Approach to Acute Cough in Adults

Approach to Acute Cough in Adults

Cough is one of the most common complaints presenting to any emergency physician or primary care practitioner – whether it is the chief complaint or an associated symptom. An acute cough is one that has been present for less than three weeks. In the era of COVID-19, a patient presenting with an acute cough can be alarming and scary. So, now more than ever, it is important to develop a strong diagnostic approach to the acute cough, which is largely a clinical diagnosis.

Differential Diagnosis of Acute Cough

*Indicates the most common causes of acute cough.
Cause Example Symptoms / warning signs
Infectious (viral/bacterial) Upper respiratory tract infection aka common cold* Rhinorrhea, nasal obstruction, sneezing, scratchy/sore throat, malaise, headache, and no signs of consolidation
Acute bronchitis* Recent upper respiratory tract infection, and absence of COPD, and absence of high fever or other systemic signs
Influenza Fever, sore throat, nasal congestion, myalgia, headache, and no signs of consolidation
Pneumonia* Fever, tachycardia, tachypnea, consolidation signs on respiratory exam, and mental status change in patients >75y old
Pertussis Whooping cough and cough-emesis
COVID-19 Fever, non-productive cough, fatigue, dyspnea, and/or other less common symptoms such as sore throat, diarrhea, headache, skin rash, and anosmia
Post-nasal drip aka upper airway cough syndrome Post-nasal drainage sensation, need to clear throat, and rhinorrhea

Allergic rhinitis aka hay fever Itching and watering of eyes, rhinorrhea, pruritis
Exacerbation of a pre-existing chronic disease Exacerbation of Asthma   History of episodic wheezing, non-productive cough, dyspnea, reversible air-flow obstruction, allergen exposure or triggered by exercise
Exacerbation of COPD Smoking history, dyspnea, signs of obstruction on respiratory exam i.e. decreased breath sounds, and irreversible air-flow obstruction
Exacerbation of CHF Dyspnea, orthopnea, peripheral edema, gallop rhythm on cardiac exam, and elevated JVP
Drug-induced ACE inhibitor use Non-productive cough, tickling or scratchy sensation in throat typically arising within 1 week of starting medication
Gastroesophageal reflux disorder (GERD)

 

Heartburn, regurgitation, dysphagia, and cough is more prominent at night
Other pulmonary causes Pulmonary embolism Clinical signs and symptoms of DVT, dyspnea, tachypnea, tachycardia, pleuritic chest pain, immobilization for 3 or more days, surgery in the past 4 weeks, history of DVT/PE, hemoptysis, and malignancy with active treatment in the past 6 months
Lung cancer Smoking history, new change in cough, hemoptysis, dyspnea, night sweats, weight loss, and signs of focal obstruction on respiratory exam i.e. decreased breath sounds
Foreign body aspiration Dyspnea, inspiratory stridor, choking, and elevated risk in children
Acute inhalation injury History of exposure to smoke (e.g. in firefighters, thermal burn victims) or chemicals (e.g. chlorine, ammonia)
Bronchiectasis Large volumes of purulent sputum, dyspnea, wheezing, and chest pain
Interstitial lung disease Non-productive cough, dyspnea, fatigue, weight loss
         

Picture the scene: A 23-year-old female presents to the emergency department with a cough that has been ongoing for one week. What are your next steps?

History

  1. Confirm the duration and timing of cough
  2. Nature of cough, i.e. whooping, hemoptysis, and productive vs non-productive?
  3. Presence of the following associated symptoms: fever, dyspnea, sore throat, headache, chest pain, heartburn, rhinorrhea, facial pressure/pain, nasal congestion, or weight loss
  4. History of any chronic lung disease (i.e. asthma, COPD), allergies, CHF, or immunosuppression?
  5. Smoking history?
  6. Medication history, i.e. ACE inhibitor use?

