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32 year old Malay male with persistent cough for 3 months (Referred Cough…
32 year old Malay male with persistent cough for 3 months
Referred Cough Syndrome
Upper Airway Cough Syndrome (UACS) :star: :star: - Nasal and Throat Symptoms
Chronic Rhinitis + Post Nasal Drip -> upper airway secretions may trigger the cough reflex
Cough is triggered immediately upon lying down, and the patient may even feel a sensation of liquid dripping into the back of the throat
Examination of the nose may reveal excess secretions, inflammed nasal mucosae, or nasal polyps.
Normal Chext X-ray
Responsive to decongestant and first generation histamine H1 receptor antagonist (not cause by sinusitis)
Gastro-esophageal Reflux Disease (GERD) :star: -> irritating the lower respiratory tract through aspiration thus stimulating esophageal-bronchial cough reflex
Heartburn or GI symptoms
Symptoms: Worsen at night
ACE-Inhibitor :star: : due to inhibition of bradykinin metabolism
5-30% of patients who starting new med
Substitute ACE-I with angiotensin receptor blocker
Cardiac Disease
Congestive Heart Failure
Paroxysmal Nocturnal Dyspnea
Symptoms: Worsen at night
Idiopathic Smoker's Cough or psychogenic cough
diagnosis of exclusion
PGC: severe stress; never woken up because of cough
ISC:
Irritant
smoking, dust
Respiratory Infection
Immunocompromised :!:
Tuberculosis :red_flag:
constitutional symptoms (fever, night sweats, weight loss), sputum production, hemoptysis, travel hx, contact hx, and immunosuppression (e.g. steroids) which may predispose to opportunistic or atypical infection
Examine for upper lobe fibrosis or collapse (dullness, tracheal deviation etc)
Non-asthmatic Eosinophilic Chronic Bronchitis :star:
Presentation: normal airway hyperresponsiveness, sputum eosinophilia + metachromatic cells (rule out if less than 3%), no arflow obstruction
Post-Infectious
Symptoms: recent flu-like symptoms with significant cough (RTI)
Persist for 1-3 months
Bronchiectasis (widening of the bronchi and bronchioles, thicken of bronchial wall)
long- standing history of daily cough and copious sputum production
Examination may reveal clubbing and coarse crepitations
Associated with UACS, asthma, GERD, and chronic bronchitis
Chronic Bronchitis
inflammation of the bronchial tubes
One type of COPD and copious amount of mucus
Sarcoidosis
dxg through chest x-ray
need to exclude other common causes first i.e. UACS and GERD
Other Lung Pathology
Asthma :star:
Symptoms: worsen at night; episodic wheezing; can present without wheeze or dyspnoea, but with cough – typically a dry cough, worst in the early morning (when bronchioles are most reactive), exacerbate by cold or exercise
Recent beta-blocker or NSAID use may precipitate asthma
Dxg: methacholine inhalation challenge / trial of inhaled bronchodilators or corticosteroid
Interstitial Lung Disease
progressive dyspnoea
history or current features (e.g. joint pain, rash) of rheumatological diseases like RA, scleroderma, ankylosing spondylitis, and lupus
Cancer
Presentation: recent change in chronic ‘smoker’s cough’, or constitutional symptoms (any weight loss or loss of appetite), progressive dyspnoea
Chronic Obstructive Pulmonary Disease
Presentation: chronic smoker; cough and progressive exertional dyspnea
Examine for wheeze
spirometry and be staged according to the GOLD classifications
Alarm Symptoms
Fever
Productive cough
Progressive dyspnea
Hemoptysis
Persistent wheezing
If present, perform rapid evaluation
(eg, chest radiography)
"Fake Coughs"
Hemoptysis
Stridor
Approach to non-obvious diagnosis
Chest CT: to look for any small nodules
Sputum studies: smear and culture including AFB
studies.
Spirometry (with methylcholine challenge tests): for cough-variant asthma which may otherwise be occult.