 5 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! 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! ACE inhibitors are known to cause cough by inhibiting the breakdown of Bradykinin 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! Beta Blockers can worsen or precipitate 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 0% 1 0% 2 0% 0% 3 4 0% 5 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 0% 1 0% 2 0% 0% 3 4 0% 5 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 0% 1 0% 2 0% 0% 3 4 0% 5 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 0% 1 0% 2 0% 0% 3 4 0% 5 This is their dog www.harbourvets.co.uk/notice_board.htm Just Kidding!