Cough

Question 1

What questions about the cough should you ask someone with a cough? (6)

Answer 1

Acute or chronic
Constant or intermittent
Productive or dry
Blood
Timing
Character

Question 2

What can whether a cough is acute or chronic tell you? And what defines chronic or acute?

Answer 2

The British Thoracic Society (BTS) defines acute as <3 weeks and chronic as >8 weeks. Between 3 and 8 weeks the cough may be due to recovering acute illness or developing chronic illness.

Question 3

What can whether a cough is constant or intermittent tell you?

Answer 3

A cough that is intermittent may suggest an extrin- sic trigger (e.g. if the patient only coughs at work there may be an allergy to something in the workplace). A cough that is constant suggests an intrinsic cause.

Question 4

What colour sputum in COPD?

Answer 4

White or clear

Question 5

What can whether a cough has blood suggest? 3 forms of haemoptysis (2, 1 and 6

Answer 5

• Blood-streaked sputum? Suggests infection or bronchiectasis.
  − Pink and frothy sputum? Suggests pulmonary oedema.
  − Frank blood (haemoptysis)? Suggests tuberculosis (TB),
  lung cancer, pulmonary embolus, bronchiectasis, or other rarer causes (e.g. Wegener’s granulomatosis, Goodpasture’s syndrome).

Question 6

What can the timing of a cough tell you? (3)

Answer 6

Asthma is classically worse at night. Pulmonary oedema or gastro-oesophageal reflux disease (GORD) can also be worse at night due to the positional effects of lying flat. Patients often report sleeping propped up on pillows to mitigate these effects. Trigger factors such as pets, cold weather, or exercise indicate asthma, as does a worsening in spring/summer.

Question 7

What can the character of a cough tell you? (5)

Answer 7

A wheezy cough suggests airway obstruction due to asthma or COPD. A bovine cough (breathy) is characteristic of vocal cord paralysis. A dry cough is suggestive of pulmonary fibrosis. A gurgling cough is sugges- tive of bronchiectasis. Pertussis infection causes a ‘whooping’ cough.

Question 8

What are the 5 characters of cough?

Answer 8

Wheezy
Bovine
Dry
Gurgling
Pertussis

Question 9

What colour sputum in bronchiectasis?

Answer 9

Green/rusty

Question 10

What colour sputum in lung abscess?

Answer 10

Green/rusty

Question 11

What does green/rusty sputum indicate?

Answer 11

Bronchiectasis or lung abscess

Question 12

What colour sputum can asthmatics have

Answer 12

Clear or yellow

Question 13

What does blood streaked sputum with cough indicate? (2)

Answer 13

Suggests infection or bronchiectasis.

Question 14

What does pink and frothy sputum with cough suggest?

Answer 14

Pulmonary oedema (CHF)

Question 15

What does frank blood with cough suggest? (6)

Answer 15

Suggests tuberculosis (TB),
lung cancer, pulmonary embolus, bronchiectasis, or other rarer causes (e.g. Wegener’s granulomatosis, Goodpasture’s syndrome

Question 16

What does a cough worse at night suggest?

Answer 16

Athma/GORD

Question 17

What does a cough worse in summer/spring indicate?

Answer 17

Asthma

Question 18

What topics of questions should you ask in someone presenting with cough?

Answer 18

First, ask open questions about the cough itself
Second, ask directed questions about factors that might be triggering the cough
Third, ask about factors that might be associated with the cough and give you clues about the underlying cause:

Question 19

What should you inquire about secondly when someone presents with cough? (7)

Answer 19

What might be triggering the cough:

Smoking
Asthma
Allergies
Recent rhinusitis/sinusitis
History of GORD
DHx (ACEi)
Travel (TB)

Question 20

What should you ask about thirdly when someone presents with cough? (8)

Answer 20

Factors that might be associated with the cough and give you clues about the underlying cause:

Fevers, night sweats, rigors, weight loss
Breathlessness
Chest pain, particularly pleuritic
Wheeze

Question 21

What drugs should you inquire about for DHx in someone presenting with a cough?