Physical Exam

  1. Vitals
  2. HEENT exam (head, eyes, ears, nose, and throat)
  3. Respiratory exam
  4. Cardiac exam, including JVP

Laboratory Tests

  • Send for COVID-19 swab according to your hospital’s guidelines
  • Order CBC if suspecting infection
  • Order ABG if dyspnea present or life-threatening cause of acute cough suspected
  • Order sputum culture if suspecting bacterial pneumonia
  • Spirometry if need to differentiate between obstructive lung disease (e.g., asthma, COPD) and restrictive lung disease (e.g., interstitial lung disease)

Imaging

  • Consider starting with a Chest X-ray if red flags for serious pathology are present >> dyspnea, hemoptysis, chest pain, weight loss, immunosuppression, significant smoking history, elderly or at risk of aspiration, tachypnea or hypoxemia, abnormal cardiac or respiratory exam, or sepsis.
  • If suspecting foreign body aspiration, need to order bronchoscopy 

Please note that treatment of the conditions that may cause acute cough are not discussed in this blog post, but can be found through medical resources such as those in the references section. Treatment for acute cough often requires treating the underlying cause.

References

  1. Boujaoude ZC, Pratter MR. Clinical approach to acute cough. Lung. 2010;188 Suppl 1(Suppl 1):S41-S46. doi:10.1007/s00408-009-9170-6
  2. Holzinger F, Beck S, Dini L, Stöter C, Heintze C. The diagnosis and treatment of acute cough in adults. Dtsch Arztebl Int. 2014;111(20):356-363. doi:10.3238/arztebl.2014.0356
  3. Madison JM, Irwin RS. Cough: A worldwide problem. Otolarynogol Clin North Am. 2010 Feb;43(1):1-13, vii.
  4. Strong Medicine. An Approach to Cough. Published 25 March, 2018. https://www.youtube.com/watch?v=LDMEtNXik-A
  5. University of Toronto. Cough and Dyspnea. 2015. http://thehub.utoronto.ca/family/cough-and-dyspnea/ Accessed 17 August, 2020.

 

Cite this article as: Sheza Qayyum, Canada, "Approach to Acute Cough in Adults," in International Emergency Medicine Education Project, November 4, 2020, https://iem-student.org/2020/11/04/approach-to-acute-cough-in-adults/, date accessed: April 21, 2021

Core EM Clerkship Topics

Core EM Clerkship Topics

In the last ten years, there are few published undergraduate emergency medicine curriculum recommendations (Hobgood et al., 2009; Manthey et al., 2010; Penciner et al., 2013; Santen et al., 2014).

Current undergraduate curriculum trends recommend longitudinal and horizontal integration, and the topic lists related to emergency medicine are extensive for medical students.

In this post, we provide International Federation for Emergency Medicine and Society for Academic Emergency Medicine’s recommendations (Manthey et al., 2010; Hobgood et al., 2009).

The chosen topics can ideally be re-discussed in the clerkship during the senior years of medical school.

  • Abdominal pain
  • Altered mental status
  • Cardiac arrest and arrhythmias
  • Chest pain
  • GI bleeding
  • Headache
  • Multiple trauma
  • Poisoning
  • Respiratory distress
  • Shock

Because the length of the rotations can vary between institutions, the topics list can be extended according to the length of the clerkship and local needs.

References and Further Reading

  • Hobgood, C., Anantharaman, V., Bandiera, G., Cameron, P., Halperin, P., Holliman, J., … & International Federation for Emergency Medicine. (2009). International Federation for Emergency Medicine model curriculum for medical student education in emergency medicine. Canadian Journal of Emergency Medicine, 11(4), 349-354.
  • Manthey, D. E., Ander, D. S., Gordon, D. C., Morrissey, T., Sherman, S. C., Smith, M. D., … & Clerkship Directors in Emergency Medicine (CDEM) Curriculum Revision Group. (2010). Emergency medicine clerkship curriculum: an update and revision. Academic Emergency Medicine, 17(6), 638-643.
  • Penciner, R. (2009). Emergency medicine preclerkship observerships: evaluation of a structured experience. Canadian Journal of Emergency Medicine, 11(3), 235-239.
  • Santen, S. A., Peterson, W. J., Khandelwal, S., House, J. B., Manthey, D. E., & Sozener, C. B. (2014). Medical student milestones in emergency medicine. Academic Emergency Medicine, 21(8), 905-911.

