Approach to cough

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  • Approach to cough

    1. 1. Approach to cough
    2. 2.  IMAGINE you are in emergency department now. A doctor asks you :
    3. 3.  IMAGINE you are in emergency department now. A doctor asks you :
    4. 4.  IMAGINE you are in emergency department now. A doctor asks you : THIS PATIENT PRESENTS WITH CHRONIC COUGH. WHAT IS YOUR APPROACH?
    5. 5.  Situation
    6. 6.  Situation
    7. 7.  Situation - Chinese Male - Middle age - Presents with chronic cough for 2 months - Initially cough with sputum, which is whitish in colour - For recent 2 weeks, associated with blood streaks - a/w SOB & fever these 2 weeks - Went to GP before for treatment
    8. 8. INTRODUCE YOURSELF!!
    9. 9. When does the cough start?
    10. 10. When does the cough start? Onset is important – Sudden onset of violent coughing may be due to inhalation of foreign body
    11. 11. When does the cough start? Onset is important – Sudden onset of violent coughing may be due to inhalation of foreign body
    12. 12. When does the cough start? Onset is important – Sudden onset of violent coughing may be due to inhalation of foreign body
    13. 13. When does the cough start? Onset is important – Sudden onset of violent coughing may be due to inhalation of foreign body Duration is important. ◦ Acute - <3 weeks ◦ Subacute - 3-8 weeks ◦ Chronic - >8 weeks
    14. 14.  Acute cough may suggest: ◦ Upper RT  Common cold  Sinusitis ◦ Lower RT  Pneumonia  Bronchitis  Exacerbation of COPD  Inhalation of bronchial irritant (eg, smoke or fumes)
    15. 15.  Acute cough may suggest: ◦ Upper RT  Common cold  Sinusitis ◦ Lower RT  Pneumonia  Bronchitis  Exacerbation of COPD  Inhalation of bronchial irritant (eg, smoke or fumes) Don’t forget!! If sudden origin, might be inhalation of foreign body!
    16. 16. Subacute Cough 3-8 Weeks Postinfectious ◦ A cough that begins with an acute respiratory tract infection and is not complicated* by pneumonia ◦ *Not complicated = Normal lung exam normal chest X-ray ◦ Resolve without treatment ◦ Cause : PND or tracheobronchitis ◦ Indication for CXR : with abn lung exam Sinusitis Asthma
    17. 17.  Chronic cough
    18. 18.  Chronic cough ◦ COPD ◦ Pulmonary TB ◦ Asthma ◦ Gastro-esophageal reflux ◦ Upper airway cough syndrome (UACS) – d2 postnasal drip (PND) ◦ Bronchiectasis ◦ Drugs (eg, ACE inhibitors) ◦ Lung malignancy ◦ Cardiac failure / pulmonary edema ◦ Pulmonary embolism ◦ Psychogenic
    19. 19. Patients with chronic coughshould have CXR if possible.
    20. 20. “I have cough for 2 months.”
    21. 21. Do you cough up anything?What?
    22. 22. Do you cough up anything?What? Yes / No – sputum
    23. 23. Do you cough up anything?What? Yes / No – sputum
    24. 24. Do you cough up anything?What? Yes / No – sputum If yes, ask about
    25. 25. Do you cough up anything?What? Yes / No – sputum If yes, ask about ◦ Frequency of sputum (How frequent?)  Cough continuously productive of purulent sputum is suggestive of chronic bronchitis and bronchiectasis. ◦ Quantity of sputum (How much?) ◦ Appearance of sputum  Is the sputum clear or discoloured?  Is there any blood in the sputum
    26. 26.  Hemoptysis (bloody sputum)
    27. 27.  Hemoptysis (bloody sputum) ◦ If with purulent and long standing sputum  CHRONIC BRONCHITIS (small amount of blood)  BRONCHIECTASIS (large amount of sputum) ◦ If with fever, recent onset, SOB :  PNEUMONIA ◦ If + LOA, LOW, H/O smoking :  BRONCHIAL CARCINOMA ◦ If sputum is pink in color and frothy :  PULMONARY EDEMA ◦ If sudden onset  PULMONARY EMBOLISM, ACUTE RT INFECTIONS
    28. 28. ◦ If had contact with TB patients / HIV status  TB◦ If with long history of SOB  CHRONIC LUNG DSS, MITRAL STENOSIS◦ If with hematuria, proteinuria  GOODPASTURE SYNDROME,  WEGENER’S GRANULOMATOSIS (h/o sinusitis)◦ If with other bleeding sites  COAGULATION DISORDER, USE OF ANTICOAGULANTS
