Episode 67: An Outpatient Approach to Cough

Welcome back to MedPod AFMC, where we explore practical real world problems in internal medicine and allied specialities. I am Major Hari Krishnan, filling in for Brigadier Muthu Krishnan, Sena Meddl, Vishnu Seva Meddl, HOD Department of Internal Medicine at AFMC. A thanks for the opportunity to host this widely popular podcast. Today, we will be discussing an essential but sometimes overlooked area, the approach to a patient presenting with a cough in the outpatient department. To discuss on this important topic and help you all formulate a systematic approach, we have Major Jayanth Kroger, assistant professor in the Department of Medicine at AFMC. Welcome Jayanth. Thank you sir, it's an honor to be part of this podcast. So Jayanth, let's start with the basics. While we are in the OPD, cough is such a common symptom that our patients present with but at times it can be challenging to evaluate properly. How should a practitioner categorize it for a structured approach? Sir, cough is best categorized based on its duration. We can classify cough as acute cough which is less than 3 weeks. It is commonly due to infections like viral upper respiratory tract infections, bacterial pneumonia or environmental retents etc. and sub-acute cough which is lasting from 3 to 8 weeks often follows acute infections such as post-infectious cough or purchases etc. and chronic cough which persists for more than 8 weeks and it is commonly due to conditions like asthma, GRD which is Gastro-isophageal reflux disease or smoking related diseases like chronic bronchitis and many others. Excellent, sir Jayanth. So now moving on, when a patient presents to you with cough, what questions do you prioritize during your history taking? So, while taking history, I divide my history into key domains as we were all taught during early MBBS days. So, I start with one set in progression. So, when did the cough start? Was it sudden or gradual? Has it worsened or changed in character? Second, type of cough? Is it dry or productive cough? A productive cough might suggest infections, bronchitis, COPD and many other conditions. A dry cough could point out to asthma, GRD, post-neural drips and many other conditions. And thirdly, we ask for associated symptoms like conditions like fever, they are suggestive of infections. Associated history of Vs indicates bronchospasm such as in asthma or COPD. Associated history of hemoptysis suggests TB, malignancy or pulmonary embolism. Chest pain could suggest pneumonia, pleurici or even some cardiac causes. And fourthly, we ask for any triggers for the cough. Any exposure to irritants like smoke, chemicals or allergens? Or is the cough worse at night? Like conditions like GRD and post-neural drips are common culprits for the night cough. Fifth, we can ask for social and medical history. Like is there any history of smoking, alcohol or other substance abuse? Any occupational exposures such as working in mines or factories? Medications like use of ACE inhibitor which can cause dry persistent cough. This detailed history often points you towards the likely cause. And like any other symptoms in medicine, history is the pivotal in reaching a differential. Very true Janth, there is nothing more helpful to a physician than a thorough history. So then after gathering a detailed history Janth, what aspects of physical examination do you emphasize upon? So after history, the physical examination can help us in narrowing down our differences. Again a structured approach prevents us from missing out the relevant findings. So I start with general appearance and vitals. You have to look for the signs of respiratory distress like tachypnea, use of accessory muscles during respiration or sinosis. You have to measure the oxygen saturation, pulse and temperatures. And going to the chest examination in inspection we have to look for the deformities like chronic diseases like barrel shaped and COPD. On auscultation you can hear the crackles which may indicate pneumonia, interstitial lung diseases or bronchitis. You may hear V's which is suggestive of bronchospasin which are common in conditions like asthma, COPD or foreign body aspiration. Or there may be absent breath sounds which could indicate pleural diffusion or pneumothorax. Going to the ENT and systemic examination you have to look for sinus tenderness or you have to look for post nasal drip, common in allergic rhinitis or sinusitis. You have to look for lymphedinopathy, hepatosclerinomegaly or signs of systemic disease like clubbing. Right. So once you are through your history and examination based on the findings that you have collected Janth, how do you approach forming a differential diagnosis for cough? So differential diagnosis depends on the history and physical findings. So you may use some pointers like the patient of acute cough may have viral URTI where in history you will get common cold symptoms mild fever and sore throat. In conditions like bacterial pneumonia there will be history of fever, productive cough and localized crackles on examination. In conditions like acute bronchitis patient may have a dry or productive cough and often it is associated with veezing. In patients with subacute cough I would think of a post infectious cough which generally follows a viral bronchitis or pneumonia. In Indian setting I would start thinking of the TB in first place and in patients with chronic cough obstructive airway diseases like asthma or COPD which may be associated with veezing, disney and cough that worsens at night with allergen exposure or smoking and etc. Another common cause would be GERD where the cough aggravates by lying down or after the meals and in cases of smoking related COPD or malignancy, chronic productive cough with history of smoking and patient may give other constitutional symptoms like weight loss, hemoptysis in such cases. Right, so now that you have a differential diagnosis with you how would you start ordering investigations in a prudent way and what would you prioritize? Yes sir investigations are guided by the clinical context we are dealing with following are the few investigations that helps you diagnose the cause of the cough. So first chest x-ray it is considered as the first line for persistent cough or in patients with red flag symptoms like weight loss or hemoptysis. It helps to identify conditions like pneumonia, malignancy or tuberculosis. Then going to the next examination investigation it is sputum examination which is another crucial investigation in patients with productive cough. It helps in diagnosing suspected infections which include DB. So sputum is sent for basic tests like gram and x-ray and staining, culture sensitivity and CB-naught which when we are thinking of TB. Next we can ask for pulmonary function test or PFTs. This help in diagnosing the obstructive airway diseases like asthma or COPD. They are very good screening for destructive pathologies like interstitial lung diseases or musculoskeletal