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Hi guys and welcome to the next video in my series, So this is going to be covering cough as a presenting complaint and then I've got a few cases. At the end. This is going to be a fairly short video because there there isn't really too much to talk about, um but I just want to go into a bit of the nuance so what is the cough just thinking generally in the background, so coughing is a protective mechanism of your airways. So when you when you have irritation of the upper airway, which is obviously innovated by the glossopharyngeal and video nerves uh This triggers the cough mechanism as a protective mechanism generally, which is generally to clear the airways and so this is just looking at a framework for approaching a patient. The cough like any other symptom, I like to approach it thinking about it like a story, So I want to know the beginning, the middle, and the end, So when did they first notice this cough, is it an acute cough, or is it a chronic cough because that will separate the french was almost immediately, for example, an acute cause of cough might be somebody with an acute exacerbation of asthma. It may be potentially because of somebody with just a chest infection in the community acquired pneumonia, whereas the chronic cause a cough might be making me think more about obstructive disease is and interstitial fibrosis and restrictive lung disease. Is, So you want to know about the onset, the duration, and how it varies over time. So is this a cough persistent or is this cough sort of getting worse and progressively worsening over time. Is this cough coming in episodes or intermittent episodes that may be thinking more about an asthma presentation. Any other associated symptoms are heavily important, and this will be related to what you think the differential diagnosis is, So if you're thinking it's just infection, you might ask about fever and a productive nature of the cough with greenish sputum. If you're thinking this is asthma, you might ask about any chest tightness and any shortness of breath. Be thinking this is potentially somebody who's having a lung cancer. You might think about constitutional symptoms of weight loss, night sweats malay night fevers and you also want to clarify it's unintentional weight loss. It's an unexplained fever are you having drenching night sweats, so this is sort of an approach Really too, considering a cough presentation and it's always important to know is this cough productive. It's a very key question you want to know is this cough productive or is it nonproductive and if it is productive what color is the sputum is it clear, white phlegm is it green and yellow spam suggestive of bronchiectasis or infection, is it bloody and hemoptysis, which might be suggesting a more red flag presentation of lung cancer or potentially somebody with TV or sometimes very rarely, but you can get hemoptysis and pulmonary embolism as well, So this is just an approach really to a patient presenting with a cough presentation, so other aspects of the history which are important to understand include the family history, the past medical history and the social history, occupational history is really important here because you want to think about risk factors for interstitial lung disease, so occupations which can give risk factors for that may include being a farmer may include being a minor may include working with avians are working with birds. Um Past medical history is important is there a past medical history of asthma or family history of atopic conditions um and smoking is obviously a massive social risk factor to consider for copd for lung cancer for a wider variety of spiritual conditions and so just running through a framework for thinking about differential, so you can split it into your lower and upper respiratory tract, so in the lower respiratory tract you can then subdivided into obstructive and restrictive lung disease so obstructive being asthma, copd, cystic fibrosis, bronchiectasis, restrictive lung diseases include interstitial lung disease, sarcoidosis or potentially, is there a history of an autoimmune condition like lupus or rheumatoid arthritis, which can cause for many of fibrosis and then you obviously want to consider lung cancer as a sort of separate chronic cause of chronic cough with somebody with constitutional symptoms. Is important to consider, but also important to understand is that lung cancer is a very, very variable presentation and can present with a wide variety of symptoms, um not not limited to just a cough, and you always want to consider a lower respiratory tract infection, which can be bacterial can be because of TB can be, if it's a child due to a viral so viral cough is very common in children because of the example example bronculitis or something else and in light of the recent events, covid 19 is also an important differential to consider and just thinking about the upper respiratory tract and differential court's of coughing the upper respiratory tract important to understand that this is primarily centered around an upper respiratory tract infection of which sinusitis is a form of upper respiratory tract infection and this is centered around post nasal drip so uh sort of secretions um from the upper respiratory tract name, from the nasal cavity um dripping down down the nasal pharynx and then down into the airways um and that can cause irritation of the airways, which can trigger the cough mechanism. Another system is potentially, is this somebody with congestive heart failure, which can cause productive cough of print, frothy sputum or is it because of a PSA for your reflux disease, So case study one is covering a 53 55 year old man presenting to the emergency department, you're the f one that initially clerking him. He complains of a cough which he's had for the past three days, so now we already know from the stem he's having an acute cough. The cough is productive for pink for the sputum. He complains he's also been having insurance of breath, what is the most likely differential diagnosis, so most likely differential diagnosis here is acute congestive cardiac failure, and this is because of the history of shortness of breath and pink frothy sputum. So case study to you have a 45 old man presenting to your GP clinic. He's complaining of a chronic cough or five months following an upper respiratory tract infection. Upon further questioning, he also has some weight loss and fevers and so has felt constantly fatigued. His sputum is bloody, so he asked hemoptysis and he's an ex smoker considering what you think the most likely differential diagnosis is what are the further steps in imagine, mint that should be recommended, so the most appropriate management steps would be to refer him for an urgent chest x ray to be performed within two weeks for suspected lung cancer, so suspected lung cancer is quite detailed um In, in sort of what you have to do and nice CKS guidelines have great referral strategy for patient's you have suspected lung cancer, so in this scenario, referring him under a to equate for chest x ray would be an appropriate um scheme following that chest x ray. If it's a high risk for potential lung cancer, you may then refer him on the, to equate to see a respiratory specialist in a lung cancer clinic. A prescription of five days of antibiotics is more appropriate for a diagnosis of community acquired pneumonia, which you can risk stratify using the crb 65 score in primary care, and if you consider that low risk, you might consider outpatient management in primary care. A post viral cough will not persist for five months, and TV is a differential to consider, however, in this patient, lung cancer is a more, is quite common and is the more severe condition to consider in terms of management and so you would be referring him under a two week wait for a chest x ray first before considering TB assessment Final case study, we have a 28 year old woman presenting to the a. N. E. With a cough, which she's had for the last three days fever and a productive cough with greenish sputum. On examination, she has crackling of the left lower base with decreased um of resonance to percussion and increased vocal resonance, and they're equal air entry on both sides. Considering what you think the most likely differential diagnosis is what are the key investigations and um tool you would consider in their management, so this is just a recap of chest infection, so this is a very common patient presenting presentation of the community acquired pneumonia and the key investigations here would be a sputum culture and a chest x ray, so there are other important investigation such as a full blood count, um crp, potentially um other investigations which you can consider, however. The key investigations here would be a sputum culture and a chest x ray curb 65. We broke briefly, spoke about is a great tool which can be used for community provide pneumonia. It enables you to risk stratify patient's based off of a few characteristics such as whether they're confused, um so they're urea level their respiratory rate, their BP, and they're sort of age, whether it's above 65 or less than 65 in age, and if there are high risk patient, you might consider it, therefore that they require admission and intravenous antibiotics and more invasive testing, so sputum culture to diagnose also uh ascertain the underlying microorganism causing their community acquired pneumonia to therefore taylor antibiotic treatment to that organism however, a is the most appropriate management scheme to choose for this patient. Thank you for listening. I put a reference to the long plural cancers referral guideline, which is quite useful. It gives you a good overview of the referral pathway fallen cancer from primary care, and this has been a short video and cough. Thank you for listening.