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Hospital Based Practice Cough.

Non specific reaction to irritation of the respiratory tract.

Commonest manifestation of lower respiratory disease.

Normally cause by infection.

Can herald more serious pathology.

Investigate any unexplained cough lasting 3 weeks or more.

Differential diagnosis of cough.

Post nasal drip.

Sinusitis Upper respiratory tract infection.

Pharyngitis Laryngitis Tracheobronchitis.

Lower respiratory tract disease.

Almost any lower respiratory pathology In particular.

Asthma.

Suspect if cough also occurs at night.

COPD

Bronchiectesis

Interstitial lung disease.

Carcinoma

Left ventricular failure.

Drugs.

ACE inhibitors Occupational agents.

Psychogenic cough.

Non respiratory causes.

Pericardial irritation

GORD Anything that causes haemoptysis.

Differential diagnosis of haemoptysis.

Acute infections.

Exacerbation of COPD Bronchiectasis.

Can cause massive haemoptysis. Bronchial CA.

Secondary deposits and benign tumours can also cause haemoptysis. This is less common than malignant tumours.

Pulmonary TB.

Common cause worldwide. Consider it in the UK as cases still occur.

PE with infarction

Left ventricular failure.

Cause pink, frothy sputum.

Vasculitis.

Goodpastures syndrome Wegeners granulomatosis

Other infections.

Lobar pneumonia.

Give rusty sputum.

Lung abscess.

Less common.

Trauma.

Chest contusion Foreign body inhalation Post intubation.

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Rare causes of haemoptysis include.

Bleeding diathesis Interstitial lung disease Mitral stenosis Idiopathic pulmonary haemosiderosis AV malformations.

Osler Weber Rendu disase. Heriditary haemorrhagic telangiectasia.

Common in exams, rare in practice.

Eisenmengers syndrome Sarcoidosis Amyloidosis Primary pulmonary hypertension Cystic fibrosis 15% of the time there is no cause found for the haemoptysis

History.

The nature of the cough may help in diagnosis.

Is it productive.

Hard, metallic brassy cough. Pressure on the trachea.

Associated with burning retrosternal pain.

Tracheitis.

Bovine cough

Laryngeal paralysis.

Usually from bronchial carcinoma infiltrating the recurrent laryngeal nerve.

Voice may be hoarse

Croup.

Causes laryngitis cough.

Cough is hard and hoarse.

Association with stridor may occur with.

Whooping cough Laryngeal obstruction

Tracheal obstruction

Hacking, infrequent cough suggests pharyngitis. An associated wheeze suggets

Asthma

Left ventricular failure.

Orthopnoea or paroxysmal nocturnal dyspnoea suggests left ventricular failure. If associated with pleuritic chest pain, suspect a PE.

Duration

The longer the duration, the less likely it is to be due to infection. Infectious contacts.

Always think of TB Especially in at risk groups.

Foreign travel or living.

Severity of the cough.

Worsening bronchospasm Vomiting Rib fractures Urinary incontinence Syncopy.

Worse at night.

Suggests asthma Can be the only symptom of asthma

Smoking.

Can cause a cough in its own right as an irritant. Is associated with malignancy.

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Drug history.

Specifically ACE inhibitors.

10 20% will have a dry, tickly cough.

Thought to be associated with increased levels of bradykinin.

More common in women than in men.

Patient may tolerate the cough when reassured that there is no serious

pathology.

Newer angiotensin receptor agonists are better tolerated as they dont

interfere with the bradykinin activation pathway. Occupational agents or exposures.

Weight loss.

Carcinoma Lung abscess Check other features of malignancy, such as altered bowel habits.

History of trauma to the chest.

Family history of bleeding disorders.

Past history of rheumatic fever.

Mitral stenosis can cause haemoptysis.

Systems review. Abdo pain suggesting GORD.

Examination.

Full general and respiratory exam should be performed.

Specifically assess.

Severity of breathlessness Respiratory rate. Anaemia.

If present, consider.

Malignancy

Connective tissue disease.

Chronic infection

Clubbing. Bronchial CA

Lung abscess

Mesothelioma

Bronchiectesis

Cystic fibrosis

Fibrosing alveolitis

Cyanosis.

COPD

Eisenmengers syndrome

Lymphadeopathy Sputum. Goitre

Does it extend retrosternally.

Specific signs of bronchial CA.

Horners sign

Paraneoplastic syndrome

Skin

DVT

Vasculitis

Facial pain.

Suggests sinusitis

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Full respiratory exam.

Bronchial breathing in lobar consolidation Fine crepetations.

Left ventricular failure

Fibrosing alveolitis Coarse crepetations.

