Approach To Cough: Mark Angelo Z. Ponferrado, MD Pre-Resident

Approach To Cough
Mark Angelo Z. Ponferrado, MD

Pre-resident
Objectives
1. To identify the causes of chronic cough in a 64 year old male
2. To define cough and discuss approach to cough and treatment

Sample Case
• R.J.
• 64 years old, Male
• Married
• Roman Catholic
• Filipino
• Born on June 22, 1956
• Known Hypertensive
• Admitted last December 16, 2020
Chief Complaint
• Cough of 9 months
History of Present illness
9 Months Prior Persistence 3 Months Prior Persistence 1 Week Prior
(+) Productive Cough Still with the above signs

(Whitish sputum) Still with the above signs and symptoms now
(-) Fever, (-) Hemoptysis, (-) and symptoms associated with Shortness
DOB, (-) Chest Pain (-) Body of Breath and Difficulty of
Weakness Chest X-ray was done = Breathing
(+) Self-medicated with Cardiomegaly
Guaifenesin (+) Co-amoxiclav and
No consult done Salbumatol nebules
History of Present illness
1 day Prior Persistence Admission
(+) Difficulty of breathing

and palpitations.
Followed up with his

private physician
Advised for Admission

Past Medical History
• (+) Hypertension = 5 years maintained on 50mg and claimed good
compliance to medications
• (-) DM
• (-) Asthma
• (-) PTB
• (-) Previous Surgeries
• (-) Allergies
Family History
• (+) Hypertension – Both Sides
• (+) Malignancy (Bukol sa baga)
• (-) DM
• (-) PTB
Personal Social History
• Former 18.5 Pack-year smoker, stopped due to the onset of symptoms
• Occasional Alcoholic Beverage drinker
• Denies illicit drug use
• Former furniture shop worker
Review of Systems
• No fever • No abdominal pain
• No chills • No constipation
• No nausea • No diarrhea
• No dysuria
• No blurring of vision
• No numbness
• No loss of vision
• No tremors
• No diplopia • No neck pain
• No sore throat • No back pain
• No congestion • No rash
• No chest pain • No swelling
• No Weight Loss • No edema
Physical Exam
Vital Signs upon arrival
BP: 130/80 mmHg
HR: 75 bpm
RR: 19 cpm
TEMP: 36.7 C
O2sat: 98% at room air
Physical Exam
Conscious, coherent, not in cardiopulmonary distress
Anicteric sclerae, pink palpebral conjunctiva, no nasoaural
discharge, no cervicolymphadenopathy, no carotid bruit, no JVP
distension
Symmetrical chest expansion, no retractions, no lagging, Decreased
breath sounds, Right lower lobe Increased tactile and vocal fremitus
Adynamic precordium, normal rate, regular rhythm, no murmur,
PMI not displaced
Flat, soft, non tender, normoactive bowel sounds
Grossly normal extremities, no cyanosis, no edema, full equal
pulses, CRT < 2 secs
Neuro Exam
Mental status: alert, cooperative, no slurring of speech, oriented to person, place and
time
GCS 15 (E4V5M6)
CN I: not assessed
CN II: normal visual acuity, optic discs not assessed
CN II, III: 2-3 mm pupil equally reactive to light, + direct/consensual reflex, no ptosis
CN III, IV, VI: intact extra ocular movements, no nystagmus
CN V: can clench teeth, + bicorneal reflex
CN VII: able to raise both eyebrows, no facial asymmetry
CN VIII: intact gross hearing
CN IX, X: good gag reflex
CN XI: able to shrug shoulders, no atrophy or fasciculations in trapezius muscle
CN XII: tongue midline, no atrophy or fasciculations
Salient Features
• 64 Y/O Male
• Known hypertensive
• Presents with chronic cough of 9 months
• (-) Fever, (-) Night Sweats, (-) Significant weight loss (-)
Hemoptysis
• (+) Decreased Breath Sounds with Increased Vocal and
Tactile Fremitus on the right mid to base lung field
Impression upon admission
• CAP-MR; COVID Suspect
CXR
Chest CT With Contrast
RESULT NORMAL VALUE
WBC Count 11.99 5.00-10.00
RBC Count 4.53 4.00-6.00
Hemoglobin 123 110-150
Hematocrit 37.4 35.0-45.0
MCV 86.4 86.0-110.0
MCH 28.9 26.0-38.0
MCHC 335 316-354
Platelet count 332 150-400
Neutrophils 66.5 55.0-65.0
Lymphocytes 22.5 25.0-35.0
Monocytes 6.7 3.0-7.0
Eosinophils 1.8 0.4-8.0
Basophils 0.0 0.0-1.0
RESULT NORMAL VALUE
BUN 2.57 2.14-7.14
CREA 73.39 44-80
AST 23.80 0-32.0
ALT 31.75 0-33.0
RBS 7.11 <7.80
SODIUM 134.3 135-145
POTASSIUM 4.71 3.4-5.3
Hba1c 4.8 % 4.0-6.0%
URINALYSIS
Color Straw Red blood cells 0-2
Transparency Clear White blood cells 2-4
Blood Negative Epithelial cells Few
Urobilinogen Negative Bacteria Rare
Ketones Normal Mucus Threads Few
Protein Negative
Nitrate Negative
Glucose Negative
Ph 0.5
Specific gravity 1.015
Leukocytes Negative
Differential Diagnoses
Acute Cough Subacute Cough Chronic Cough
• Tracheobronchitis • Inflammatory
• Respiratory Tract Infection • Infectious
• Aspiration • Neoplastic
• Inhalation of noxious • Cardiovascular
chemicals
Pulmonary Tuberculosis
RULE IN RULE OUT
• Chronic Cough • (-) Weight Loss
• (+) DOB • (-) Night Sweats
• (+) SOB • (-) Hemoptysis
Post-nasal drip syndrome
RULE IN RULE OUT
• Chronic Cough • (-) Frequent Throat
Clearing,
• (-) Rhinorrhea
• (-)Sneezing
• (-) Inflamed/
edematous nasal
mucosa
Gastroesophageal Reflux
RULE IN RULE OUT
• (+) DOB • (-) Night Sweats
• (+) SOB • (-) Hemoptysis
Chronic Obstructive Pulmonary Disease
RULE IN RULE OUT
• Sputum Production • (-) Night Sweats
• (+) 18.5 pack year • (-) Hemoptysis
smoker
Pulmonary Malignancy
RULE IN RULE OUT
• (+) 18.5 Pack-year • (-) Night Sweats
smoker • (-) Hemoptysis
Obstructive Pneumonia secondary to pulmonary mass probably malignant
Hypertension St. II Controlled
COVID 19 Negative
Cough
• Forceful expulsion of air from the lungs that helps to clear secretions,
foreign bodies, and irritants from the airway
• Cough performs an essential protective function for human airways

