Chronic Cough

Case scenario

A 42 year old non-smoking woman presents with a three month history of cough after a coryzal illness. The cough is worse in the morning and rarely produces sputum.

She is not short of breath, and she has been taking an angiotensin converting enzyme (ACE) inhibitor for two years for hypertension.

common:

asthma,

chronic obstructive pulmonary disease,

postnasal drip,

gastro-oesophageal reflux disease (GORD),

drug (ACE inhibitor) induced

and

rare but more serious causes.

"Red flag" symptoms
In both smokers and non-smokers, certain features require early investigation:

• Copious production of sputum (indicating bronchiectasis)
  
• Fever, sweats, weight loss, haemoptysis (indicating tuberculosis, lymphoma, bronchial carcinoma)
  
• Considerable breathlessness with the cough (indicating heart failure, obstructive airways disease, fibrotic lung disease).

Clinical features to be elicited:

• Duration and frequency of cough
  
• Pattern of cough: productive or dry, nocturnal, postural, or associated with food
  
• Haemoptysis or chest pain
  
• Smoking history and exposure to dust
  
• Use of ACE inhibitors
  
• Red flags—for example, breathlessness, sweats, weight loss
  
• Absence of focal chest signs (including normal heart sounds)
  
• Results of spirometry or serial peak expiratory flow rate if asthma or chronic obstructive pulmonary disease is likely or if a first test of treatment fails
  
• Chest x ray if patient smokes or red flag is present; consider also if first test of treatment fails

Ref:Education > BMJ 2009;338:b1218, doi: 10.1136/bmj.b1218 (Published 24 April 2009)