COUGH
COUGH: Excerpt from Algorithmic Diagnosis of Symptoms and Signs
Ask the following questions:
- Is it acute or chronic? Acute onset of a cough would suggest an acute URI, viral pneumonia, or bronchopneumonia. A chronic cough is more suggestive of pneumoconiosis, chronic bronchitis, emphysema, bronchiectasis, tuberculosis, carcinoma of the lung, or bronchial asthma.
- Is there exposure to toxic fumes? The most common toxic fume is cigarette smoke. However, if one asks the patient's occupation one might find that he is a miner and therefore pneumoconiosis comes to mind. One might find that he is an aircraft maker or shipbuilder, in which case berylliosis and asbestosis would come to mind, or that he is a farmer and, therefore, farmer's lung would come to mind.
- Is there significant sputum production? If so, what is the nature of the sputum? Purulent sputum would suggest a pneumonia, abscess, tuberculosis, or bronchiectasis; bloody sputum would suggest carcinoma of the lung, tuberculosis, and bronchiectasis; mucoid sputum would suggest asthma. If the sputum is foamy, one would consider congestive heart failure, mitral stenosis, and inhalation of poison gas.
- Is there fever? If there is fever associated with the cough, obviously one would suspect an infectious process to be present. This could be viral or bacterial. Most likely the patient has bronchopneumonia, but the possibility of an abscess or pulmonary infarct would still have to be entertained.
- What other symptoms and signs are associated with the cough? The first thing to be considered would be dyspnea. In acute cases dyspnea would be a sign of congestive heart failure, pulmonary embolism and, of course, advancing pneumonia. In chronic cases dyspnea would be a sign of emphysema, chronic pulmonary fibrosis, and chronic congestive heart failure. Wheezing would be a sign of asthma or congestive heart failure, but of course it is also found in pulmonary emphysema. Cardiomegaly would suggest congestive heart failure and if there is an associated murmur, that makes congestive heart failure even more likely. If there is hepatosplenomegaly, one would suspect a systemic disease involving the lungs such as periarteritis nodosa or other collagen diseases.
- Is the patient taking drugs? Angiotensin-converting enzyme (ACE) inhibitors such as captopril are well known to cause cough.
DIAGNOSTIC WORKUP
If there is nasal stuffiness and a postnasal drip, a trial of antihistamines or decongestants is indicated before starting an expensive workup. All patients require a CBC and differential count, a sedimentation rate, and a chemistry panel. A sputum for routine smear and culture should be done, and in chronic cases a sputum for AFB culture and smear must be done. One should keep a high index of suspicion for
Mycoplasma pneumoniae
and Legionnaire's disease. Also, sputum for fungi culture should be done on chronic cases.
Asthma can be further elucidated and confirmed by doing a sputum for eosinophils. Carcinoma of the lung can be confirmed with a sputum for Pap smear. If there is fever, blood cultures may be useful and febrile agglutinins should also be done. An x-ray of the chest with anteroposterior, lateral, and apical lordotic views should be done, and when a tumor is suspected, tomography should be done or a CT scan. In cases of chronic cough, skin testing for coccidioidomycosis, cystoplasmosis, tuberculosis, and blastomycosis should be done. A Kveim test to rule out sarcoidosis may be necessary. When these tests fail to make a diagnosis, bronchoscopy and possibly bronchograms to look for a bronchiectasis should be done. Lung biopsy may be necessary also. Pulmonary function tests should be done in suspected cases of emphysema and asthma. Allergy skin testing is extremely valuable in cases of asthma. Look for alpha 1-antitrypsin deficiency in difficult cases. If congestive heart failure is suspected, an arm-to-tongue circulation time would be valuable. A trial of diuretics may also assist in the diagnosis. If reflux esophagitis is suspected, prolonged monitoring of esophageal pH may be diagnostic. A trial of therapy with an H
2
antagonist may also be diagnostic.
Book Source Details
- Book Title: Algorithmic Diagnosis of Symptoms and Signs
- Author(s): R. Douglas Collins
- Year of Publication: 2003
- Copyright Details: Algorithmic Diagnosis of Symptoms and Signs, Copyright © 2003 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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