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Trans Number: 11
- important to note
NTK nice to know :)
I. INTRODUCTION
A. Definition of Cough
Figure 1. Broncholiths
EXAM 2
April 4, 2016
Exogenous Source
o Smoke
o Dust
o Fumes
o Foreign bodies
Endogenous Source
o Upper airway mucus (i.e. post nasal drip)
o Gastric contents (i.e. GERD)
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Figure 3. Afferent and efferent limbs of the cough reflex arc. The
cough center is still not well studied but believed to be integrated in the
medulla oblongata.
H. Production of Cough
Inspiratory
o Negative flow rate
Recovery
o Restorative inspiration
Flow and Subglottic Pressures During the Phases of
Cough
Figure 4. This shows the flow of air and pressure in the subglottis
during the different phases of cough. Note that the pressure is
highest at the start of the expiratory phase.
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Guillan-Barre,
stroke
patients
(aspiration
pneumonia)
Polio
Cystic Fibrosis
Pseudomonas
COPD
Asthma
Chronic Bronchitis
Smoking
Complex of glycoproteins.
Figure 5. Mucin in goblet cell (L) and mucus tethering in asthma (R)
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Frequent hospitalization
Viscosity of mucus
Ciliary effectiveness
Mucus plugs
Airway Resistance
Infections
O. Diagnostic Approach
Determine Duration of Cough
Innocuous
Stimuli
Noxious Stimuli
Figure 14. Chest X-ray with a mass with striated borders. It turned out
to be lung cancer as the cause of the cough of the patient
Figure 12. Diagram on cough reflex sensitization. Y-axis: cough
reflex sensitivity, X-axis: Time point viral infection
Chest Radiograph
o Can identify the presence of chest wall,
pleural, lung parenchymal and mediastinal lesions or
abnormalities
o Note: Check if pulmonary involvement or not.
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Purulent
Blood
Eosinophilia
cough
Gastroesophageal
Reflux
Disease (GERD)
Cough-Variant Asthma
Differentiate Restrictive and
Obstructive DOs
Detect Reversible versus
Non-reversible
Airflow
Obstruction
Endobronchial tumors
Chest tumor
interstitial lung disease
Transers note: this part will most probably going to be asked in the
exam. J
Symptoms
Hemoptysis
Breathlessness
Fever
Chest Pain
Weight Loss
Signs
Tachypnea
Cyanosis
Dull chest
Bronchial breathing
Crackles
Pulmonary embolus
Congestive heart failure
DISEASE
Upper
airway
syndrome (UACS)
o
o
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Cough-Variant Asthma
Asthma
GERD
From 2018:
Top Causes of Chronic Cough in the Philippines (DavidWang AS, Balgos A, Roa Jr. CC, Dantes R, et. al., Chest
130:199S, 2006.)
1. Asthma
2. PNDS
3. PTB
4. COPD / CB
5. Post-infectious cough
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Transers note: Dra. Wang just passed through this part due to time
constraint.
Case 1:
tickle in throat
Throat clearing
Hoarseness
Nasal congestion
pharyngeal
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Episodic/intermittent cough
Dyspnea
Heartburn
Regurgitation
Acidic taste
Dysphagia
Epigastric pain
Hoarseness
Sore throat
Throat clearing
cough receptors
Laryngoscopic Findings
Edema
Erythema
Ventricular obliteration
Pseudosulcus
Postcricoid hyperplasia
Aggravating Factors
Lying supine
Coffee/Tea
Carbonated drinks
Citrus fruits
Diagnostics
Lifestyle modification
Airway Eosinophilia
Normal Spirometry
Same as asthma
Unresponsive to bronchodilators
X. Post-Infectious Cough
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Pathophysiology
Dry cough
Scratchy throat
A diagnosis of exclusion
Answer: FALSE
2. Which phase may not be critical to effective coughing?
a. Glottic closure
b. Comprehensive
c. Expiratory
Answer: A
Love Letters from Block B:
1. The following are the most common causes of chronic
cough, EXCEPT:
a. Non asthmatic eosinophilic bronchitis
b. Gastrointestinal Reflux
c. Upper airway cough syndrome
d. Lung cancer
e. Asthma induced chronic cough
Answer: D
2. What is the most important step in the diagnostic
approach to a patient with acute cough?
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Answer: C
Answer: D
Answer: C
14. A 20 year old female with a history of prior PTB
complication of chronic cough with whitish, viscoid sputum that
causes precordial chest pain when forcefully expectorated.
She is unable to sleep at night due to the cough. At present,
she has no other complaints. She has inspiratory crackles in
the right upper lung field. Sputum AFB smear, and TB culture
are negative. Chest x-ray shows residual TB scars, and
bronchiectatic change in the upper lung field area. Which type
of medication will you prescribe to improve the quality of this
patient and reduce her symptoms?
a. an antitussive
b. a protussive
c. an anti-leukotiene
d. an inhaled corticosteroid
e. a broad spectrum antibiotic
Answer: B
Answer: C
9. 20/M complains of chronic cough, nasal congestion,
sneezing, postnasal drip, itchy throat, and watery eyes. PE
reveals congested nasal mucosa and cobblestone
appearance of posterior pharyngeal mucosa. Following the
anatomic diagnostic protocol in the evaluation of cough, which
afferent limbs of the reflex pathway are most likely involved?
A. Phrenic and vagus nerves
B. Trigeminal and glossopharyngeal nerves
C. Spinal motor and recurrent laryngeal nerves
D. Trigeminal and phrenic nerves
E. AOTA
Answer: B
10. A 40 year old laundrywoman from Paco complains of
cough productive of whitish, blood-tinged sputum, fever,
malaise, and anorexia of 4 weeks duration. Self-medication
with paracetamol and lagundi tablets provide some relief. PE is
unremarkable. Which laboratory test will you prioritize to
determine the diagnosis of this patients condition?
A. CBC
B. Spirometry
C. Chest radiograph
D. Sputum GS, CS
E. Sputum AFB smears
Answer: E
11. Which phase in the process of cough is characterized by a
rapid deceleration of gas flow rates?
A. Inspiratory
B. Compressive
C. Expiratory
D. Recovery
E. Glottic closure
10
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