Differentials

Common

Upper airway cough syndrome (UACS; postnasal drip)

History

frequent throat clearing, postnasal drip, nasal discharge, nasal obstruction or sneezing typical, halitosis

Exam

mucopurulent secretions in the nasopharynx and oropharynx or cobblestone appearance of posterior oropharynx

1st investigation
  • therapeutic trial:

    response to empiric therapy with antihistamine and decongestant

    More
Other investigations

    Asthma

    History

    wheezing, chest tightness, dyspnea, symptom variability, strong family history of asthma/atopic disease, cough, paroxysms, exacerbation by irritants or seasonal exposures; cough may sometimes be the principal or sole symptom, usually worse at night (cough-variant asthma)

    Exam

    wheezing and prolonged expiratory phase on pulmonary exam

    1st investigation
    • spirometry (FEV1/FVC ratio and bronchodilator reversibility [BDR] test):

      FEV1/forced vital capacity (FVC) ratio: below the lower limit of normal (LLN; if available) or <70% (if LLN not available) is positive for airflow obstruction; BDR test: improvement in FEV1 of 12% or more in response to beta agonists (or to a treatment trial with corticosteroids), together with an increase in volume of 200 mL or more is positive for reversibility of airway obstruction

      More
    • peak expiratory flow (PEF):

      may be reduced; may be variability (>10%) of measurements recorded at different times of the day

      More
    Other investigations
    • fractional exhaled nitric oxide (FeNO):

      elevated (>40 parts per billion)

      More
    • other noninvasive airway inflammation biomarkers (blood and sputum eosinophil counts and eosinophilic cationic protein):

      elevated

    • therapeutic trial:

      improvement in symptoms following a 2-4 week course of an inhaled corticosteroid or a leukotriene receptor antagonist

    • bronchoprovocation testing:

      provocative concentration of methacholine causing a 20% fall in FEV1 (PC20) <4 mg/mL

      More
    • CBC:

      normal or elevated eosinophils and/or neutrophilia

    • serum IgE antibodies:

      elevated antigen-specific IgE antibodies

      More
    • skin-prick allergy testing:

      may be positive for allergen

      More

    Gastroesophageal reflux disease (GERD)

    History

    heartburn, dysphagia, acid regurgitation, association of cough with slouched posture, phonation, rising from bed, or eating suggest reflux disease; may be silent​

    Exam

    no differentiating features on exam, may be overweight or obese

    1st investigation
    • therapeutic trial of proton-pump inhibitors (PPIs):

      relief of symptoms

      More
    Other investigations
    • 24-hour esophageal pH monitoring:

      pH <4 for 4% or more of monitoring time and coinciding with cough is consistent with pathologic acid exposure

      More
    • barium esophagram:

      reflux

      More

    Nonasthmatic eosinophilic bronchitis (NAEB)

    History

    chronic nonproductive cough; no differentiating features on history

    Exam

    no differentiating features on exam

    1st investigation
    • sputum or bronchoalveolar lavage (BAL) differential count:

      eosinophilia

      More
    Other investigations
    • FeNO:

      elevated

      More
    • therapeutic response to inhaled steroids:

      present

      More

    Chronic bronchitis/COPD

    History

    history of smoking may be present; cough may produce sputum; dyspnea, especially exertional, may accompany the cough

    Exam

    mild cases: most respiratory exams are normal, may show quiet breath sounds, prolonged expiratory phase, rhonchi, or wheezes; advanced cases: cyanosis, barrel chest, use of accessory muscles of inspiration, increased S2 over left sternal border, or peripheral edema

    1st investigation
    • spirometry:

      reduced FEV1 and forced vital capacity (FVC); postbronchodilator FEV1/FVC ratio <0.70 (airflow limitation)

      More
    其他检查
    • chest x-ray:

      hyperinflation, but may not be present in some cases

      更多
    • pulmonary function tests:

      increased residual volume (RV), increased total lung capacity (TLC), decreased diffusing capacity of lung for carbon monoxide (DLCO)

      更多
    • ABG:

      hypoxemia, hypercapnia

      更多

    Angiotensin-converting enzyme inhibitor (ACE inhibitor)

    ანამნეზი

    dry cough, typically associated with tickling or scratching sensation in the throat; cough may begin within days or months of initiating ACE inhibitor therapy

