Cough Station

Presenting Complaint: Tony presents with a 2-week history of a cough. He states that he has already been to the GP that started him on antibiotics but the cough is still present. 

Symptoms (SOCRATES):

Site: Lower respiratory tract

Onset: 2 weeks ago

Character: ‘I’ve been coughing up green sputum. I thought the antibiotics would work but they haven’t. It’s actually getting worse.’ 

Radiation: Nil

Associated symptoms: Fever - ‘My highest temperature I recorded was 39 degrees.’ Feeling breathless over the past few days - ‘I haven’t been doing much and feel out of breath.’ Almost fainted today. I’ve had a headache and just feel so tired.’ No haemoptysis or wheeze present. 

Time: Cough is sporadic - ‘I was initially bringing up tiny amounts of green phlegm, now it’s like teaspoons.’

Exacerbating/Alleviating factors: Paracetamol helped with fever. Cough still present - nothing has helped. 

Severity: Haven’t been able to go to work - ‘I can barely get around the house or move from bed the past few days.’

Systemic Symptoms:

- Feverish

- Night Sweats: None

- Unintended Weight Loss: No

- Chest or Shoulder Tip Pain: None

- Oedema: None

- Rashes or Skin Changes: None

- Headache: None

- Change in Bowel Habits: None

- Urinary symptoms: None

Past Medical History:

- No significant medical conditions

- No previous surgeries or hospitalisations

Drug History:

• On the final day of a 5-day course of oral amoxicillin. 
• OTC - Paracetamol, cold and flu medicine.
• No use of herbal supplements or alternative therapies

Allergies: NKDA

Family History: 

• Dad had TB before patient was born - successfully treated

Social History:

- Occupation: Marketing consultant. If asked specifically - No known exposure to asbestos, silica or any dust. 

- Activities of Daily Living & Hobbies: Does DIY at home. Helps wife with chores

- Smoking: Non-smoker

- Alcohol: 1 or 2 pints of beer on the weekends.

- Recreational Drug Use: None

- No travel history

- Pets (only if specifically asked) - Used to have a hamster. Never owned any birds. 

Ideas, Concerns, and Expectations:

• Ideas - “Is it some sort of infection?”
• Concerns - “I’m really finding it difficult to catch my breath now, am I dying?”

Expectations - “Could you give me some better antibiotics?”

Physical Examination:

Observations:

- Respirations: 18 breaths/min.

- Oxygen Saturation: 96% on room air.

- Blood Pressure: 118/75 mmHg.

- Pulse: 88 beats/min.

- Consciousness: Alert and oriented.

- Temperature: 38.2 Celsius.

- NEWS Total Score: 1

General Inspection:

- Appears mildly unwell and slightly flushed

- No obvious jaundice or skin lesions, slight pallor noted.

- No visible scars or marks indicating previous surgeries.

Hands:

- No clubbing, pallor, or tremor.

- Capillary refill time <2 seconds

- Regular pulse

Face:

- Mild facial flushing noted.

- No jaundice or scleral icterus.

- Mucous membranes slightly dry.

Neck:

- JVP not raised.

- No scars or palpable lymphadenopathy.

Chest:

Mildly increased work of breathing observed.

Percussion notes dull over the left lower lung zone.

Reduced breath sounds with coarse crackles heard at the both lung bases.

Normal heart sounds, no murmurs or added sounds.

Abdomen:

Soft, non-distended.

No tenderness on palpation.

No hepatomegaly or splenomegaly.

Bowel sounds present and normal.

Other:

- No peripheral or sacral oedema.

- Calves soft and non-tender.

- Examination of lower limbs normal.

Choose EITHER examiner viva questions OR patient communication questions

Patient questions (1-4):

1. "Could my cough be a sign of cancer?"

“The most common causes for coughs tend to be the simple causes such as pneumonia, which is a type of chest infection. This is normally treated with antibiotics. However, if a cough persists after treatment with other symptoms, such as weight loss or fatigue, this is an indicationfor further investigation.”

2.“Is pneumonia infectious and if so what can I do to stop other people catching it from me? Can I go to work or carry on withmy usual activities?”

