Case Answers:

Case answers will be presented after review of the HPI.

  Answer 1

• productive or nonproductive and character and quantity of any sputum
• exacerbating or precipitating factors
• temporal worsening: hour of day, day of week
• any symptoms of post-nasal drip or frequent throat clearing
• any over the counter meds
• any symptoms of heartburn or sour taste in mouth associated
• dyspnea
• seasonal association
• antecedent URI
• cold induced or exercise induced wheezing
• known allergies
• smoker
• sexual orientation/habits/drug usage
• does it awaken pt from sleep

Answer 2

HEENT:  sinus tenderness, nasal polyps or inflammation, posterior pharyngeal discharge……all signs of post nasal drip
- hairs on TMs……rarely seen but may cause cough
- JVD……CHF may be associated with cough

Lungs:  diffuse wheezing…..asthma
- focal wheezing…….endobronchial obstruction
- crackles……interstitial lung disease

Extremities:  edema…..CHF
- clubbing……interstitial lung disease, bronchiectasis

Answer 3
By far the three most common causes of chronic cough are:

• post nasal drip syndrome
• cough-variant asthma
• gastroesophageal reflux disease

Other, much less frequently identified, causes include: bronchitis, bronchiectasis, lung cancer, interstitial lung disease, foreign body aspiration, erosion of a calcified lymph node into the airways (broncholith), and others.

Answer 4
This patient gives little in the history and physical to suggest any particular diagnosis. As such one would consider the three most likely diagnoses of post-nasal drip, cough-variant asthma, and GERD.

Answer 5
The most cost-effective strategy at this point would be to recommend a therapeutic trial of a combined anti-histamine decongestant along with a nasal steroid spray for 2 to 3 weeks and then reevaluate.

Answer 6
If the patient does not respond at all to empiric anti-post-nasal drip therapy, it is recommended that patients be evaluated for asthma. In most circumstances this implies pulmonary function testing, including methacholine challenge.

Answer 7
Yes. Cough-variant asthma is common and describes those patients who develop cough, without dyspnea, wheezing, and/or chest tightness, as a result of bronchial hyperreactivity and bronchoconstriction.

Answer 8
For patients with mild persistent asthma, an inhaled corticosteroid used on a regular basis, along with a beta-agonist used on a PRN basis, is recommended. Occasionally, patients with predominantly nocturnal cough may be treated with either theophylline or salmeterol used before bedtime.

Answer 9
The next recommendation would be to pursue the possibility of underlying GERD. Most physicians would recommend a therapeutic trial of H2-blockers although many times high dose proton pump inhibitors are required. Whether to pursue formal esophageal pH monitoring or upper endoscopy is controversial.

Answer 10
Surprisingly, most authorities do not recommend obtaining a chest X-ray in the work-up of chronic cough until after post-nasal drip, cough-variant asthma, and GERD have been evaluated as above. However, if the patient were older and/or a chronic smoker, one would likely obtain a chest X-ray early on.