WHAT IS COUGH? - CLINICAL APPROACH USING QUESTIONS
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| Approach to patient with Cough |
Coughing is reflex mechanism of body to clear breathing passages from irritants, foreign particles and secretions like mucus. But the main question is, how do we approach a patient who is Coughing?
Earlier, we discussed how to take CLINICAL HISTORY OF PATIENTS in medical words, and RESPIRATORY SYSTEM EXAMINATION, while in this blog, we will reveal everything that can be asked about Cough to reach the diagnosis. Go through the questions and memorise them, for coughing is one of the most common symptom of disease.
QUESTION 1- HOW LONG HAVE YOU BEEN SUFFERING THESE COUGH EPISODES?
Duration of cough can classify Cough in three subtypes :-
1. Acute cough- It is cough for less than 3 weeks.
Causes-
• Upper respiratory tract infection- Common cold, acute bacterial sinusitis, pertussis, exacerbations of chronic obstructive pulmonary disease (COPD), allergic rhinitis.
• Lower respiratory tract infection- Pneumonia, aspiration, other infections.
• Miscellaneous- Left ventricular failure.
2. Subacute cough- It is cough with duration ranging between 3 to 8 weeks.
Causes- Post infectious cough, bacterial sinusitis, asthma.
3. Chronic cough- Cough for more than 8 weeks and can be due to any of the following causes :-
Causes-
• 95% cases- Upper airway cough syndrome (UACS) caused by nose and sinuses, asthma, gastro esophageal reflux disease (GERD), chronic bronchitis due to cigarette or other irritants, bronchiectasis, non-asthmatics eosinophilic bronchitis (NAEB) or ACE-Inhibitors.
• 5% remaining cases- Bronchogenic carcinoma, carcinomatosis, sarcoidosis, tuberculosis, left ventricular failure, aspiration.
QUESTION 2- DOES THE COUGH EPISODES SHOW VARIATION AT DAYTIME, NIGHT OR MORNING?
It is known as Diurnal variations of Cough. It can be significant as :-
• Worse in night and early morning- Asthma, congestive heart failure (CHF).
• Worse on waking up in morning- chronic bronchitis.
QUESTION3- IS THERE ANY DIFFERENCE ON COUGH IN RELATION WITH POSTURE?
It is Postural variations of Cough. It can be significant in bronchiectasis, lung abscess, bronchopleural fistula.
• Increased on supine position- GERD and cardiac diseases.
QUESTION 4- WHAT ARE THE PRECIPITATING FACTORS?
• Cold/ Smoke/ Dust/ Exertion- Asthma
• Swallowing of liquids- Neuromuscular disease of oropharynx
QUESTION 5- DO YOU GET SPUTUM ON COUGHING?
This can categorize cough on terms of Dry cough and Productive cough. Dry cough is without sputum while Productive cough is associated with sputum often coming out during cough.
• Dry cough- Interstitial lung disease (ILD), acute dry pleurisy.
• Wet cough- Bronchiectasis, lung abscess, empyema, resolution stage of lobar pneumonia, pulmonary edema, bronchitis, COPD, asthma, pneumonia.
QUESTION 6- WHAT IS THE COLOR OF SPUTUM IF ANY?
Color of sputum greatly helps in differential diagnosis of the coughing symptom. Following are the causes of sputum colors:-
Serous (watery)-
• Clear sputum- Normal
• Clear, White or Pinky froth- Pulmonary edema
• Clear to white (acute)- Viral respiratory tract infections
Mucoid-
• Clear to gray- Chronic bronchitis (COPD)
• Yellow to white- Asthma
• Yellow - Acute bronchitis
• Rusty golden yellow- Acute pneumonia
• Green- Pneumonia, lung abscess, chronic bronchitis, bronchiectasis, cystic fibrosis
• Brown- Chronic bronchitis (could be green, yellow, brown)
• Brown to green- Chronic pneumonia
• Brown to black- Coal worker's pneumoconiosis
• Brown to red/black- Tuberculosis, lung cancer
• Bloody- Pulmonary embolism (Refer to hemoptysis)
QUESTION 7-WHAT IS THE NATURE OF COUGH? IS ANYTHING PARTICULAR?
Cough can present with very specific characteristics which can be tracked down to a typical diagnosis:
1. Bovine cough- Non-explosive cough which is seen in recurrent laryngeal nerve palsy which is commonly due to bronchogenic carcinoma.
