Vanderbilt University School of Medicine
VC3 – Vanderbilt Core Clinical Curriculum

Cough 

 

Cough is a very common presenting complaint of patients. It is also an important presenting symptom for a variety of disorders, some of which are serious and life-threatening. The most common causes of chronic cough are benign or self-limiting problems, yet large resources may be expended to exclude life-threatening diseases. Recognizing the benign causes of cough and how they can be distinguished in a cost effective way from serious causes, such as cancer and pneumonia, are important training problems for third year medical students.
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Prerequisites

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Describe and discuss:

  • anatomy and physiology of the respiratory system
  • anatomy and physiology of the upper airway and sinuses
  • physiology of the cough reflex
  • immunology related to host immunity

Demonstrate:

  • ability to take a medical history
  • ability to perform a  physical exam of the chest
  • ability to complete a gram stain
  • basic communication skills

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Apply Medical Knowledge in the Clinical Encounter

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1.     Describe the criteria used to classify a cough as chronic and a cough as productive.

2.     Describe the signs and symptoms associated with the most common causes of acute cough.

3.     Describe the signs and symptoms associated with the most common causes of chronic cough to differentiate on etiology from another.

4.     Describe the signs and symptoms of variant asthma and its precipitants.

5.     Describe the pathogenic, epidemiologic, and pathophysiologic differences between:

  • community-acquired vs. hospital-acquired pneumonia
  • lobar vs. interstitial pneumonia
  • normal host vs. immuno-compromised pneumonia
  • aspiration pneumonia vs. viral/bacterial pneumonia

6.     Describe the effect of old age on the pathogenic, epidemiologic, and pathophysiologic factors for each of the pneumonias listed above in #5.

7.     Describe the differences in pathogens and clinical presentation for chronic and acute pneumonia.

8.     Describe the pathophysiology of lung abscess, post-obstructive pneumonia, and pseudotumor.

9.     Describe the indications for pneumococcal and influenza immunization.

10.  Describe the severe complications of acute bacterial pneumonia (bacteremia, sepsis, emphysema, meningitis, metastatic microabscesses).

11.  Describe the patients who are at risk for impaired or deficient immunity.

12.  Describe the community health risks of undetected or inadequately treated tuberculosis.

13.  Describe the role of antibiotic control programs and other hospital basic support systems in the case of patient’s pneumonia.

14.  Describe how lab studies would help in the evaluation of cough, including their indications, limitations, and cost.

15.  Describe how imaging studies would help in the evaluation of cough, including their indications, limitations, and cost.

 

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Diagnose

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1.     Obtain, document, and present an age-appropriate medical history that differentiates among etiologies of disease.

2.     Perform a physical exam to establish the diagnosis and severity of disease including:

  • measuring respiratory rate, level of respiratory distress
  • examining the nasal cavity
  • recognizing the pharyngeal signs of post-nasal drip syndrome
  • determining ease of air movement, presence of crackles or wheezes
  • distinguishing pleural effusion from pulmonary consolidation
  •  identifying the following by exam:

 

  • pleural effusion
  • consolidation
  • acute bronchitis
  • interstitial lung disease
  • chronic obstructive diseases

 

3.     Generate a prioritized differential diagnosis that recognizes specific history and physical exam findings that distinguish chronic from acute cough and suggests a specific etiology.

4.     Recommend when to order diagnostic and laboratory tests, both prior to and after initiating treatment, based on the differential diagnosis. Justify ordering tests and interpret the results (with consultation). Consider test cost and performance characteristics as well as patient preferences.

  •  sinus CT examination
  • chest x-ray examination
  • barium swallow
  • gram stain of sputum
  • sputum culture and susceptibility reports
  • arterial blood gases
  • sputum cytology
  • acid fast stain of sputum (Zieht-Neelsen)
  •  pulmonary function testing
  • cell count and chemistries of pleural fluid

5.     Define the indications for and interpret (with consultation) the significance of the results of arterial blood gas.

6.     Define indications for, perform and interpret (with consultation) a sputum gram stain.

7.     Record, present, research, critique, and manage clinical information.

 

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Develop a Management Plan

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1.  Describe and discuss indications, mechanism of action, side effects, adverse reactions, and significant interactions of medications that could be prescribed for patients with cough.

2. Demonstrate commitment to using cost-benefit considerations in the selection of drug therapies for chronic cough, including over the counter medications. Locate information about the cost of alternative regimens.

3. Describe and compare the cost-effectiveness of:

  • various agents within each class of medications
  • interventional strategies
  • surgical approaches

4.  Design an approach to treatment for the patient with cough based on the diagnosis, evidence about treatment options, patient characteristics, and patient preferences. Include, if indicated:

  • the treatment of post-nasal drip, allergic rhinitis, gastroesophageal reflux, and variant asthma
  • cough suppression, identifying the benefit and risks of cough suppressant therapy
  • assessment of atopic disease, including the indications for allergen skin testing
  • identification of the presence of potential complications of bacterial and viral pneumonias including:
  • respiratory failure
    • meningitis
    • bacteremia/sepsis
  • empyema
  • pericarditis
  • selection of an appropriate antimicrobial therapy for:
  • pneumococcal pneumonia
  • hemophillus pneumonia
  • aspiration/post-obstructive pneumonia
  • staphylococcal pneumonia
  • mycoplasma pneumonia
  • acute bronchitis
  • acute sinusitis
  • legionella

5.   Formulate a prognosis for the patient with cough based on the diagnosis, treatment plan, and patient characteristics

6.   Communicate the diagnosis, treatment plan, and prognosis of the disease to patients and their families in a caring and compassionate manner, reflecting an understanding of the emotional impact of the diagnosis and its potential effect on lifestyle.

7.   Provide education for the patient about his or her treatment plan.

8.   Provide counseling to patients when indicated about the following issues related to prevention:

  • environmental contributors to their disease
  • allergen skin testing
  • pneumococcal and influenza immunizations
  • smoking cessation
  • over the counter nasal decongestants sprays

9.   Refer for psychological support if indicated.

10.  Access and utilize appropriate information systems to ascertain information about health system and community resources.

11.  Plan for follow-up.

 

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Differential Diagnosis

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Signs and symptoms associated with the most common causes of acute cough

  • viral tracheitis
  • bronchitis
  • pneumonia
  • foreign body in children

Signs and symptoms associated with the most common causes of chronic cough

  • post nasal drip, allergic rhinitis
  • asthma
  • gastroesophageal reflux
  • cigarette smoking
  • medication side effects (ACE inhibitors)
  • pneumonia
  • COPD
  • lung cancer
  • pulmonary tuberculosis
  • CHF
  • Interstitial lung disease