Cough is one of the most common symptoms to present in general practice. It may be the presenting symptom of many serious disorders, but also of a vast range of self-limiting or minor conditions. It is a great cause of concern to patients who may interpret it as a ‘chest infection’ requiring antibiotics, cancer or pretty much anything else. Understanding the patient’s ideas and concerns is vital in unpicking symptoms and giving patients tailored advice.
Cough
More or less any respiratory condition may produce cough, together with a fair number of non-respiratory ones. Most adults presenting with a cough of short duration will have an URTI. Look for confirmatory coryzal symptoms and manage symptomatically. Exploring the patients’ concerns is important if you are to educate them to manage their own symptoms and be less reliant on medical services in future. However, in patients with pre-existing respiratory disease a URTI may precipitate an exacerbation and this risk should be factored into your management.
Persistent coughs of more than 3 weeks’ duration should be explored in more detail. Most of these will turn out to be either serial URTIs (the presence of a young family makes this almost inevitable) or a relatively long-lasting infection. Related to this, post infectious coughs can follow mycoplasma (primary atypical) pneumonia and whooping cough, which often presents atypically in adulthood. Campaigns encouraging patients with a cough of longer than 3 weeks to see the doctor aim at early identification of lung cancer. It remains to be seen if this will be effective, but protracted cough is a very common symptom in general practice with many causes.
Of the more serious causes of cough the two huge contributors are COPD and asthma. Asthma is common and under-diagnosed. Mild asthma presents with a cough rather than wheeze and there is often nothing to find when the patient appears in surgery. Sputum production is part of the pathology of asthma and eosinophils colour it bright green. Coloured sputum is therefore not synonymous with infection or need for antibiotics. COPD is under-diagnosed even more than asthma, particularly when mild. It should always be considered in those aged above 40 years especially if the patient is or was a smoker. A ‘smoker’s cough’ is quite likely to represent mild COPD (see Chapter 40).
Other respiratory causes of cough include bronchiectasis, a long history of recurrent cough and often foul sputum are charactreristic; a childhood history of whooping cough or inhaled foreign body may be found. Listen for the characteristic patches of treacly crepitations. In lung fibrosis, with its characteristic dry cough, an occupational history may be helpful and consider rheumatological causes.
Haemoptysis (although common in COPD) should always make you consider tuberculosis (ask about 
weight loss, night sweats and more common in immigrants, homeless and the immunocompromised) and lung cancer (see Figure 39b). Consider lung irritants: apart from smoking look for occupational causes – working in dusty or polluted atmospheres, which includes exposure to pollution from road traffic.
Mild degrees of heart failure frequently produce cough (usually dry and almost never the classic pink-tinged frothy sputum). Outside the chest consider oesophageal reflux (worse when lying down at night and more common in obese patients).
Remember certain drugs produce cough, particularly the ACE inhibitors. Patients may not associate starting the drug with the onset of their symptoms, which may in turn take weeks to settle when the drug is discontinued. The problem does not usually occur with ARB drugs, so it is worth switching on suspicion and monitoring to ensure the cough does settle (and if not investigating further).
Lung Cancer
Background
- Most common cancer worldwide.
- Most common cause of cancer death in the UK. Around 39,000 new cases per year; rate stable for men, rising for women following smoking habits.
- Secondary cancers in lung from kidney, prostate, breast, bone, gastrointestinal tract, cervix and ovary are all very common – they are not covered further here.
- Most (90%) patients are smokers: risk rises with amount smoked. Other aetiological factors include asbestos, occupational exposure (e.g. nickel, arsenic, chromium, uranium).
- 80% aged over 60 years at diagnosis, rare below 40 years.
- Much lung cancer is silent until a late stage.
- UK 5-year survival rates (9%) are below Europe (12%) and USA (15%), probably as a result of late presentation.
Symptoms
Symptoms are non-specific. Have a low threshold of suspicion in patients:
- Progressively above age 40
- With risk factors – smoking, COPD, asbestos, previous history of cancer.
Consider in patients with unexplained cough (longer than 3 weeks):
Haemoptysis
