9. Situation
- Chinese Male
- Middle age
- Presents with chronic cough for 2 months
- Initially cough with sputum, which is whitish in colour
- For recent 2 weeks, associated with blood streaks
- a/w SOB & fever these 2 weeks
- Went to GP before for treatment
14. When does the cough start?
Onset is important – Sudden onset of violent
coughing may be due to inhalation of foreign
body
15. When does the cough start?
Onset is important – Sudden onset of violent
coughing may be due to inhalation of foreign
body
16. When does the cough start?
Onset is important – Sudden onset of violent
coughing may be due to inhalation of foreign
body
17. When does the cough start?
Onset is important – Sudden onset of violent
coughing may be due to inhalation of foreign
body
Duration is important.
◦ Acute - <3 weeks
◦ Subacute - 3-8 weeks
◦ Chronic - >8 weeks
18.
19. Acute cough may suggest:
◦ Upper RT
Common cold
Sinusitis
◦ Lower RT
Pneumonia
Bronchitis
Exacerbation of COPD
Inhalation of bronchial irritant (eg, smoke or fumes)
20. Acute cough may suggest:
◦ Upper RT
Common cold
Sinusitis
◦ Lower RT
Pneumonia
Bronchitis
Exacerbation of COPD
Inhalation of bronchial irritant (eg, smoke or fumes)
Don’t forget!! If sudden origin, might be
inhalation of foreign body!
21. Subacute Cough 3-8 Weeks
Postinfectious
◦ A cough that begins with an acute respiratory tract
infection and is not complicated* by pneumonia
◦ *Not complicated = Normal lung exam normal chest
X-ray
◦ Resolve without treatment
◦ Cause : PND or tracheobronchitis
◦ Indication for CXR : with abn lung exam
Sinusitis
Asthma
29. Do you cough up anything?
What?
Yes / No – sputum
30. Do you cough up anything?
What?
Yes / No – sputum
31. Do you cough up anything?
What?
Yes / No – sputum
If yes, ask about
32. Do you cough up anything?
What?
Yes / No – sputum
If yes, ask about
◦ Frequency of sputum (How frequent?)
Cough continuously productive of purulent sputum is
suggestive of chronic bronchitis and bronchiectasis.
◦ Quantity of sputum (How much?)
◦ Appearance of sputum
Is the sputum clear or discoloured?
Is there any blood in the sputum
35. Hemoptysis (bloody sputum)
◦ If with purulent and long standing sputum
CHRONIC BRONCHITIS (small amount of blood)
BRONCHIECTASIS (large amount of sputum)
◦ If with fever, recent onset, SOB :
PNEUMONIA
◦ If + LOA, LOW, H/O smoking :
BRONCHIAL CARCINOMA
◦ If sputum is pink in color and frothy :
PULMONARY EDEMA
◦ If sudden onset
PULMONARY EMBOLISM, ACUTE RT INFECTIONS
36.
37. ◦ If had contact with TB patients / HIV status
TB
◦ If with long history of SOB
CHRONIC LUNG DSS, MITRAL STENOSIS
◦ If with hematuria, proteinuria
GOODPASTURE SYNDROME,
WEGENER’S GRANULOMATOSIS (h/o sinusitis)
◦ If with other bleeding sites
COAGULATION DISORDER, USE OF ANTICOAGULANTS
40. Black carbon specks in sputum
◦ SMOKING
Rust coloured
◦ PNEUMONIA (usu pneumococcal)
41. Black carbon specks in sputum
◦ SMOKING
Rust coloured
◦ PNEUMONIA (usu pneumococcal)
42. Black carbon specks in sputum
◦ SMOKING
Rust coloured
◦ PNEUMONIA (usu pneumococcal)
Purulent (yellowish / green)
◦ The discoloration is due to neutrophil myeloperoxidase (it is green
in colour)
◦ BRONCHIECTASIS
◦ PNEUMONIA
43. Black carbon specks in sputum
◦ SMOKING
Rust coloured
◦ PNEUMONIA (usu pneumococcal)
Purulent (yellowish / green)
◦ The discoloration is due to neutrophil myeloperoxidase (it is green
in colour)
◦ BRONCHIECTASIS
◦ PNEUMONIA
Foul smelling dark coloured
◦ LUNG ABSCESS (ANAEROBIC)
44. Black carbon specks in sputum
◦ SMOKING
Rust coloured
◦ PNEUMONIA (usu pneumococcal)
Purulent (yellowish / green)
◦ The discoloration is due to neutrophil myeloperoxidase (it is green
in colour)
◦ BRONCHIECTASIS
◦ PNEUMONIA
Foul smelling dark coloured
◦ LUNG ABSCESS (ANAEROBIC)
Mucoid (white / milky)
45. Black carbon specks in sputum
◦ SMOKING
Rust coloured
◦ PNEUMONIA (usu pneumococcal)
Purulent (yellowish / green)
◦ The discoloration is due to neutrophil myeloperoxidase (it is green
in colour)
◦ BRONCHIECTASIS
◦ PNEUMONIA
Foul smelling dark coloured
◦ LUNG ABSCESS (ANAEROBIC)
Mucoid (white / milky)
46. Black carbon specks in sputum
◦ SMOKING
Rust coloured
◦ PNEUMONIA (usu pneumococcal)
Purulent (yellowish / green)
◦ The discoloration is due to neutrophil myeloperoxidase (it is green
in colour)
◦ BRONCHIECTASIS
◦ PNEUMONIA
Foul smelling dark coloured
◦ LUNG ABSCESS (ANAEROBIC)
Mucoid (white / milky)
Frothy sputum
◦ PULMONARY EDEMA
72. Characters of cough
Ask the patient to cough several times
Lack of the usual explosive beginning may
indicate vocal cord paralysis (the ‘bovine’
cough).