How to make the most of your EM Clerkship

How to make the most of your EM Clerkship

Emergency Medicine has something for everyone!

Starting the Emergency Medicine (EM) Clerkship is one of the most exciting times of any medical student’s life, regardless of whichever specialty they plan on specializing in because EM has something for everyone. It is like solving all those questions that begin with ‘A patient presents to the Emergency Department with…’ but in reality, at a faster pace and with more tricky situations. This can make students feel overwhelmed, as they find themselves juggling between books and resources as to which one to follow or which topics to learn, and I am here for just that! To share the approach that helps many students get the hang of EM and make the most of their time in one of the best learning environments of any hospital.

Prepare a list of common conditions

The basic approach would be first to jot down all the problems you can think of.

Here is a list to help you get started: Core EM Clerkship Topics

There are problems that you may be heard a lot such as Chest Pain, Heart Failure, Shock (and it’s types), Acute Coronary Syndrome, Sepsis, Pulmonary edema, Respiratory Failure, Coma, Stroke, Hypoglycemia, Subarachnoid Hemorrhage, Fractures, Head Trauma, Status Epilepticus, Diabetic Ketoacidosis, and Anaphylaxis.

As every doctor you meet will always say, common is common, so always focus on things that you have heard and seen most about, read about them, make notes on their clinical features, differentials, investigations and management. Most importantly, do not forget to read about the ABCDE approach in every critically ill and trauma patient.

Brush up on your history taking and examination skills

Know what to ask and when to ask. Patients in the ED are not in their most comfortable composure, so try to practice and frame questions that provide you with just enough information to make a diagnosis in the least possible time.
The same goes for examination, never forget the basics of examination and their importance. Practice examination as much as you can and you will automatically see it come to you naturally at a faster pace. Also, do not forget focused history and physical examination is a cornerstone of EM practice and saves a lot of time.
Where investigations can help you exclude a differential, 80% of your diagnosis will be built from what you ask, what you see and what you feel. Keep in mind that if you are not thinking or looking for something, you will not see and find it. So, be suspicious of life, organ and limb-threatening problems.

Read about common ED procedures

ABG, Intubation, Central Lines, FAST Scan, Suturing, Catheter and Cannula placement are some of them. As a medical student, you will probably not be required to perform any, but it is good to have an idea about the procedures when you see them. If you can practice, then that is even better, ask a resident or intern to show you how and you can have a go yourself under their supervision! Remember, “see one, do one, teach one.”

Watch videos on examination, interpreting X-rays, & procedural skills

Youtube is an asset when it comes to medical education, make good use of it. There are also plenty of videos on the iEM website that you can watch and learn from.

Interpretation of ECG & X-rays

Google is your best friend for this! You have the list of common conditions, all you need to do is a google search on the most common ECG findings and x-rays in medical emergencies and you will be good to go. You can also always learn these from the doctors around you in the ED, as the more you see and try to interpret, the better you get at differentiating the normal from abnormal.

Books

Before the rotation

Before the rotation, read a review book, recall your basic knowledge from internal medicine/family medicine and surgery because EM almost covers all of the acute problems of those fields. Moreover, do not forget, EM is an independent specialty and has its’ own textbooks.

iEM Clerkship book is a very good source to get started with! Download Now! – iEM Book (iBook and pdf)

If you are the kind, who likes solving questions, the Pretest Emergency Medicine is a great source.

During the rotation

During the rotation – Learning what you see is the best way to keep things in your long term memory. After your shift ends, and you go home, get some rest, recall the cases of the day and read about them on Up to Date/ Medscape or any resource that you prefer, this will help you relate what you saw with what you are reading and will help you recall it better later on.

These are just a few tips to help in making the most of your EM rotation. Remember to study hard, but also practice, brush up on your communication skills, talk to patients, be there for them. The EM Clerkship prepares you for life as a doctor, as you practice every aspect of medicine during this time and learn to answer questions about acute medical problems and their severity when asked by those around you.

