Core Clinical Problems

1
Core Clinical Problems

• Cough

2
A man presents to you with coughing

• What would you like to know?

3
Cough

• Onset?
• Duration?
• Character?
• Nocturnal?
• Precipitating factors?
• Relieving factors?
• Sputum?
• Haemoptysis?
• Association?

4
Cough

• Onset?
• Duration?
• Character?
• Nocturnal?
• Precipitating factors?
• Relieving factors?
• Sputum?
• Haemoptysis?
• Association?

• Recent or long standing (Chronic)

5
Cough

• Onset?
• Duration?
• Character?
• Nocturnal?
• Precipitating factors?
• Relieving factors?
• Sputum?
• Haemoptysis?
• Association?

• Chronicity
• Pertussis
• TB
• Foreign body
• Asthma
• Drugs
• Bronchiectasis
• ILD

6
Cough

• Onset?
• Duration?
• Character?
• Nocturnal?
• Precipitating factors?
• Relieving factors?
• Sputum?
• Haemoptysis?
• Association?

• Brassy?
• Pressure on the trachea?

7
Cough

• Onset?
• Duration?
• Character?
• Nocturnal?
• Precipitating factors?
• Relieving factors?
• Sputum?
• Haemoptysis?
• Association?

• Hollow/Bovine?
• Laryngeal nerve palsy causing vocal cord
  dysfunction

8
Cough

• Onset?
• Duration?
• Character?
• Nocturnal?
• Precipitating factors?
• Relieving factors?
• Sputum?
• Haemoptysis?
• Association?

• Barking?
• Acute Epiglottitis

9
Cough

• Onset?
• Duration?
• Character?
• Nocturnal?
• Precipitating factors?
• Relieving factors?
• Sputum?
• Haemoptysis?
• Association?

• Dry?
• GORD
• Drugs (e.g. ACEI)

10
Cough

• Onset?
• Duration?
• Character?
• Nocturnal?
• Precipitating factors?
• Relieving factors?
• Sputum?
• Haemoptysis?
• Association?

• Change in character of a chronic cough should
  make you consider other pathology.

11
Cough

• Onset?
• Duration?
• Character?
• Nocturnal?
• Precipitating factors?
• Relieving factors?
• Sputum?
• Haemoptysis?
• Association?

• Asthma
• Also Early morning

12
Cough

• Onset?
• Duration?
• Character?
• Nocturnal?
• Precipitating factors?
• Relieving factors?
• Sputum?
• Haemoptysis?
• Association?

• Usually in asthma
• Emotion
• Weather
• Wind
• Rain
• Cold
• Dust
• Allergies
• Exercise
• Drugs

13
Cough

• Onset?
• Duration?
• Character?
• Nocturnal?
• Precipitating factors?
• Relieving factors?
• Sputum?
• Haemoptysis?
• Association?

• Avoidance of precipitating factors!

14
Cough

• Onset?
• Duration?
• Character?
• Nocturnal?
• Precipitating factors?
• Relieving factors?
• Sputum?
• Haemoptysis?
• Association?

• Presence?
• Colour
• Volume
• Consistency
• Pattern
• Consider
• Infections
• COPD
• CF
• Bronchiectatsis

15
Cough

• Onset?
• Duration?
• Character?
• Nocturnal?
• Precipitating factors?
• Relieving factors?
• Sputum?
• Haemoptysis?
• Association?

• Presence?
• Colour
• Volume
• Consistency
• Pattern
• Will be covered elsewhere!

16
Cough

• Onset?
• Duration?
• Character?
• Nocturnal?
• Precipitating factors?
• Relieving factors?
• Sputum?
• Haemoptysis?
• Association?

• Breathlessness
• Sputum
• Chest pain
• Wheeze
• Hoarseness
• Post nasal drip

17
Meet Mr Coughing 61 years old
www.badvertising.org/pages/0220How20To20BA...
18
Presentation

• Cough productive of white sputum most days over
  the past 2 years
• Life long smoker (30 per day)
• Gets breathless going up the stairs

Mr Coughing 61
19
What do you think he has?

1. Asthma
2. COPD
3. Lung Cancer
4. Sarcoid
5. Rhinitis

20
What test would you like next?

1. Spirometry
2. Spirometry with reversibility
3. Chest x-ray
4. Peak flow diary
5. Sputum cytology

21
What test would you like next?

1. Spirometry
2. Spirometry with reversibility
3. Chest x-ray
4. Peak flow diary
5. Sputum cytology

• Confirm obstructive picture
• Assess severity
• Lack of reversibility more often found in COPD
  than asthma

Mr Coughing 61
22
How would you like to treat him?

1. Smoking cessation
2. Smoking cessation plus CombiventR 2 puffs QDS
3. Beclomethasone 200 2 puffs BD
4. Pulmonary Rehabilitation
5. Salbutamol 2 puffs PRN

23
Unwell!

• He becomes unwell with fevers, sweats, increasing
  cough and sputum volume.
• Sputum is now green
• He also complains of right sided pleuritic chest
  pain and had a few crackles at the right base on
  chest auscultation

Mr Coughing 61
24
What do you think has happened?

