1. Core Clinical Problems Cough

2. A man presents to you with coughing What would you like to know?

3. Cough  Onset?  Duration?  Character?  Nocturnal?  Precipitating factors?  Relieving factors?  Sputum?  Haemoptysis?  Association?

4. Cough  Onset?  Duration?  Character?  Nocturnal?  Precipitating factors?  Relieving factors?  Sputum?  Haemoptysis?  Association?  Recent or long standing (Chronic)

5. Cough  Onset?  Duration?  Character?  Nocturnal?  Precipitating factors?  Relieving factors?  Sputum?  Haemoptysis?  Association?  Chronicity  Pertussis  TB  Foreign body  Asthma  Drugs  Bronchiectasis  ILD

6. Cough  Onset?  Duration?  Character?  Nocturnal?  Precipitating factors?  Relieving factors?  Sputum?  Haemoptysis?  Association?  Brassy? Pressure on the trachea?

7. Cough  Onset?  Duration?  Character?  Nocturnal?  Precipitating factors?  Relieving factors?  Sputum?  Haemoptysis?  Association?  Hollow/Bovine? Laryngeal nerve palsy causing vocal cord dysfunction

8. Cough  Onset?  Duration?  Character?  Nocturnal?  Precipitating factors?  Relieving factors?  Sputum?  Haemoptysis?  Association?  Barking? Acute Epiglottitis

9. Cough  Onset?  Duration?  Character?  Nocturnal?  Precipitating factors?  Relieving factors?  Sputum?  Haemoptysis?  Association?  Dry?  GORD  Drugs (e.g. ACEI)

10. Cough  Onset?  Duration?  Character?  Nocturnal?  Precipitating factors?  Relieving factors?  Sputum?  Haemoptysis?  Association? Change in character of a chronic cough should make you consider other pathology.

11. Cough  Onset?  Duration?  Character?  Nocturnal?  Precipitating factors?  Relieving factors?  Sputum?  Haemoptysis?  Association?  Asthma Also Early morning

12. Cough  Onset?  Duration?  Character?  Nocturnal?  Precipitating factors?  Relieving factors?  Sputum?  Haemoptysis?  Association?  Usually in asthma  Emotion  Weather  Wind  Rain  Cold  Dust  Allergies  Exercise  Drugs

13. Cough  Onset?  Duration?  Character?  Nocturnal?  Precipitating factors?  Relieving factors?  Sputum?  Haemoptysis?  Association?  Avoidance of precipitating factors!

14. Cough  Onset?  Duration?  Character?  Nocturnal?  Precipitating factors?  Relieving factors?  Sputum?  Haemoptysis?  Association?  Presence?  Colour  Volume  Consistency  Pattern  Consider  Infections  COPD  CF  Bronchiectatsis

15. Cough  Onset?  Duration?  Character?  Nocturnal?  Precipitating factors?  Relieving factors?  Sputum?  Haemoptysis?  Association?  Presence?  Colour  Volume  Consistency  Pattern  Will be covered elsewhere!

16. Cough  Onset?  Duration?  Character?  Nocturnal?  Precipitating factors?  Relieving factors?  Sputum?  Haemoptysis?  Association?  Breathlessness  Sputum  Chest pain  Wheeze  Hoarseness  Post nasal drip

17. www.badvertising.org/pages/02%20How%20To%20BA... Meet Mr Coughing 61 years old

18. 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

19. What do you think he has? 1.Asthma 2.COPD 3.Lung Cancer 4.Sarcoid 5.Rhinitis

20. What test would you like next? 1.Spirometry 2.Spirometry with reversibility 3.Chest x-ray 4.Peak flow diary 5.Sputum cytology

21. 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

22. 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 Rehabilitation 5.Salbutamol 2 puffs PRN

23. 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

24. What do you think has happened? 1.Lung carcinoma 2.Lower respiratory tract infection 3.Upper respiratory tract infection 4.Pneumothorax 5.Pulmonary Embolism

25. This is his CXR Mr Coughing 61 www.meddean.luc.edu/.../pulmonar/cxr/segm.htm

26. How would you like to treat him? 1.Oxygen 2.Nebulisers 3.Antibiotics 4.Prednisolone 5.All of these

27. 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

28. 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

29. This is his HRCT Mr Coughing 61 brighamrad.harvard.edu/.../hcache/211/full.html

30. What is the diagnosis? 1.Pulmonary fibrosis 2.Hypersensitivity Pneumonitis 3.Lung cancer 4.Lymphangioleiom yomatosis 5.Bronchiectasis

31. 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

32. This is his CXR Mr Coughing 61

33. 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

34. This is his Bronchoscopy Mr Coughing 61

35. Where is the tumour? 1.Left Upper Lobe 2.Bronchus intermedius 3.Right middle lobe 4.Right lower lobe 5.Left Lower lobe

36. www.lumen.luc.edu/.../mech/cases/case9/list.htm

37. Mrs Coughing 49 www.tbalert.org/resources/resources.php

38. 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

39. Which of the following blood pressure tablets might be relevant in her symptoms? 1.Ramipril 2.Bendrofluazide 3.Nifedipine 4.Atenolol 5.None of them!

40. Which of the following Blood pressure tablets might be relevant in her symptoms? 1.Ramipril 2.Bendrofluazide 3.Nifedipine 4.Atenolol 5.None of them! Mrs Coughing 49

41. Which of the following Blood pressure tablets might be relevant in her symptoms? 1.Ramipril 2.Bendrofluazide 3.Nifedipine 4.Atenolol 5.None of them!  ACE inhibitors are known to cause cough by inhibiting the breakdown of Bradykinin Mrs Coughing 49

42. Which of the following Blood pressure tablets might be relevant in her symptoms? 1.Ramipril 2.Bendrofluazide 3.Nifedipine 4.Atenolol 5.None of them!  Beta Blockers can worsen or precipitate underlying asthma Mrs Coughing 49

43. 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

44. This is her Spirometry  FEV1 1.6L (76%)  FVC2.4L (83%)  FEV1/FVC 67% Mrs Coughing 49

45. How would you treat her? 1.Salbutamol 2 puffs PRN 2.Salbutamol 2 puffs PRN + Becotide 200 2 puffs B.D. 3.Nebulised Salbutamol 4.Theophylline 5.Tiotropium

46. How would you treat her? 1.Salbutamol 2 puffs PRN 2.Salbutamol 2 puffs PRN + Becotide 200 2 puffs B.D. 3.Nebulised Salbutamol 4.Theophylline 5.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

47. 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

48. What would you advise? 1.Life style measures 2.Anti reflux treatment 3.Dietary modification 4.Exercise 5.All of the above

49. Miss Coughing 23

50. 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

51. www.patient.co.uk/showdoc/40001001/

52. What is your next step? 1.Dermatology referral 2.Arrange skin biopsy 3.Spirometry 4.CXR 5.Peak Flow diary

53. This is her CXR Miss Coughing 23 adam.about.com/encyclopedia/1613.htm

54. This is her CXR Miss Coughing 23 adam.about.com/encyclopedia/1613.htm

55. What is the likely diagnosis? 1.Tuberculosis 2.Non Tuberculous mycobacterium 3.Breast cancer 4.Lymphoma 5.Sarcoidosis

56. This is their dog www.harbourvets.co.uk/notice_board.htm

57. Just Kidding!