COUGH   6A

A 32-year-old man presents to the urgent care clinic with 4 weeks of cough. He describes a recent illness, coinciding with the onset of his cough, with nasal congestion, sore throat, fatigue, and myalgias. His other symptoms have since subsided, but his cough has continued. He denies any shortness of breath, fevers, or weight loss. He does not smoke cigarettes or use any illicit drugs. His vital signs and physical examination findings are normal.

What are the salient features of this patient’s problems? How do you think through his problems?

Salient features: 4-week time course; recent viral illness with resolution of all symptoms except cough; no shortness of breath, fevers, or weight loss; nonsmoker; normal vital signs and physical examination findings

How to think through: Cough is common and usually benign but can be the presenting symptom of a serious illness. First, consider if the patient has risk factors for a serious underlying cause of his cough. (Here, apparently, there are no risk factors; he is young and a nonsmoker and has no chronic medical problems, immunodeficiency, or recent travel.) Next, think through the serious causes of cough that one must never overlook. What features reassure us that he does not have pneumonia? (Absence of sputum, pleuritic chest pain, dyspnea, fever, hypoxia, tachycardia, or abnormal lung examination, e.g., rales or egophony.) What features reassure us that he does not have cancer? (No smoking history, weight loss, or hemoptysis.) What reassures us that he does not have tuberculosis? Interstitial lung disease? Cardiac disease? Next, consider the most likely diagnoses. Does a duration of 4 weeks qualify as acute, subacute, or chronic cough? Are there infectious causes that fit with his presentation? (Pertussis.) What is the most likely cause? (Postinfectious bronchospasm [or virus-induced wheezing] is common; a minimally productive cough persists for several weeks despite resolution of all other symptoms.)

How should he be counseled and treated? (He should be reassured that prolonged cough after a viral upper respiratory infection is common; bronchodilator therapy is effective for symptom control.) If his cough persists, what additional risk factor information should be gathered? (Explicit travel history, asthma history, occupational or other exposures, HIV risk factors.)

COUGH   6B

What are the essentials of diagnosis and general considerations regarding cough?

Essentials of Diagnosis

Age, duration of cough, dyspnea (at rest or with exertion), tobacco use history

Vital signs (temperature, respiratory rate, heart rate)

Chest examination

General Considerations

Cough results from stimulation of mechanical or chemical afferent nerve receptors in the bronchial tree.

Cough illness syndromes are defined as acute (<3 weeks), persistent (>3 weeks), or chronic (>8 weeks).

Postinfectious cough lasting 3 to 8 weeks is termed subacute cough to distinguish this distinct clinical entity from acute and persistent cough.

The prevalence of pertussis infection in adults with a cough lasting more than 3 weeks is 20%, although the exact prevalence is difficult to ascertain because of the limited sensitivity of diagnostic tests.

Stay updated, free articles. Join our Telegram channel

Join