    29. 29.  Black carbon specks in sputum ◦ SMOKING
    30. 30.  Black carbon specks in sputum ◦ SMOKING Rust coloured ◦ PNEUMONIA (usu pneumococcal)
    31. 31.  Black carbon specks in sputum ◦ SMOKING Rust coloured ◦ PNEUMONIA (usu pneumococcal)
    32. 32.  Black carbon specks in sputum ◦ SMOKING Rust coloured ◦ PNEUMONIA (usu pneumococcal) Purulent (yellowish / green) ◦ The discoloration is due to neutrophil myeloperoxidase (it is green in colour) ◦ BRONCHIECTASIS ◦ PNEUMONIA
    33. 33.  Black carbon specks in sputum ◦ SMOKING Rust coloured ◦ PNEUMONIA (usu pneumococcal) Purulent (yellowish / green) ◦ The discoloration is due to neutrophil myeloperoxidase (it is green in colour) ◦ BRONCHIECTASIS ◦ PNEUMONIA Foul smelling dark coloured ◦ LUNG ABSCESS (ANAEROBIC)
    34. 34.  Black carbon specks in sputum ◦ SMOKING Rust coloured ◦ PNEUMONIA (usu pneumococcal) Purulent (yellowish / green) ◦ The discoloration is due to neutrophil myeloperoxidase (it is green in colour) ◦ BRONCHIECTASIS ◦ PNEUMONIA Foul smelling dark coloured ◦ LUNG ABSCESS (ANAEROBIC) Mucoid (white / milky)
    35. 35.  Black carbon specks in sputum ◦ SMOKING Rust coloured ◦ PNEUMONIA (usu pneumococcal) Purulent (yellowish / green) ◦ The discoloration is due to neutrophil myeloperoxidase (it is green in colour) ◦ BRONCHIECTASIS ◦ PNEUMONIA Foul smelling dark coloured ◦ LUNG ABSCESS (ANAEROBIC) Mucoid (white / milky)
    36. 36.  Black carbon specks in sputum ◦ SMOKING Rust coloured ◦ PNEUMONIA (usu pneumococcal) Purulent (yellowish / green) ◦ The discoloration is due to neutrophil myeloperoxidase (it is green in colour) ◦ BRONCHIECTASIS ◦ PNEUMONIA Foul smelling dark coloured ◦ LUNG ABSCESS (ANAEROBIC) Mucoid (white / milky) Frothy sputum ◦ PULMONARY EDEMA
    37. 37. CHRONIC COUGH
    38. 38. CHRONIC COUGH Productive ◦ COPD (mucoid / purulent) ◦ TB (bloodstained) ◦ Bronchiectasis (purulent) ◦ Pulmonary edema (pink, frothy) ◦ Lung cancer (bloodstained) ◦ PE (sudden onset, bloodstained)
    39. 39. CHRONIC COUGH Productive ◦ COPD (mucoid / purulent) ◦ TB (bloodstained) ◦ Bronchiectasis (purulent) ◦ Pulmonary edema (pink, frothy) ◦ Lung cancer (bloodstained) ◦ PE (sudden onset, bloodstained) Nonproductive ◦ Asthma ◦ Post-nasal drip (UACS) ◦ GORD ◦ Drugs (ACE-I)
    40. 40. “Initially I coughed with whitishsputum, now it is in red color.”
    41. 41. Associated symptoms
    42. 42. Associated symptoms Fever, recent symptoms, SOB ◦ PNEUMONIA
    43. 43. Associated symptoms Fever, recent symptoms, SOB ◦ PNEUMONIA Postnasal drip, sinus congestion, headache ◦ UACS ◦ When asked to cough, they clear the throat
    44. 44. Associated symptoms Fever, recent symptoms, SOB ◦ PNEUMONIA Postnasal drip, sinus congestion, headache ◦ UACS ◦ When asked to cough, they clear the throat Wakes a patient up ◦ CARDIAC FAILURE, GORD, ASTHMA
    45. 45. Associated symptoms Fever, recent symptoms, SOB ◦ PNEUMONIA Postnasal drip, sinus congestion, headache ◦ UACS ◦ When asked to cough, they clear the throat Wakes a patient up ◦ CARDIAC FAILURE, GORD, ASTHMA Worse in morning ◦ COPD
    46. 46. Associated symptoms Fever, recent symptoms, SOB ◦ PNEUMONIA Postnasal drip, sinus congestion, headache ◦ UACS ◦ When asked to cough, they clear the throat Wakes a patient up ◦ CARDIAC FAILURE, GORD, ASTHMA Worse in morning ◦ COPD h/o stroke, neurogenic dysphagia ◦ ASPIRATION PNEUMONIA
    47. 47.  Wheezing ◦ ASTHMA (episodic wheezing) ◦ FB / TUMOR (monophonic wheezing – intraluminal obstruction)
    48. 48.  Wheezing ◦ ASTHMA (episodic wheezing) ◦ FB / TUMOR (monophonic wheezing – intraluminal obstruction) Burning chest pain ◦ GORD
    49. 49.  Wheezing ◦ ASTHMA (episodic wheezing) ◦ FB / TUMOR (monophonic wheezing – intraluminal obstruction) Burning chest pain ◦ GORD Pleuritic chest pain ◦ PE, PNEUMONIA