    გასინჯვა

    no specific exam findings

    პირველი გამოკვლევა
    • stop ACE inhibitor use:

      resolution of cough

      მეტი
    სხვა გამოკვლევები

      Pneumonia

      ანამნეზი

      fever, malaise, cough, usually productive of sputum, chest pain

      გასინჯვა

      dullness to percussion, decreased breath sounds, and presence of rales

      პირველი გამოკვლევა
      • chest x-ray:

        infiltrate suggestive of pneumonia

      სხვა გამოკვლევები
      • WBC (blood):

        usually elevated but nonspecific

      • serum C-reactive protein (CRP):

        may be elevated

        მეტი
      • sputum Gram stain and culture:

        presence of microorganisms and leukocytes in a good sputum sample (<25 squamous epithelial cells per field) supports the diagnosis of respiratory tract infection

      Postinfectious cough

      ანამნეზი

      cough of duration between 3 and 8 weeks following symptoms of acute respiratory infection; nasal/sinus congestion, nonpurulent nasal discharge, sore throat

      გასინჯვა

      diagnosis is clinical and one of exclusion

      პირველი გამოკვლევა
      • chest x-ray:

        normal, rules out pneumonia

      სხვა გამოკვლევები
      • WBC (blood):

        usually elevated but nonspecific

      • sputum Gram stain and culture:

        presence of microorganisms and leukocytes in a good sputum sample (<25 squamous epithelial cells per field) supports the diagnosis of respiratory tract infection

      Bordetella pertussis infection

      ანამნეზი

      paroxysms of cough, post-tussive vomiting, or inspiratory whooping sound; more likely if local epidemiology suggests increased prevalence

      გასინჯვა

      petechiae and conjunctival hemorrhages may result from cough paroxysms; lung examination is typically normal

      პირველი გამოკვლევა
      • nasopharyngeal culture (if symptoms <2 weeks):

        positive

        მეტი
      სხვა გამოკვლევები
      • polymerase chain reaction, and/or serology (if symptoms present >4 weeks):

        positive

      იშვიათია

      Lung cancer

      ანამნეზი

      history of tobacco smoking, change in character of chronic cough, hemoptysis, hoarseness, chest pain, weight loss, superior vena cava syndrome (localized edema of face and upper extremities, facial plethora, distended neck and chest veins), symptoms related to distant metastases and advanced stages of cancer

      გასინჯვა

      central lung cancers may cause unilateral localized wheezing; superior vena cava syndrome; cachexia and symptoms related to distant metastases (e.g., bone pain) are late symptoms

      პირველი გამოკვლევა
      • chest x-ray:

        presence of the lesion

        მეტი
      სხვა გამოკვლევები
      • CT chest:

        presence of the lesion and locoregional disease

      • sputum cytology:

        may document presence of malignant cells

      • bronchoscopy:

        presence of tumor

        მეტი

      Bronchiectasis and chronic suppurative lung disease

      ანამნეზი

      cough productive of large amounts of mucopurulent sputum, diurnal variation (e.g., worse in the morning), positional worsening; dyspnea, wheezing, hemoptysis; paroxysmal cough nonproductive of sputum may sometimes be present

      გასინჯვა

      crackles and wheezing, predominantly over lower lobes; clubbing in a minority of patients

      პირველი გამოკვლევა
      • chest x-ray:

        increased bronchovascular markings

        მეტი
      • high-resolution CT chest:

        bronchial dilatation, size of the bronchi exceeding the size of the accompanying artery, lack of tapering of the bronchi at the lung peripheries

        მეტი
      სხვა გამოკვლევები
      • pulmonary function tests:

        irreversible obstructive defect, with FEV1/forced vital capacity (FVC) <70%

        მეტი

      Interstitial lung disease

      ანამნეზი

      dyspnea of subacute onset dominates the clinical picture; cough typically dry

      გასინჯვა

      dry, velcro crackles, typically over lung bases; clubbing may be present

      პირველი გამოკვლევა
      • chest x-ray:

        increased interstitial markings

        მეტი
      • high-resolution CT chest:

        interstitial pneumonitis: patchy, predominantly basilar and subpleural reticular changes with honeycombing and traction bronchiectasis in later stages of the disease

        მეტი
      სხვა გამოკვლევები
      • pulmonary function tests:

        restrictive pattern with total lung capacity <80%, functional residual capacity <80%, and vital capacity <80%, with diffusion capacity for CO <80%

        მეტი
      • biopsy:

        pattern of usual interstitial pneumonia

      Sarcoidosis

      ანამნეზი

      most patients asymptomatic; symptomatic patients: shortness of breath, dyspnea on exertion, and chest pain are present in minority of patients; low-grade fever; other symptoms reflect involvement of various organs

