Cough

Cough: Excerpt from The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter

Désirée A. Lie

Cough is among the top 10 reasons for visits to family physicians in the United States. It accounts for 200 to 400 million episodes of illness per year. Three causal conditions increasing in frequency over the past two decades are asthma, gastroesophageal reflux disease (GERD), and chronic obstructive airways disease (COPD) (1,2). Bronchitis is one of the most common causes of cough in the primary care setting (3).

Approach

A. Cough characteristics. In evaluating cough as a symptom (4), a distinction has to be made among the following:

1. Normal versus pathologic cough

2. Acute (<3 weeks) versus chronic (>3 weeks) cough

3. Respiratory versus nonrespiratory causes

4. Pediatric versus adult conditions

B. Special concerns. Failure to improve with appropriate management over 4 weeks signals a need for more extensive workup to exclude tuberculosis (TB), adult-onset asthma, penicillin-resistant pneumococcus, lung cancer, and immunosuppression.

History

A. Characteristics of the cough. What is the type of cough (barking, brassy, wheezy, nocturnal, paroxysmal)? What are the duration, timing, and triggers? Are there associated symptoms of fever, sputum production, dypsnea, hemoptysis, and weight loss? Are there clear relieving factors? Ask specifically about postnasal drip as patients often do not volunteer this information. A good history is the key to diagnosis.

1. Upper respiratory causes most commonly relate to postnasal drip. In adults, sinusitis, pharyngitis, and allergic rhinitis should be considered. In children, concomitant otitis media should be excluded.

2. Lower respiratory causes include lung (bronchitis, asthma, pneumonia, bronchiectasis, and in children, foreign body aspiration) and cardiac [congestive heart failure (CHF) and mitral stenosis].

3. Nonrespiratory causes include GERD, drug effects [e.g., angiotensin converting enzyme (ACE)-inhibitors], and psychogenic.

B. Smoking patients should be identified early as bronchitis and lung cancer are possibilities. Passive smoking is also a risk factor, especially in children. Office visits for cough represent teachable moments for smoking cessation education. Smoking cessation has been shown to reduce respiratory symptoms by 50%.

 C. Psychosocial impact of the cough reflects severity and the need for further workup. Has the patient missed school or work? Is the sleeping partner disturbed? Is there avoidance of exercise because it triggers cough? In chronic, episodic cough, a correct diagnosis of asthma can considerably improve quality of life. A psychogenic cause for cough and behavioral problems in children may be unmasked here.

D. Other information. Associated chest pain should direct the history toward pleurisy or rib fracture secondary to chronic cough. Occupational exposures (toxic fumes, chemicals, birds and animals), systemic diseases [rheumatoid arthritis, breast and prostate cancer metastases, human immunodeficiency virus disease (HIV)] and drug exposure (ACE-inhibitors, cyclophosphamide, and methotrexate) are important factors to consider in the cause. Cough with significant weight loss should trigger a workup for TB, HIV, or lung cancer in the smoker.

Physical examination

 A. Focused physical examination (PE) should include vital signs (temperature, pulse, respiratory rate, and blood pressure), ear, nose, sinuses, throat (ENST), and a full lung examination with the chest uncovered. Normal lung examination often excludes pneumonia but not asthma, bronchitis, COPD, GERD, or lung cancer. It is more effective to examine the lung before the ENST in young children because the ENST examination is more traumatic and can induce crying. In the older patient, especially the postmenopausal woman, rib palpation may be included to isolate fracture secondary to osteoporosis.

 B. Additional PE. The cardiovascular examination is directed at a diagnosis of CHF. Associated lymphadenopathy suggests infection or neoplasm. Wasting can be ominous (cancer or HIV). Abdominal examination may reveal a tender enlarged liver in CHF, or epigastric tenderness in GERD (Chapters 7.5 and 9.6).

Testing

A. Clinical laboratory tests. Most acute presentations of cough do not require blood, urine, or other laboratory tests. White blood count with differential and blood cultures are indicated for pneumonia. Gram’s stain and culture of sputum are rarely practical in the office. A purified protein derivative (PPD) test should be placed early if TB is suspected, unless the patient is known to be anergic or thought to have overwhelming active TB disease. Systemic causes require testing specific to the disease in question.

B. Radiologic tests. A chest x-ray study is not indicated for upper respiratory causes or bronchitis. It is only useful when pneumonia, TB, COPD, CHF, or cancer (primary or metastatic) are being considered. Computed tomography of the sinuses is more sensitive and specific than PE to differentiate sinusitis from other causes of cough.

C. Pulmonary function tests. The simple peak flow meter used with a therapeutic trial of bronchodilators will identify most cases of asthma. This important test should be supervised by the physician or an experienced nurse. Additional testing is suggested for COPD and pulmonary fibrosis.

D. Invasive tests. Bronchoscopy is useful for foreign body aspiration, cancer, or chronic interstitial lung disease. Esophageal pH monitoring will most likely confirm suspected GERD.

Diagnostic assessment

A thorough history is vital to accurate diagnosis. Acute cough is likely to be infectious. A pertinent observation is that physicians overtreat acute bronchitis with antibiotics. The literature suggests that most cases are viral in origin and antibiotics are ineffective. Chronic cough has a longer list of differential diagnoses. Asthma tends to be underdiagnosed in adults and children. Smoking-related causes should prompt educational intervention and workup, especially in older patients. GERD is a diagnosis often missed because it is not considered. Often, more than one office visit is needed to unravel the cause of chronic cough. Up to 80% of cases have multiple causes (5). Making an accurate diagnosis is essential to successful treatment. Of cough presentation, 90% can be adequately managed in the family physician’s office, although it can take 3 to 5 months to arrive at a correct diagnosis in some cases (2). Referral to a pulmonary specialist is needed only in complicated cases (e.g., cancer, occupational and connective tissue diseases, and failed therapy).

References

1. Weiss BD. 20 common problems in primary care. New York: McGraw-Hill, 1999.

2. Lawler WR. An office approach to the diagnosis of chronic cough. Am Fam Physician 1998;58(9):2015–2022.

3. Heath JM. Chronic bronchitis: primary care management. Am Fam Physician 1998;57(10):2365–2372, 2376–2378.

4. Irwin RS. Managing cough as a defense mechanism and as a symptom. A consensus report of the American College of Chest Physicians. Chest 1998;114:133S–181S.

5. Irwin RS. Silencing chronic cough. Hosp Pract 1999;34:53–60.>

Book Source Details

• Book Title: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
• Author(s): Robert B. Taylor (editor)
• Year of Publication: 2000
• Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2000 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter Authors: Robert B. Taylor (editor) Publisher: Lippincott Williams & Wilkins Copyright: 2000 ISBN: 0-78172-094-X

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