and lungs.
Cough Mechanism
• Spontaneous cough is triggered by stimulation of sensory nerve
endings that are thought to be primarily rapidly adapting receptors C
fibers
Assessment of Chronic Cough
• The physical examination seeks clues suggesting the presence of
cardiopulmonary disease, including findings such as wheezing or
crackles on chest examination
• In virtually all instances, evaluation of chronic cough merits a chest

radiograph.
Management
• Admit to the ward • Therapeutics:
• IVF: PNSS 1L x 80cc/hr 1. Piperacillin + Tazobactam
• DIET: LSLF 4.5g TIV Q6
• Diagnostics: CBC with PC, 2. Levofloxacin 750 TIV OD
PT PTT with INR, BUN, 3. Omeprazole 40mg/ tab 1
CREA, Na, K, UA, Sputum tab OD
GS/CS, CXR PA, 12 L ECG, 4. Paracetamol 300mg TIV
Chest CT with Contrast
5. Amlodipine 10mg/tab 1
tab OD
Thank you so much for listening!

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Approach To Cough

Mark Angelo Z. Ponferrado, MD

2. To define cough and discuss approach to cough and treatment

(+) Productive Cough Still with the above signs

(+) Difficulty of breathing

Followed up with his

Advised for Admission

• Cough performs an essential protective function for human airways

• In virtually all instances, evaluation of chronic cough merits a chest

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