Case Questions for Discussion:

1. What historical questions do you want to ask about the cough? What is the significance of each; what diagnoses does each suggest?  Answer

She denies any post nasal drip or heartburn symptoms. She states the cough is dry, and worse at night. She occasionally takes Tums7 and mints. She denies dyspnea, chest tightness, or wheezing. She cannot specifically recall any preceding colds. She has no known allergies and denies any triggers to her cough. She is a non-smoker and denies HIV risk factors.    

2. What specific physical findings are you looking for, and what is the significance of each?   Answer

On physical examination, she is mildly overweight. She appears comfortable, with a RR of 12, with no accessory muscles use. HEENT exam reveals no sinus tenderness, normal appearing nasal mucosa, pharynx is without discharge or cobblestoning in the posterior aspect. Tympanic membranes are without hairs or cerumen. Neck is free of masses or thyromegaly. Lungs are clear to auscultation. Cardiac, abdominal and extremity exams are normal.    

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Questions for Discussion:

3. What are the most common causes of cough?  Answer
4. What is your prioritized differential diagnosis now, and why? Answer
5. What would you recommend at this point. Answer 

The patient returns in three weeks and reports little improvement.  

6. What would you now recommend?   Answer

PFTs show normal spirometry, but reactive airways by methacholine challenge.      

7. Even though the patient denies dyspnea, chest tightness and/or wheezing, is it likely that her cough is due to asthma? Answer
8. Based upon the NHLBI guidelines, what would you recommend? Answer
9. What would you next recommend if she fails to respond?  Answer
10. When would you consider ordering a chest X-ray?  Answer

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