University of South Florida
CASE ONE: Mrs. L. Windermere is a 73-year-old woman under your care for more than a decade. She has no chronic medical conditions and comes in once a year in the spring just to “catch up.” In this visit her only complaint is a cough. It started a month or two ago following a cold. She hadn’t been very ill – just some congestion and rhinorrhea. After those symptoms mostly resolved, she developed this cough. She asks, “Is there something you can give me for this cough?” 1. How is cough categorized? Is this a chronic cough?
According to Pratter, Brightling, Boulet, and Irwin, (2006), based on duration, cough can be divided into three categories: acute, lasting < 3 weeks; subacute, lasting between 3 and 8 weeks; and chronic, lasting > 8 weeks. Pratter et al. (2006) stated the “gold standard” for assessing the accuracy of diagnosis and the effectiveness of the physician’s management of a patient’s cough is the response to specific treatment. Pratter et al. (2006) found with acute cough the most important first step is to decide whether the acute cough is potentially life threatening (Pneumonia, Severe Exacerbation of Chronic obstructive pulmonary disorder (COPD), Pulmonary embolism (PE), or Heart Failure) or not (Upper respiratory infection (URI), Lower respiratory infection (LRI), Asthma, Bronchiectasis, Upper Airway Cough Syndrome (UACS), and COPD). Pratter et al. (2006) found that in managing patients with subacute cough the first step is to determine whether or not the cough has followed an obvious preceding respiratory infection. According to Pratter et al. (2006), if the subacute cough does not appear to be infectious in nature, it should be evaluated and managed as if it were a chronic cough however subacute cough frequently starts with an acute upper respiratory tract infection and lingers on typically falling into the category of postinfectious cough. Pratter et al. (2006) found that chronic cough is often due to more than one condition being simultaneously present and the starting point is the medical history, physical examination, and chest x-ray. A few things to consider when thinking chronic cough according to Pratter et al. (2006) are: whether the patient is on an Ace Inhibitor, a smoker, history of Tuberculosis (TB), Asthma, Gastroesophageal Reflux Disease (GERD), UACS, and Nonasthmatic eosinophilic bronchitis (NAEB). Mrs. Windermere’s cough is not technically considered a chronic cough yet. Mrs. Windermere has not had the cough for more than 8 weeks but has had it longer than 3 weeks. The cough has persisted post upper respiratory infection and therefore is classified as subacute postinfectious according to Pratter et al. (2006). 2. What’s on your differential at this point? What more would you like to know to narrow it down? My differentials at this point are Bronchitis, UACS, Asthma, Pertussis and GERD. I would like to know if she has had any fever. I would ask whether the cough is productive or non-productive and if it is productive I would like to know the color, consistency, and amount produced. I would like to know if she has a history of Asthma and if she has ever had wheezing in the past. I would ask her if she smokes or if she lives with someone who smokes. I would want to know if she has been taking an Ace Inhibitor. I would like to know if she has been experiencing any persistent rhinorrhea or nasal congestion, whether she has ever suffered from seasonal allergies, and if she has a history of GERD or heartburn. It would be important to know if she has been around anyone who has been ill recently and whether she has had any recent travel. CASE ONE CONTINUED: The patient tells you that she thought she just had a cold with no fever and no cough. The cough itself is mostly dry, occasionally productive of light yellow sputum. She’s never wheezed. She’s a life-long non-smoker as is her husband; she...
References: Bhatt SP, Nanda S, and Kintzer JS. The Lady Windermere Syndrome: Primary Care Respiratory Journal (2009); 18(4): 334-336. http://doi:10.4104/pcrj.2009.00019
Pratter MR, Brightling CE, Boulet LP, and Irwin RS. An Empiric Integrative Approach to the Management of Cough: ACCP Evidence-Based Clinical Practice Guidelines. Chest 2006, 129(1_suppl):222S-231S. http://journal.publications.chestnet.org/data/Journals/CHEST/22039/222S.pdf
Tofts RP, Olivera E, and Ferrer G. Investigate a chronic cough: Cleveland Clinic center for Continuing Education (2011); 78(2): 84-89. http://www.clevelandclinicmeded.com/medicalpubs/ccjm/investigating-chronic-cough-2-2011/
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