Cite this article as: Sumaiya Hafiz, UAE, "How to make the most of your EM Clerkship," in International Emergency Medicine Education Project, October 4, 2019, https://iem-student.org/2019/10/04/how-to-make-the-most-of-your-em-clerkship/, date accessed: April 21, 2021

17 years old girl, previously known healthy, vomited blood!

720 - variceal bleeding

17 years old girl, previously known healthy, vomited blood!
This is an extremely serious symptom. Although this patient’s vitals were totally in the normal range, actively vomiting blood should warn physicians to act immediately to protect further deterioration in the patient. This may even include early airway protection because we simply do not want them to aspirate any blood. Having a normal vitals with this picture does not mean anything, and should not create a relaxing environment in the treatment/resuscitation bay. Honestly, this patient should go directly to resuscitation bed from the triage.

Steps are straightforward. Protect the airway if necessary, start oxygen like in any other critically ill patient during/for primary evaluation(survey). Open the two large bore IV line, give fluid bolus, order type, and cross, and be ready for any deterioration in the BP and starting blood (ORh-). Obviously, even starting a transfusion earlier may be appropriate. Activating GI team for emergency endoscopy is necessary. However, some institutions may not have this luxury 24 hours. Therefore, other measures such as mechanical compressions with Sengstaken-Blakemore tube and some medications can be an only option. This patients final diagnosis was Variceal Bleeding. 

To learn more about management please read two GI bleeding chapters below.

Massive Gastrointestinal Bleeding by Dan O’Brien

Gastrointestinal Bleeding by Moira Carrol, Gurpreet Mudan, and Suzanne Bentley

Core Topics for EM Clerkship

Core EM clerkship topics recommended by SAEM are ready for students. Feel free to read or listen. And, do not forget to share with your colleagues or students. Sharing is caring!

Shock

by Maryam AlBadwawi Introduction Shock, in simple terms, is a reduced circulatory blood flow state within the body. The inadequate circulation deprives the tissues of its

Read More »

Chest Pain

by Asaad S Shujaa Introduction Chest pain is one of the most common symptoms presented in the emergency department (ED), and it is worrisome because

Read More »

Gastrointestinal Bleeding

by Moira Carrol, Gurpreet Mudan, and Suzanne Bentley Case Presentation A 61-year-old man with a history of liver cirrhosis secondary to chronic EtOH abuse presents to

Read More »

Headache

by Matevz Privsek and Gregor Prosen Introduction Headache is a subjective feeling of pain, crushing, squeezing or stabbing anywhere in the head. They are typically

Read More »

Respiratory Distress

by Ebru Unal Akoglu Case Presentation A 40-year-old female with a history of diabetes mellitus presents with a complaint of 6 days cough and muscle

Read More »

Multiple Trauma

by Pia Jerot and Gregor Prosen Case Presentation A 28-year old male was a restrained driver in a head-on motor vehicle collision. He was entrapped and

Read More »

Poisonings

by Harajeshwar Kohli and Ziad Kazzi Case An 18-year-old, previously healthy female, presents to the Emergency Department with nausea, vomiting, and tremors. She states 45

Read More »

Cardiac Arrest

by Abdel Noureldin and Falak Sayed Quick link to Spanish Version Introduction A 23-year-old female was brought into the emergency department. Her frantic family members

Read More »

Altered Mental Status

by Murat Cetin, Begum Oktem, Mustafa Emin Canakci  Case Presentation An 80-year-old female presents to the emergency department with a tendency to sleep (altered mental

Read More »

Abdominal Pain

by Shaza Karrar Case Presentation A 39-year-old female presented to the emergency department (ED) complaining of right-lower-quadrant (RLQ) pain; pain duration was for 1-day, associated

Read More »

A 69-year-old male with altered mental status

In case you didn’t encounter an elderly with altered mental status today!

631.1 - subdural

A 69-year-old male was brought to the ED by EMS because of altered mental status described by relatives. He hardly communicates and is not oriented. He has a motor weakness on the left upper and lower extremities 2 and 3 out of 5, respectively. BP: 183/88 mmHg. Other vitals are in normal range. CT scan image is given. What is next?

iEM Education Project Team uploads many clinical picture and videos to the Flickr and YouTube. These images are free to use in education. You can also support this global EM education initiative by providing your resources. Sharing is caring!

