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9. Obesity
Part III
Respiratory
187© Springer International Publishing AG 2018
E. Sydney et al. (eds.), Handbook of Outpatient Medicine,
https://doi.org/10.1007/978-3-319-68379-9_10
Introduction
Cough is one of the most common presentations to both pri-
mary and secondary care providers. In most cases, the cause
of cough can be identified with history, physical examination,
and simple diagnostic tests. Sometimes chronic cough can be
challenging to diagnose and treat and will require referral to
a specialist.
Decision-Making/Differential Diagnosis
Cough can be divided into acute, subacute, and chronic
based on the duration of the symptom. Acute cough exists
for less than 3 weeks, while chronic cough persists more than
8 weeks [1]. Acute cough is most commonly caused by upper
Chapter 10
Cough
Israa Soghier and Kiyoshi Kinjo
I. Soghier, MBChB, MS
Jacobi Medical Center, Pulmonary Critical Care,
1400 Pelham Pkway, Bronx, NY 10461, USA
e-mail: Israa.Soghier@nbhn.net
K. Kinjo, MD, MSc (*)
Department of Internal Medicine, Okinawa Chubu Hospital,
281 Miyazao, Uruma City, Okinawa 904-2293, Japan
e-mail: kiyoshi_kinjo@hotmail.com
188
Cough
Acute (<3 weeks)
Viral UR (commonest)
Bacterial
tracheobronchitis
Pneumonia
Acute exacerbation of
asthma, COPD or CHF
Pulmonary embolism
Pneumothorax
Acute interstitial
pneumonias
Inhaled foreign body
Toxic fume
Subacute (3-8 weeks)
Post infectious cough Asthma
Upper airway cough
syndrome
GERD
laryngopharyneal reflux
ACE inhibitor
Post infectious
COPD
Bronchiectasis
Interstitial lung disease
Cancer
Tuberculosis
Pertussis
Chronic (>8 weeks)
Fig. 10.1 Differential diagnosis of cough
I. Soghier and K. Kinjo
189
respiratory infections. Other causes include pneumonia,
bacterial tracheobronchitis, acute exacerbation of asthma,
chronic obstructive pulmonary disease (COPD), congestive
heart failure (CHF), and pulmonary embolism (PE). It can
also be an early presentation of chronic cough.
Subacute cough is most often due to postinfectious cough.
Bordetella pertussis may play a significant role. Other etiolo-
gies overlap with chronic cough.
Chronic cough should be evaluated with a stepwise
approach. After excluding the serious and obvious causes,
diagnostic work-up should focus on asthma, gastroesopha-
geal reflux disease (GERD), and rhinosinusitis (Fig. 10.1).
More than one condition was found to be contributing to the
persistence of chronic cough in up to 62% of patients [1].
Key History and Physical Exam
History taking should focus on the onset, duration of the
cough, and presence of associated symptoms like postnasal
drip, wheezing, dyspnea, and heartburn. One study suggested
that the characteristics and timing of the cough are not usually
helpful [2]. Significant sputum production points to an under-
lying pulmonary disease, e.g., bronchiectasis. Many patients
report cough starting after an upper respiratory tract infec-
tion. Searching for triggers/aggravating factors including
exposures, both at home and at work, tobacco use, and drugs
may help identify the etiology. A history of past respiratory
or heart disease should be elicited. A family history of cough
can be seen in atopic patients and in those with an anatomic
or neurological abnormality [3].
Acute cough is relatively easy to evaluate. When a patient
presents with cough accompanied by fever, rhinorrhea, mal-
aise, and myalgia/arthralgia with history of a sick contact and
he/she looks relatively healthy, the likely diagnosis is upper
respiratory infection.
