A 36-year-old man comes to your office because of a persistent cough that has been bothering him for the past 3 months. His cough is dry and is more frequent during the evenings. He also notes frequent nasal congestion, especially when he is exposed to dusts and cold weather. He reports no hemoptysis, weight loss, wheezing, fever, or changes in his appetite.
- What additional questions would you ask to learn more about his cough?
- How would you classify his cough based on the duration to help with the diagnosis?
- Can you make a definite diagnosis through an open-ended history followed by focused questions?
- What are the alarm features when evaluating a patient with cough?
Cough is the most common complaint encountered by office-based healthcare practitioners in the United States.1 It is important in the clearance of excessive secretions and foreign objects from the airways and is a contributing factor in the spread of infection from person to person. Cough is a mechanical reflex that involves a deep inspiration, which increases lung volume, followed by muscle contraction against a closed glottis, and then sudden opening of the glottis. Although cough may often only be a minor annoyance, it can also be a sign of severe underlying disease.
The clinician faced with a patient with an unexplained cough needs a systematic, integrated approach to this problem.2 This will limit unnecessary testing and will lead to the proper diagnosis and treatment. History and physical examination are paramount in the diagnosis of cough. First, seek potential alarm features that could represent serious illness. Second, determine the duration of the cough to narrow the differential diagnosis.
Based on duration, cough can be divided into the following 3 categories: acute, lasting less than 3 weeks; subacute, lasting between 3 and 8 weeks; and chronic, lasting greater than 8 weeks.3
|Acute cough||Episodes of cough lasting < 3 weeks.|
|Asthma||Disease characterized by episodic bronchospasm (reactive airways) and thick mucous secretions most frequently related to an allergic condition.|
|Bronchiectasis||Disorder characterized by dilated bronchial walls with chronic excessive sputum production.|
|Chronic bronchitis||Included in the spectrum of chronic obstructive pulmonary disease. Presence of chronic productive cough for 3 months in each of 2 successive years.|
|Chronic cough||Persistent cough lasting longer than 8 weeks.|
|Chronic obstructive pulmonary disease (COPD)||Disease state characterized by airflow limitation that is not fully reversible. The airflow limitation is usually both progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases.|
|Gastroesophageal reflux disease (GERD)||Reflux of the gastric contents into the esophagus, upper airway, and tracheobronchial tree (lung).|
|Hemoptysis||Cough with expectoration of bloody sputum or blood.|
|Upper airway cough syndrome (UACS)||Previously known as "postnasal drip syndrome"; characterized by abundant secretions from the upper respiratory tract that drip into the oropharynx and tracheobronchial tree, causing cough.|