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OSCE Chart Cough (KK)(1)

OSCE Chart Cough (KK)(1)

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Published by api-26938624
Here is the cough section...all by its lonesome! Good luck!
Here is the cough section...all by its lonesome! Good luck!

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Published by: api-26938624 on Oct 17, 2008
Copyright:Attribution Non-commercial


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Page 1 of 4
Key Questions
What these questions will tell you
Physical Exam
Lab Tests
How long have you had a cough?
Note general appearance
Do you have nasal congestion or a sore throat?
Do you have a headache?
Sputum Culture
Subacute/chronic cough:
Asses Mental Status
Are you short of breath?
Sweat test
Do you have a history of heart failure?
Do you have a history of asthma?
What does the nature of the sputum tell me?
Does it have an odor?
Listen to the cough
Consistency and color of sputum?
Palpate the chest
Clear, mucoid sputum indicates allergic disorder.
How much sputum have you coughed up?
Any blood in the sputum?
What does the nature of the cough tell me?
Is the cough getting worse or more frequent?
Symptom &
tells you if it is acute (<3wks), subacute (between
3 to 8 wks), or chronic (>8wks).
Complete blood
cell count

Runny nose with cough and mild fever, followed
by persistent cough for more than one week with
clear off-white mucus greater in the morning
suggests bronchitis.

If patient is in acute
distress with oxygen
deprivation, dehydration,
and fever think bacterial
pneumonia first. If oxygen
deprivation is present but
no fever, consider foreign
body aspiration, acute
heart failure, or pulmonary

may indicate acute
infection (elevated
white blood cell

count). Eosinophilia
indicates atopy.
Do you have or have you had a fever and or

Temperature less then 38.3 C (101F) with yellow
sputum, malaise, nasal congestion and acute
cough suggests viral etiology.
Acute cough of a more serious nature is
associated with a fever greater then 38.3 C

nasal congestion with facial pain or pressure
(h/a) may be a sign of sinusitus as the cause of

dx's specific
infectious agents.

usually suggests a physical obstruction of the
airway by a foreign body or the effects of acute

Diminished level of
consciousness, confusion,
and restlessness are likely
manifestations of hypoxia.
Frequently pt's with a
pulmonary embolus
express a sence of
impending doom.

>60 mEqu/L of
chloride is diagnosic
of cystic fibrosis.

A person with hearth failure reports: orthopnea,
paroxysmal nocturnal dyspnea, cough with
possible frothy sputum, possible wt gain with
swollen feet and ankles and often a history of
heart disease.

Tuberculin skin

Acute exacerbation of asthma is characterized by
an irritating nonproductive cough that can
progress to tachypnea, dyspnea, wheezing,
cyanosis, fatigue, and respiratory and cardiac

Examine the head and

Called the Mantoux
test. If skin reaction
is less then 5mm it
is considered
negative, between 5
to 9mm is
considered a weak
positive, 9 to 14mm
diameter is
considered an
positive, and over
15mm is a strong

Most important triggars of asthma in children are
viral infections, especially respiratory syncytial
virus, parainfluenza viruses and rhinoviruses.

Erythema of upper
respiratory tract mucous
membranes, accompanied
by enlarged anterior cervial
nodes, is a common
finding in an upper
respiratory tract infection.
Observe for jugular venous
distention; this may be a
sign of heart failure.

If a child: Have you noticed the child putting
small objects in his or her mouth?
Consider a foreign body aspiration in any child
with a sudden and unexpected onset of cough.
malodorous sputum suggests amaerobic
infection of he lungs and sinuses.
Very thick, tenacious, dark sputum is
characteristic of bronchiectasis.
is it dry or moist. Whooping
or honking.

Cloudy and thick sputum suggests lower
respiratory tract infection or increaased nuber of
eosinophils from an asthmatic process.

Look for tenderness,
depression, bulges, and
crepitus. Assess for chest
symmetry by mesuring
diaphragmatic expantion
and chest excursion.

Viral bronchitis causes < two tablespoons of
mucopurulent sputum per day. Bacterial
bronchitis has > two tablespoons of
mucopurulent sputum per day.

Hemoptysis indicates a more serious disease,
such as bacterial pneumonia, acute inflammatory
bronchitis, cystic fibrosis, tumor, or a foreign

Assess for vocal fremitus-
dence tissue conducts
sound better than does air;
thus conditions such as
pneumonia, heart failure,
and tumors may increase

fremitus. Fremitus is

deacreased in
pneumothorax, asthma
and emphysema.

If cough is progressivly getting worse it may
indicate pertussis. In children a worsening cough
that is worse at night and sounds 'brassy' may
indicate croup. Persistent paroxysmal coughing
is often associated with asthma.

Page 2 of 4
Percuss the chest
What type of work do you do?
What does the cough sound like?
Auscultate heart sounds
Is anyone else at home or at school or work ill? May indicate exposure to respiratory viruses.
May indicate allergies, asthma.
Tells you they may possibly have TB.
What time of day is the cough most

If cough awakens person at night this may
indicate: asthma, chronic bronchitis or GERD or
heart failure.

Sever cough in the early morning indicates
postnasal drip, cystic fibrosis, or bronchiectasis.
Resonance (long, low-
pitch) over most lung fields.

(abnormally long, low-
pitched) may signal
emphysema or

pneumothorax. Dullness

or flatness may be pleural effusion, pneumonia, or a large tumor.

Cough worse at night indicates croup, postnasal drip, lower respiratory tract infection, and allergic reaction.

Review occupation and hobbies. Asbestos or
coal dust exposure increases a person's risk of
lung disease. Aerosol sprays, insecticides,
chemical exposures and saw dust an cause

Throat clearing cough indicates postnasal drip.
Dry, brassy cough indicates allergy or habit
cough. Loose or moist cough indicates cystic
fibrosis or asthma.