      გასინჯვა

      most often normal; skin lesions (erythema nodosum and maculopapular skin lesions), enlargement of lacrimal glands, lymphadenopathy in cervical, supraclavicular, or axillary areas; redness of eye, tearing, and photophobia may represent uveitis

      პირველი გამოკვლევა
      • chest x-ray:

        various findings, bilateral hilar and mediastinal lymphadenopathy, reticular infiltrates; fibrosis with decreased lung volumes in late sarcoidosis

        მეტი
      სხვა გამოკვლევები
      • chest CT with high-resolution cuts:

        bilateral hilar and mediastinal lymphadenopathy, interstitial infiltrates

      • pulmonary function tests:

        often normal, but may show nonspecific reduction in diffusion capacity, obstruction, restriction, or mixed picture

        მეტი
      • bronchoscopy with biopsy:

        noncaseating granuloma is supportive, but other granulomatous disorders should be reasonably excluded with special stains and clinical assessment

        მეტი

      Tuberculosis (TB)

      ანამნეზი

      residence in/visit to high-prevalence area; immunosuppressed status (e.g., HIV infection, immunosuppressant medication, transplant recipients, diabetes, dialysis treatment); epidemiological risk factors, particularly close contact with active TB; history of anorexia, malaise, weight loss, fever, or night sweats; chronic cough productive of sputum, occasionally associated with hemoptysis

      გასინჯვა

      fever, cachexia, tachycardia; asymmetry in chest movement and dullness to percussion due to pleural effusion, bronchial breathing, crackles, rales due to an infiltrate or rhonchi in presence of significant bronchial purulence; palpable extrathoracic lymphadenopathy is uncommon

      პირველი გამოკვლევა
      • chest x-ray:

        may demonstrate atelectasis from airway compression, pleural effusion, consolidation, pulmonary infiltrates, mediastinal or hilar lymphadenopathy, upper zone fibrosis

        მეტი
      • sputum acid-fast bacilli smear and culture:

        presence of acid-fast bacilli (Ziehl-Neelsen stain) in specimen

        მეტი
      • nucleic acid amplification tests (NAAT):

        positive for M tuberculosis

        მეტი
      სხვა გამოკვლევები
      • bronchoscopy and bronchoalveolar lavage:

        positive for acid-fast bacilli

        მეტი
      • lateral flow urine lipoarabinomannan (LF-LAM) assay:

        positive

        მეტი
      • contrast-enhanced chest computed tomography scan:

        primary TB: mediastinal tuberculous lymphadenitis with central node attenuation and peripheral enhancement, delineated cavities; postprimary TB: centrilobular nodules and tree-in-bud pattern

        მეტი

      Recurrent aspiration

      ანამნეზი

      dysphagia, association of cough with eating/drinking, fear of choking with eating/drinking; may have history of neurologic disease including stroke, multiple sclerosis, Parkinson disease

      გასინჯვა

      signs of neurologic disease such as stroke, multiple sclerosis, Parkinson disease

      პირველი გამოკვლევა
      • chest x-ray:

        persistent lower lobe infiltrates

      • swallow evaluation:

        aspiration

        მეტი
      სხვა გამოკვლევები

        Zenker diverticulum

        ანამნეზი

        dysphagia present in the majority of patients; regurgitation of bland undigested food; frequent aspiration; noisy deglutition (gurgling); halitosis; voice changes

        გასინჯვა

        halitosis, voice changes

        პირველი გამოკვლევა
        • barium esophagram:

          positive contrast within the structure connected to the posterior wall of esophagus is consistent with a diverticulum

          მეტი
        სხვა გამოკვლევები
        • endoscopy:

          visualization of diverticulum

        Thoracic aortic aneurysm (TAA)

        ანამნეზი

        most patients have no symptoms attributable to TAA at the time of diagnosis; most common initial symptom is vague pain, which can occur in the chest, back, flank, or abdomen; hoarseness due to stretching or compression of left recurrent laryngeal nerve; tracheal deviation, persistent cough, or other respiratory symptoms such as shortness of breath or chest pain; dysphagia (uncommon) due to compression of the esophagus by the aneurysm; sudden and catastrophic hemoptysis or hematemesis; neurologic deficits including paraplegia

