Symptom &
Key Questions What these questions will tell you
Background
How long have you had a cough?
Acute:
Cough
Do you have nasal congestion or a sore throat?
Do you have or have you had a fever and or
chills?
Do you have a headache?
Subacute/chronic cough:
Are you short of breath?
Do you have a history of heart failure?
Do you have a history of asthma?
If a child: Have you noticed the child putting Consider a foreign body aspiration in any child
small objects in his or her mouth?
What does the nature of the sputum tell me?
Does it have an odor?
Consistency and color of sputum?
How much sputum have you coughed up?
Any blood in the sputum?
What does the nature of the cough tell me?
Is the cough getting worse or more frequent?
Physical Exam Lab Tests
tells you if it is acute (<3wks), subacute (between Note general appearance Complete blood
3 to 8 wks), or chronic (>8wks). cell count
Runny nose with cough and mild fever, followed If patient is in acute
by persistent cough for more than one week with distress with oxygen
clear off-white mucus greater in the morning deprivation, dehydration, may indicate acute
suggests bronchitis. and fever think bacterial infection (elevated
pneumonia first. If oxygen white blood cell
count). Eosinophilia
Temperature less then 38.3 C (101F) with yellow deprivation is present but indicates atopy.
sputum, malaise, nasal congestion and acute no fever, consider foreign
cough suggests viral etiology. body aspiration, acute
Acute cough of a more serious nature is heart failure, or pulmonary
associated with a fever greater then 38.3 C embolism.
(<101F).
nasal congestion with facial pain or pressure Sputum Culture
(h/a) may be a sign of sinusitus as the cause of
cough.
Asses Mental Status dx's specific
infectious agents.
usually suggests a physical obstruction of the Sweat test
airway by a foreign body or the effects of acute Diminished level of >60 mEqu/L of
asthma. consciousness, confusion, chloride is diagnosic
and restlessness are likely of cystic fibrosis.
A person with hearth failure reports: orthopnea, manifestations of hypoxia.
paroxysmal nocturnal dyspnea, cough with Frequently pt's with a
possible frothy sputum, possible wt gain with pulmonary embolus
swollen feet and ankles and often a history of express a sence of
heart disease. impending doom.
Tuberculin skin
Testing
Acute exacerbation of asthma is characterized by Examine the head and Called the Mantoux
an irritating nonproductive cough that can neck test. If skin reaction
progress to tachypnea, dyspnea, wheezing, is less then 5mm it
cyanosis, fatigue, and respiratory and cardiac is considered
failure. negative, between 5
to 9mm is
considered a weak
Most important triggars of asthma in children are Erythema of upper positive, 9 to 14mm
viral infections, especially respiratory syncytial respiratory tract mucous diameter is
virus, parainfluenza viruses and rhinoviruses. membranes, accompanied considered an
by enlarged anterior cervial intermediate
nodes, is a common positive, and over
finding in an upper 15mm is a strong
with a sudden and unexpected onset of cough. respiratory tract infection. positive.
Observe for jugular venous
distention; this may be a
sign of heart failure.
malodorous sputum suggests amaerobic Listen to the cough
infection of he lungs and sinuses.
Very thick, tenacious, dark sputum is is it dry or moist. Whooping
characteristic of bronchiectasis. or honking.
Cloudy and thick sputum suggests lower Palpate the chest
respiratory tract infection or increaased nuber of
eosinophils from an asthmatic process.
Clear, mucoid sputum indicates allergic disorder. Look for tenderness,
depression, bulges, and
Viral bronchitis causes < two tablespoons of crepitus. Assess for chest
mucopurulent sputum per day. Bacterial symmetry by mesuring
bronchitis has > two tablespoons of diaphragmatic expantion
mucopurulent sputum per day. and chest excursion.
Hemoptysis indicates a more serious disease, Assess for vocal fremitus-
such as bacterial pneumonia, acute inflammatory dence tissue conducts
bronchitis, cystic fibrosis, tumor, or a foreign sound better than does air;
body. thus conditions such as
pneumonia, heart failure,
and tumors may increase
If cough is progressivly getting worse it may fremitus. Fremitus is
indicate pertussis. In children a worsening cough deacreased in
that is worse at night and sounds 'brassy' may pneumothorax, asthma
indicate croup. Persistent paroxysmal coughing and emphysema.
is often associated with asthma.
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What time of day is the cough most
bothersome?
What type of work do you do?
What does the cough sound like?
Is anyone else at home or at school or work ill? May indicate exposure to respiratory viruses. Examine the skin and
Environmental exposure to irritants, smoke,
pollen, dust or animals?
Does the patient smoke? And is the cough
geting better or worse?
Do you have any chronic health problems, heart Chronic lung and heart disease may present with
disease or high blood pressure?
Are you HIV + or are you receiving treatments
for cancer?
Have you been exposed to TB? Family hx of TB, Tells you they may possibly have TB.
international travel, inner city habitation?
If cough awakens person at night this may Percuss the chest
indicate: asthma, chronic bronchitis or GERD or
heart failure.
Sever cough in the early morning indicates Resonance (long, low-
postnasal drip, cystic fibrosis, or bronchiectasis. pitch) over most lung fields.
Hyperreonance
Cough worse at night indicates croup, postnasal (abnormally long, low-
drip, lower respiratory tract infection, and allergic pitched) may signal
reaction. emphysema or
pneumothorax. Dullness
Review occupation and hobbies. Asbestos or or flatness may be pleural
coal dust exposure increases a person's risk of effusion, pneumonia, or a
lung disease. Aerosol sprays, insecticides, large tumor.
chemical exposures and saw dust an cause
cough.
Throat clearing cough indicates postnasal drip. Auscultate breath
Dry, brassy cough indicates allergy or habit sounds
cough. Loose or moist cough indicates cystic
fibrosis or asthma.
Paroxysmal cough is seen in asthma, pertussis, Pt breaths through mouth
cystic firbrosis and occationally after inhalation of slowly and deeply.
foreign body. A barking, croupy cough indicates Presents, type, and
an irritation in the glottic or subglottic area. location of both normal and
abnormal breath sounds.
A sudden short burst of a cough in infants called Auscultate heart sounds
a staccato cough indicates Chlamydia
trachomatis.
A harsh, dry cough caused by airway location of normal and
compression from enlarged nodes seems to abnormal heart sounds,
occur with tuberculosis or fungal infection. heart rate and rhythm.
Note any murmurs, their
grade, location and
radiation.
extremities
May indicate allergies, asthma. Note cyanosis of the oral
cavity (central cyanosis)-
Chronic cough due to smoking. A change in the associated with low arterial
chronic cough of a smoker may indicate a new saturation and may result
and serious problem: pneumonia or lung cancer. from inadequate gas
exchange in the lungs from
cardiac shunting.
cough, indicating an exacerbation and/or
complication of the disease.
Cancer therapy and HIV and administration of Blueish color of extremities
steroids should raise suspicion of (peripheral cyanosis) may
immunocompromise, which tends to increase risk be observed in pt's with low
for infectious lung problems. venous saturation,
resulting in vascular
occlution or reduced CO
Clubbing of nails is a
manifestation of chronic
tissue hypoxia, which
occurs with chronic lung
disease. Edema of the
lower limbs may be a sign
of increased right heart
filling pressure, coused by
lung disease or left
ventricular failure.
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 DDX
Condition History Physical Findings Diagnostic Studies
Common Cold Self limiting viral infection of URT generally caused by red and swollen nasal mucosa with none
rhinovirus. secretions present, mild pharyngeal
erythema, and enlarged cervical lymphnodes.