    50. 50.  Wheezing ◦ ASTHMA (episodic wheezing) ◦ FB / TUMOR (monophonic wheezing – intraluminal obstruction) Burning chest pain ◦ GORD Pleuritic chest pain ◦ PE, PNEUMONIA
    51. 51.  Wheezing ◦ ASTHMA (episodic wheezing) ◦ FB / TUMOR (monophonic wheezing – intraluminal obstruction) Burning chest pain ◦ GORD Pleuritic chest pain ◦ PE, PNEUMONIA LOA, LOW, h/o smoking ◦ Lung carcinoma
    52. 52.  Wheezing ◦ ASTHMA (episodic wheezing) ◦ FB / TUMOR (monophonic wheezing – intraluminal obstruction) Burning chest pain ◦ GORD Pleuritic chest pain ◦ PE, PNEUMONIA LOA, LOW, h/o smoking ◦ Lung carcinoma Appears after meal / drinking ◦ GORD ◦ TRACHEO-ESOPHAGEAL FISTULA (rare)
    53. 53.  Wheezing ◦ ASTHMA (episodic wheezing) ◦ FB / TUMOR (monophonic wheezing – intraluminal obstruction) Burning chest pain ◦ GORD Pleuritic chest pain ◦ PE, PNEUMONIA LOA, LOW, h/o smoking ◦ Lung carcinoma Appears after meal / drinking ◦ GORD ◦ TRACHEO-ESOPHAGEAL FISTULA (rare) Joint pain, dry eyes, LN enlargement ◦ SLE, SJOGREN (with interstitial lung dss)
    54. 54. “I have difficulty in breathing and fever for the past 2 weeks.”
    55. 55. Characters of cough
    56. 56. Characters of cough Ask the patient to cough several times
    57. 57. Characters of cough Ask the patient to cough several times
    58. 58. Characters of cough Ask the patient to cough several times Lack of the usual explosive beginning may indicate vocal cord paralysis (the ‘bovine’ cough).
    59. 59. Characters of cough Ask the patient to cough several times Lack of the usual explosive beginning may indicate vocal cord paralysis (the ‘bovine’ cough).
    60. 60. Characters of cough Ask the patient to cough several times Lack of the usual explosive beginning may indicate vocal cord paralysis (the ‘bovine’ cough). A muffled, wheezy, ineffective cough suggests obstructive pulmonary disease.
    61. 61. Characters of cough Ask the patient to cough several times Lack of the usual explosive beginning may indicate vocal cord paralysis (the ‘bovine’ cough). A muffled, wheezy, ineffective cough suggests obstructive pulmonary disease.
    62. 62. Characters of cough Ask the patient to cough several times Lack of the usual explosive beginning may indicate vocal cord paralysis (the ‘bovine’ cough). A muffled, wheezy, ineffective cough suggests obstructive pulmonary disease. A very loose productive cough suggests excessive bronchial secretions due to chronic bronchitis, pneumonia or bronchiectasis.
    63. 63.  A dry, irritating cough may occur with chest infection, asthma, carcinoma of bronchus or acid irritation of the lungs in GORD. It is also typical of cough produced by ACE-I.
    64. 64.  A dry, irritating cough may occur with chest infection, asthma, carcinoma of bronchus or acid irritation of the lungs in GORD. It is also typical of cough produced by ACE-I.
    65. 65.  A dry, irritating cough may occur with chest infection, asthma, carcinoma of bronchus or acid irritation of the lungs in GORD. It is also typical of cough produced by ACE-I. A barking or croupy cough may suggest problem with URT or pertussis infection.
    66. 66.  A dry, irritating cough may occur with chest infection, asthma, carcinoma of bronchus or acid irritation of the lungs in GORD. It is also typical of cough produced by ACE-I. A barking or croupy cough may suggest problem with URT or pertussis infection.
    67. 67.  A dry, irritating cough may occur with chest infection, asthma, carcinoma of bronchus or acid irritation of the lungs in GORD. It is also typical of cough produced by ACE-I. A barking or croupy cough may suggest problem with URT or pertussis infection. DO NOT ignore the change in character of a chronic cough – it may signify a new problem (eg malignancy, infection).
