CLINICAL APPROACH CLINICAL APPROACH TO A PATIENT WITH TO A PATIENT WITH COUGH… HISTORY COUGH… HISTORY TAKINGTAKING

►Protective mechanismProtective mechanism►Seeks MEDICAL CARESeeks MEDICAL CARE

Discomfort from cough itselfDiscomfort from cough itself

Interference with normal Interference with normal lifestylelifestyle

Concern for cause of coughConcern for cause of cough

HISTORYHISTORY

1.Onset & Duration1.Onset & Duration

Acute :- URTI; pneumonia; Acute :- URTI; pneumonia; aspiration; foreign aspiration; foreign

body; body; pulmonary emboli; CHFpulmonary emboli; CHF

Chronic :-COPD; bronchogenic CA; Chronic :-COPD; bronchogenic CA; post nasal drip; post nasal drip; asthma; asthma; GERD; TB; ILD; GERD; TB; ILD;

psychogenicpsychogenic

2.Character and timing2.Character and timing

Short,dry irritating cough with Short,dry irritating cough with pain behind jaw or neck:- pain behind jaw or neck:-

PharyngealPharyngeal

Harsh,irritative and repetitive Harsh,irritative and repetitive with stridor and cyanosis:- with stridor and cyanosis:-

LaryngealLaryngeal

Productive: amount; colour; Productive: amount; colour; consistency; smellconsistency; smell

Large amounts:-Large amounts:-

a)regular coughing up-a)regular coughing up-bronchiectasis bronchiectasis

b)Single occasion-lung abcess, b)Single occasion-lung abcess, empyemaempyema

c)Pink frothy-Pulm edemac)Pink frothy-Pulm edema

Types of sputumTypes of sputum

TypesTypes AppearancAppearancee

CauseCause

SerousSerous Clear,watery Clear,watery frothy pinkfrothy pink

A/c pulm A/c pulm edemaedema

MucoidMucoid Clear grey- Clear grey- white viscidwhite viscid

C/c C/c bronchitis, bronchitis, COPD,AsthmCOPD,Asthmaa

PurulentPurulent Yellow/greenYellow/green BronchopulmBronchopulmonary onary infectioninfection

RustyRusty Rusty,golden Rusty,golden yellowyellow

PneumococcPneumococcal al pneumoniapneumonia

FROTHY SPUTUMFROTHY SPUTUM

PURULENT SPUTUMPURULENT SPUTUM

RUSTY SPUTUMRUSTY SPUTUM

Foul smelling sputum- Foul smelling sputum- bronchiectasis, bronchiectasis, lung lung abcess, empyemaabcess, empyema

Solid matter present in viscid Solid matter present in viscid secretions in asthma, allergic secretions in asthma, allergic brochopulmonary aspergillosis, brochopulmonary aspergillosis, necrotic tumour, foreign bodynecrotic tumour, foreign body

Haemoptysis;- C/c bronchitis, Haemoptysis;- C/c bronchitis, Bronchiectasis, Bronchogenic Bronchiectasis, Bronchogenic carcinoma, Pulmonary emboli, carcinoma, Pulmonary emboli, Pulmonary edemaPulmonary edema

3.Diurnal variation3.Diurnal variation

Cough which gets worse in Cough which gets worse in night and early morning :- night and early morning :- AsthmaAsthma

Persistent moist cough on Persistent moist cough on waking up in smokers :- C/c waking up in smokers :- C/c bronchitisbronchitis

4.Seasonal variation4.Seasonal variation

Asthma, C/c bronchitisAsthma, C/c bronchitis

5.Postural variation5.Postural variation

Bronchiectasis, Lung abcess, Bronchiectasis, Lung abcess,

6.Aggravating & Relieving 6.Aggravating & Relieving factorsfactors

Cold,smoke,dust,exertion:- Cold,smoke,dust,exertion:- asthma asthma

Swallowing of liquids:- NM d/s Swallowing of liquids:- NM d/s of oropharynxof oropharynx

Otogenic cough:- impacted wax or Otogenic cough:- impacted wax or

foreign body in ext auditory foreign body in ext auditory meatus:…..subsides with removal meatus:…..subsides with removal of cause of cause

7.Associated symptoms7.Associated symptoms

Fever:- RTI; lung abcess; Fever:- RTI; lung abcess;

Chest pain:-Bronchitis, Chest pain:-Bronchitis, bronchogenic bronchogenic

carcinomacarcinoma

Pleuritic chest pain:-Pleurisy, Pleuritic chest pain:-Pleurisy, pleural effusion,bronchiectasispleural effusion,bronchiectasis

Dyspnoea:- COPD, Asthma, ILD, Dyspnoea:- COPD, Asthma, ILD, Pneumonia, Bronchogenic Pneumonia, Bronchogenic carcinoma, Sarcoidosis, CHF carcinoma, Sarcoidosis, CHF ( orthopnoea & PND)( orthopnoea & PND)