“Yes, pneumonia can be infectious, depending on the cause. Pneumonia caused by bacteria or viruses (such as atypical pneumonia) can spread to others through respiratory droplets when you cough, sneeze, or talk. However, it is not as easily spread as a cold or flu.

To prevent it from spreading: practice good hygiene, wear a mask, avoid close contact.

Depending on how you feel, it may be best to stay at home to let the cough and fever settle. Once your symptoms improve, you may return to work. Avoid strenuous tasks until fully recovered.”

3.“Why am I coughing up phlegm?”

"When your lungs are infected, your body produces phlegm as part of the immune response to trap and clear out the germs. This may contain dead bacteria and immune cells as well. It’s normal to cough it up while your body fights the infection."

4.“Why did my antibiotics not work?”

"Atypical pneumonia is caused by bacteria that don’t respond to common antibiotics like amoxicillin, which targets typical bacteria. We will switch you to a different class of antibiotic which may be more effective such as a macrolide (e.g., azithromycin), which is better at treating these bacteria."

Examiner questions (1-6):

1.Please interpret the findings of this CXR for me

Answer:

• Identifies bilateral heterogeneous areas of increased radiopacity in lower zones
• Comments that these areas of increased opacity are likely infective in nature
• Identifies as atypical pneumonia or pneumonia 

2.Please interpret these ABG results for me

Answer:

• Identifies the patient has acidaemia.
• Identifies acidaemia is likely metabolic in origin given low PaCO2 and low bicarb (therefore metabolic acidosis) with incomplete respiratory compensation due to low PaCO2.
• Identifies the patient has low PaO2 with low PaCO2 (due to raised resp rate) indicating Type 1 respiratory failure.
• Offers summary of ABG: partially compensated high anion gap metabolic acidosis with Type 1 respiratory failure.

3.What are your differential diagnosis

• Atypical pneumonia - scant sputum, dry to productive cough (lasts for weeks), extrapulmonary symptoms (malaise, low grade fever, headache, myalgia, sore throat)
• Pneumonia - productive cough, fever, pleuritic chest pain, malaise
• COPD - chronic productive cough, increased SOB, wheeze, often history of smoking (not this due to cxr findings, persistent symptoms after antibiotic treatment and symptoms)
• Bronchiectasis - chronic foul smelling productive cough, recurrent respiratory tract infections, finger clubbing (signs aren’t present)

4.What initial investigations would you recommend for Tony based on his presenting complaint?

• Full set of observations
• Bloods → FBC, U&Es, LFTs, CRP
• Sputum culture 
• Blood cultures
• Arterial blood gas
• Legionella and pneumococcal urinary antigen: this should be requested in those with moderate or high-severity CAP or where other risk factors exist.
• Atypical pneumonia serology screening - Chlamydia, Legionella and Mycoplasma.

 Imaging:

• CXR

5.What scoring system is used for determining the severity of pneumonia?

The severity of community-acquired pneumonia can then be calculated using the CURB-65 score.

• Confusion: new onset, which may be defined as an abbreviated mental test (AMT-10) score ≤8
• Urea: of >7 mmol/L
• Respiratory rate: ≥30 breaths/minute
• Blood pressure: <90 mmHg systolic or ≤60 mmHg diastolic
• Age: ≥65 years

Each criterion scores one point, with the total used to guide hospital admission, treatment, critical care escalation and mortality.

Score 0-1: low risk

• Consider outpatient treatment

Score 2: moderate risk

• Consider inpatient or hospital-supervised outpatient treatment

Score 3-5: high risk

• Admission for inpatient treatment with consideration for discussion with critical care if achieving the higher end of the range

In the community setting, urea may be removed, with CRB-65 utilised instead.

6.What is the management for atypical pneumonia

• Antibiotics → always check local guidelines:
  • Low severity: clarithromycin, or erythromycin (if pregnant)
  • Medium severity:  amoxicillin with clarithromycin or erythromycin (in pregnancy).
  • High severity: Co-amoxiclav with clarithromycin or oral erythromycin (in pregnancy).
• Important to rationalise antibiotics based on culture sensitivities once they’re available
• Supportive care: Patients should be assessed for hydration status, haemodynamic stability, and adequacy of gas exchange. Oxygen and ventilation should be started immediately if needed.