Bronchiectesis

Cystic fibrosis

Pleural rub.

Pulmnonary infarction

Carcinoma or foreign body gives.

Wheeze that doesnt disappear on coughing.

Suggests blocked major airway.

Listen to the heart.

Mitral stenosis Pericardial rub

Pulmonary hypertension. Loud pulmonary component of second heart sound.

Right ventricular heave

Pulmonary systolic murmur

Prominant waves in JVP

Investigations.

FBC.

Anaemia occurs with malignancies. U&E

As baseline. Vasculitis will cause renal damage and high urea and creatinine.

CXR. Pneumonia Carcinoma Interstitial lung disease Bronchiectesis Bilateral hilar lymphadeopathy.

Sarcoidosis

TB

Sputum.

MC&S Zeihl Neilson stain if TB suspected.

Oxygen saturation and ABGs.

Pharyngoscopy.

If upper respiratory cause suspected. Ventilation perfusion scan.

If PE suspected. Bronchoscopy.

Brushing Biopsy Lavage.

Peak flow diary.

In asthma Spirometry.

If airway disease suspected. High resolution CT.

Presence and degree of.

Interstitial lung disease Bronchiectesis

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Gastroscopy or barium meal.

If GORD suspected.

Fibrosing alveolitis.

Also known as idiopathic pulmonary fibrosis or cryptogenic fibrosing alveolitis.

Commonest cause of interstitial lung disease.

Involves inflammatory cell infiltrate and pulmonary fibrosis of unknown cause.

Symptoms.

Dry cough

Exertional dysponea

Malaise

Weight loss

Arthralgia

Signs.

Cyanosis

Finger clubbing

Fine end inspiratory crepetations.

Complications.

Type 1 respiratory failure Increased risk of lung cancer.

Tests.

Blood.

ABGs Raised CRP Imunoglobulins

30% ANA positive

10% rheumatoid factor positive.

CXR.

Reduced lung volume Bilateral, lower zone reticulo nodular shadows.

Honeycombed appearance. Advanced disease.

MRI.

Shows similar pattern as CXR More sensitive than CXR. Essential tool for diagnosis.

Spirometry.

Restrictive picture. Reduced transfer factor.

Broncho alveolar lavage.

May indicate activity of alveolitis. Raised lymphocytes.

Good response and prognosis.

Raised neutrophils or eosinophils. Poor response and prognosis.

Diethylene triamine penta acetic acid (TCDTPA scan)

May reflect disease activity. Lung biopsy.

May be needed for diagnosis.

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Management.

Large proportion of patients have chronic, irreversible disease that wont respond to treatment.

High dose Prednisolone Halve dose after 4 weeks, then maintain for a year. 20% of patients will respond.

Cyclophosphamide + Prednisolone.

Alternate disease. Monitor response with.

Systems enquiry. CXR Lung function test.

Consider lung transplantation

Prognosis.

50% alive at 5 years.

Survival ranges from 1 20 years.

Mitral stenosis

Causes.

Rheumatic fever

Congenital

Mucopolysaccharidoses

Endocardial fibroelastosis

Maligant carcinoid

Prosthetic valves.

Presentation.

Dyspnoea

Fatigue Palpatations

Chest pain

Systemic emboli

Haemoptysis

Chronic bronchitis like picture.

Signs.

Malar flush

Low volume pulse

AF

Tapping, non displaced apex beat.

On auscultation

Palpable S1 Opening snap Rumbling mid diastolic murmur

Head best in expiration with patient in left lateral position.

Prolonged murmur suggests severe disease.

Complications.

Pulmonary hypertension

Emboli

Pressure from large left atrium on local structures.

Hoarse voice due to compression of recurrent laryngeal nerve. Dysphagia due to compression of oesophagus Bronchial obstruction

Infective endocarditis.

Rare.

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Investigations

ECG. AF P mitrale if in sinus rhythm.

CXR.

Left atrial enlargement. Pulmonary oedema Mitral valve calcivication

Echo.

Diagnostic Significant stenosis is present if valve orifice is < 1 cm2/ m2 body surface area.

Management.

If in AF, rate control is crucial.

Anticoagulate with warfarin.

Diuretics. Decrease preload Reduce pulmonary venous congestion.

If medical management fails.

Indication for cardiac catheterisation.

Previous valvotomy.

Signs of other valve disease

Angina

Severe pulmonary hypertension

Calcified mitral valve.

Balloon valvuloplasty.

If pliable, non calcified valve.

Open mitral valvotomy Valve replacement.

Oral penicillin prophylaxis for.

Surgical procedures Dental procedures Recurrent rheumatic fever.