Auscultate breath

Paroxysmal cough is seen in asthma, pertussis,
cystic firbrosis and occationally after inhalation of
foreign body. A barking, croupy cough indicates
an irritation in the glottic or subglottic area.

Pt breaths through mouth
slowly and deeply.
Presents, type, and
location of both normal and
abnormal breath sounds.

A sudden short burst of a cough in infants called
a staccato cough indicates Chlamydia

A harsh, dry cough caused by airway
compression from enlarged nodes seems to
occur with tuberculosis or fungal infection.

location of normal and
abnormal heart sounds,
heart rate and rhythm.
Note any murmurs, their
grade, location and

Examine the skin and
Environmental exposure to irritants, smoke,
pollen, dust or animals?

Note cyanosis of the oral
cavity (central cyanosis)-
associated with low arterial
saturation and may result
from inadequate gas
exchange in the lungs from
cardiac shunting.

Does the patient smoke? And is the cough
geting better or worse?

Chronic cough due to smoking. A change in the
chronic cough of a smoker may indicate a new
and serious problem: pneumonia or lung cancer.

Do you have any chronic health problems, heart
disease or high blood pressure?

Chronic lung and heart disease may present with
cough, indicating an exacerbation and/or
complication of the disease.

Are you HIV + or are you receiving treatments
for cancer?

Cancer therapy and HIV and administration of
steroids should raise suspicion of
immunocompromise, which tends to increase risk
for infectious lung problems.

Blueish color of extremities
(peripheral cyanosis) may
be observed in pt's with low
venous saturation,
resulting in vascular
occlution or reduced CO

Have you been exposed to TB? Family hx of TB,
international travel, inner city habitation?

Clubbing of nails is a
manifestation of chronic
tissue hypoxia, which
occurs with chronic lung
disease. Edema of the
lower limbs may be a sign
of increased right heart
filling pressure, coused by
lung disease or left
ventricular failure.

Page 3 of 4
Physical Findings
Diagnostic Studies
Common Cold
Bordetella pertussis infection
Physical exam may be in normal limits.
Acute bronchitis
inflammation of the lung airways.
Chronic Bronchitis
Bronchogenic Carcinoma
Self limiting viral infection of URT generally caused by

red and swollen nasal mucosa with
secretions present, mild pharyngeal
erythema, and enlarged cervical lymphnodes.

Chronic Obstructive
Pulmonary Disease (COPD)

consists primarily of emphysema and chronic
bronchitis. Acute exacerbation of COPD includes 3
clinical findings: worsening dyspnea, increase in
sputum purulence and increase in sputum volume.

Barrel chest, tachypnea and distant breath

Chest radiography will show
hyperexpansion of the lungs, and
spirometry will indicate airflow
obstruction when emphysema is

Whooping cough is an acute infeton of the respiratory
tract. Begins with malaise, cough, coryza, anorexia
and progresses to high-pitched inspiratory 'whoop'.

associated with extemely high white
blood cell count.

associated with dyspnia, pleuritic chest pain, cough
with greenish or rusty-colored sputum, fever, and

fever, tachycardia and tachypnea, inspiratory
crackles, asynchronous breathing and vocal
fremitus, dull percussion sound over area of
consolidation, and bronchophony.

Chest radiography, complete blood
cell count and sputum and nasal
cultures are confirmatory.

lung auscultation reveals diffuse rhonchi on
white blood cell count is normal or
slightly elevated.
Croup (Acute

inflammation or edema of the subglottic area causes
obstruction of the airways of the larynx, trachea, or
bronchi. Parainfluenza most common cause.
Hoarseness, inspiratory stridor, barking cough worse
at night.

Inspiratory stridor, suprasternal and
intercostal retractions, and an increased
respiratory rate are seen.

Posteroanterior neck views of
radiographs show steeple sign
(narrowing of the air column at the

Postnasal drainage

most common cause of chronic cough. Dry, throat
clearing cough, sensation of something in the back of
the troat and nasal congestion.

Mucus in posterior pharynx or a cobblestone
appearance of the posterior pharynx.

Sinus radiographs, CT scan of
sinuses and allergy testing may be
indicated if this syndrome is
suspected to be the cause of cough.

most common cause of chronic cough in children.
Dry, worse at night, exercise related and often
triggared by URTI.

May hear prolonged expiratory phase,
crackles that clear with coughing, and overt or
latent wheeze with forced expiration.

Chest radiograph may show hyper
inflation during acute attacks.
Pulmonary function testing with and
without an aerosolized
sympathommetic bronchodilator is

patient expectorates sputum on most days during a
period spanning at least 3 consecutive months for
more then 2 successive years. Raspy, hacking

possible rhonchi that clear with coughing,
resonance to dull chest, possible barrel chest,
prolonged expiration, and possible wheezing.

Chest radiograph and pulmonary
function tests are indicated.
Hemoptysis in a cigarette smoker as well as wt loss
and or SOB.

enlarged suprascapular lymphnodes, dull
chest percussion over the tumor, increased
breath sounds distal to the tumor.

Chest radiograph and CT scan
indicated in hemoptysis cases.

Brassy cough. At first minimally productive with
yellow or green mucus usually on arising in the
morning. As disease progresses cough becomes
more productive.

In adults, a multinodular infiltrate above or
behind the clavical suggests recurrence of an
old TB infection. In younger persons with
recent infection unilateral pleural effusion is

often seen.

Sputum examination, the finding of
acid-fast bacilli in a sputum smear is
strong evidence. Definitive dx is
made only on results of a culture.

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