73. Characters of cough
Ask the patient to cough several times
Lack of the usual explosive beginning may
indicate vocal cord paralysis (the ‘bovine’
cough).
74. Characters of cough
Ask the patient to cough several times
Lack of the usual explosive beginning may
indicate vocal cord paralysis (the ‘bovine’
cough).
A muffled, wheezy, ineffective cough suggests
obstructive pulmonary disease.
75. Characters of cough
Ask the patient to cough several times
Lack of the usual explosive beginning may
indicate vocal cord paralysis (the ‘bovine’
cough).
A muffled, wheezy, ineffective cough suggests
obstructive pulmonary disease.
76. Characters of cough
Ask the patient to cough several times
Lack of the usual explosive beginning may
indicate vocal cord paralysis (the ‘bovine’
cough).
A muffled, wheezy, ineffective cough suggests
obstructive pulmonary disease.
A very loose productive cough suggests
excessive bronchial secretions due to chronic
bronchitis, pneumonia or bronchiectasis.
77.
78. A dry, irritating cough may occur with chest
infection, asthma, carcinoma of bronchus or
acid irritation of the lungs in GORD. It is also
typical of cough produced by ACE-I.
79. A dry, irritating cough may occur with chest
infection, asthma, carcinoma of bronchus or
acid irritation of the lungs in GORD. It is also
typical of cough produced by ACE-I.
80. A dry, irritating cough may occur with chest
infection, asthma, carcinoma of bronchus or
acid irritation of the lungs in GORD. It is also
typical of cough produced by ACE-I.
A barking or croupy cough may suggest
problem with URT or pertussis infection.
81. A dry, irritating cough may occur with chest
infection, asthma, carcinoma of bronchus or
acid irritation of the lungs in GORD. It is also
typical of cough produced by ACE-I.
A barking or croupy cough may suggest
problem with URT or pertussis infection.
82. A dry, irritating cough may occur with chest
infection, asthma, carcinoma of bronchus or
acid irritation of the lungs in GORD. It is also
typical of cough produced by ACE-I.
A barking or croupy cough may suggest
problem with URT or pertussis infection.
DO NOT ignore the change in character of a
chronic cough – it may signify a new problem
(eg malignancy, infection).
107. Do you take any medicines?
ACE-I
Drugs that induced GORD
◦ Anticholinergics
◦ Beta blockers
◦ Bronchodilators for asthma
◦ Calcium channel blockers
◦ Dopamine active drugs (eg for Parkinson’s dss)
◦ Progestin
◦ Sedatives
◦ Tricyclic antidepressants
108. Do you take any medicines?
ACE-I
Drugs that induced GORD
◦ Anticholinergics
◦ Beta blockers
◦ Bronchodilators for asthma
◦ Calcium channel blockers
◦ Dopamine active drugs (eg for Parkinson’s dss)
◦ Progestin
◦ Sedatives
◦ Tricyclic antidepressants
Oral contraceptive pills – induce PE
109. Do you take any medicines?
ACE-I
Drugs that induced GORD
◦ Anticholinergics
◦ Beta blockers
◦ Bronchodilators for asthma
◦ Calcium channel blockers
◦ Dopamine active drugs (eg for Parkinson’s dss)