Chronic Obstructive consists primarily of emphysema and chronic Barrel chest, tachypnea and distant breath Chest radiography will show
Pulmonary Disease (COPD) bronchitis. Acute exacerbation of COPD includes 3 sounds. hyperexpansion of the lungs, and
Exacerbation clinical findings: worsening dyspnea, increase in spirometry will indicate airflow
sputum purulence and increase in sputum volume. obstruction when emphysema is
present.

Bordetella pertussis infection Whooping cough is an acute infeton of the respiratory Physical exam may be in normal limits. associated with extemely high white
tract. Begins with malaise, cough, coryza, anorexia blood cell count.
and progresses to high-pitched inspiratory 'whoop'.
Pneumonia associated with dyspnia, pleuritic chest pain, cough fever, tachycardia and tachypnea, inspiratory Chest radiography, complete blood
with greenish or rusty-colored sputum, fever, and crackles, asynchronous breathing and vocal cell count and sputum and nasal
chills. fremitus, dull percussion sound over area of cultures are confirmatory.
consolidation, and bronchophony.

Acute bronchitis inflammation of the lung airways. lung auscultation reveals diffuse rhonchi on white blood cell count is normal or
expiration. slightly elevated.

Croup (Acute inflammation or edema of the subglottic area causes Inspiratory stridor, suprasternal and Posteroanterior neck views of
laryngotracheobronchitis) obstruction of the airways of the larynx, trachea, or intercostal retractions, and an increased radiographs show steeple sign
bronchi. Parainfluenza most common cause. respiratory rate are seen. (narrowing of the air column at the
Hoarseness, inspiratory stridor, barking cough worse top).
at night.

Postnasal drainage most common cause of chronic cough. Dry, throat Mucus in posterior pharynx or a cobblestone Sinus radiographs, CT scan of
syndrome clearing cough, sensation of something in the back of appearance of the posterior pharynx. sinuses and allergy testing may be
the troat and nasal congestion. indicated if this syndrome is
suspected to be the cause of cough.

Asthma most common cause of chronic cough in children.
Dry, worse at night, exercise related and often
triggared by URTI.
May hear prolonged expiratory phase, Chest radiograph may show hyper
crackles that clear with coughing, and overt or inflation during acute attacks.
latent wheeze with forced expiration. Pulmonary function testing with and
without an aerosolized
sympathommetic bronchodilator is
positive.

Chronic Bronchitis patient expectorates sputum on most days during a possible rhonchi that clear with coughing, Chest radiograph and pulmonary
period spanning at least 3 consecutive months for resonance to dull chest, possible barrel chest, function tests are indicated.
more then 2 successive years. Raspy, hacking prolonged expiration, and possible wheezing.
cough.

Bronchogenic Carcinoma Hemoptysis in a cigarette smoker as well as wt loss
and or SOB.
Tuberculosis Brassy cough. At first minimally productive with
yellow or green mucus usually on arising in the
morning. As disease progresses cough becomes
more productive.
enlarged suprascapular lymphnodes, dull
chest percussion over the tumor, increased
breath sounds distal to the tumor.
In adults, a multinodular infiltrate above or
behind the clavical suggests recurrence of an
old TB infection. In younger persons with
recent infection unilateral pleural effusion is
often seen.
Chest radiograph and CT scan
indicated in hemoptysis cases.
Sputum examination, the finding of
acid-fast bacilli in a sputum smear is
strong evidence. Definitive dx is
made only on results of a culture.

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