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Key Feature 1a: In patients presenting with an acute cough: Include serious causes (ex: pneumothorax, pulmonary embolism [PE]) in the differential diagnosis. Skill: Clinical Reasoning, Selectivity Phase: Hypothesis generation Key Feature 1b: In patients presenting with an acute cough: Diagnose a viral infection clinically, principally by taking an appropriate history. Skill: Clinical Reasoning Phase: Diagnosis Key Feature 1c: In patients presenting with an acute cough: Do not treat viral infections with antibiotics. (Consider antiviral therapy if appropriate.) Skill: Clinical Reasoning Phase: Treatment Key Feature 2: In pediatric patients with a persistent (or recurrent) cough, generate a broad differential diagnosis (ex: gastroesophageal reflux disease [GERD], asthma, rhinitis, presence of a foreign body, pertussis). Skill: Clinical reasoning Phase: Hypothesis generation Key Feature 3a: In patients with a persistent (ex: for weeks) cough: Consider non-pulmonary causes (ex: GERD, congestive heart failure, rhinitis), as well as other serious causes (ex: cancer, PE) in the differential diagnosis. (Do not assume that the child has viral bronchitis). Skill: Clinical Reasoning, Selectivity Phase: Hypothesis generation, Diagnosis Key Feature 3b: In patients with a persistent (ex: for weeks) cough: Investigate appropriately. Skill: Clinical Reasoning Phase: Investigation Key Feature 4: Do not ascribe a persistent cough to an adverse drug effect (ex: from an angiotensin-converting enzyme inhibitor) without first considering other causes. Skill: Clinical Reasoning Phase: Diagnosis Cough is a very non-specific symptom. The differential is very broad. Approaching cough requires beginning with a history and physical examination that would be very much tailored to the information you gather along the way. In any case, it is always important to ask early on if the patient has any shortness of breath. And on physical examination, it's important to look for abnormal vital signs or other abnormal signs such as may be found on examination of the chest. If the patient presents without signs of general distress, with vital signs all in the normal range, and without abnormal findings on an appropriate physical examination, then the probability of serious causes of acute cough are less likely. In fact, in a patient without any clinical suggestion of any irritant exposures (ex: in the workplace) and without a past history of underlying disease that would suggest possible alternative diagnoses (ex: acute COPD exacerbation), the acute onset clinically unremarkable cough that lasts at least 5 days (and up to 3 weeks) is most likely acute bronchitis, and it is most likely due to a virus, for which antibiotics are not indicated. If the cough is accompanied by other features suspicious for influenza (ex: myalgia, headache, sore throat, rhinitis), consider testing and treating for this if a patient would be at increased risk for complications from it. UpToDate provides a table of the characteristics that could make a patient high risk in the setting of suspected influenza infection:  Of course, the diagnosis of a benign acute bronchitis can only be made with confidence in hindsight, once a patient's cough has cleared up according to plan. If this doesn't happen, it's important to have patients return for further assessment, perhaps now with new symptoms or demonstrating new signs that were not present when they initially presented and that might suggest an alternative diagnosis. In an adult who has started an ACE inhibitor around the time when the cough started, consider that this could be the presentation of this medication's notorious side effect. At the same time, people on ACE inhibitors may have other things going on leading them to have developed the cough, so it's important not to anchor too quickly on this being the reason for the cough.
In younger pediatric patients with a persistent or recurrent cough, it is particularly important to keep a broad differential in mind as it can be difficult to obtain an accurate history. Etiologies to keep in mind for a cough in the pediatric population include gastroesophageal reflux disease, asthma, rhinitis, the presence of a foreign body, and pertussis (aka "whooping cough"). Consider a work-up or trial of empiric treatment for these possible reasons. And the longer the cough goes on, the more extensive the differential should be (ex: congestive heart failure, pulmonary embolism, cancer). Sometimes some patients will be diagnosed with the unsatisfying "nonspecific cough" (aka idiopathic cough). But it is important to at least due your due diligence and be sure you have ruled out any of the real serious reasons. This doesn't mean you should pan-scan all of your 5 year old patients with nonspecific coughs, but it does mean to at the very least do a thorough clinical assessment and investigations as indicated to be sure you haven't missed anything life-altering.
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Chronic Obstructive Pulmonary Disease Key Feature 1: In all patients presenting with symptoms of prolonged or recurrent cough, dyspnea, or decreased exercise tolerance, especially those who also have a significant smoking history, suspect the diagnosis of chronic obstructive pulmonary disease (COPD). Skill: Clinical Reasoning Phase: Hypothesis generation, Diagnosis Key Feature 2: When the diagnosis of COPD is suspected, seek confirmation with pulmonary function studies (ex: FEV1). Skill: Clinical Reasoning Phase: Investigation Key Feature 3: In patients with COPD, use pulmonary function tests periodically to document disease progression. Skill: Clinical Reasoning Phase: Investigation, Follow-up Cough Key Feature 5: In smokers with persistent cough, assess for chronic bronchitis (chronic obstructive pulmonary disease) and make a positive diagnosis when it is present. (Do not just diagnose a smoker’s cough.) Skill: Clinical Reasoning Phase: Hypothesis generation, Diagnosis In order to diagnose cases of COPD, it needs to be on your radar. It is also common, so if it's not on your radar, you are almost certainly missing "opportunities" to diagnose this disease. It should be part of your differential for any prolonged (i.e., longer than expected for the attributed disease, with a common example being the viral cough that seems to linger longer in people who smoke) or recurrent cough (like the prolonged cough, this may point to some underlying lack of lung resiliency to cope with stress). COPD is significantly more common in patients with a significant smoking history (at least 10 pack years), although it is also more common in patients who are exposed to other lung toxins as well, such as working or living in an environment with significant fumes (industrial occupations, second hand smoke, etc.). It is possible for COPD to occur sans such exposures, but the point of noting the correlation is mostly to prompt you to think of COPD whenever any patient admits to a significant smoking history, and inquiring about smoking and other substances is basic information to assess on all patients at every new visit or selectively in follow-up visits. Again, regardless, the possibility of COPD has a home in the differential diagnoses for the following common clinical presentations: Chronic cough
Dyspnea
Fatigue
If COPD is EVER suspected, further workup is warranted by spirometry. If a patient meets the criteria for a diagnosis of COPD, it is important to recognize the disease as chronic and progressive, and warranting regular followup reassessment such as every 3-6 months depending on the patient's clinical stability. Spirometry at leat every year (if stable, but otherwise sooner) is part of providing comprehensive chronic disease management. In the table above I have provided the diagnostic criteria for COPD by spirometry. Early on in the disease process, however, the patient who has underlying chronic lung changes may not have findings on spirometry that are significant enough to meet the threshold for COPD. However, these patients may still meet the diagnostic criteria for chronic bronchitis, which is a clinical diagnosis and defined as having a productive cough for 3 months in 2 consecutive years without another etiology for the cough. It is important to explain to patients that they don't just likely have a cough because they smoke, but to explain to them that there is enough evidence to suggest irreversible lung changes are happening because of smoking.
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