◦ Progestin
◦ Sedatives
◦ Tricyclic antidepressants
Oral contraceptive pills – induce PE
110. Do you take any medicines?
ACE-I
Drugs that induced GORD
◦ Anticholinergics
◦ Beta blockers
◦ Bronchodilators for asthma
◦ Calcium channel blockers
◦ Dopamine active drugs (eg for Parkinson’s dss)
◦ Progestin
◦ Sedatives
◦ Tricyclic antidepressants
Oral contraceptive pills – induce PE
NSAIDs and beta blockers can cause bronchospasm
111. Do you take any medicines?
ACE-I
Drugs that induced GORD
◦ Anticholinergics
◦ Beta blockers
◦ Bronchodilators for asthma
◦ Calcium channel blockers
◦ Dopamine active drugs (eg for Parkinson’s dss)
◦ Progestin
◦ Sedatives
◦ Tricyclic antidepressants
Oral contraceptive pills – induce PE
NSAIDs and beta blockers can cause bronchospasm
112. Do you take any medicines?
ACE-I
Drugs that induced GORD
◦ Anticholinergics
◦ Beta blockers
◦ Bronchodilators for asthma
◦ Calcium channel blockers
◦ Dopamine active drugs (eg for Parkinson’s dss)
◦ Progestin
◦ Sedatives
◦ Tricyclic antidepressants
Oral contraceptive pills – induce PE
NSAIDs and beta blockers can cause bronchospasm
Cytotoxic agents can cause interstitial lung dss
113. Do you take any medicines?
ACE-I
Drugs that induced GORD
◦ Anticholinergics
◦ Beta blockers
◦ Bronchodilators for asthma
◦ Calcium channel blockers
◦ Dopamine active drugs (eg for Parkinson’s dss)
◦ Progestin
◦ Sedatives
◦ Tricyclic antidepressants
Oral contraceptive pills – induce PE
NSAIDs and beta blockers can cause bronchospasm
Cytotoxic agents can cause interstitial lung dss
114. Do you take any medicines?
ACE-I
Drugs that induced GORD
◦ Anticholinergics
◦ Beta blockers
◦ Bronchodilators for asthma
◦ Calcium channel blockers
◦ Dopamine active drugs (eg for Parkinson’s dss)
◦ Progestin
◦ Sedatives
◦ Tricyclic antidepressants
Oral contraceptive pills – induce PE
NSAIDs and beta blockers can cause bronchospasm
Cytotoxic agents can cause interstitial lung dss
Steroids
133. Social history
Smoking
◦ 1 pack year = 20 cigarettes/day for 1 year
134. Social history
Smoking
◦ 1 pack year = 20 cigarettes/day for 1 year
Occupational exposure
◦ Farming
◦ Mining
◦ Asbestos exposure
135. Social history
Smoking
◦ 1 pack year = 20 cigarettes/day for 1 year
Occupational exposure
◦ Farming
◦ Mining
◦ Asbestos exposure
Animals at home (birds?)
136. Social history
Smoking
◦ 1 pack year = 20 cigarettes/day for 1 year
Occupational exposure
◦ Farming
◦ Mining
◦ Asbestos exposure
Animals at home (birds?)
137. Social history
Smoking
◦ 1 pack year = 20 cigarettes/day for 1 year
Occupational exposure
◦ Farming
◦ Mining
◦ Asbestos exposure
Animals at home (birds?)
Recent travel
138. Social history
Smoking
◦ 1 pack year = 20 cigarettes/day for 1 year
Occupational exposure
◦ Farming
◦ Mining
◦ Asbestos exposure
Animals at home (birds?)
Recent travel
139. Social history
Smoking
◦ 1 pack year = 20 cigarettes/day for 1 year
Occupational exposure
◦ Farming
◦ Mining
◦ Asbestos exposure
Animals at home (birds?)
Recent travel
TB contact
144. Physical examination -
inspection
Place patient in sitting position (be comfortable)
General appearances
◦ Breathlessness
◦ Cachetic
◦ Alopecia
◦ On oxygen mask?
145. Physical examination -
inspection
Place patient in sitting position (be comfortable)
General appearances
◦ Breathlessness
◦ Cachetic
◦ Alopecia
◦ On oxygen mask?
RR (>25/min tachypnea)
146. Physical examination -
inspection
Place patient in sitting position (be comfortable)
General appearances
◦ Breathlessness
◦ Cachetic
◦ Alopecia
◦ On oxygen mask?
RR (>25/min tachypnea)
147. Physical examination -
inspection
Place patient in sitting position (be comfortable)
General appearances
◦ Breathlessness
◦ Cachetic
◦ Alopecia
◦ On oxygen mask?