    68. 68. Aggravating factors
    69. 69. Aggravating factors Cold weather
    70. 70. Aggravating factors Cold weather
    71. 71. Aggravating factors Cold weather Exertion
    72. 72. Aggravating factors Cold weather Exertion
    73. 73. Aggravating factors Cold weather Exertion Emotion/anxiety
    74. 74. Aggravating factors Cold weather Exertion Emotion/anxiety
    75. 75. Aggravating factors Cold weather Exertion Emotion/anxiety Food
    76. 76. Aggravating factors Cold weather Exertion Emotion/anxiety Food
    77. 77. Aggravating factors Cold weather Exertion Emotion/anxiety Food Work ◦ Occupational asthma (symptoms improved during weeekends)
    78. 78. Aggravating factors Cold weather Exertion Emotion/anxiety Food Work ◦ Occupational asthma (symptoms improved during weeekends) Smoke ◦ COPD
    79. 79. Relieving factors
    80. 80. Relieving factors Prop-up position
    81. 81. Relieving factors Prop-up position
    82. 82. Relieving factors Prop-up position Nebulisers
    83. 83. Relieving factors Prop-up position Nebulisers
    84. 84. Relieving factors Prop-up position Nebulisers GTN
    85. 85. Scope of problems How illness has affected you? Any medications used? Useful? Functional status now Progression of illness
    86. 86. Do you take any medicines?
    87. 87. Do you take any medicines? ACE-I
    88. 88. Do you take any medicines? ACE-I
    89. 89. Do you take any medicines? ACE-I Drugs that induced GORD ◦ Anticholinergics ◦ Beta blockers ◦ Bronchodilators for asthma ◦ Calcium channel blockers ◦ Dopamine active drugs (eg for Parkinson’s dss) ◦ Progestin ◦ Sedatives ◦ Tricyclic antidepressants
    90. 90. Do you take any medicines? ACE-I Drugs that induced GORD ◦ Anticholinergics ◦ Beta blockers ◦ Bronchodilators for asthma ◦ Calcium channel blockers ◦ Dopamine active drugs (eg for Parkinson’s dss) ◦ Progestin ◦ Sedatives ◦ Tricyclic antidepressants Oral contraceptive pills – induce PE
    91. 91. Do you take any medicines? ACE-I Drugs that induced GORD ◦ Anticholinergics ◦ Beta blockers ◦ Bronchodilators for asthma ◦ Calcium channel blockers ◦ Dopamine active drugs (eg for Parkinson’s dss) ◦ Progestin ◦ Sedatives ◦ Tricyclic antidepressants Oral contraceptive pills – induce PE
    92. 92. Do you take any medicines? ACE-I Drugs that induced GORD ◦ Anticholinergics ◦ Beta blockers ◦ Bronchodilators for asthma ◦ Calcium channel blockers ◦ Dopamine active drugs (eg for Parkinson’s dss) ◦ Progestin ◦ Sedatives ◦ Tricyclic antidepressants Oral contraceptive pills – induce PE NSAIDs and beta blockers can cause bronchospasm
    93. 93. Do you take any medicines? ACE-I Drugs that induced GORD ◦ Anticholinergics ◦ Beta blockers ◦ Bronchodilators for asthma ◦ Calcium channel blockers ◦ Dopamine active drugs (eg for Parkinson’s dss) ◦ Progestin ◦ Sedatives ◦ Tricyclic antidepressants Oral contraceptive pills – induce PE NSAIDs and beta blockers can cause bronchospasm
    94. 94. Do you take any medicines? ACE-I Drugs that induced GORD ◦ Anticholinergics ◦ Beta blockers ◦ Bronchodilators for asthma ◦ Calcium channel blockers ◦ Dopamine active drugs (eg for Parkinson’s dss) ◦ Progestin ◦ Sedatives ◦ Tricyclic antidepressants Oral contraceptive pills – induce PE NSAIDs and beta blockers can cause bronchospasm Cytotoxic agents can cause interstitial lung dss
    95. 95. Do you take any medicines? ACE-I Drugs that induced GORD ◦ Anticholinergics ◦ Beta blockers ◦ Bronchodilators for asthma ◦ Calcium channel blockers ◦ Dopamine active drugs (eg for Parkinson’s dss) ◦ Progestin ◦ Sedatives ◦ Tricyclic antidepressants Oral contraceptive pills – induce PE NSAIDs and beta blockers can cause bronchospasm Cytotoxic agents can cause interstitial lung dss
    96. 96. Do you take any medicines? ACE-I Drugs that induced GORD ◦ Anticholinergics ◦ Beta blockers ◦ Bronchodilators for asthma ◦ Calcium channel blockers ◦ Dopamine active drugs (eg for Parkinson’s dss) ◦ Progestin ◦ Sedatives ◦ Tricyclic antidepressants Oral contraceptive pills – induce PE NSAIDs and beta blockers can cause bronchospasm Cytotoxic agents can cause interstitial lung dss Steroids
    97. 97. Past medical illness
    98. 98. Past medical illness IHD / HPT / valvular heart dss / DM
    99. 99. Past medical illness IHD / HPT / valvular heart dss / DM
    100. 100. Past medical illness IHD / HPT / valvular heart dss / DM Pulm TB, childhood infections, asthma b4
    101. 101. Past medical illness IHD / HPT / valvular heart dss / DM Pulm TB, childhood infections, asthma b4
    102. 102. Past medical illness IHD / HPT / valvular heart dss / DM Pulm TB, childhood infections, asthma b4 Gastritis, OGDS b4
    103. 103. Family history
    104. 104. Family history Asthma / COPD
    105. 105. Family history Asthma / COPD
    106. 106. Family history Asthma / COPD Lung carcinoma
    107. 107. Family history Asthma / COPD Lung carcinoma
    108. 108. Family history Asthma / COPD Lung carcinoma TB
    109. 109. Family history Asthma / COPD Lung carcinoma TB
    110. 110. Family history Asthma / COPD Lung carcinoma TB CTD (eg, SLE)
    111. 111. Social history
    112. 112. Social history Smoking ◦ 1 pack year = 20 cigarettes/day for 1 year
    113. 113. Social history Smoking ◦ 1 pack year = 20 cigarettes/day for 1 year Occupational exposure ◦ Farming ◦ Mining ◦ Asbestos exposure
    114. 114. Social history Smoking ◦ 1 pack year = 20 cigarettes/day for 1 year Occupational exposure ◦ Farming ◦ Mining ◦ Asbestos exposure Animals at home (birds?)
