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Chronic Cough Differential diagnosis

http://bestpractice.bmj.com/best-practice/monograph/69/diagnosis/differential-diagnosis.html Common
Upper airway cough syndrome (postnasal drip) History Exam

1st test therapeutic trial: response to empirical therapyMore

Other tests

frequent throat clearing, mucopurulent secretions in the postnasal drip, nasal nasopharynx and oropharynx or discharge, nasal obstruction orcobblestone appearance of sneezing typical, halitosis posterior oropharynx Asthma History Exam

1st test spirometry with bronchodilator: reversible obstructive ventilatory defect; increase in FEV1 with bronchodilator 12% or more from baseline or 10% or more of predicted FEV1; FEV1/FVC <80% [18] More

wheezing, chest tightness, dyspnoea, symptom variability, strong FHx of wheezing and asthma/atopic disease, prolonged cough, paroxysms, expiratory exacerbation by phase on irritants or seasonal pulmonary exposures; cough may examination sometimes be the sole symptom (coughvariant asthma) [7] Gastro-oesophageal reflux disease (GORD) History Exam

Other tests morning vs midday peak expiratory flow (PEF) recording: variability >20%More exhaled nitric oxide (ENO): elevatedMore bronchoprovocation testing: provocative concentration of methacholine causing a 20% fall in FEV1 (PC20) <4 mg/mLMore

1st test

heartburn, dysphagia, acid regurgitation, association of cough no with slouched differentiating posture or eating features on suggest reflux examination disease; may be silent [17]

therapeutic trial of doublestrength proton-pump inhibitors (PPIs) for 8 weeks: alleviation of symptoms may require 8 weeks of double-strength PPI therapy, so the trial should not be considered ''negative'' before 8 weeks More

Other tests 24-hour oesophageal pH monitoring: pH <4 for 4% or more of monitoring time and coinciding with cough is consistent with pathological acid exposure More barium oesophagram: refluxMore

Non-asthmatic eosinophilic bronchitis (NAEB) History Exam chronic nonno differentiating productive cough; no features on differentiating examination features on hx

1st test sputum or bronchoalveolar lavage (BAL) differential count: eosinophiliaMore


Other tests exhaled nitric oxide (ENO): elevatedMore therapeutic response to inhaled steroids: presentMore

Chronic bronchitis History

Exam mild cases: most respiratory hx of smoking may examinations are normal, may be present; cough show quiet breath sounds, may produce prolonged expiratory phase, sputum; dyspnoea, rhonchi, or wheezes; advanced especially cases: cyanosis, barrel chest, use exertional, may of accessory muscles of accompany the inspiration, increased S2 over left cough sternal border, or peripheral oedema

1st test

Other tests

PFT: decreased FEV1, FEV1/FVC <70%, residual volume >120%, total lung capacity >120%, diffusion capacity for CO <80%More

CXR: hyperinflation, but may not be present in some cases

Angiotensin-converting enzyme inhibitor (ACE inhibitor) History dry cough, typically associated with tickling or scratching sensation in the throat; cough may begin within days or months of onset of ACE inhibitor therapy Pneumonia History Exam 1st test

Exam no specific examination findings

1st test stop ACE inhibitor use: resolution of coughMore

Other tests

fever, malaise, cough, usually productive of sputum, chest pain

dullness to percussion, decreased breath sounds, and presence of rales

CXR: infiltrate suggestive of pneumonia

Other tests WCC (blood): usually elevated but non-specific sputum Gram stain and culture: presence of microorganisms and leukocytes in a good sputum sample (<25 squamous epithelial cells per field) supports the diagnosis of respiratory tract infection

Post-infectious cough History

Exam

1st test

Other tests

cough of duration between 3 and 8 weeks following normal CXR; symptoms of acute diagnosis is respiratory infection; clinical and nasal/sinus congestion, non- one of purulent nasal discharge, exclusion sore throat [28]

CXR: normal, rules out pneumonia

WCC (blood): usually elevated but non-specific sputum Gram stain and culture: presence of microorganisms and leukocytes in a good sputum sample (<25 squamous epithelial cells per field) supports the diagnosis of respiratory tract infection

Bordetella pertussis infection History

Exam

1st test

paroxysms of cough, petechiae and post-tussive vomiting, or conjunctival inspiratory whooping haemorrhages may sound; more likely if result from cough local epidemiology paroxysms; lung suggests increase examination is prevalence typically normal

nasopharyngeal culture (if symptoms <2 weeks): positiveMore

Other tests rapid PCR, and/or serology (if symptoms present >4 weeks): positive

Uncommon
Lung cancer History hx of tobacco smoking, change in character of chronic cough, haemoptysis, hoarseness, chest pain, weight loss, superior vena cava syndrome (localised oedema of face and upper extremities, facial plethora, distended neck and chest veins), symptoms related to distant metastases and advanced stages of cancer Exam central lung cancers may cause unilateral localised wheezing; superior vena cava syndrome; cachexia and symptoms related to distant metastases (e.g., bone pain) are late symptoms 1st test