RR (>25/min tachypnea)
Appearances of hand
◦ Finger clubbing
◦ Flapping tremor
◦ Tar staining
◦ Wasting / weakness of intrinsic muscles of hand
◦ Wristing swelling and tenderness (HPOA)
◦ Pulse – bounding pulse / pulsus paradoxus / …
148.
149. Face
◦ Facial edema and cyanosis
◦ Facial plethora
◦ Ptosis, miosis
◦ Pursed lip breathing
◦ Central cyanosis (seen in tongue)
◦ Skin changes related to CTD
150. Face
◦ Facial edema and cyanosis
◦ Facial plethora
◦ Ptosis, miosis
◦ Pursed lip breathing
◦ Central cyanosis (seen in tongue)
◦ Skin changes related to CTD
151. Face
◦ Facial edema and cyanosis
◦ Facial plethora
◦ Ptosis, miosis
◦ Pursed lip breathing
◦ Central cyanosis (seen in tongue)
◦ Skin changes related to CTD
Neck
◦ Increased JVP
◦ Cervical LN
◦ Hoarseness of voice
152.
153. Chest
◦ Barrel chest
◦ Radiation marks (erythema and thickening)
◦ Use of accessory muscles of respiration
◦ Harrison’s sulcus
◦ Prominent veins
◦ Reduced chest wall movement
170. Causes of tracheal displacement
Towards the side of the lung lesion
◦ Upper lobe collapse
◦ Upper lobe fibrosis
◦ Pneumonectomy
171. Causes of tracheal displacement
Towards the side of the lung lesion
◦ Upper lobe collapse
◦ Upper lobe fibrosis
◦ Pneumonectomy
Away from the side of the lung lesion
(uncommon)
◦ Massive pleural effusion
◦ Tension pneumothorax
172. Causes of tracheal displacement
Towards the side of the lung lesion
◦ Upper lobe collapse
◦ Upper lobe fibrosis
◦ Pneumonectomy
Away from the side of the lung lesion
(uncommon)
◦ Massive pleural effusion
◦ Tension pneumothorax
Upper mediastinal mass (eg, retrosternal
goiter)
186. Added sounds
◦ Wheeze
Polyphonic and bilateral
COPD (low-pitched wheeze, aka rhonchi, from larger bronchi)
Asthma (high-pitched wheeze, from smaller bronchi)
Monophonic and localized
Inhaled FB
Lung cancer
Bronchial stenosis
◦ Crackles (low pitched : rales ; high pitched : crepitation)
Fine
COPD : 1-4 per inspiration
Cardiac failure : 4-9 per inspiration
Interstitial lung dss (fibrosis) : up to 14 per inspiration
Coarse
Bronchiectasis
◦ Pleural rub
187.
188. Vocal resonance
◦ Found under same situations as vocal fremitus
◦ When found with bronchial breath sounds, highly
suggestive of lung consolidation
189. Vocal resonance
◦ Found under same situations as vocal fremitus
◦ When found with bronchial breath sounds, highly
suggestive of lung consolidation
If lung consolidation is suspected, test for
◦ Aegophony : when patient says ‘e’ as in ‘bee’, it
sounds like ‘a’ in ‘bay’
◦ Whispering pectoriloquy
Ask patient to whisper ‘99’, the whispered sound is
heard clearly over the chest wall through consolidated
lung
190.
191. I would like to finish my examination by
checking the
◦ Fever chart
◦ History of smoking
◦ Sputum test
◦ Bedside peak flow meter or spirometry
◦ Oxygen saturation
195. So now, what is cough?
Coughing is a protective response to irritation
of sensory receptors in the submucosa of the
upper airways or bronchi.
196. So now, what is cough?
Coughing is a protective response to irritation
of sensory receptors in the submucosa of the
upper airways or bronchi.
197. So now, what is cough?
Coughing is a protective response to irritation
of sensory receptors in the submucosa of the
upper airways or bronchi.
Cough is the fifth most common outpatient
symptom and its differential diagnosis is fairly
extensive
200. The most common causes of cough are
◦ Postnasal drip
◦ Asthma
>75 % in most cases
◦ GORD/LPR
(laryngopharyngeal reflux)
* 99 % of chronic cough in non-smoking healthy
adults
201. The most common causes of cough are
◦ Postnasal drip
◦ Asthma
>75 % in most cases
◦ GORD/LPR
(laryngopharyngeal reflux)
* 99 % of chronic cough in non-smoking healthy
adults
206. Psychogenic cough
A diagnosis of exclusion
Most common in adolescents with concomitant
emotional disorders
207. Psychogenic cough
A diagnosis of exclusion
Most common in adolescents with concomitant
emotional disorders
208. Psychogenic cough
A diagnosis of exclusion
Most common in adolescents with concomitant
emotional disorders
Does not produce sputum
209. Psychogenic cough
A diagnosis of exclusion
Most common in adolescents with concomitant
emotional disorders
Does not produce sputum
210. Psychogenic cough
A diagnosis of exclusion
Most common in adolescents with concomitant
emotional disorders
Does not produce sputum
Usually does not occur at night
211. Psychogenic cough
A diagnosis of exclusion
Most common in adolescents with concomitant
emotional disorders
Does not produce sputum
Usually does not occur at night
212. Psychogenic cough
A diagnosis of exclusion
Most common in adolescents with concomitant
emotional disorders
Does not produce sputum
Usually does not occur at night
Not affected by commonly used cough
suppresants
213. I would like to divide my approach to
investigation in 3 ways, which are blood
biochemical investigation, radiological
investigations, and lastly, special tests.