From experts to our students! – “Poisoning”

Happy educational week!

You can listen all EM clerkship core topics.

Do you need clinical images/videos?

Visit our Flickr channel

Visit our YouTube channel

SAEM/CDEM EM Clerkship Core Topics

Abdominal Pain

by Shaza Karrar Case Presentation A 39-year-old female presented to the emergency department (ED) complaining of right-lower-quadrant (RLQ) pain; pain duration was for 1-day, associated

Read More »

Altered Mental Status

by Murat Cetin, Begum Oktem, Mustafa Emin Canakci  Case Presentation An 80-year-old female presents to the emergency department with a tendency to sleep (altered mental

Read More »

Cardiac Arrest

by Abdel Noureldin and Falak Sayed Quick link to Spanish Version Introduction A 23-year-old female was brought into the emergency department. Her frantic family members

Read More »

Poisonings

by Harajeshwar Kohli and Ziad Kazzi Case An 18-year-old, previously healthy female, presents to the Emergency Department with nausea, vomiting, and tremors. She states 45

Read More »

Multiple Trauma

by Pia Jerot and Gregor Prosen Case Presentation A 28-year old male was a restrained driver in a head-on motor vehicle collision. He was entrapped and

Read More »

Respiratory Distress

by Ebru Unal Akoglu Case Presentation A 40-year-old female with a history of diabetes mellitus presents with a complaint of 6 days cough and muscle

Read More »

Headache

by Matevz Privsek and Gregor Prosen Introduction Headache is a subjective feeling of pain, crushing, squeezing or stabbing anywhere in the head. They are typically

Read More »

Gastrointestinal Bleeding

by Moira Carrol, Gurpreet Mudan, and Suzanne Bentley Case Presentation A 61-year-old man with a history of liver cirrhosis secondary to chronic EtOH abuse presents to

Read More »

Chest Pain

by Asaad S Shujaa Introduction Chest pain is one of the most common symptoms presented in the emergency department (ED), and it is worrisome because

Read More »

Shock

by Maryam AlBadwawi Introduction Shock, in simple terms, is a reduced circulatory blood flow state within the body. The inadequate circulation deprives the tissues of its

Read More »

Core EM Clerkship Topics

Core EM Clerkship Topics

Core EM clerkship topics recommended by SAEM are ready for students. Feel free to read or listen. And, do not forget to share with your colleagues and students. Sharing is caring!

Shock

by Maryam AlBadwawi Introduction Shock, in simple terms, is a reduced circulatory blood flow state within the body. The inadequate circulation deprives the tissues of its

Read More »

Chest Pain

by Asaad S Shujaa Introduction Chest pain is one of the most common symptoms presented in the emergency department (ED), and it is worrisome because

Read More »

Gastrointestinal Bleeding

by Moira Carrol, Gurpreet Mudan, and Suzanne Bentley Case Presentation A 61-year-old man with a history of liver cirrhosis secondary to chronic EtOH abuse presents to

Read More »

Headache

by Matevz Privsek and Gregor Prosen Introduction Headache is a subjective feeling of pain, crushing, squeezing or stabbing anywhere in the head. They are typically

Read More »

Respiratory Distress

by Ebru Unal Akoglu Case Presentation A 40-year-old female with a history of diabetes mellitus presents with a complaint of 6 days cough and muscle

Read More »

Multiple Trauma

by Pia Jerot and Gregor Prosen Case Presentation A 28-year old male was a restrained driver in a head-on motor vehicle collision. He was entrapped and

Read More »

Poisonings

by Harajeshwar Kohli and Ziad Kazzi Case An 18-year-old, previously healthy female, presents to the Emergency Department with nausea, vomiting, and tremors. She states 45

Read More »

Cardiac Arrest

by Abdel Noureldin and Falak Sayed Quick link to Spanish Version Introduction A 23-year-old female was brought into the emergency department. Her frantic family members

Read More »

Altered Mental Status

by Murat Cetin, Begum Oktem, Mustafa Emin Canakci  Case Presentation An 80-year-old female presents to the emergency department with a tendency to sleep (altered mental

Read More »

Abdominal Pain

by Shaza Karrar Case Presentation A 39-year-old female presented to the emergency department (ED) complaining of right-lower-quadrant (RLQ) pain; pain duration was for 1-day, associated

Read More »

Today’s Headache

In case you didn’t encounter headache today!

