Case 18: Cough

Opening scenario

Anna Campbell, a 21-year-old female; , comes to the student health clinic because of a cough.

Vital signs

• Temperature: 98.6°F (37°C)
• Blood pressure: 120/70 mm Hg
• Heart rate: 80/min
• Respirations: 18/min

Examinee tasks

• Take a focused history.
• Perform a relevant physical examination (do not perform corneal reflex, breast, pelvic/genitourinary, or rectal examinations).
• Explain the preliminary differential diagnoses and initial workup plan to the patient.
• Write the patient notes after leaving the room.

Patient instructions

• Act like your cough really annoys you.
• At some point during the encounter, start coughing uncontrollably and observe whether the examinee offers you a drink of water and/or a tissue.
• You are not aware of the meanings of medical terms (e.g., spirometry) and ask for clarification if the examinee uses them.
• Use the checklists below for history, physical examination, and communication and interpersonal skills.

Challenge: Say “Do you think you can make sure this cough goes away? It is really bothering me!”

Hovering over or clicking on the speech bubbles in the lists below will reveal extra information about the adjacent term. However, clicking on links will cause you to navigate away from the current case, at which point your progress (i.e., your check marks) will be lost. If you do want more information on a subject, either open the link in a new tab or wait until you and your partner have finished the case and reviewed the check marks. Following the link to the patient note form or the abbreviation list will not interrupt your progress.

History of present illness

• Chief complaint
• I have a cough that is really bothering me.
  • Cough productive of sputum
  • Not usually; . But in the past few days, yes, I have been coughing up some gunk.
  • Color of sputum
  • It is greenish.
  • Volume of sputum
  • I would say about 1 teaspoon per day.
  • Blood in sputum
  • No.
• Onset
• 3–4 months ago.
• Constant/intermittent
• It comes and goes.
• Precipitating events
• The first time I had it was at one of my gymnastics classes. Nothing special was really going on with me at the time though.
• Progression
• It had been the same until about 4 days ago, but then it suddenly got a lot worse.
• Previous episodes
• No.
• Frequency
• On and off, until 4 days ago. Now I have it several times a day.
• Alleviating factors
• Nothing really.
• Aggravating factors
• When exercising I will suddenly have a big cough attack and have to stop. It is so annoying.
• Associated symptoms
• Sometimes when I have the cough attacks, I also feel like I cannot catch my breath, which is scary.

Review of systems specific to recurrent cough

• Recent travel
• No.
• Headache
• No.
• Nausea/vomiting
• No.
• Fever/chills
• Hmm, I felt a bit hot in the evening the past 2 days.
• Night sweats
• No.
• Fatigue
• No.
• Racing of the heart
• None.
• Chest pain
• For the past 4 days, my cough has been painful.
• Urinary problems
• None.
• Bowel problems
• None.
• Sleep problems
• For the past month, this cough has woken me up several times during the night, so my sleep has not been as good as it normally is.
• Appetite
• Normal.
• Weight changes
• No.
• Recent infections
• Well, I have a cold, if that is what you mean.
  • Symptoms of upper respiratory infection
  • I have had a runny nose for the past 5 days.
• Exposure to tuberculosis
• No.
• Exposure to fumes/dust
• No.
• Exposure to animals/pets
• No.

Past medical history, family history, social history

• Past medical history
• I have eczema.
• Allergies
• I think I am allergic to horses. My eczema has always gotten worse when I have gone riding.
• Medications
• I use a couple of different moisturizing creams for my eczema, and when it gets really bad I have to use a hydrocortisone cream.
• Hospitalizations
• Never, thank God!
• Ill contacts
• No.
• Past surgical history
• No.
• Family history
• My mom also has eczema.
• Work
• I am going to college to become a graphic designer.
• Home
• I live in a dorm.
• Alcohol
• Sometimes I drink a beer at parties, but I do not drink regularly.
• Recreational drugs
• I smoke marijuana sometimes or try one of the pills I get offered at the parties I go to. But I do not take something everyday or anything like that.
• Tobacco
• I do not smoke cigarettes, only marijuana once in a while.
• Exercise
• I have done gymnastics since I was little, and I am on the college gymnastics team, but now I have trouble getting through practice because of these awful cough attacks.