Answer 21

ACEi

Question 22

What do fevers, night sweats, rigors, weight loss suggest in someone presenting with cough? (3)

Answer 22

These suggest malignancy, TB, or another severe infection.

Question 23

What does breathlessness suggest in someone presenting with cough and what does it indicate against? (4 and 2)

Answer 23

This would be in keeping with asthma, COPD, pneumonia, or pulmonary oedema but rarer in lung cancer or GORD.

Question 24

What does chest pain, especially pleuritic, suggest in someone presenting with cough? (6)

Answer 24

This may indicate pneumonia, pneumothorax, pulmonary embolism, or viral pleurisy. Equally it may be due to muscle strain secondary to vigorous coughing, or a fractured rib following trauma.

Question 25

What does wheeze suggest in someone presenting with cough? (3)

Answer 25

This suggests obstruction of the airways such as that found in asthma, COPD, or tumours compressing an airway.

Question 26

DDx of an acute dry cough? (9)

Answer 26

Asthma Rhinitis/sinusitis with
post-nasal drip
Upper respiratory tract
infection
(pharyngitis, laryngitis, tracheitis)
Drug induced, e.g. ACE inhibitors
Smoke/toxin inhalation
Inhaled foreign body
Lung cancer (causing obstruction of a major bronchus)
Pulmonary oedema (secondary to heart failure)

Question 27

DDx of a chronic dry cough? (10)

Answer 27

Asthma
GORD
Post-nasal drip
Smoking
Lung cancer
Drug induced
COPD
Pulmonary oedema (secondary to heart failure)
Non-asthmatic eosinophilic bronchitis
Psychogenic

Question 28

DDx of an acute productive cough? (4)

Answer 28

Lower respiratory tract infection
(pneumonia, bronchitis)
COPD
TB

Question 29

DDx of a chronic productive cough? (5)

Answer 29

Bronchiectasis TB
Lung cancer
(If congenital: cystic fibrosis or Kartagener’s syndrome)

Question 30

What signs on examination of someone presenting with cough suggests an infectious cause? (systemic 3, respiratory 4, lungs 4, and 1 other)

Answer 30

• Systemic features: Is she pyrexic? Is she sweating? Is she tachycardic?
• Respiratory distress: Is her respiratory rate increased? Is she having difficulty breathing – can she complete sentences, is she using her accessory muscles? Is she peripherally cyanosed? Is she confused (you can assess confusion with an Abbreviated Mental Test Score (AMTS); see Chapter 2)? These give an idea of the severity of her condition.
• Tender cervical lymphadenopathy: in a patient with a cough, this suggests infection in the upper respiratory tract.
• Lungs: reduced chest expansion, focal dull percussion note, breath sounds (reduced in effusion, bronchial sounding in pneumonia), and vocal resonance.

Question 31

How can you distinguish between consolidation and effusion on examination

Answer 31

Vocal resonance distinguishes between consolidation, which increases resonance, and effusion, which diminishes it.

Question 32

What are breath sounds in effusion

Answer 32

Reduced

Question 33

What are breath sounds in pneumonia

Answer 33

Bronchial

Question 34

What signs should you see on examination of someone with COPD? (4 and 1 sign is in 5 manifestations)

Answer 34

• Chest wall deformities (e.g. hyperexpansion or ‘barrel chest’).
• Intercostal recession: a sign of severe COPD.
• Signs of right heart failure due to her COPD (‘cor pulmonale’), such as periph- eral oedema, raised jugular venous pressure (JVP), a parasternal heave, a loud or palpable P2 heart sound, or tricuspid regurgitation.
• Asterixis: even though some COPD patients are chronic CO2 retainers, asterixis can be seen if COPD deteriorates and CO2 levels rise significantly.