        გასინჯვა

        generally no obvious physical findings in chest area unless tracheal deviation is present; patients with an abdominal component may have a pulsatile abdominal mass similar to pure abdominal aortic aneurysms; signs of arterial perfusion differentials in both upper and lower extremities; evidence of visceral ischemia; focal neurologic deficits; murmur of aortic regurgitation; bruits

        პირველი გამოკვლევა
        • chest radiograph:

          widened mediastinum, prominence of the aortic knob, or tracheal deviation

        სხვა გამოკვლევები
        • spiral CT of chest with three-dimensional reconstructions:

          visualization of aneurysm, seen as an increase in size of a section of the aorta

        • MRI and magnetic resonance angiography:

          visualization of aneurysm, seen as an increase in size of a section of the aorta

        Foreign body

        ანამნეზი

        abrupt onset, more common in young children

        გასინჯვა

        may be asymptomatic or show signs of airways obstruction, including cough, wheeze, decreased breath sounds, dyspnea, or fever

        პირველი გამოკვლევა
        • laryngoscopy/bronchoscopy:

          visualization of foreign body

        • chest x-ray:

          visualization of foreign body (if object is radiopaque)

        სხვა გამოკვლევები
        • chest CT:

          visualization of foreign body

        Hypersensitivity pneumonitis

        ანამნეზი

        occupational/environmental exposure to allergens (e.g., farmers, bird breeders), progressive dyspnea, fatigue, and weight loss

        გასინჯვა

        clubbing, increased respiratory rate, inspiratory crackles over lower lung fields

        პირველი გამოკვლევა
        • chest x-ray:

          fibrotic changes; loss of lung volume particularly affecting the upper lobes

        სხვა გამოკვლევები
        • chest CT:

          features of fibrosis

        • IgG testing:

          high titers with antigen-specific antibodies

        Bronchiolitis

        ანამნეზი

        age <1 year, cough, wheeze, and dyspnea, history of prematurity, underlying cardiopulmonary disease or immunodeficiency

        გასინჯვა

        high respiratory rate, accessory muscle use, retractions, wheezes, crackles, purulent secretions on bronchoscopy

        პირველი გამოკვლევა
        • chest x-ray:

          consolidation and atelectasis in severe disease

        სხვა გამოკვლევები
        • virology:

          may be positive for respiratory syncytial virus

          მეტი
        • high-resolution CT scan:

          signs of small airways disease

        Tropical filarial pulmonary eosinophilia

        ანამნეზი

        Travel to endemic area (sub-Saharan Africa, Indian subcontinent, southeast Asia, Oceania); dry, paroxysmal cough, frequently nocturnal

        გასინჯვა

        frequently normal; wheezing, rhonchi, crackles may be present on lung exam; some patients develop hepatosplenomegaly

        პირველი გამოკვლევა
        • blood count with differential:

          eosinophilia

        • chest x-ray:

          increased interstitial markings

        სხვა გამოკვლევები
        • filarial antibody levels:

          elevated

        • serum IgE:

          elevated

        Cough hypersensitivity syndrome (somatic cough, psychogenic cough, unexplained chronic cough, refractory chronic cough)

        ანამნეზი

        extensive evaluation has ruled out other causes; patients may report an urge to cough triggered by itch, scratchy throat, tickle or globus sensation; cough improves following behavior modification

        გასინჯვა

        usually unremarkable

        პირველი გამოკვლევა
        • none:

          extensive evaluation has already ruled out other causes

          მეტი
        სხვა გამოკვლევები

          Obstructive sleep apnea/hypopnea syndrome (OSAHS)

          ანამნეზი

          snoring, diurnal somnolence, agitation and sweating at night, headache, morning xerostomia (dry mouth) and sore throat, depressed mood, irritability, loss of libido; total score of ≥11 on Epworth sleepiness scale supports the diagnosis

          გასინჯვა

          elevated BP, obesity, nasal obstruction, macroglossia, tonsillar hypertrophy, obstruction by the palate, low soft palate, retrognathism, micrognathia

          პირველი გამოკვლევა
          • polysomnography:

            apnea/hypopnea index ≥15 episodes/hour (in the absence of symptoms) or ≥5 events/hour associated with the typical symptoms of OSAM

            მეტი
          • portable multichannel sleep tests:

            Respiratory Event Index (REI) of ≥15 episodes/hour or REI ≥5 with symptoms or comorbidities

            მეტი
          სხვა გამოკვლევები
          • fiber optic endoscopy:

            may see nasal polyps or tumors, or hypertrophic lingual tonsils

          ამ მასალის გამოყენება ექვემდებარება ჩვენს განცხადებას