Wheeze:- asthmaWheeze:- asthma

“ “cough variant asthma”cough variant asthma”

Nasal discharge, tickling Nasal discharge, tickling sensation in throat:- Postnasal sensation in throat:- Postnasal dripdrip

Loss of weight:- bronchogenic Loss of weight:- bronchogenic carcinomacarcinoma

Stridor:-FB,Laryngeal nerve Stridor:-FB,Laryngeal nerve involvmentinvolvment

Hoarseness of voice:-Lary.N Hoarseness of voice:-Lary.N invlvmtinvlvmt

Heart burn, regurgitation:- GERDHeart burn, regurgitation:- GERD

Erythema nodosum:-SarcoidosisErythema nodosum:-Sarcoidosis

HISTORY OF PAST ILLNESS

COPD, Asthma, Postnasal drip, COPD, Asthma, Postnasal drip, GERDGERD

R/c or complicated Pneumonia, R/c or complicated Pneumonia, tuberculosis.whooping cough:- tuberculosis.whooping cough:- BronchiectasisBronchiectasis

ImmunosuppressionImmunosuppression

Surgery ;bed restSurgery ;bed rest

BCG vaccinationBCG vaccination

Personal historyPersonal history

Loss of appetite, sleepLoss of appetite, sleep

SmokingSmoking

Occupational exposureOccupational exposure

Allergy or atopyAllergy or atopy

FAMILY HISTORYFAMILY HISTORY

Chronic bronchitis with Chronic bronchitis with emphysema, Respiratory emphysema, Respiratory allergy, Asthma, Cystic allergy, Asthma, Cystic fibrosisfibrosis

TBTB

TREATMENT HISTORYTREATMENT HISTORY

Angiotensin Converting Angiotensin Converting

Enzyme InhibitorsEnzyme Inhibitors

Past treatment of d/s like Past treatment of d/s like allergies,asthma,pneumonia,Tallergies,asthma,pneumonia,TB,BronchitisB,Bronchitis

ImmunosuppressantsImmunosuppressants

……DDsDDs1.Pneumonia:-fever, cough,dyspnoea, 1.Pneumonia:-fever, cough,dyspnoea,

rigor,night sweatsrigor,night sweats

2.Asthma:-episodic wheeze,dyspnea, 2.Asthma:-episodic wheeze,dyspnea, c/c dry or productive cough worst at c/c dry or productive cough worst at night,chest tightnessnight,chest tightness

3.COPD:-persistent cough,large 3.COPD:-persistent cough,large amount sputum,shortness of breathamount sputum,shortness of breath

4.Bronchiectasis:-c/c 4.Bronchiectasis:-c/c cough,copious amount of foul cough,copious amount of foul smelling sputum, smelling sputum, hemoptysis,pleuritic chest pain, hemoptysis,pleuritic chest pain, dyspnoea,loss of weight,anemiadyspnoea,loss of weight,anemia

5.Bronchogenic carcinoma:-new 5.Bronchogenic carcinoma:-new cough/change in cough,dyspnoea, cough/change in cough,dyspnoea, hemoptysis,anorexia,loss of hemoptysis,anorexia,loss of weight, chest painweight, chest pain

6.Tuberculosis:-cough 6.Tuberculosis:-cough

(dry…purulent(dry…purulent

… …blood streaks in blood streaks in

sputum),sputum),

anorexia,LOW,anorexia,LOW,

night sweats,night sweats,

evening rise of evening rise of

temperaturetemperature

7.ILD:-insidous onset exertional 7.ILD:-insidous onset exertional dyspnoea,cough dyspnoea,cough

8.CHF:-exertional dyspnoea,cough, 8.CHF:-exertional dyspnoea,cough, fatigue,orthopnea.PND,edemafatigue,orthopnea.PND,edema

9.Sarcoidosis:-9.Sarcoidosis:-cough,dyspnoea,erythema cough,dyspnoea,erythema nodosum, eye nodosum, eye inflammation,fatigue,feverinflammation,fatigue,fever

10.Cystic fibrosis:-c/c or r/c cough 10.Cystic fibrosis:-c/c or r/c cough with sputum,dyspnoea,wheeze, with sputum,dyspnoea,wheeze, hemoptysis..young adult hemoptysis..young adult

11.Post nasal drip;-nasal 11.Post nasal drip;-nasal discharge… mucoid or discharge… mucoid or mucopurulent,tickle in throatmucopurulent,tickle in throat

12.GERD:-cough,heart burns, 12.GERD:-cough,heart burns, regurgitationregurgitation

13.Laryngeal inflammation:-cough, 13.Laryngeal inflammation:-cough, hoarseness of voice,stridorhoarseness of voice,stridor

14.FB:-cough,stridor,history14.FB:-cough,stridor,history

15.ACEI:-dry cough starting within 15.ACEI:-dry cough starting within 1-6 months of treatment1-6 months of treatment

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