    115. 115. Social history Smoking ◦ 1 pack year = 20 cigarettes/day for 1 year Occupational exposure ◦ Farming ◦ Mining ◦ Asbestos exposure Animals at home (birds?)
    116. 116. Social history Smoking ◦ 1 pack year = 20 cigarettes/day for 1 year Occupational exposure ◦ Farming ◦ Mining ◦ Asbestos exposure Animals at home (birds?) Recent travel
    117. 117. Social history Smoking ◦ 1 pack year = 20 cigarettes/day for 1 year Occupational exposure ◦ Farming ◦ Mining ◦ Asbestos exposure Animals at home (birds?) Recent travel
    118. 118. Social history Smoking ◦ 1 pack year = 20 cigarettes/day for 1 year Occupational exposure ◦ Farming ◦ Mining ◦ Asbestos exposure Animals at home (birds?) Recent travel TB contact
    119. 119. Physical examination -inspection
    120. 120. Physical examination -inspection Place patient in sitting position (be comfortable)
    121. 121. Physical examination -inspection Place patient in sitting position (be comfortable)
    122. 122. Physical examination -inspection Place patient in sitting position (be comfortable) General appearances ◦ Breathlessness ◦ Cachetic ◦ Alopecia ◦ On oxygen mask?
    123. 123. Physical examination -inspection Place patient in sitting position (be comfortable) General appearances ◦ Breathlessness ◦ Cachetic ◦ Alopecia ◦ On oxygen mask? RR (>25/min  tachypnea)
    124. 124. Physical examination -inspection Place patient in sitting position (be comfortable) General appearances ◦ Breathlessness ◦ Cachetic ◦ Alopecia ◦ On oxygen mask? RR (>25/min  tachypnea)
    125. 125. Physical examination -inspection Place patient in sitting position (be comfortable) General appearances ◦ Breathlessness ◦ Cachetic ◦ Alopecia ◦ On oxygen mask? RR (>25/min  tachypnea) Appearances of hand ◦ Finger clubbing ◦ Flapping tremor ◦ Tar staining ◦ Wasting / weakness of intrinsic muscles of hand ◦ Wristing swelling and tenderness (HPOA) ◦ Pulse – bounding pulse / pulsus paradoxus / …
    126. 126.  Face ◦ Facial edema and cyanosis ◦ Facial plethora ◦ Ptosis, miosis ◦ Pursed lip breathing ◦ Central cyanosis (seen in tongue) ◦ Skin changes related to CTD
    127. 127.  Face ◦ Facial edema and cyanosis ◦ Facial plethora ◦ Ptosis, miosis ◦ Pursed lip breathing ◦ Central cyanosis (seen in tongue) ◦ Skin changes related to CTD
    128. 128.  Face ◦ Facial edema and cyanosis ◦ Facial plethora ◦ Ptosis, miosis ◦ Pursed lip breathing ◦ Central cyanosis (seen in tongue) ◦ Skin changes related to CTD Neck ◦ Increased JVP ◦ Cervical LN ◦ Hoarseness of voice
    129. 129.  Chest ◦ Barrel chest ◦ Radiation marks (erythema and thickening) ◦ Use of accessory muscles of respiration ◦ Harrison’s sulcus ◦ Prominent veins ◦ Reduced chest wall movement
    130. 130.  Lower extremities ◦ Proximal muscle weakness - LEMG ◦ Ankle edema
    131. 131. Physical examination - palpation
    132. 132. Physical examination - palpation Tenderness over sinuses
    133. 133. Physical examination - palpation Tenderness over sinuses Position of trachea – important
    134. 134. Physical examination - palpation Tenderness over sinuses Position of trachea – important Tracheal tug
    135. 135. Physical examination - palpation Tenderness over sinuses Position of trachea – important Tracheal tug Lymph nodes (cervical, supraclavicular, …)
    136. 136. Physical examination - palpation Tenderness over sinuses Position of trachea – important Tracheal tug Lymph nodes (cervical, supraclavicular, …) Chest expansion
    137. 137. Physical examination - palpation Tenderness over sinuses Position of trachea – important Tracheal tug Lymph nodes (cervical, supraclavicular, …) Chest expansion Hoover’s sign
    138. 138. Physical examination - palpation Tenderness over sinuses Position of trachea – important Tracheal tug Lymph nodes (cervical, supraclavicular, …) Chest expansion Hoover’s sign Vocal fremitus
    139. 139. Physical examination - palpation Tenderness over sinuses Position of trachea – important Tracheal tug Lymph nodes (cervical, supraclavicular, …) Chest expansion Hoover’s sign Vocal fremitus Rib tenderness
