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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 medical students.

Required Skills/Procedures:

1. Perform situation-appropriate (problem-focused or complete) history and physical examinations
2. Interpret clinical information to formulate a prioritized differential diagnosis
3. Guide the creation of a patient-specific management plan

Appropriate Setting: Inpatient and Outpatient

Expected level of Responsibility: Direct supervision with real patients

Learning Topics during encounters with a patient with COUGH can include:

Medical Knowledge Learning Topics related to COUGH:

1. Criteria used to classify a cough as chronic and a cough as productive
2. Signs and symptoms associated with the most common causes of acute cough
3. Signs and symptoms associated with the most common causes of chronic cough in order to differentiate one etiology from another
4. Signs and symptoms of variant asthma and its precipitants.
5. Pathogenic, epidemiologic, and pathophysiologic differences between:

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

6. The effect of age on pathogenic, epidemiologic, and pathophysiologic factors for each of the pneumonias listed above in #5
7. Similarities and differences in etiologic pathogens and clinical presentation for acute and chronic pneumonia
8. Pathophysiology of lung abscess, post-obstructive pneumonia, and pseudotumor
9. Indications for pneumococcal and influenza immunization
10. Complications of acute bacterial pneumonia (e.g., bacteremia, sepsis, emphysema, meningitis, metastatic microabscesses)
11. Identification of patients at risk for impaired or deficient immunity
12. Community health risks of undetected or inadequately treated tuberculosis
13. The roles of antibiotic stewardship programs and other hospital basic support systems for patients with pneumonia
14. Laboratory studies that may assist in the evaluation of cough, including indications, limitations, and cost
15. Imaging studies that may assist in the evaluation of cough, including indications, limitations, and cost

Diagnostic Evaluation Learning Topics related to COUGH:

1. Age-appropriate medical history taking, documentation, and presentation that differentiate among etiologies of disease
2. Physical examination to establish the diagnosis and severity of disease, including:

  • measurement of respiratory rate, level of respiratory distress
  • examination of the nasal cavity
  • recognition of the pharyngeal signs of post-nasal drip syndrome
  • determination of the ease of air movement, presence of crackles or wheezes
  • differentiation of pleural effusion from pulmonary consolidation
  • identification of an underlying disorder by exam, including:
    • pleural effusion
    • consolidation
    • acute bronchitis
    • interstitial lung disease
    • chronic obstructive diseases

3. Prioritized differential diagnosis generation that recognizes specific history and physical exam findings, including those that distinguish acute from chronic cough and suggest a specific etiology
4. The use and timing of diagnostic and laboratory testing, both prior to and after initiating treatment, in consideration of the differential diagnosis, test performance, cost, and patient preferences, such as:

  • 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 (Ziehl Neelsen)
  • pulmonary function testing
  • cell count and chemistries of pleural fluid

5. Indications for and interpretation of the significance of the results of an arterial blood gas
6. Indications for and interpretation of a sputum gram stain

Management Plan Learning Topics related to COUGH:

1. Indications, mechanism of action, side effects, adverse reactions, and significant interactions of medications that could be prescribed for patients with cough
2. Cost-benefit considerations in the selection of therapies for chronic cough, including the use of over-the-counter medications and the identification of the cost of alternative regimens
3. Cost and cost-effectiveness of:

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

4. Therapeutic approach to the patient with cough based on the diagnosis, evidence about treatment options, patient characteristics, and patient preferences, such as:

  • the treatment of post-nasal drip, allergic rhinitis, gastroesophageal reflux, and variant asthma
  • 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
    • haemophilus pneumonia
    • aspiration/post-obstructive pneumonia
    • staphylococcal pneumonia
    • mycoplasma pneumonia
    • acute bronchitis
    • acute sinusitis
    • legionella pneumonia

5. Prognostic formulation a prognosis for the patient with cough based on the diagnosis, treatment plan, and patient characteristics
6. Communication to patients and families about the diagnosis, treatment plan, and prognosis of the disease in a caring and compassionate manner, reflecting an understanding of the emotional impact of the diagnosis and its potential effect on lifestyle
7. Patient education regarding the treatment plan
8. Patient counseling 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. Psychological support referral if indicated
10. Use of appropriate information systems to ascertain information about health system and community resources
11. Follow-up planning

Potential Differential Diagnosis Topics Include:

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