1. Lung carcinoma
2. Lower respiratory tract infection
3. Upper respiratory tract infection
4. Pneumothorax
5. Pulmonary Embolism

25
This is his CXR
www.meddean.luc.edu/.../pulmonar/cxr/segm.htm
Mr Coughing 61
26
How would you like to treat him?

1. Oxygen
2. Nebulisers
3. Antibiotics
4. Prednisolone
5. All of these

27
6 months later

• After making a good recovery, he presents 6
  months later to his GP who asks you to see him at
  your out patient chest clinic
• You note that he has had at least 3 chest
  infections since his discharge from hospital.
• He still smokes!
• Examining him you note finger clubbing, bilateral
  inspiratory coarse crackles at the lung bases on
  chest auscultation

Mr Coughing 61
28
What investigation would you like next?

1. CT chest
2. High Resolution CT chest (HRCT)
3. Arterial Blood Gases
4. Pulmonary Function tests
5. Bronchoscopy

29
This is his HRCT
brighamrad.harvard.edu/.../hcache/211/full.html
Mr Coughing 61
30
What is the diagnosis?

1. Pulmonary fibrosis
2. Hypersensitivity Pneumonitis
3. Lung cancer
4. Lymphangioleiomyomatosis
5. Bronchiectasis

31
One year later

• Mr coughing notices that his cough has changed
  character over the past couple of weeks
• He has also noticed 5kg weight loss over the past
  month and had one episode of haemoptysis a week
  ago

Mr Coughing 61
32
This is his CXR
Mr Coughing 61
33
What should you do next?

1. Sputum cytology
2. Sputum microscopy
3. Bronchoscopy and CT chest staging
4. Lateral CXR
5. Give him Tranexaemic acid

34
This is his Bronchoscopy
Mr Coughing 61
35
Where is the tumour?

1. Left Upper Lobe
2. Bronchus intermedius
3. Right middle lobe
4. Right lower lobe
5. Left Lower lobe

36
www.lumen.luc.edu/.../mech/cases/case9/list.htm
37
www.tbalert.org/resources/resources.php
Mrs Coughing 49
38
History

• This 49-years-old lady has had a dry cough for a
  few months.
• Her BMI is 36
• She doesnt smoke
• She takes Gaviscon plus a tablet for her blood
  pressure which she cant recall

Mrs Coughing 49
39
Which of the following blood pressure tablets
might be relevant in her symptoms?

1. Ramipril
2. Bendrofluazide
3. Nifedipine
4. Atenolol
5. None of them!

40
Which of the following Blood pressure tablets
might be relevant in her symptoms?

1. Ramipril
2. Bendrofluazide
3. Nifedipine
4. Atenolol
5. None of them!

Mrs Coughing 49
41
Which of the following Blood pressure tablets
might be relevant in her symptoms?

1. Ramipril
2. Bendrofluazide
3. Nifedipine
4. Atenolol
5. None of them!

• ACE inhibitors are known to cause cough by
  inhibiting the breakdown of Bradykinin

Mrs Coughing 49
42
Which of the following Blood pressure tablets
might be relevant in her symptoms?

1. Ramipril
2. Bendrofluazide
3. Nifedipine
4. Atenolol
5. None of them!

• Beta Blockers can worsen or precipitate
  underlying asthma

Mrs Coughing 49
43
More history

• She tells you that her cough is quite bad first
  thing in the morning and sometimes wakes her up
  during the night
• She also wheezes whenever she tries to catch the
  bus

Mrs Coughing 49
44
This is her Spirometry

• FEV1 1.6L (76)
• FVC 2.4L (83)
• FEV1/FVC 67

Mrs Coughing 49
45
How would you treat her?

1. Salbutamol 2 puffs PRN
2. Salbutamol 2 puffs PRN Becotide 200 2 puffs
   B.D.
3. Nebulised Salbutamol
4. Theophylline
5. Tiotropium

46
How would you treat her?

1. Salbutamol 2 puffs PRN
2. Salbutamol 2 puffs PRN Becotide 200 2 puffs
   B.D.
3. Nebulised Salbutamol
4. Theophylline
5. Tiotropium

• You need to give her PEF meter and ask her to
  keep a diary
• Review her in a week
• Advise her to return promptly if her symptoms
  worsen

Mrs Coughing 49
47
3 months later

• Your treatment has been helpful
• She has no cough during the night but still has a
  dry cough during the day occasionally
• She also complains of quite bad heartburn and
  indigestion

Mrs Coughing 49
48
What would you advise?

1. Life style measures
2. Anti reflux treatment
3. Dietary modification
4. Exercise
5. All of the above

49
Miss Coughing 23
50
Their daughter!

• Usually keeps well
• Eczema as a child
• Presents with dry cough, lethargy and generalised
  aches and pains
• She has also developed a painful red lesion on
  her left shin

Miss Coughing 23
51
www.patient.co.uk/showdoc/40001001/
Miss Coughing 23
52
What is your next step?

1. Dermatology referral
2. Arrange skin biopsy
3. Spirometry
4. CXR
5. Peak Flow diary

53
This is her CXR
adam.about.com/encyclopedia/1613.htm
Miss Coughing 23
54
This is her CXR
adam.about.com/encyclopedia/1613.htm
Miss Coughing 23
55
What is the likely diagnosis?

1. Tuberculosis
2. Non Tuberculous mycobacterium
3. Breast cancer
4. Lymphoma
5. Sarcoidosis

56
This is their dog
www.harbourvets.co.uk/notice_board.htm
57
Just Kidding!