Cough

Cough is the one of the most common symptoms presenting to general practice.  It is also the predominant symptom of the common cold.  However, cough is not always a benign symptom, and requires a focused approach to determine the cause and appropriate management.

History

  • Describe the cough: wet/dry, productive, itchy, painful, harsh/barking
  • Duration/onset: acute (<3 weeks); subacute (3-8 weeks); chronic (>8 weeks)
  • Progression: worsening/improving (when were symptoms worst); is the cough worse at certain times of the day; is it present at night
  • Exacerbating/relieving features: anything makes it better/worse e.g. exercise
  • Any associated symptoms:
    • Sore throat
    • Blocked nose
    • Sputum – describe the character/amount etc
    • Shortness of breath
    • Haemoptysis- again, describe appearance/amount etc
    • Wheeze
    • Fever and other constitutional symptoms e.g. fatigue, weight loss, malaise/lethargy, sweats etc
    • Chest pain
  • Ask about past medical history and drug history
    • Asthma and COPD
    • Other airways disease
    • GORD
    • CVS history
    • ACE inhibitors
    • Neuromuscular problems
    • Previous similar episodes
  • Ask about family history/contact history
    • Cough/respiratory tract infection
    • COPD
    • Cancer
    • TB
    • Asthma
  • Ask about social history
    • Smoking
      • + people living with the patient (do they smoke)
    • Occupation (any exposure to chemicals etc)
    • Any travel to ‘exotic’ places?
    • New pets?

Examination (Full Respiratory)

  • General
    • Inspect from the end of the bed: does the patient look well/unwell (do they require ABCDE approach?)?; are there any inhalers?; is the patient on oxygen?; sputum pots? etc
    • Inspect the patient’s hand for clubbing (Lung Ca; bronchiectasis); any nicotine staining; cyanosis; delayed capillary refill; CO2 flap/asterixis (both hands go down at same time cf liver flap)
    • Check the radial pulse
    • Inspect the face for cushingoid features (moon face); signs of anaemia/central cyanosis;
  • Neck
    • Palpate for any lymphadenopathy
    • Inspect the JVP
      • Ask the patient to relax their head/neck and turn it slightly to the left/right by about 30-45°
      • Observe the pulsation of the JVP.
        • If the JVP is not seen or is very faint, deeply push the upper right quadrant up under the ribcage- this may help to see the JVP (hepatojugular reflex)
      • The JVP is measured, in cm, as the vertical height (NOT direct distance) from the sternal angle
    • Palpate above the sternal notch with your middle three fingers to check the trachea is central
      • Trachea deviates away in pneumothorax/effusion and towards collapse/consolidation
  • Chest
    • Inspect for any abnormalities e.g. scars, pigeon chest, barrel chest (COPD),
    • Check respiratory rate
    • Check for chest expansion by placing your hands around the chest with thumbs in the midline.  Ask the patient to take a deep breath (symmetrical reduction in COPD; asymmetrical in effusion/empyema/consolidation/collapse)
    • Percuss the zones of the lungs (front and back), comparing sides as you go (dullness indicates consolidation/fluid/)
    • Auscultate breath sounds in each of the lung zones
    • Perform tactile vocal fremitus and whispering pectoriloquy (see here)

Differential Diagnosis

  • Acute
    • Common cold/URTI
    • Acute Bronchitis
    • Asthma
    • Exacerbation of COPD or chronic bronchitis
    • Influenza
    • Pneumonia
    • Acute bacterial sinusitis
    • Pertussis
    • Allergic rhinitis
    • PE (rarer)
    • Pneumothorax (rare cause of cough)
    • Cancer
    • ACE inhibitor use
  • Chronic
    • COPD
    • Bronchiectasis
    • Chronic bronchitis
    • Chronic postnasal drip
    • Smokers cough
    • Interstitial lung disease (rarer)
    • GORD
    • Occupational exposure
    • Post-infectious cough
    • ACE inhibitor use
  • Other less common causes include cardiovascular causes e.g. heart failure; infection e.g. TB; neoplasia e.g. bronchial carcinoma; aspiration of foreign body; restrictive lung disease e.g. pulmonary fibrosis

Investigations

  • If the patient has abnormal chest signs on examination, a CXR may be warranted.  Other imaging e.g. CT scans, is not often used for investigation of cough in isolation but may be requested if other investigations, symptoms and signs are abnormal
  • If asthma/COPD is suspected, pulmonary function tests (/peak flow) may be useful in assessing the severity
  • A FBC and CRP may be helpful in diagnosing an infective cause; similarly throat swabs/sputum cultures

Management

  • With chronic cough, a ‘test of treatment’ approach to a diagnosis may be helpful, particularly in general practice (provided there are no red flags e.g. copious sputum, fever, sweats, weight loss, haemoptysis, considerable SOB)
    1. Remember to try lifestyle measures first e.g. stopping smoking
    2. Try stopping ACE inhibitors where appropriate
    3. At this stage further investigations e.g. CXR, spirometry/peak flow etc can be useful to exclude need for specialist referral
    4. Depending on the history, trial of asthma treatment, PPIs or antihistamines/nasal steroid (asthma, reflux/GORD, postnasal drip- respectively)
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