232. ABG
◦ To assess oxygenation status
ESR
◦ Sensitive but not specific indicator of dss
◦ ESR can increase in any inflammation, age, anemia
(esp sickle cell anemia), polycythemia
◦ Used as indicator for chronic dss
233. ABG
◦ To assess oxygenation status
ESR
◦ Sensitive but not specific indicator of dss
◦ ESR can increase in any inflammation, age, anemia
(esp sickle cell anemia), polycythemia
◦ Used as indicator for chronic dss
CRP
◦ Same with ESR, but changes more rapidly
◦ Increases in hours, but falls down in 2-3 days
◦ Usage : to monitor response of treatment and dss
activity
234.
235. Blood C&S
◦ If suspected bacteremia (aerobic and anaerobic)
236. Blood C&S
◦ If suspected bacteremia (aerobic and anaerobic)
Sputum AFB, C&S
◦ 3 times, early morning samples
237. Blood C&S
◦ If suspected bacteremia (aerobic and anaerobic)
Sputum AFB, C&S
◦ 3 times, early morning samples
Mycobacterium PCR
238. Blood C&S
◦ If suspected bacteremia (aerobic and anaerobic)
Sputum AFB, C&S
◦ 3 times, early morning samples
Mycobacterium PCR
239. Blood C&S
◦ If suspected bacteremia (aerobic and anaerobic)
Sputum AFB, C&S
◦ 3 times, early morning samples
Mycobacterium PCR
Urine UFEME, C&S
◦ Hematuria and proteinuria can be seen in Goodpasteur’s
dss
240. Blood C&S
◦ If suspected bacteremia (aerobic and anaerobic)
Sputum AFB, C&S
◦ 3 times, early morning samples
Mycobacterium PCR
Urine UFEME, C&S
◦ Hematuria and proteinuria can be seen in Goodpasteur’s
dss
Serum tumor marker
◦ Not routinely done, as lung tumor does not have any
tumor marker
241.
242. CXR
◦ Signs of pneumonia
◦ Signs of hyperinflation
◦ Signs of lung tumor – well defined circumscribed lesion,
cannonball appearance
◦ TRO pneumothorax, pleural effusion
243. CXR
◦ Signs of pneumonia
◦ Signs of hyperinflation
◦ Signs of lung tumor – well defined circumscribed lesion,
cannonball appearance
◦ TRO pneumothorax, pleural effusion
CT
◦ If see lung tumor in CXT
244. CXR
◦ Signs of pneumonia
◦ Signs of hyperinflation
◦ Signs of lung tumor – well defined circumscribed lesion,
cannonball appearance
◦ TRO pneumothorax, pleural effusion
CT
◦ If see lung tumor in CXT
HRCT
◦ In suspected bronchiectasis
245. CXR
◦ Signs of pneumonia
◦ Signs of hyperinflation
◦ Signs of lung tumor – well defined circumscribed lesion,
cannonball appearance
◦ TRO pneumothorax, pleural effusion
CT
◦ If see lung tumor in CXT
HRCT
◦ In suspected bronchiectasis
ECG
◦ TRO CVS causes
249. If treatment fails
Viral vs. Bacterial Rhinosinusitis
◦ Viral
Most Common
Treat empirically
◦ Bacterial
Less Common
Treat in cases of treatment failure
Treat for set criteria
250. Criteria for Bacterial
Rhinosinusitis
Treatment failure + 2 of following :
◦ Maxillary tooth ache
◦ Purulent nasal discharge
◦ Abnormal sinus transillumination
◦ Discolored nasal discharge
251. Treatment
Antihistamine + Pseudoephedrine
+
Oxymetazoline (Afrin)
+
Antibiotics against Haemopholis influenza
and Streptococcus pneumonia
(Bactrim TMP/Sulfa or Amoxacillin)
