Nov 29 2011

Initial Evaluation of Cough

Cough is the most common chief complaint for patients who present to their primary care physician. Therefore, it is imperative to have a systematic method of working up the cause. An article published in the Journal of the American Academy of Nurse Practitioners in August 2009 provides a good way of working up cough in the primary care setting through implementing the American College of Chest Physicians (ACCP) guidelines.

The first important question to ask the patient is about how long the cough has lasted. Cough can be divided up into three categories based upon the time course.

  • Acute: < 3 weeks
  • Subacute: 3 – 8 weeks
  • Chronic: > 8 weeks

Acute cough is the most common. It usually appears after a viral infection and goes away on its own in less than three weeks.

Subacute cough usually appears after an infection as well, but the infection could be viral or bacterial. The most common causes include pneumonia, Bordatella pertussis (whooping cough), and bronchitis. Other causes include upper airway cough syndrome (UACS), asthma, gastroesophageal reflux disease (GERD), and angiotensin converting enzyme (ACE) inhibitors.

Chronic cough is most commonly caused by UACS, asthma, GERD, smoking (because of chronic bronchitis), and ACE inhibitors. Other causes include pneumonia, pertussis, bronchitis, nonasthmatic eosinophilic bronchitis (NAEB), bronchiectasis, psychogenic cough, bronchogenic carcinoma, left ventricular failure, sarcoidosis, and tuberculosis.

Another important question to ask in the history of present illness is what makes the cough better or worse. If it gets worse during eating, think about aspiration. If it gets worse at night, think about GERD, UACS, and congestive heart failure (CHF). If there is sputum production, think about bronchitis. If there is a positive history of sick contacts, think about infectious causes.

Significant diseases to ask about in the past medical history include asthma, hypertension, hyperlipidemia, coronary artery disease, tuberculosis, cancer, and AIDS.

Key medications to ask about are ACE inhibitors and angiotensin receptor blockers (ARB). Both of these medications can cause a dry cough, although ARBs do so less commonly than ACE inhibitors.

An important immunization to ask about is pertussis. Even though this vaccination is widely given, whooping cough is still important to consider in the differential.

Significant social history to ask about is smoking. Think about chronic bronchitis and lung cancer in smokers. Also ask about exposure to occupational or environmental pollutants (such as pesticides), and contact with pets including birds and farm animals.

Main questions to ask in the review of systems:

  • Fever, chills, night sweats, and weight loss (think about infection and cancer)
  • Postnasal drip (think about UACS)
  • Pleuritic chest pain (think about pneumonia)
  • Wheezing and dyspnea (think about asthma)
  • Orthopnea (think about CHF)
  • Hemoptysis (think about pneumonia and tuberculosis)
  • Reflux and heartburn (think about GERD)

This is a good starting point to evaluate the patient with cough. It is important to classify the cough as acute, subacute, or chronic, and to provide adequate follow-up until the cause is determined. A large part of establishing the cause is evaluating the response to treatment of the most common conditions stated above.

Gahbauer, M. and Keane, P. (2009), “Chronic cough: Stepwise application in primary care practice of the ACCP guidelines for diagnosis and management of cough.” Journal of the American Academy of Nurse Practitioners, 21: 409–416. doi: 10.1111/j.1745-7599.2009.00432.x <>.

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