    140. 140. Physical examination - palpation Tenderness over sinuses Position of trachea – important Tracheal tug Lymph nodes (cervical, supraclavicular, …) Chest expansion Hoover’s sign Vocal fremitus Rib tenderness Apex beat ◦ Shift ◦ Situs inversus
    141. 141. Physical examination - palpation Tenderness over sinuses Position of trachea – important Tracheal tug Lymph nodes (cervical, supraclavicular, …) Chest expansion Hoover’s sign Vocal fremitus Rib tenderness Apex beat ◦ Shift ◦ Situs inversus Palpable liver ◦ Liver span normal : COPD ◦ Liver span increases : metastasis from lung carcinoma
    142. 142. Causes of tracheal displacement
    143. 143. Causes of tracheal displacement Towards the side of the lung lesion ◦ Upper lobe collapse ◦ Upper lobe fibrosis ◦ Pneumonectomy
    144. 144. Causes of tracheal displacement Towards the side of the lung lesion ◦ Upper lobe collapse ◦ Upper lobe fibrosis ◦ Pneumonectomy Away from the side of the lung lesion (uncommon) ◦ Massive pleural effusion ◦ Tension pneumothorax
    145. 145. Causes of tracheal displacement Towards the side of the lung lesion ◦ Upper lobe collapse ◦ Upper lobe fibrosis ◦ Pneumonectomy Away from the side of the lung lesion (uncommon) ◦ Massive pleural effusion ◦ Tension pneumothorax Upper mediastinal mass (eg, retrosternal goiter)
    146. 146. Physical examination -percussion
    147. 147. Physical examination -percussion Of chest ◦ Hyperresonance (COPD) ◦ Dullness (consolidation, pleural thickening) ◦ Stony dull (pleural effusion)
    148. 148. Physical examination -percussion Of chest ◦ Hyperresonance (COPD) ◦ Dullness (consolidation, pleural thickening) ◦ Stony dull (pleural effusion) Liver dullness
    149. 149. Physical examination -percussion Of chest ◦ Hyperresonance (COPD) ◦ Dullness (consolidation, pleural thickening) ◦ Stony dull (pleural effusion) Liver dullness
    150. 150. Physical examination -percussion Of chest ◦ Hyperresonance (COPD) ◦ Dullness (consolidation, pleural thickening) ◦ Stony dull (pleural effusion) Liver dullness Cardiac dullness
    151. 151. Physical examination -auscultation
    152. 152. Physical examination -auscultation Decreased breath sounds ◦ COPD ◦ Pleural effusion ◦ Pneumothorax ◦ Pneumonia ◦ Large neoplasm ◦ Pulmonary collapse
    153. 153. Physical examination -auscultation Decreased breath sounds ◦ COPD ◦ Pleural effusion ◦ Pneumothorax ◦ Pneumonia ◦ Large neoplasm ◦ Pulmonary collapse Bronchial breath sounds ◦ Lung consoidation (common) ◦ Localised pulmonary fibrosis ◦ Lung collapse uncommon ◦ Pleural effusion
    154. 154. Physical examination -auscultation Decreased breath sounds ◦ COPD ◦ Pleural effusion ◦ Pneumothorax ◦ Pneumonia ◦ Large neoplasm ◦ Pulmonary collapse Bronchial breath sounds ◦ Lung consoidation (common) ◦ Localised pulmonary fibrosis ◦ Lung collapse uncommon ◦ Pleural effusion
    155. 155.  Added sounds
    156. 156.  Added sounds ◦ Wheeze  Polyphonic and bilateral  COPD (low-pitched wheeze, aka rhonchi, from larger bronchi)  Asthma (high-pitched wheeze, from smaller bronchi)  Monophonic and localized  Inhaled FB  Lung cancer  Bronchial stenosis ◦ Crackles (low pitched : rales ; high pitched : crepitation)  Fine  COPD : 1-4 per inspiration  Cardiac failure : 4-9 per inspiration  Interstitial lung dss (fibrosis) : up to 14 per inspiration  Coarse  Bronchiectasis ◦ Pleural rub
    157. 157.  Vocal resonance ◦ Found under same situations as vocal fremitus ◦ When found with bronchial breath sounds, highly suggestive of lung consolidation
    158. 158.  Vocal resonance ◦ Found under same situations as vocal fremitus ◦ When found with bronchial breath sounds, highly suggestive of lung consolidation If lung consolidation is suspected, test for ◦ Aegophony : when patient says ‘e’ as in ‘bee’, it sounds like ‘a’ in ‘bay’ ◦ Whispering pectoriloquy  Ask patient to whisper ‘99’, the whispered sound is heard clearly over the chest wall through consolidated lung
    159. 159.  I would like to finish my examination by checking the ◦ Fever chart ◦ History of smoking ◦ Sputum test ◦ Bedside peak flow meter or spirometry ◦ Oxygen saturation
    160. 160.  So now, what is cough?