450 - subacute-chronic subdural haematoma

iEM Education Project Team uploads many clinical picture and videos to the Flickr and YouTube. These images are free to use in education. You can also support this global EM education initiative by providing your resources. Sharing is caring!

Give Me A Headache!

Headache

by Matevz Privsek and Gregor Prosen, Slovenia

A 52-year old male comes to the ED with a severe headache. A triage nurse gives you his chart and says that his vital signs are normal, but he does not look well. You start to question the patient, and the following history is obtained: his headache started approximately six hours ago. He was working in his office when he started to feel squeezing-like sensation in his head. The pain has gotten worse since then, but it is still tolerable. It is independent of any physical activity or position. He already had a few similar episodes of this kind of headache in the past two years, but now the pain does not go away after aspirin as it did previously. He denies trauma as well as any associated symptoms, e.g. no visual disturbances, hearing loss, weakness, dizziness, stiff neck, loss of consciousness. He is otherwise a healthy, non-smoker, with no regular therapy or known allergies. His clinical exam is unremarkable. Conscious, GCS 15, alert and oriented, normal skin color. Blood pressure 135/82 mm Hg, pulse 78/min, 14 breaths/min, SpO2 99%, body temperature 36,4 °C. Neurologic exam shows no declines from normal, as well as the rest of the physical exam.

 

slovenia
Matev Privsek, Slovenia
Gregor Prosen, Slovenia

How many headache patients you may encounter today?

Touch Me

3-5% of all ED patients

So, theoretically, if your ED sees 300 patients a day. You have a chance to see 9-15 patients in 24 hours. Not bad! 3-5 in an 8 hours shift.
Answer

What is your diagnosis ?

You set up an intravenous cannula, draw blood for testing, and gave the patient some parenteral analgesics (metamizole 2.5 g, ketoprofen 100 mg) along with 500 ml of normal saline. You put him into the observation room. Lab results (complete blood count, basic biochemistry panel) came back in 2 hours and are completely normal. The patient now feels much better, with almost no headache at all. Repeated vital signs and clinical exam are again unremarkable. You explain to the patient that most likely he had a tension headache, warn him about red flags regarding headaches, and discharge him home with a prescription for peroral analgesics with a follow-up at his general physician.

GI Bleeding in 12 min

Gastrointestinal Bleeding​

by Moira Carrol, Gurpreet Mudan, and Suzanne Bentley, USA

A 61-year-old man with a history of liver cirrhosis secondary to chronic EtOH abuse presents to the Emergency Department (ED) with a complaint of vomiting bright red blood that began prior to arrival. He arrives actively vomiting; a significant amount of blood is noted in his emesis basin. He is now complaining of dizziness and appears pale.

Overview

Gastrointestinal bleeding (GIB) can be generalized into two categories based on the site of bleeding. Upper GIB (UGIB) is defined as any bleeding that occurs proximal to the ligament of Trietz near the terminal duodenum. Lower GIB (LGIB) is any bleeding that occurs distal to the ligament extending to the rectum. Most GIB seen in the ED is attributed to UGIB with an incidence of 90 per 100,000 population. LGIB, on the other hand, presents with a rate of 20 per 100,000 population. LGIB is more commonly seen in the elderly but has a wide range of presentations and causes. As a result, the approach to LGIB has been less standardized.

In a patient without kidney disease, a BUN to Creatinine ratio is an important parameter to decide UGIB presence.

What is the magic number of BUN/Cr ratio?

Touch Me

BUN/Cr

In a patient without kidney disease, a BUN to Creatinine ratio that is elevated to greater than or equal to 36 is strongly associated with UGIB.
Answer