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ESSENTIAL INQUIRIES

  • Age, tobacco or cannabis use, occupational history, environmental exposures, and duration of cough.

  • Dyspnea (at rest or with exertion).

  • Vital signs (heart rate, respiratory rate, body temperature).

  • Chest examination.

  • Chest radiography when unexplained cough lasts more than 3–6 weeks.

GENERAL CONSIDERATIONS

Cough is the most common symptom for which patients seek medical attention. Cough adversely affects personal and work-related interactions, disrupts sleep, and often causes discomfort of the throat and chest wall. Most people seeking medical attention for acute cough desire symptom relief; few are worried about serious illness. Cough results from stimulation of mechanical or chemical afferent nerve receptors in the bronchial tree. Effective cough depends on an intact afferent–efferent reflex arc, adequate expiratory and chest wall muscle strength, and normal mucociliary production and clearance.

CLINICAL FINDINGS

A. Symptoms

Distinguishing acute (less than 3 weeks), persistent (3–8 weeks), and chronic (more than 8 weeks) cough illness syndromes is a useful first step in evaluation. Postinfectious cough lasting 3–8 weeks has also been referred to as subacute cough to distinguish this common, distinct clinical entity from acute and chronic cough.

1. Acute cough

In healthy adults, most acute cough syndromes are due to viral respiratory tract infections. Additional features of infection such as fever, nasal congestion, and sore throat help confirm this diagnosis. Dyspnea (at rest or with exertion) may reflect a more serious condition, and further evaluation should include assessment of oxygenation (pulse oximetry or arterial blood gas measurement), airflow (peak flow or spirometry), and pulmonary parenchymal disease (chest radiography). The timing and character of the cough are not very useful in establishing the cause of acute cough syndromes, although cough-variant asthma should be considered in adults with prominent nocturnal cough, and persistent cough with phlegm increases the likelihood of chronic obstructive pulmonary disease (COPD). The presence of posttussive emesis or inspiratory whoop in adults modestly increases the likelihood of pertussis, and the absence of paroxysmal cough and the presence of fever decrease its likelihood. Uncommon causes of acute cough should be suspected in those with heart disease (heart failure [HF]) or hay fever (allergic rhinitis) and those with occupational risk factors (such as farmworkers).

2. Persistent and chronic cough

Cough due to acute respiratory tract infection resolves within 3 weeks in the vast majority (more than 90%) of patients. Pertussis should be considered in adolescents and adults with persistent or severe cough lasting more than 3 weeks, and in selected geographic areas where its prevalence approaches 20% (although its exact prevalence is difficult to ascertain due to the limited sensitivity of diagnostic tests).

When angiotensin-converting enzyme (ACE) inhibitor therapy, acute respiratory tract infection, and chest radiograph abnormalities are absent, most cases of persistent and chronic cough are due to (or exacerbated by) postnasal drip (upper airway cough syndrome), ...

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