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Cough

Rationale

Cough is a very common presenting complaint of patients. It is also an important presenting symptom for a variety of disorders, some of which are serious and life threatening. The most common causes of chronic cough are benign or self-limiting problems, yet large resources may be expended to exclude life-threatening disease. Recognizing the benign causes of cough and how they can be distinguished in a cost effective way from serious causes, such as cancer and pneumonia, are important training problems for third year medical students.

Prerequisites

Prior knowledge, skills and attitudes acquired during the pre-clinical (basic science) years should include:

  1. anatomy and physiology of the respiratory system
  2. anatomy and physiology of the upper airway and sinuses
  3. physiology of the cough reflex
  4. immunology related to host immunity
  5. ability to perform a medical history and physical exam of the chest
  6. microbiology including doing a gram stain

Specific Learning Objectives

  1. Knowledge: Student should be able to define and describe:
    1. the criteria used to classify a cough as chronic and a cough as productive
    2. signs and symptoms associated with the most common causes of acute cough:
      1. viral tracheitis
      2. bronchitis
      3. pneumonia
    3. signs and symptoms associated with the most common causes of chronic cough:
      1. post nasal drip
      2. asthma
      3. gastroesophageal reflux
      4. cigarette smoking
      5. lung cancer
      6. TB
      7. CHF
    4. signs and symptoms of variant asthma and its precipitants
    5. the pathogenic, epidemiologic, and pathophysiologic differences between:
      1. community-acquired vs. hospital-acquired pneumonia
      2. lobar vs. interstitial pneumonia
      3. normal host vs. immunocompromised pneumonia
      4. aspiration pneumonia vs. viral/bacterial pneumonia
    6. the effect of old age on the pathogenic, epidemiologic and pathophysiologic factors for each of the pneumonias listed above in A5
    7. the differences in pathogens and clinical presentation for chronic and acute pneumonia
    8. the pathophysiology of lung abscess, post-obstructive pneumonia, and pseudotumor
    9. the indications for pneumococcal and influenza immunization
    10. the severe complications of acute bacterial pneumonia (bacteremia, sepsis, emphysema, meningitis, metastatic microabscesses)
    11. patients who are at risk for impaired or deficient immunity
    12. the community health risks of undetected or inadequately treated tuberculosis
    13. the role of antibiotic control programs and other hospital basic support systems in the case of patient’s pneumonia
  2. Skills: Students should demonstrate specific skills including:
    1. history-taking skills: Students should be able to obtain, document and present an age-appropriate medical history, that differentiates among etiology of disease, to:
      1. obtain a thorough history of environmental/occupational allergies and determine the likelihood of atopic disease
      2. assess a patient for symptoms of gastroesphageal reflux disease
    2. physical exam skills: Students should be able to perform a physical exam to establish the diagnosis and severity of disease including:
      1. respiratory rate, effect of breathing, level of respiratory distress
      2. examination of the nasal cavity when possible
      3. recognize the pharyngeal signs of post-nasal drip syndrome
      4. distinguish rales from rhonchi and wheezes
      5. determine the presence of wheezes on forced exhalation
      6. distinguish pleural effusion from pulmonary consolidation
      7. identify the following by physical exam:
      8. pleural effusion
      9. consolidation
      10. acute bronchitis
      11. interstitial lung disease
      12. chronic obstructive diseases
    3. differential diagnosis: Students should be able to generate a prioritized differential diagnosis including:
      1. recognizing specific history and physical exam findings that both suggest chronic rather than acute cough, and suggest a specific etiology of acute cough
    4. laboratory interpretation: Students should be able to recommend when to order diagnostic and laboratory tests and be able to interpret them, both prior to and after initiating treatment based on the differential diagnosis, including consideration of test cost and performance characteristics as well as patient preferences
      1. laboratory and diagnostic, when appropriate, tests should include:
        • sinus CT examination
        • chest x-ray examination
        • barium swallow
        • cinesophagogram
        • gram stain of sputum
        • sputum culture and susceptibility reports
        • arterial blood gases
        • sputum cytology
        • acid fast stain of sputum (Zieht-Neelsen)
        • pulmonary function testing
        • cell count and chemistries of pleural fluid
    5. communication skills: Students should be able to:
      1. explain specific treatment plans for the individual patient’s situation
      2. counsel and educate patients about:
      3. environmental contributors to their disease
      4. allergen skin testing
      5. pneumococcal and influenza immunizations
      6. smoking cessation
      7. over the counter nasal decongestants sprays
    6. basic procedural skills: Students should be able to perform:
      1. arterial blood gas
      2. sputum gram stain
    7. management skills: Students should be able to design an appropriate evaluation and treatment plan for patients including:
      1. the treatment of post-nasal drip, allergic rhinitis, gastroesophageal reflux, and variant asthma
      2. suppressing cough, identifying the benefit and risks of cough suppressant therapy
      3. assessing atopic disease, including the indications for allergen skin testing
      4. identifying the presence of potential complications of bacterial and viral pneumonias including:
        • respiratory failure
        • meningitis
        • bacteremia/sepsis
        • empyema
        • pericarditis
        • selecting appropriate antimicrobial therapy for:
        • pneumococcal pneumonia
        • hemophillus pneumonia
        • aspiration/post-obstructive pneumonia
        • staphylococcal pneumonia
        • mycoplasma pneumonia
        • acute bronchitis
        • acute sinusitis
        • legionella
      5. including locating information about the cost of alternative regimens
      6. accessing and utilizing appropriate information systems and resources to help delineate issues related to cough
  3. Attitudes and Professional Behaviors: Students should be able to:
    1. demonstrate commitment to using cost-benefit considerations in the selection of drug therapies for chronic cough, including over the counter medications
    2. appreciate the functional disruption of a patient’s life caused by these illnesses