Influenza has similar symptoms but is usually more severe
and can only be differentiated from viruses causing common
cold by specific testing. It can cause serious complications such
10. Cough
190
as pneumonia, acute respiratory distress syndrome, multi-
organ failure, and death. Certain patients are more susceptible
to poor outcomes, specifically elderly patients (>65 years) and
those with chronic diseases like diabetes, heart failure, chronic
pulmonary diseases including asthma and COPD, renal failure,
cancer, immunosuppressive conditions, e.g., HIV, and those
receiving immunosuppressive drugs [4].
The most important differential diagnosis is pneumonia.
Pneumonia is usually not accompanied by rhinorrhea or
other upper respiratory symptoms. Purulent sputum is com-
monly seen in pneumonia, but purulence is not specific to
pneumonia (sinusitis and bronchitis can be also associated
with purulent sputum). “Atypical pneumonia” presents often
with a dry cough. Bronchial breathing or crackles can be
present when auscultating the chest.
The Infectious Diseases Society of America (IDSA) and
the American Thoracic Society (ATS) recommend using a
prediction score, either the CURB-65 score (Table 10.1) [5]
or the pneumonia severity index (PSI) (Table 10.2) [6], to
determine whether the patient can be treated as an outpa-
tient or requires hospitalization [7]. The CURB-65 score is
less well validated than the PSI but is easier to calculate [8].
Implementing the PSI results in fewer admissions without an
Table 10.1 CURB-65 score
Confusion
Urea >20 mg/dL
Respiratory rate >=30 breaths/min
Blood pressure (systolic <90 mmHg or diastolic =<60 mmHg)
Age >=65 years
1 point is assigned per criterion
0–1 points: risk of death <3%. Treat as outpatient
2 points: risk of death 9%. Consider hospitalization
≥3 points: risk of death 15–40%. Hospitalize and consider
intensive care admission especially if 4 or 5 points
I. Soghier and K. Kinjo
191
Table 10.2 Pneumonia severity index (PSI)
Sex
M (0 points)
F (−10 points)
Demographic factors
Age (1 point for each year)
Nursing home resident (10 points)
Comorbid illness
Neoplastic disease (30 points)
Chronic liver disease (20 points)
Heart failure (10 points)
Cerebrovascular disease (10 points)
Chronic renal disease (10 points)
Physical exam findings
Altered mental status (20 points)
Respiratory rate ≥30/min (20 points)
Systolic blood pressure <90 mmHg (20 points)
Temperature <35 °C (95 °F) or ≥40 °C (104 °F) (15 points)
Pulse ≥125/min (10 points)
Laboratory and radiographic findings
Arterial pH <7.35 (30 points)
Blood urea nitrogen ≥30 mg/dL (20 points)
Sodium <130 mEq/L (20 points)
Glucose ≥250 mg/dL (10 points)
Hematocrit <30% (10 points)
Partial pressure of arterial oxygen <60 mmHg or oxygen
saturation <90% (10 points)
(continued)
10. Cough
192
increase in adverse events [9]. Other factors should also be
taken into consideration, e.g., the ability to reliably take oral
medications, the patient’s functional status, other comorbidi-
ties, and their social situation. Obtaining routine diagnostic
tests to identify an etiologic diagnosis, e.g., blood and sputum
culture, is optional for patients with community acquired
pneumonia treated at home due to their low yield and small
impact on clinical care [7].
Patients who are candidates for outpatient therapy and
have no major comorbidities (chronic heart or lung disease,
Table 10.2 (continued)
Pleural effusion (10 points)
Score Risk
class
Risk Mortality
rate (%)
≤50 years + no
points
I Low 0.1 Outpatient
≤70 II Low 0.6
71–90 III Low 0.9 Outpatient
or short
hospitalization
91–130 IV Moderate 9.3
Hospital
≥130 V High 27
Table 10.3
Differentiation among asthma, COPD, and CHF
exacerbation
Asthma COPD CHF
Cough Dry/scant sputum Purulent
sputum
Frothy pink
sputum
Orthopnea + + +
Night symptom Late night to early
morning
Early night
Leg edema − − Often
Weight gain − − +
I. Soghier and K. Kinjo