Core Clinical
Problems
Cough
A man presents to
you with coughing
What would you like to know?
Cough
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Onset?
Duration?
Character?
Nocturnal?
Precipitating factors?
Relieving factors?
Sputum?
Haemoptysis?
Association?
Cough
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Onset?
Duration?
Character?
Nocturnal?
Precipitating factors?
Relieving factors?
Sputum?
Haemoptysis?
Association?
 Recent or long standing
(Chronic)
Cough
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Onset?
Duration?
Character?
Nocturnal?
Precipitating factors?
Relieving factors?
Sputum?
Haemoptysis?
Association?
 Chronicity
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Pertussis
TB
Foreign body
Asthma
Drugs
Bronchiectasis
ILD
Cough
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Onset?
Duration?
Character?
Nocturnal?
Precipitating factors?
Relieving factors?
Sputum?
Haemoptysis?
Association?
 Brassy?
Pressure on the trachea?
Cough
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Onset?
Duration?
Character?
Nocturnal?
Precipitating factors?
Relieving factors?
Sputum?
Haemoptysis?
Association?
 Hollow/Bovine?
Laryngeal nerve palsy
causing vocal cord
dysfunction
Cough
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Onset?
Duration?
Character?
Nocturnal?
Precipitating factors?
Relieving factors?
Sputum?
Haemoptysis?
Association?
 Barking?
Acute Epiglottitis
Cough
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Onset?
Duration?
Character?
Nocturnal?
Precipitating factors?
Relieving factors?
Sputum?
Haemoptysis?
Association?
 Dry?
 GORD
 Drugs (e.g. ACEI)
Cough
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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
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Onset?
Duration?
Character?
Nocturnal?
Precipitating factors?
Relieving factors?
Sputum?
Haemoptysis?
Association?
 Asthma
Also Early morning
Cough
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Onset?
Duration?
Character?
Nocturnal?
Precipitating factors?
Relieving factors?
Sputum?
Haemoptysis?
Association?
 Usually in asthma
 Emotion
 Weather
 Wind
 Rain
 Cold
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Dust
Allergies
Exercise
Drugs
Cough
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Onset?
Duration?
Character?
Nocturnal?
Precipitating factors?
Relieving factors?
Sputum?
Haemoptysis?
Association?
 Avoidance of
precipitating factors!
Cough
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
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Onset?
Duration?
Character?
Nocturnal?
Precipitating factors?
Relieving factors?
Sputum?
Haemoptysis?
Association?
 Presence?
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Colour
Volume
Consistency
Pattern
 Consider
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Infections
COPD
CF
Bronchiectatsis
Cough
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Onset?
Duration?
Character?
Nocturnal?
Precipitating factors?
Relieving factors?
Sputum?
Haemoptysis?
Association?
 Presence?


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
Colour
Volume
Consistency
Pattern
 Will be covered
elsewhere!
Cough

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
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


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!