2. Whooping cough- High pitched whoop sound or gasp causing severe coughing fits. It follows as cough and then deep inspiration with whoop noise. It occurs in bordetella pertussis.
3. Barking cough- It occurs in Croup (viral, mild fever of 100 F, shows steeple sign on x-ray), epiglottitis (muffed up/hot potato voice with high fever, thumb print sign on x-ray) or bacterial tracheitis (high grade fever).
4. Brassy cough- It has a typical metallic sound and occurs in laryngeal carcinoma.
5. Spluttering cough- Cough during swallowing which occurs in tracheo-esophageal fistula.
6. Foul-smelling cough- It is typical of bronchiectasis, lung abscess or empyema.
7. Hacking cough- It is pharyngeal cough which occurs in heavy smokers, beginning of tuberculosis (short and dry cough with rough and loud sound).
QUESTION 8- IS THERE ANY BLOOD IN COUGH?
Haemoptysis or coughing blood is a serious sign and should be immediately considered during differential diagnosis. Following are the causes of blood in sputum :-
• Inflammatory lung disease- Bronchitis, tuberculosis, pneumonia, bronchiectasis, lung abscess.
• Neoplasm of lung- Bronchial adenoma, lung cancer.
• Cardiovascular system- Mitral stenosis, left ventricular failure, deep venous thrombosis (DVT) with pulmonary embolism.
• Miscellaneous- Pulmonary vasculitis, hemorrhagic diathesis, anticoagulant therapy, Good-Pasteur's syndrome, trauma to the legs.
QUESTION 9- WHAT ARE THE ASSOCIATED SYMPTOMS WITH THE COUGH?
Following associated symptoms with cough are better clue in further assessing the disease :-
• Fever- Respiratory tract infection, lung abscess.
• Chest pain- Bronchitis, cancer, pulmonary embolism, pneumonia, gastroesophageal reflux disease (GERD).
• Pleuritic chest pain- Pleurisy, pleural effusion, bronchiectasis.
• Dyspnoea- COPD, asthma, bronchiectasis, bronchial adenoma/cancer, acute pneumonia, tuberculosis, sarcoidosis, cor pulmonale, congestive heart failure, occupational (eg. pneumoconiosis).
• Wheeze- Asthma, COPD.
• Stridor- Foreign body, laryngeal nerve involvement.
• Nasal discharge or tickling sensation in throat- Post-nasal drip.
• Loss of weight- Bronchogenic cancer.
• Hoarseness of voice- Laryngeal nerve involvement.
• Heartburn/Regurgitation- GERD
• Erythema nodosum- Sarcoidosis
QUESTION 10- WHAT IS THE TREATMENT HISTORY?
Certain drugs can cause coughing of which, most important are ACE-Inhibitors and Beta-Blockers.
DIFFERENTIAL DIAGNOSIS FOR SOME COMMON CONDITIONS
Following diseases show characteristic patterns of symptoms :-
1. Pneumonia- Cough, fever, dyspnoea, rigor, night sweats, chest pain.
2. Asthma- Cough- chronic and dry/productive at night, episodic wheezes, dyspnea, chest tightness.
3. Chronic obstructive pulmonary disease (COPD)- Cough- persistent, large amount of sputum, shortness of breath. {COPD= Emphysema, chronic bronchitis, some forms of bronchiectasis and refractory asthma}
4. Bronchiectasis- Cough- chronic, copious amount of foul smelling sputum, hemoptysis, pleuritic chest pain, dyspnoea, loss of weight, anemia.
5. Bronchogenic carcinoma- Cough- new/changed pattern, dyspnoea, hemoptysis, anorexia, loss of weight, chest pain.
6. Tuberculosis- Cough (dry/purulent/blood streaks), anorexia, night sweats, evening rise of temperature, loss of weight.
7. Interstitial lung disease (ILD)- Cough, insidious onset exertional dyspnoea.
8. Congestive heart failure (CHF)- Cough, exertional dyspnoea, cough, fatigue, orthopnoea, paroxysmal nocturnal dyspnoea (PND), edema.
9. Sarcoidosis- Cough, dyspnoea, erythema nodosum, eye inflammation, fatigue, fever.
10. Cystic fibrosis- Cough- chronic or relapsing with sputum, dyspnea, wheeze, hemoptysis, mostly young adults affected.
11. Post-nasal drip- Cough, nasal discharge which is mucoid or mucopurulent, tickle in throat.
12. GERD- Cough, heartburns, regurgitation.Labels: Fourth year MBBS, Medicine, Students