• Washed hands
• Used respectful draping
• Head, eyes, ears, nose, and throat examination
  • Inspection of the oropharynx
• Neck examination
  • Palpation of the lymph nodes of the head and neck
• Cardiovascular examination
  • Auscultation of the heart
• Chest examination
  • Inspection of the chest
  • Palpation of the chest
  • Percussion of the lung fields
  • Auscultation of the lungs
  • Examination for fremitus
• Extremities
  • Inspection of the hands

Patient interaction

• Examinee knocked on the door.
• Examinee introduced him- or herself and identified his/her role.
• Examinee correctly used the patient's name.
• Examinee asked open-ended questions.
• Examinee listened attentively (did not interrupt the patient).
• Examinee showed interest in the patient as a person (i.e., appeared caring and showed respect).
• Examinee demonstrated the ability to support the patient's emotions (i.e., offered words of support, asked for clarification).
• Examinee discussed initial diagnostic impressions with the patient.
• Examinee explained the management plan.
• Examinee used non-medical terms and provided reasons for planned steps in management.
• Examinee evaluated the patient's agreement with the next diagnostic steps.
• Examinee asked about concerns or questions.

Counseling and challenge

• Examinee offered counseling on recreational drugs.
• Examinee offered tissue and/or water during patient's cough attack.
• Examinee reacted appropriately to challenge.

Suggested response to challenge: “Ms. Campbell, I can understand that you are bothered by your cough. At this point, unfortunately, I can't say exactly what is causing it. I would like to run some tests first to find the right diagnosis, and then start you on an appropriate treatment once we know exactly what is going on. There are many treatable causes of cough, and we have an array of medications that can help, depending on the cause. My team and I will make sure that we do our best to help you. Do you have any other questions or concerns?”

Patient note

Differential diagnoses

1. Asthma: Intermittent coughing spells and dyspnea brought on by specific triggers (e.g., exercise, allergen exposure) are the hallmark of asthma, the most likely diagnosis in this case. The patient is young, otherwise healthy, and has a personal and family history of atopic dermatitis and allergy, which are often associated with asthma.
2. Acute bronchitis: Symptoms of productive, painful cough and low-grade fever following an upper respiratory infection support the diagnosis of acute bronchitis in this patient. Acute bronchitis is viral in > 90% of cases and as such does not usually require antibiotic treatment. However, this patient's symptoms pre-date her URI and are aggravated by exercise, making asthma a more likely diagnosis. The worsening of symptoms over the past few days is probably due to bronchial hyperresponsiveness to increased mucus production.
3. Atypical pneumonia: Dry cough, dyspnea, and low-grade fever are clinical features of atypical pneumonia, in which the pulmonary examination is often unremarkable, which is the case here. School children and young adults are typically affected, and the disease can take a subacute course, lasting several weeks. However, the intermittent nature of this patient's cough, the fact that the cough has specific triggers, her personal and family history of atopic dermatitis and allergies, and her current symptoms of a URI make this diagnosis the least likely of the three.

Diagnostic studies

• Arterial blood gas analysis, pulse oximetry: to assess the severity of the condition and test whether the patient's blood is sufficiently oxygenated
• CBC with differential: A WBC count can help determine if an infection is present and if it is bacterial or viral. Eosinophilia may be seen on CBC in asthma patients.
• Peak flow monitoring: for monitoring response to a trial of bronchodilator therapy
• Pulmonary function testing (PFTs): PFTs are the first-line diagnostic test for asthma and will show a decreased FEV₁ and other signs of obstructive lung disease. The obstruction is reversible when bronchodilators are administered.
• Methacholine challenge test: used to provoke symptoms in patients with intermittent asthma who have normal PFTs
• CXR: to rule out pneumonia

Other differential diagnoses to consider

• Post-nasal drip syndrome
• GERD
• Hypersensitivity pneumonitis
• See also the overview of cough.