Case 19: Cough

Opening scenario

Maria Wright, a 53-year-old female; , comes to the doctor's office because of a cough.

Vital signs

• Temperature: 98.6°F (37°C)
• Blood pressure: 135/80 mm Hg
• Heart rate: 80/min
• Respirations: 22/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

• Cough regularly throughout the entire encounter and observe whether the examinee offers you a drink of water and/or tissue.
• You are not aware of the meanings of medical terms (e.g., ECG) and ask for clarification if the examinee uses them.
• Use the checklists below for history, physical examination, and communication and interpersonal skills.

Challenge: When the examinee counsels you to stop smoking, say “What is the point of quitting now, when I am already sick with a cough?”

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.
  • Productive
  • Yes, I always cough up some gunk.
  • Blood in sputum
  • No.
  • Color of sputum
  • It is yellowish.
  • Volume of sputum
  • Maybe 1–2 teaspoons per day.
• Onset
• I do not really know. I have had a cough for the past 5 years, but now it is getting worse.
• Constant/intermittent
• It is there all the time. But it is worse in the morning.
• Precipitating events
• None.
• Progression
• Yes, like I said, it has been getting worse over the past few months.
• Previous episodes
• As I said, I have had a cough for quite some time.
• Frequency
• Every day.
• Alleviating factors
• Nothing.
• Aggravating factors
• Breathing in deeply.
• Associated symptoms
• None.

Review of systems specific to chronic cough

• Recent travel
• No.
• Swelling of the ankles
• I think they are always a little swollen, but maybe they are just big.
• Fever/chills
• No.
• Night sweats
• No.
• Fatigue
• Yes, I have felt more tired than usual the past couple of months.
• Racing of the heart
• None.
• Chest pain
• None.
• Shortness of breath
• Yes, when I walk up two flights of stairs I lose my breath.
• Urinary problems
• I have to get up to use the bathroom a lot at night.
• Bowel problems
• None.
• Sleep problems, multiple pillows
• No.
• Appetite
• Normal.
• Weight changes
• I lost 6.6 pounds in the past 3 months. I was not even trying but I cannot say I mind losing some weight.
• Recent infections
• None.
• Symptoms of upper respiratory infection
• No.
• Exposure to tuberculosis, last PPD
• No, never. My last skin test for tuberculosis for work was normal.

Past medical history, family history, social history

• Past medical history
• I have high blood pressure, which was diagnosed 5 years ago.
• Allergies
• None.
• Medications
• Yes, I take lisinopril.
• Hospitalizations
• I had a c-section for the birth of my daughter.
• Ill contacts
• None.
• Past surgical history
• Only the c-section.
• Family history
• My father died because of a heart attack when he was 70.
• Work
• I work in a supermarket.
• Home
• I live with my husband and our daughter.
• Alcohol
• A glass of wine every other day.
• Recreational drugs
• I hate this illegal stuff and would never use it.
• Tobacco
• Yes I smoke. I have smoked about 2 packs a day for 35 years.
• Exercise
• I do not have time for that.

• Washed hands
• Used respectful draping
• Neck examination
  • Evaluation of JVD
  • Palpation of the lymph nodes of the head and neck
• Cardiovascular examination
  • Auscultation of the heart
  • Palpation of the radial pulse
  • Palpation of the apical impulse
  • Examination for hepatojugular reflux
• Chest examination
  • Inspection of the chest
  • Palpation of the chest
  • Percussion of the lung fields
  • Auscultation of the lungs
  • Examination for vocal fremitus
• Extremities
  • Inspection of the hands
  • Examination for pitting edema

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 the patient a tissue and water when she had a coughing attack.
• Examinee offered counseling on smoking cessation.
• Examinee offered counseling on support options for regular exercise.
• Examinee reacted appropriately to challenge.

Suggested response to challenge: “Ms. Wright, I understand why you feel like there is no point in stopping to smoke now. However, even after smoking for a long time, quitting can often help you recover from a chronic cough and prevent your problems from getting worse. Also, smoking can cause diseases of the heart and the vessels in your body, which can ultimately result in a heart attack or stroke. By quitting now, you'll significantly decrease the risk of suffering from any of these diseases in the future. At this hospital, we have programs to help you quit smoking and there are also some medical options that we can try out, like nicotine replacement therapy. If you are interested, we can figure out what would work best for you together. How does that sound?”

Patient note

Differential diagnoses

1. Chronic obstructive pulmonary disease (COPD): A chronic cough productive of yellow sputum in a patient with a significant smoking history (70 pack years) should always raise concern for COPD, which is a common disease in the US. Patients typically have a cough that is worse in the mornings and dyspnea on exertion. Advanced stages of COPD can manifest with fatigue, weight loss, and peripheral edema, as reported by this patient.
2. Congestive heart failure (CHF): A history of shortness of breath on exertion, nocturia, fatigue, peripheral edema, and a chronic cough are all consistent with CHF. While this patient has several risk factors for CHF, such as arterial hypertension, a smoking history, and lack of exercise, her weight loss and the normal cardiac examination make this diagnosis less likely than COPD.
3. Lung cancer: Smoking causes approximately 90% of lung cancers, and the risk increases with the number of pack years. Symptoms such as unintentional weight loss, fatigue, cough, and shortness of breath should raise further suspicion for lung cancer. Although this diagnosis should certainly be ruled out, this patient's risk factors, lack of hemoptysis, and symptoms of COPD and CHF put this diagnosis slightly lower on the list of differential diagnoses.

Diagnostic studies

• Arterial blood gas analysis and pulse oximetry: to assess for oxygen saturation and acid-base balance
• ECG: can show signs of left or right ventricular hypertrophy in CHF as well as signs of concurrent heart conditions (e.g., arrhythmias, cardiac ischemia)
• Transthoracic echocardiogram: gold standard for evaluating patients with heart failure
• Pulmonary function testing: would show a decreased FVC and FEV₁, as well as an increased residual volume, intrathoracic gas volume, and total lung capacity in COPD
• BNP, NT-pro BNP: The level of BNP is proportional to ventricular volume and pressure overload. High levels of BNP in patients with classic symptoms of CHF confirm the diagnosis (high predictive index).
• Chest x-ray: used to assess for signs of COPD (e.g., hyperlucency, horizontal ribs, and widened intercostal spaces), signs of CHF (e.g., cardiomegaly or pulmonary congestion), and signs of lung cancer (e.g., solitary nodule, mediastinal widening)

Other differential diagnoses to consider

• Bronchiectasis
• Bronchiolitis obliterans
• Emphysema
• See also cough.