pulmonary disorders
Cough in Adults
Evaluation of Cough
 should cover the duration and characteristics of the cough (eg, whether dry or productive of sputum or blood, and whether it is accompanied by Dyspnea , should seek symptoms of possible cause, including runny nose and sore throat (upper respiratory infection [ Common Cold ], postnasal drip); fever, chills, and pleuritic chest pain ( should note recent respiratory infections (ie, within previous 1 to 2 months); history of Allergic Rhinitis , Vital signs should be reviewed for the presence of tachypnea and fever. General examination should look for signs of respiratory distress and chronic illness (eg, wasting, lethargy). Examination of the nose and throat should focus on appearance of the nasal mucosa (eg, color, congestion) and presence of discharge (external or in posterior pharynx). Ears should be examined for foreign bodies, masses, or signs of infection. The cervical and supraclavicular areas should be inspected and palpated for lymphadenopathy. A full lung examination is done, particularly including adequacy of air entry and exit; symmetry of breath sounds; and presence of crackles, wheezes (diffuse or localized), or both. Signs of consolidation (eg, egophony, dullness to percussion) should be sought. The following findings are of particular concern: Dyspnea Hemoptysis Weight loss Persistent fever Risk factors for TB or HIV infection Some findings point to particular diagnoses ( Evaluation reference —see table Other important findings are less specific. For example, the color (eg, yellow, green) and thickness of sputum do not help differentiate bacterial from other causes. Wheezing may occur with several causes. Pulse oximetry and chest x-ray should be done in patients with red flag findings of dyspnea or hemoptysis and patients in whom suspicion of pneumonia or other parenchymal lung disease is high. A chest x-ray and testing for TB and HIV infection should be done in patients with weight loss or risk factors for those infections. For many patients without red flag findings, clinicians can base the diagnosis on history and physical examination findings and begin treatment without testing. For patients without a clear cause but no red flag findings, many clinicians empirically begin treatment for postnasal drip (eg, antihistamine and decongestant combinations, nasal corticosteroid sprays, or nasal muscarinic antagonist sprays), airway hyperreactivity (eg, inhaled corticosteroid or short-acting beta-adrenergic agonist), or gastroesophageal reflux disease (eg, proton pump inhibitors, H2 blockers). An adequate response to these interventions usually precludes the need for further evaluation. A chest x-ray should be done in patients with chronic cough in whom presumptive treatment is ineffective. If the x-ray findings are unremarkable, many clinicians sequentially test for asthma (pulmonary function tests withmethacholinechallenge if standard spirometry is normal), sinus disease (sinus CT), and gastroesophageal reflux disease (esophageal pH monitoring). Sputum culture is helpful for patients with a possible indolent infection, such as pertussis, TB, or nontuberculous mycobacterial infection. Chest CT and possibly bronchoscopy should be done in patients in whom lung cancer or another bronchial tumor is suspected (eg, patients with a long smoking history, nonspecific constitutional signs) and in patients in whom empiric therapy has failed and who have inconclusive findings on preliminary testing. 1.Morice AH, Millqvist E, Bieksiene K, et al: ERS guidelines on the diagnosis and treatment of chronic cough in adults and children.Eur Respir J55(1): 1901136, 2020. doi: 10.1183/13993003.01136-2019 