CXR: presence of the lesionMore

Other tests CT chest: presence of the lesion and locoregional disease sputum cytology: may document presence of malignant cells bronchoscopy: presence of tumourMore

Bronchiectasis and chronic suppurative lung disease History Exam cough productive of large crackles and amounts of mucopurulent wheezing, sputum, diurnal variation (e.g., predominantly over worse in the morning), lower lobes; positional worsening; dyspnoea, clubbing in the wheezing, haemoptysis; minority of patients

1st test CXR: increased bronchovascular markingsMore high-resolution CT chest: dilatations of the bronchi, size of

Other tests

PFT: irreversible obstructive defect, with FEV1/FVC

paroxysmal cough nonproductive of sputum may sometimes be present

the bronchi exceeding the size of the accompanying artery More

<70%

Interstitial pulmonary fibrosis History Exam

dyspnoea of sub- dry, velcro acute onset crackles, dominates the typically over clinical picture; lung bases; cough typically clubbing may dry be present

1st test CXR: increased interstitial markingsMore high-resolution CT chest: interstitial pneumonitis: patchy, predominantly basilar and sub-pleural reticular changes with honeycombing and traction bronchiectasis in later stages of the diseaseMore

Other tests

PFT: restrictive pattern with total lung capacity <80%, functional residual capacity <80%, and vital capacity <80%, with diffusion capacity for CO <80% biopsy: pattern of usual interstitial pneumonia

Sarcoidosis History Exam 1st test

most patients most often normal; skin asymptomatic; lesions (erythema symptomatic nodosum and patients: shortness of maculopapular skin breath, dyspnoea on lesions), enlargement of exertion, and chest lacrimal glands, pain are present in lymphadenopathy in minority of patients; cervical, supraclavicular, low-grade fever; or axillary areas; redness other symptoms of eye, tearing, and reflect involvement photophobia may of various organs represent uveitis

CXR: various findings, bilateral hilar and mediastinal lymphadenopathy, reticular infiltrates; fibrosis with decreased lung volumes in late sarcoidosisMore

Other tests chest CT with highresolution cuts: bilateral hilar and mediastinal lymphadenopathy, interstitial infiltrates PFTs (spirometry, lung volumes, diffusion capacity): often normal, but may show non-specific reduction in diffusion capacity, obstruction, restriction, or mixed picture More bronchoscopy with biopsy: non-caseating granuloma is supportive, but other granulomatous disorders should be reasonably excluded with special stains and clinical

assessmentMore

Tuberculosis History Exam

fever, cachexia, residence in/visit to hightachycardia; asymmetry prevalence area, close in chest movement and contact with active TB; dullness to percussion hx of anorexia, malaise, due to pleural effusion, weight loss, fever, or bronchial breathing, night sweats; chronic crackles, rales due to an cough productive of infiltrate or rhonchi in sputum, occasionally presence of significant associated with bronchial purulence; haemoptysis; palpable extra-thoracic immunosuppressed lymphadenopathy is status, especially AIDS uncommon

1st test CXR: primary TB: mid-lung infiltrate; secondary TB: predominantly upper lobe infiltrates with distinct tendency for fibrosis and volume lossMore

Other tests

sputum Gram stain and culture: presence of acid-fast bacilli (Ziehl-Neelsen stain) in sputum or bronchoalveolar lavage (BAL) More tuberculin skin test: positiveMore QuantiFERON: positiveMore

Foreign body History

Exam may be asymptomatic or abrupt show signs of airways onset, more obstruction, including common in cough, wheeze, decreased young breath sounds, dyspnoea, children or fever

1st test

Other tests

laryngoscopy/bronchoscopy: visualisation of foreign body CXR: visualisation of foreign body (if object is radio-opaque)

chest CT: visualisation of foreign body

Hypersensitivity pneumonitis History

Exam clubbing, occupational/environmental exposure increased to allergens (e.g., farmers, bird respiratory rate, breeders), progressive dyspnoea, inspiratory fatigue, and weight loss crackles over lower lung fields

1st test CXR: fibrotic changes; loss of lung volume particularly affect the upper lobes

Other tests

chest CT: features of fibrosis

Bronchiolitis History age <1 year, cough, wheeze, and dyspnoea, hx of prematurity, underlying cardiopulmonary disease or Exam high respiratory rate, accessory muscle use, retractions, wheezes, crackles, purulent

1st test CXR: consolidation and atelectasis in severe

Other tests virology: may be positive for respiratory syncytial

immunodeficiency

secretions on bronchoscopy

disease

virusMore high-resolution CT scan: signs of small airways disease

Recurrent aspiration History dysphagia, association of cough with eating/drinking, fear of choking with eating/drinking; may have hx of neurological disease including stroke, multiple sclerosis, Parkinson's disease Exam

1st test CXR: persistent lower lobe infiltrates swallow evaluation: aspiration More

Other tests

signs of neurological disease such as stroke, multiple sclerosis, Parkinson's disease

Psychogenic cough History extensive evaluation has ruled out other causes Exam cough improves following behaviour modification or psychiatric therapy

1st test none: extensive evaluation has already ruled out other causes

Other tests