Cough on the CCFP exam

Approach

• Before you call it viral, ask about sudden one-sided chest pain, breathlessness, coughing blood and clot risks. A collapsed lung and a clot in the lung can start this way.
• Diagnose a viral illness from the history: an outbreak, sick contacts, fever, aches, a runny nose.
• Suspect a clot? Set the probability with a decision rule, such as the Wells score. Then get a D-dimer (a blood test for clots) when the rule calls for one.
• Low probability and a negative highly sensitive D-dimer: no CT angiogram (a dye scan of the lung arteries) and no lung scan.
• No antibiotic for an adult cough from a likely viral infection, even past a week. Treat only if you suspect bacterial pneumonia.
• Warn that a viral cough lasts about 18 days on average. Many patients expect 5 to 7.
• Oseltamivir is approved for uncomplicated flu when symptoms began no more than 2 days ago, from age 1. A healthy patient on day 4 is outside that window.

Approach

• Keep five causes in view: reflux, asthma, rhinitis with postnasal drip, an inhaled object, and pertussis (whooping cough).
• Ask about a choking spell, even one weeks ago. After the first coughing fit, an inhaled object can go quiet.
• A wheeze on one side, or one area that sounds quiet, points to a blocked airway, not asthma.
• Consider an X-ray when the wheeze has no allergy pattern or cold behind it. Focal chest signs are a reason to image.
• Refer to a specialist when the story fits an inhaled object.
• Pertussis brings spells of coughing, a whoop and vomiting after coughing. It can be mild in people who were immunized.
• Under age 6, asthma is a clinical diagnosis, since objective tests are hard to get. In older children, confirm it with testing.

Approach

• Think outside the lungs: reflux, heart failure, rhinitis with postnasal drip, and medicines such as angiotensin-converting enzyme (ACE) inhibitors.
• Keep the dangerous causes on the list: lung cancer, a clot in the lung, tuberculosis. Ask about smoking, weight loss, coughing blood and night sweats.
• In a child, do not settle on a lingering viral bronchitis. Work through reflux, asthma, rhinitis, an inhaled object and pertussis.
• Confirm chronic obstructive pulmonary disease (COPD) with spirometry (a breathing test) before any long-term inhaler. For asthma, get objective testing; if it is not quick to get, treat, reassess, and test when you can.
• In a wheezy child, a long course is one reason for a chest X-ray. So are low oxygen, focal chest signs and severe distress.
• Suspect a clot? Set the probability first. Low probability with a negative highly sensitive D-dimer means no CT.
• No antibiotic for an adult cough after a viral infection, even past a week, unless you suspect bacterial pneumonia.

Approach

• ACE inhibitors, the blood pressure pills ending in -pril such as ramipril, can cause a dry cough that lasts.
• The cough usually goes only after the drug is stopped or the dose is lowered.
• The product monograph lists the drug as one cause to weigh, not the only one.
• Ask what else fits: heart failure, reflux, postnasal drip, asthma, smoking or cancer.
• Coughing blood, weight loss, breathlessness or fever need a work-up, whether or not she stops the drug.
• If the drug is to blame, the cough should settle once it is stopped. If it does not, keep looking.

Approach

• Ask about daily cough with phlegm, breathlessness on exertion, chest infections that linger, and how much the patient has smoked.
• Order spirometry before and after a bronchodilator (a reliever puff).
• FEV1 is the air blown out in 1 second. FVC is all the air blown out. After the bronchodilator, a ratio below 0.70 confirms COPD.
• Many people with COPD are never diagnosed. They still have more flare-ups, pneumonia and deaths.
• Do not start a long-term inhaler until spirometry confirms COPD. Without testing, smokers with symptoms get inhalers they do not need.
• Name the diagnosis and help the patient quit. Quitting is part of COPD care from the start.