disorders. In some cases we ask for advanced imaging like high-resolution CT which can give us important clues in diagnosis of many acute to chronic cases. If these are normal then we can ask for ENT referral for checking chronic post-nazel drip. We can ask for esophageal pH monitoring or endoscopy if we are suspecting GEID as the cause of the cough. Right, that is a very succinct and very helpful approach. So you mentioned x-rays as a very important tool in the diagnosis of cough. Are there cases of cough with normal chest radiograph also? Yes sir, this is a very important question sir. Patients with cough can have a normal chest radiograph and the list is exhaustive. To discuss a few we have like conditions like upper airway cough syndrome which was previously referred to as post-nazel drip. It is usually associated with rhinitis or sinusitis presenting with sensation of mucus dripping at the back of the throat. Secondly we have conditions like asthma which often presents with cough variant asthma with no wheezing and pulmonary function tests are mostly diagnostic in these conditions. Thirdly we can have conditions like gastroesophageal reflux disease in which cough is typically worsened at night or after the means. Diagnosis is usually clinical but isophageal pH monitoring or a trial of proton pump inhibitor can help in diagnosis of GERD. Then condition like chronic bronchitis in early stages it may present with chronic productive cough before changes on imaging starts appearing. Then we have conditions like drug induced cough. Most notably it is caused by ACE inhibitors as we give it frequently in the OPDs and patient usually comes with complaints of cough after starting the ACE inhibitors. However these conditions usually, this condition usually resolves after discontinuation of the drug. Then we have conditions like habitual or psychogenic cough. It is often seen in children or stressed adults. The history is critical and the cough tends to disappear during the sleep. Then we have rare conditions like pertussis in which there is persistent paroxysmal cough with whooping sound can be confirmed with PCR or serology and occult interstitial lung diseases in which early stages of disease like conditions like hypersensitive pneumonitis may not show on X-ray but they are picked up on higher imaging like HRCT. And lastly we have few more rare causes like eosinophilic bronchitis which is diagnosed by sputum eosinophilic count and tracheomalacia or airway collapse which requires bronchoscopy or dynamic imaging. We are very exhaustive list indeed Jainth. Now moving forward, once you made your diagnosis, how do you approach managing such cases on an OPD basis? They are not discussing inpatient or specialist way of managing but I would just like to know for the MOs and RDRUG's undergraduates who are listening to this. So, how should they start managing patients of cough? So, sir as we have discussed through that treatment will depend on the underlying course what we are dealing with. So, which we will get through after detailed history and examination. So, the management which can be done at a non specialist level. So, for acute viral cough we have to give reinsured the patient, hydration of the patient and symptomatic treatment like anti histaminex or lozenzis and we have to try as much as possible avoid the use of antibiotics unless there is a clear evidence of bacterial infection. So, we have seen like over the counter use of antibiotics has been there and which has been now giving rise to the antimicrobial resistance also. So, we have to be very cautious with the use of the antibiotic in acute viral cough. In conditions like for bacterial pneumonia is definitely we have to start with empirical antibiotic based on the local resistance pattern or more specifically based on the hospital antibiotic policy and then we can switch over to the culture sensitive antibiotics after getting the reports and for chronic conditions like asthma or COPD we can use inhaled corticosteroids along with bronchodilators and we have to ensure the smoking cessation and we have to ensure the pulmonary rehabilitation exercises and for conditions like GERD lifestyle changes and proton pump inhibitors are the drug of choice. For any red flag cases there should be patient should be thoroughly investigated to rule out any malignancy or conditions like chronic infections like tuberculosis. Yes, speaking of red flag gen which you brought out twice in during this discussion what are they and as you mentioned about immediate referral of such cases what are the absolute indication for referral or urgent intervention in the case of cough. Sir red flags are symptoms or signs which potentially indicate the presence of sinister underlying disease. So, MO or even in fact a specialist should be watch out for all the symptoms or signs. Signs like hemoptasis, symptoms like hemoptasis especially massive or recurrent. So, approach to hemoptasis I believe was covered in one of the episodes of Metcord listeners can please refer to that for detailed approach to a patient with hemoptasis and symptoms like persistent weight loss, fever, night sweats, severe breathlessness, hypoxia or rapidly worsening these symptoms and suspicions of malignancy, tuberculosis or significant cardiac involvement. Right, so that was a very comprehensive discussion and before we wrap up any advice for our students and the medical officers in pay free on how to tackle cough in their OPDs. Absolutely sir, whenever you encounter a patient in OPDs please listen carefully to the history because the diagnosis lies in the history itself and these systematic use a step by step approach for examination and differential diagnosis. Don't rush for test, avoid over investigation and there is no use of doing any of the test without clinical indication and educate the patients like many coughs are usually benign and self limiting you have to just reassure them and do the proper symptomatic management. So, thank you Jayan for such a comprehensive discussion. Today with your help we have learnt how to approach a patient with cough in the OPD starting with a thorough history and physical examination followed by a systematic use of investigation and a thoughtful consideration of differential even when initial findings like chest x-ray are normal and Jayan, your emphasis on tailoring the evaluation to each patient's context avoiding unnecessary tests and focusing on patient education is truly invaluable and this conversation I believe will undoubtedly help our listeners enhance their clinical practice and confidence in managing such cases when they encounter. Thank you sir, for the opportunity it's always pleasure to learn together. And finally to all our listeners remember that while cough may often seem like a routine symptom a meticulous approach can unearth significant underlying causes and lead to better patient outcomes. Thank you all for tuning into Medford A/C. Until next time, stay curious and keep learning. Goodbye.