    161. 161.  So now, what is cough?
    162. 162.  So now, what is cough? Coughing is a protective response to irritation of sensory receptors in the submucosa of the upper airways or bronchi.
    163. 163.  So now, what is cough? Coughing is a protective response to irritation of sensory receptors in the submucosa of the upper airways or bronchi.
    164. 164.  So now, what is cough? Coughing is a protective response to irritation of sensory receptors in the submucosa of the upper airways or bronchi. Cough is the fifth most common outpatient symptom and its differential diagnosis is fairly extensive
    165. 165.  The most common causes of cough are
    166. 166.  The most common causes of cough are ◦ Postnasal drip ◦ Asthma >75 % in most cases ◦ GORD/LPR (laryngopharyngeal reflux) * 99 % of chronic cough in non-smoking healthy adults
    167. 167.  The most common causes of cough are ◦ Postnasal drip ◦ Asthma >75 % in most cases ◦ GORD/LPR (laryngopharyngeal reflux) * 99 % of chronic cough in non-smoking healthy adults
    168. 168. Psychogenic cough
    169. 169. Psychogenic cough A diagnosis of exclusion
    170. 170. Psychogenic cough A diagnosis of exclusion
    171. 171. Psychogenic cough A diagnosis of exclusion Most common in adolescents with concomitant emotional disorders
    172. 172. Psychogenic cough A diagnosis of exclusion Most common in adolescents with concomitant emotional disorders
    173. 173. Psychogenic cough A diagnosis of exclusion Most common in adolescents with concomitant emotional disorders Does not produce sputum
    174. 174. Psychogenic cough A diagnosis of exclusion Most common in adolescents with concomitant emotional disorders Does not produce sputum
    175. 175. Psychogenic cough A diagnosis of exclusion Most common in adolescents with concomitant emotional disorders Does not produce sputum Usually does not occur at night
    176. 176. Psychogenic cough A diagnosis of exclusion Most common in adolescents with concomitant emotional disorders Does not produce sputum Usually does not occur at night
    177. 177. Psychogenic cough A diagnosis of exclusion Most common in adolescents with concomitant emotional disorders Does not produce sputum Usually does not occur at night Not affected by commonly used cough suppresants
    178. 178. I would like to divide my approach toinvestigation in 3 ways, which are blood biochemical investigation, radiological investigations, and lastly, special tests.
    179. 179. FBC
    180. 180. FBC Low Hb ◦ Chronic cough  poor oral intake  malnutrition  anemic ◦ Sputum with blood streaks ◦ Anemia in mycoplasma pneumonia (atypical)
    181. 181. FBC Low Hb ◦ Chronic cough  poor oral intake  malnutrition  anemic ◦ Sputum with blood streaks ◦ Anemia in mycoplasma pneumonia (atypical) High WCC ◦ Infection ?
