Case 31: Cough

Opening scenario

Antonio Ray, a 58-year-old male, comes to the emergency department because of a cough.

Vital signs

• Temperature: 98.6°F (37°C)
• Blood pressure: 135/80 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

• Cough into a tissue every now and then.
• If the examinee asks you to show them the tissue you are coughing into, show them a tissue with (fake) blood on it.
• You are frightened about your condition and afraid of receiving bad news from the physician.
• You are not aware of the meanings of medical terms (e.g., CT) and ask for clarification if the examinee uses them.
• Use the checklists below for history, physical examination, and communication and interpersonal skills.

Challenge: Ask “Can you not just prescribe me some medication? I really cannot afford any expensive tests!”

Hovering over 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 will not interrupt your progress.

History of present illness

• Chief complaint
• I have a cough that just is not going away.
  • Productive
  • Yes, I cough up some phlegm.
    • Color
    • Dark and sometimes red.
    • Blood
    • I do think it is blood, actually. That scares me.
    • Volume
    • Oh, I would say about 1/2–1 teaspoon every time I really cough.
• Onset
• About 4 weeks ago.
• Constant/intermittent
• It is there all the time, but especially worse in the morning, I would say.
• Precipitating events
• I did have a cold 4 weeks ago, but I got over the runny nose and all, and only the cough lingered.
• Progression
• It feels like it is getting worse.
• Previous episodes
• I have had a smoker's cough in the morning for a few years now. But over the past 4 weeks it has gotten really bad and I have it all day long.
• Frequency
• Daily.
• Alleviating factors
• None.
• Aggravating factors
• None.
• Associated symptoms
• No.

Review of systems specific to chronic cough and hemoptysis

• Recent travel
• Yes, I worked in India for the past 3 years.
• Fever/chills
• I have felt like I might have a fever now and then over the past few weeks, yes.
• Night sweats
• I also sweat more than usual at night. I even have to get up and change my pyjamas.
• Fatigue
• Yes, I have felt more tired than usual the past couple of weeks.
• Rash/skin changes
• No.
• Chest pain
• Sometimes I have some pain on the right side of my chest.
  • Pain worsened by deep breathing
  • Yes.
• Shortness of breath
• Yes, going hiking or up the stairs to my apartment on the third floor.
• Sleep problems
• Sometimes I wake up drenched in sweat. Other than that, I sleep fine.
• Appetite
• Alright, I guess.
• Weight changes
• I lost 5 kg (11 lbs) in the past 3 months.
  • Intended weight loss
  • No.
• Recent infections
• None other than the cold 4 weeks ago.
• Symptoms of upper respiratory infection
• No.
• Exposure to tuberculosis
• I worked in India at an orphanage for 3 years. I returned 6 months ago. Some of the children had tuberculosis, I think.
  • Last PPD
  • My last PPD was ages ago, and back then it was normal.
• Exposure to pets
• No.
• Exposure to mold
• Not that I know of.
• Muscular weakness
• Not that I have noticed – other than being tired all time.
• Tingling/numbness
• No.

Lung cancer can cause neurological issues, either due to paraneoplastic manifestations (e.g., Lambert-Eaton syndrome) or direct nerve infiltration (e.g., Pancoast syndrome).

Past medical history, family history, social history

• Past medical history
• Chronic bronchitis.
• Allergies
• None.
• Medications
• Salmeterol inhaler and ipratropium inhaler.
  • Effective against current symptoms
  • No, they no longer seem to help at all.
• Hospitalizations
• None.
• Ill contacts
• Not since I got back from India.
• Past surgical history
• None.
• Family history
• My father died of lung cancer.
• Work
• I am a medical aid worker.
• Home
• I live alone, but I have a girlfriend.
• Alcohol
• No.
• Recreational drugs
• None.
• Tobacco
• Yes, I smoke. I have smoked 2 packs a day for the past 30 years or so, just like my father did.

• 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
• Back examination
  • Examination of the spine
• 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
  • Inspection of the tissue the patient is holding
    • Bloody tissue (evidence of hemoptysis)
• 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 smoking cessation.
• Examinee reacted appropriately to challenge.

Suggested response to challenge: “Mr. Ray, I understand your concern. I do not know right now what exactly is causing your cough. There is a possibility that you have a serious infection or other disease that can cause a lot of harm to you if it is not treated properly. I would like to run some tests to figure out exactly what is causing your symptoms and to determine the right treatment for you. Regarding the costs of these tests, I would like to get you in contact with our social workers. I am optimistic that they will be able to provide you with help and can discuss any financial issues with you. Would you be interested in that? Do you have any other questions?”

Patient note

Differential diagnoses

1. Lung cancer: This patient is a heavy smoker, is within the peak incidence range for lung cancer (50–70 years), and has a positive family history as well as classic constitutional symptoms. He also has a new, progressive cough, in addition to his prior “smoker's cough,” and sputum tinged with blood. Screening for lung cancer must be conducted in a smoker this age with these symptoms.
2. Pulmonary tuberculosis: Because of his exposure in India (a country where tuberculosis is endemic), this patient is also at risk for tuberculosis, which would present with chronic cough, hemoptysis, and constitutional symptoms. However, his age and smoking history make lung cancer more likely.
3. COPD exacerbation: Fever, worsening cough, and hemoptysis can be symptoms of COPD exacerbation, and this patient's symptoms began after an upper respiratory infection, which would also be consistent with this diagnosis. However, the fact that the patient is in very little distress and has accompanying constitutional symptoms (particularly night sweats) makes another diagnosis more likely.

Diagnostic studies

• Pulse oximetry: to determine the degree of respiratory distress
• Arterial blood gas analysis (ABG): to determine if respiratory acidosis is present
• Sputum gram stain, microscopy with acid-fast stain, cytology, and routine and mycobacterial culture: Sputum Gram stain and cultures could determine a mycobacterial or bacterial cause for this patient's cough. Cytology might be helpful if malignancy is present.
• CBC with differential: Leukocytosis suggests an underlying infection. A WBC count with left shift can help determine if an infection is bacterial or viral.
• CXR: to screen for lung cancer and pulmonary tuberculosis ; could also provide imaging of other potential causes of hemoptysis, such as pneumonia and bronchiectasis; should be compared with a prior x-ray if available
• Chest CT: indicated to assess the probability of malignancy if no previous CXR is available for this patient or if a new lesion is detected on CXR

Other differential diagnoses to consider

• Bronchiectasis or exacerbation of bronchiectasis
• Pneumonia
• Pulmonary arteriovenous malformation
• Vasculitis (e.g., microscopic polyangiitis)
• See also cough.