Question 35

Neutrophilia is found in which type of infection

Answer 35

Bacterial

Question 36

Why would you take an ABG in hospital presenting with respiratory illness

Answer 36

To assess gas exchange to then monitor it

Question 37

What Ix should you do in someone presenting with a respiratory illness in hospital to monitor it

Answer 37

ABG

Question 38

What Ix should you do in someone suspected of a lung infection? (6)

Answer 38

ABG to monitor progress
FBC to look at WCC
CRP
U&E’s to check hydration and kidney perfusion (urea)
CXR
ECG to rule out ischaemia or AF secondary to pneumonia, may show right heart strain

Question 39

Why do we do an ECG in patients with a lung infection

Answer 39

You must perform this to rule out ischaemia or atrial fibrillation secondary to pneumonia. It may also show right heart strain in some patients with COPD.

Question 40

Why is a sputum culture not useful and what do we do instead? What is the indication?

Answer 40

Sputum cultures are rarely useful as the sputum will contain all the com- mensal flora that is normally found in the upper respiratory tract. However, broncho- alveolar lavage may be performed to get a sputum sample free of this flora and thereby identify the offending organism, but this is only done if a pneumonia does not respond to conventional antibiotic treatment suggesting infection with an atypical organism.

Question 41

What is the CURB-65 score, what is it used for, and how is it calculated? How should she be managed?

Answer 41

The CURB-65 score can be used to calculate severity of pneumonia and therefore determine the need for hospitalization. Each criteria scores 1 point and 2 or more requires admission to hospital.

Confusion (new to the patient), defined as an AMTS of ≤8/10 Urea >7 mM
Respiratory rate >30/minute
Blood pressure <90 systolic and/or <60 diastolic >65 years old

Question 42

Complications of pneumonia (6)

Answer 42

• Spread of infection: pleural effusion, empyema, abscess, septicaemia
• Damage to local structures: bronchiectasis, pneumothorax

Question 43

3 most common causes of chronic cough in a non-smoker?

Answer 43

Asthma, post-nasal drip and GORD

Question 44

How to diagnose for asthma

Answer 44

Measurements of either peak expiratory flow (PEF) or forced expiratory volume in 1 second (FEV1) – both of these are reduced in obstructive airways disease such as asthma and COPD
However, asthma is char- acterized by variability in PEF and FEV1, either in response to treatment (e.g. with an inhaled short-acting bronchodilator) or spontaneously (e.g. diurnal variation).

Question 45

What drug can cause a dry cough and how?

Answer 45

ACE inhibitors can cause a dry cough in 10–20% of patients. This is because ACE is also responsible for breaking down the inflammatory bradykinins in the lungs. Thus, inhibition of ACE leads to a build up of bradykinins and lung inflammation, triggering cough.

Question 46

Which patients should not necessarily be given 100% oxygen and why?

Answer 46

• The airways contain significant amounts of mucus that impairs ventilation.
• The lungs are hyperinflated, making them less efficient at moving air.
• The hypoxic vasoconstriction mechanism is blunted. This usually ensures that areas of lung that are poorly ventilated are supplied with less blood, so that gas exchange only occurs in well-ventilated areas. If this mechanism no longer works well, blood travels through poorly ventilated areas of the lung and is not well oxygenated.

Question 47

How should you administer oxygen to a COPD patient

Answer 47

Ising ‘Venturi’ masks, which allow oxygen to be delivered at safer, smaller, fixed ratios (from 24% to 40%)

Question 48

You see a patient in clinic with lung cancer who has a bovine cough. Can you explain this symptom?

Answer 48

It is likely that this patient has a recurrent laryngeal nerve (RLN) palsy.

Question 49

Which side a RLN palsy more common in and why?

Answer 49

RLN palsy is more common on the left than the right. The left branch of the RLN loops around the arch of the aorta and thus has a longer intrathoracic course (and hence is more likely to be affected by chest pathology) than the right branch – which loops around the right subclavian artery. Damage to the recurrent laryngeal nerve is most commonly due to malignancy (e.g. a Pancoast apical lung tumour) or surgery (e.g. neck surgery).