    182. 182.  High neutrophils ◦ Bacterial
    183. 183.  High neutrophils ◦ Bacterial High lymphocytes ◦ Viral
    184. 184.  High neutrophils ◦ Bacterial High lymphocytes ◦ Viral Low lymphocytes ◦ Atypical Legionella pneumonia
    185. 185.  High neutrophils ◦ Bacterial High lymphocytes ◦ Viral Low lymphocytes ◦ Atypical Legionella pneumonia High eosinophils ◦ Allergy ◦ Parasites
    186. 186.  High neutrophils ◦ Bacterial High lymphocytes ◦ Viral Low lymphocytes ◦ Atypical Legionella pneumonia High eosinophils ◦ Allergy ◦ Parasites High monocytes ◦ Chemotherapy
    187. 187. RP
    188. 188. RP Signs of dehydration ◦ Hyponatremia ◦ Hyperkalemia
    189. 189. RP Signs of dehydration ◦ Hyponatremia ◦ Hyperkalemia Hyponatremia ◦ Legionella pneumonia
    190. 190. RP Signs of dehydration ◦ Hyponatremia ◦ Hyperkalemia Hyponatremia ◦ Legionella pneumonia High urea and creatinine ◦ legionella pneumonia
    191. 191. LFT
    192. 192. LFT Low albumin ◦ Chronic illness ◦
    193. 193. LFT Low albumin ◦ Chronic illness ◦ High ALT & AST ◦ legionella pneumonia
    194. 194.  ABG ◦ To assess oxygenation status
    195. 195.  ABG ◦ To assess oxygenation status ESR ◦ Sensitive but not specific indicator of dss ◦ ESR can increase in any inflammation, age, anemia (esp sickle cell anemia), polycythemia ◦ Used as indicator for chronic dss
    196. 196.  ABG ◦ To assess oxygenation status ESR ◦ Sensitive but not specific indicator of dss ◦ ESR can increase in any inflammation, age, anemia (esp sickle cell anemia), polycythemia ◦ Used as indicator for chronic dss CRP ◦ Same with ESR, but changes more rapidly ◦ Increases in hours, but falls down in 2-3 days ◦ Usage : to monitor response of treatment and dss activity
    197. 197.  Blood C&S ◦ If suspected bacteremia (aerobic and anaerobic)
    198. 198.  Blood C&S ◦ If suspected bacteremia (aerobic and anaerobic) Sputum AFB, C&S ◦ 3 times, early morning samples
    199. 199.  Blood C&S ◦ If suspected bacteremia (aerobic and anaerobic) Sputum AFB, C&S ◦ 3 times, early morning samples Mycobacterium PCR
    200. 200.  Blood C&S ◦ If suspected bacteremia (aerobic and anaerobic) Sputum AFB, C&S ◦ 3 times, early morning samples Mycobacterium PCR
    201. 201.  Blood C&S ◦ If suspected bacteremia (aerobic and anaerobic) Sputum AFB, C&S ◦ 3 times, early morning samples Mycobacterium PCR Urine UFEME, C&S ◦ Hematuria and proteinuria can be seen in Goodpasteur’s dss
    202. 202.  Blood C&S ◦ If suspected bacteremia (aerobic and anaerobic) Sputum AFB, C&S ◦ 3 times, early morning samples Mycobacterium PCR Urine UFEME, C&S ◦ Hematuria and proteinuria can be seen in Goodpasteur’s dss Serum tumor marker ◦ Not routinely done, as lung tumor does not have any tumor marker
    203. 203.  CXR ◦ Signs of pneumonia ◦ Signs of hyperinflation ◦ Signs of lung tumor – well defined circumscribed lesion, cannonball appearance ◦ TRO pneumothorax, pleural effusion
    204. 204.  CXR ◦ Signs of pneumonia ◦ Signs of hyperinflation ◦ Signs of lung tumor – well defined circumscribed lesion, cannonball appearance ◦ TRO pneumothorax, pleural effusion CT ◦ If see lung tumor in CXT
    205. 205.  CXR ◦ Signs of pneumonia ◦ Signs of hyperinflation ◦ Signs of lung tumor – well defined circumscribed lesion, cannonball appearance ◦ TRO pneumothorax, pleural effusion CT ◦ If see lung tumor in CXT HRCT ◦ In suspected bronchiectasis
    206. 206.  CXR ◦ Signs of pneumonia ◦ Signs of hyperinflation ◦ Signs of lung tumor – well defined circumscribed lesion, cannonball appearance ◦ TRO pneumothorax, pleural effusion CT ◦ If see lung tumor in CXT HRCT ◦ In suspected bronchiectasis ECG ◦ TRO CVS causes
    207. 207. Special tests LN biopsy Mantoux’s test Pleural tap
    208. 208. Acute cough Common cold / viral rhinosinusitis ◦ Symptoms :  Rhinorrhea  Sneezing  Nasal obstruction  PND ◦ Signs  +/- fever  +/- throat irritation  Normal chest auscultation ◦ Diagnostic  No lab / CXR
    209. 209.  Treatment ◦ Antihistamin (H1) + pseudoephedrine ◦ OR ◦ Naproxen
    210. 210. If treatment fails Viral vs. Bacterial Rhinosinusitis ◦ Viral  Most Common  Treat empirically ◦ Bacterial  Less Common  Treat in cases of treatment failure  Treat for set criteria
    211. 211. Criteria for BacterialRhinosinusitis Treatment failure + 2 of following : ◦ Maxillary tooth ache ◦ Purulent nasal discharge ◦ Abnormal sinus transillumination ◦ Discolored nasal discharge
    212. 212. Treatment Antihistamine + Pseudoephedrine + Oxymetazoline (Afrin) + Antibiotics against Haemopholis influenza and Streptococcus pneumonia (Bactrim TMP/Sulfa or Amoxacillin)

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