Acute Cough
Differential Overview
❑ Viral upper respiratory infection
❑ Asthma
❑ Sinusitis
❑ Mycoplasma bronchitis
❑ Pneumonia
❑ Gastroesophageal reflux
❑ Congestive heart failure
❑ ACE inhibitor
❑ Aspiration
❑ Cough in HIV
❑ Thermal
❑ Fume inhalation
❑ Pertussis
❑ Lung abscess
Diagnostic Approach
The main issue in diagnosis is differentiating respiratory viruses, which cause most cases, from bacterial infection such as pneumonia, which would benefit from treatment with antibiotics, and from influenza, for which antivirals are effective. The classic presentation of bacterial pneumonia is acute onset with a progressive course marked by cough productive of yellow or green sputum, fever to 100˚ to 104˚F with chills or rigors, and pleuritic chest pain. The patient often appears “toxic.” The affected lung will often have coarse rales and bronchial breath sounds, and there may be localized percussive dullness. Viral pneumonia is associated with upper respiratory signs such as nasal congestion and sore throat, and by a nonproductive cough. Use of the Pneumonia diagnosis rule is helpful: Temperature .37.8˚C (100˚F); pulse .100; rales; decreased breath sounds; and no asthma each score 1.
Detection of induced bronchial hyperreactivity (reactive airways disease), which benefits from bronchodilator or corticosteroid treatment, is also important. Wheezing, shortness of breath, and a predisposition (atopy or smoker) are helpful clinical clues.
A cough appearing mostly at night suggests congestive heart failure or reflux. Confusion and absence of fever are common presenting findings in older adults.
Clinical Findings
Viral upper respiratory infection Concurrent nasal congestion, scratchy sore throat, or laryngitis is usually found. The cough is often “irritative.” Wheezing may occur especially in smokers and atopic individuals.
Asthma Bilateral expiratory wheezing with prolonged expiratory phase is diagnostic of asthma. Occasionally cough without wheezing can also be caused by bronchospasm (“cough-variant asthma”).
Sinusitis There is usually a sensation of postnasal drainage and of the cough originating in the throat rather than in the lungs. Mucous can often be observed in the pharynx. Focal symptoms of sinusitis, such as purulent nasal discharge and maxillary fullness/tenderness, are also present.
Mycoplasma bronchitis Mycoplasma is difficult to distinguish from viral bronchitis, as it produces a fever and a dry, hacking cough that progresses to one productive of purulent sputum. Epidemiologic data is helpful, i.e., spread among family contacts with a 2- to 3-week latency. Bullous myringitis is unusual, but if seen strongly suggests mycoplasma. Chlamydia pneumoniae produces a similar clinical picture.
Pneumonia Sudden onset, spiking fever with rigors, cough producing purulent sputum, dyspnea, pleuritic chest pain, systemic toxicity, and localized consolidative lung findings (rales) all point to pneumonia. Rusty sputum is classic for pneumococcus.
Gastroesophageal reflux Reflux occurs more frequently at night and is accompanied by heartburn.
Congestive heart failure Left heart failure is suggested by a dry cough awakening the patient, in the presence of unexplained tachycardia, S3 gallop, fine bibasilar rales, exertional dyspnea, and/or orthopnea.
ACE inhibitor An irritative, nonproductive cough coincides temporally with the use of the drug.
Aspiration Foreign body aspiration can produce a prominent expulsive cough, and unilateral or focal wheezing.
Cough in HIV Productive cough suggests bacterial pneumonia. Pneumocystis produces a dry cough and dyspnea that is subacute and progressive. Pleuritic chest pain can occur with spontaneous pneumothorax in Pneumocystis or Kaposi. Tuberculosis is suggested by hemoptysis.
Thermal Inhalation of cold air, especially in patients who have reactive airways and in those who are exercising, may cause coughing or wheezing.
Fume inhalation Tobacco, smoke, and volatile chemical inhalation are obvious, but ambient air pollutants can be more subtle causes.
Pertussis Paroxysms of cough end in a loud inspiratory “whoop” with expectoration of a mucous plug. A frenulum ulcer may appear due to tongue protrusion with dental abrasion.
Lung abscess It is marked by the sudden appearance of a large amount of purulent, foul-smelling sputum.
Pictures
Book Source Details
- Book Title: Field Guide to Bedside Diagnosis
- Author(s): David S. Smith
- Year of Publication: 2007
- Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2008 Williams & Wilkins.
More About Causes of Pneumonia
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More About This Book:
Title: Field Guide to Bedside Diagnosis
Authors: David S. Smith
Publisher: Lippincott Williams & Wilkins
Copyright: 2007
ISBN: 0-78178-165-5
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