1. Cough Mudher Al-khairalla

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

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 Mr Coughing 61

20. What do you think he has? 1.Asthma 2.COPD 3.Lung Cancer 4.Sarcoid 5.Rhinitis Mr Coughing 61

21. What test would you like next? 1.Spirometry 2.Spirometry with reversibility 3.Chest x-ray 4.Peak flow diary 5.Sputum cytology Mr Coughing 61

22. What test would you like next? 1.Spirometry 2.Spirometry with reversibility 3.Chest x-ray 4.Peak flow diary 5.Sputum cytology Mr Coughing 61

23. 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

24. How would you like to treat him? 1.Smoking cessation 2.Smoking cessation plus Combivent R 2 puffs QDS 3.Beclomethasone 200 2 puffs BD 4.Pulmonary Rehabilitation 5.Salbutamol 2 puffs PRN Mr Coughing 61

25. How would you like to treat him? 1.Smoking cessation 2.Smoking cessation plus Combivent R 2 puffs QDS 3.Beclomethasone 200 2 puffs BD 4.Pulmonary Rehabilitation 5.Salbutamol 2 puffs PRN Mr Coughing 61

26. 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

27. What do you think has happened? 1.Lung carcinoma 2.Lower respiratory tract infection 3.Upper respiratory tract infection 4.Pneumothorax 5.Pulmonary Embolism Mr Coughing 61

28. What do you think has happened? 1.Lung carcinoma 2.Lower respiratory tract infection 3.Upper respiratory tract infection 4.Pneumothorax 5.Pulmonary Embolism Mr Coughing 61

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

30. How would you like to treat him? 1.Oxygen 2.Nebulisers 3.Antibiotics 4.Prednisolone 5.All of these Mr Coughing 61

31. How would you like to treat him? 1.Oxygen 2.Nebulisers 3.Antibiotics 4.Prednisolone 5.All of these! Mr Coughing 61

32. 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

33. 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 Mr Coughing 61

34. 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 Mr Coughing 61

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

36. What is the diagnosis? 1.Pulmonary fibrosis 2.Hypersensitivity Pneumonitis 3.Lung cancer 4.Lymphangioleiomyomatosis 5.Bronchiectasis Mr Coughing 61

37. What is the diagnosis? 1.Pulmonary fibrosis 2.Hypersensitivity Pneumonitis 3.Lung cancer 4.Lymphangioleiomyomatosis 5.Bronchiectasis Mr Coughing 61

38. 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

39. This is his CXR Mr Coughing 61

40. 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 Mr Coughing 61

41. 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 Mr Coughing 61

42. This is his Bronchoscopy Mr Coughing 61

43. Where is the tumour? 1.Left Upper Lobe 2.Bronchus intermedius 3.Right middle lobe 4.Right lower lobe 5.Left Lower lobe Mr Coughing 61

44. What should you do next? 1.Left Upper Lobe 2.Bronchus intermedius 3.Right middle lobe 4.Right lower lobe 5.Left Lower lobe Mr Coughing 61

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

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

47. 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

48. 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

49. 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

50. 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

51. 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

52. 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

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

54. What is the most likely diagnosis? 1.Asthma 2.COPD 3.Sarcoid 4.Pulmonary embolism 5.Non Specific interstitial pneumonitits Mrs Coughing 49

55. What is the most likely diagnosis? 1.Asthma 2.COPD 3.Sarcoid 4.Pulmonary embolism 5.Non Specific interstitial pneumonitits Mrs Coughing 49

56. 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 Mrs Coughing 49

57. 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 Mrs Coughing 49

58. 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

59. 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

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

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

62. Miss Coughing 23

63. 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

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

65. What is your next step? 1.Dermatology referral 2.Arrange skin biopsy 3.Spirometry 4.CXR 5.Peak Flow diary Miss Coughing 23

66. What is your next step? 1.Dermatology referral 2.Arrange skin biopsy 3.Spirometry 4.CXR 5.Peak Flow diary Miss Coughing 23

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

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

69. What is the likely diagnosis? 1.Tuberculosis 2.Non Tuberculous mycobacterium 3.Breast cancer 4.Lymphoma 5.Sarcoidosis Miss Coughing 23

70. What is the likely diagnosis? 1.Tuberculosis 2.Non Tuberculous mycobacterium 3.Breast cancer 4.Lymphoma 5.Sarcoidosis Miss Coughing 23

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

72. Just Kidding!