Question

Imagine you are a physician in the 1820. In at least 200 words describe the techniques that you would use for diagnosing a patient who came to you with a raspy cough, and why you think these techniques are appropriate.

Answer 1

In 1820, history collection is the main technique used for identifying diseases. So, when a patient came with raspy cough, the following questions was asked:

A) HISTORY AND EXAMINATION

A careful history and thorough physical examination are critical in the evaluation of a patient with chronic cough. Postnasal drip usually causes symptoms such as the sensation of ‘something dripping into the throat’, frequent throat clearing, nasal congestion, itch or nasal running. Asthma might be suggested if the cough is present or worse at night or in the early morning only. It is usually associated with dyspnoea and wheeze or tight chest but these may be absent in cough-variant asthma.

• duration – days, weeks, months or years
• course – constant, worsening, intermittent, diurnal variation
• triggers – allergens, irritants, swallowing, position
• dry or productive (nature and volume of sputum) – clear/ white/grey (mucoid), yellow/green (purulent) or bloody (haemoptysis)
• other – shortness of breath, chest pain, wheeze/tightness, loss of weight, fever, sweating.

On examination, one should listen to the type of cough and look for signs, particularly the following:

• general – distress, fever, sweating, loss of weight, cyanosis, clubbing
• respiratory – respiratory rate, hyperinflation, dullness, crackles, wheeze, bronchial breathing, pleural rub

B) DIAGNOSIS

Common causes/types of cough	Description and associated features
Chronic bronchitis	Cough productive of sputum for most days for at least 3 months of a year for at least 2 years, usually mucoid, but may be purulent during infective exacerbations.
Acute Bronchitis	Dry or purulent, with central burning chest pain; short duration
Pneumonia	Purulent or rusty, often with associated pleuritic chest pain, shortness of breath and fever; short duration
Bronchiectasis	Usually large volumes of purulent sputum, sometimes offensive, often associated with clubbing and coarse crackles transmitted to the mouth; long duration
Lung abscess	Usually large volumes of purulent sputum, sometimes offensive, often associated with fever, clubbing and amphoric breathing; usually long duration
Tuberculosis	Dry, purulent or bloody, often associated with fever, night sweats, loss of weight (LOW); long duration
Lung Cancer	Dry, purulent or bloody, occasionally ‘bovine’ (vocal cord palsy) or ‘brassy’ (central airway compression), often associated with LOW
Interstitial lung disease	Usually dry, often associated with fine crackles; long duration
Pulmonary edema	Dry or productive (pink froth or blood), often associated with orthopnoea and paroxysma