Infectious Cough
A 24-year-old woman presents with 4 days of cough, rhinorrhea, sore throat, and low-grade fever. She denies dyspnea or chest pain. Lung exam is clear. Vitals are normal. What is the most appropriate next step?
A. Chest X-ray
B. Antibiotics
C. Supportive care
D. CT chest
E. Steroids
What is supportive care?
Explanation:
Acute cough (<3 weeks) is most commonly viral → no antibiotics
A previously healthy 3-year-old boy is brought to the emergency department after a sudden episode of coughing and choking while playing with small toys. Since then, he has had persistent cough and decreased breath sounds on the right side. He is afebrile. Chest x-ray is normal. What is the next best step in management?
A. Repeat chest x-ray in 24 hours
B. Trial of albuterol
C. Bronchoscopy
D. Oral corticosteroids
E. Start antibiotics
What is bronchoscopy?
Explanation:
Classic foreign body aspiration:
Suspected foreign body → immediate bronchoscopy even if imaging is normal
A hospitalized patient develops a cough and fever 5 days after being intubated. Examination reveals coarse crackles, and chest X-ray shows new infiltrates. What is the etiology of the cough?
A. Community-acquired pneumonia
B. Aspiration pneumonitis
C. Ventilator-associated pneumonia
D. Tuberculosis
E. Acute bronchitis
What is ventilator-associated pneumonia?
Explanation: VAP is defined as pneumonia occurring >48 hours after intubation, presenting with new infiltrates and fever.
A 30-year-old man presents with cough for 5 days after a cold. He has no fever, hemoptysis, or dyspnea. Physical exam is normal. What is the best next step?
A. Chest X-ray
B. Antibiotics
C. Reassurance and supportive care
D. CT scan
E. Bronchoscopy
What is reassurance and supportive care?
Learning Objective: Acute cough without red flags → no imaging
A 70-year-old man presents with chronic cough that worsens when lying flat. He also reports dyspnea on exertion and lower extremity edema. Exam reveals bibasilar crackles. What is the most likely cause?
A. Asthma
B. GERD
C. Heart failure
D. Pneumonia
E. TB
What is heart failure?
Learning Objective: Orthopnea + cough → CHF
A 52-year-old man presents with fever, productive cough with rust-colored sputum, and pleuritic chest pain. On exam, he has bronchial breath sounds and dullness to percussion over the right lower lobe. CXR shows lobar consolidation. What is the most likely organism?
A. Mycoplasma pneumoniae
B. Streptococcus pneumoniae
C. Legionella pneumophila
D. Staphylococcus aureus
E. Influenza
What is Streptococcus pneumoniae
Explanation:
Classic lobar pneumonia + rust sputum
A 4-year-old boy is brought to the clinic for a persistent cough lasting 3 weeks. His symptoms began after a viral upper respiratory infection. The cough is worse at night and occasionally wakes him from sleep. His mother notes he sometimes coughs when running around at daycare. He has no fever. Physical exam reveals mild expiratory wheezing. Oxygen saturation is normal. Which of the following is the most likely diagnosis?
A. Post-infectious cough
B. Asthma
C. Foreign body aspiration
D. Pneumonia
E. Allergic rhinitis
What is Asthma?
Explanation:
Nighttime cough + Exercise-induced symptoms + Wheezing = Asthma
Post-infectious cough does not typically cause wheezing or exercise symptoms
A 60-year-old man with hypertension started lisinopril 2 weeks ago. He now presents with a persistent dry cough that started shortly after starting the medication. He denies fever, sputum production, or hemoptysis. Vitals are normal and exam is unremarkable. What is the etiology of this cough?
A. Histamine release
B. Increased bradykinin
C. Decreased prostaglandins
D. Increased leukotrienes
E. Decreased nitric oxide
What is increased bradykinin
Explanation: ACE inhibitors block the breakdown of bradykinin, leading to accumulation and a chronic dry cough.
A 28-year-old woman presents with cough for 4 weeks following a viral illness. She has no fever or dyspnea. CXR is normal. What is most likely diagnosis?
A. Asthma
B. GERD
C. Post-infectious cough
D. TB
E. Pneumonia
What is post-infectious cough?
Explanation:
Subacute cough (3–8 weeks) = post-viral, self-limited
A 28-year-old pregnant woman (2nd trimester) presents with dry cough and mild URI symptoms. No fever or dyspnea. Which medication is safest?
A. Codeine
B. Dextromethorphan
C. Ibuprofen
D. ACE inhibitor
E. Warfarin
A 28-year-old pregnant woman (2nd trimester) presents with dry cough and mild URI symptoms. No fever or dyspnea.
Which medication is safest?
A. Codeine
B. Dextromethorphan
C. Ibuprofen
D. ACE inhibitor
E. Warfarin
What is Dextromethorphan?
Learning Objective: Safe cough med in pregnancy = dextromethorphan;
codeine = neonatal withdrawal syndrome; NSAIDs = can affect fetal circulation and amniotic fluid levels; ACE inhibitors = contraindicated/fetal renal dysfunction; warfarin = contraindicated/fetal hemorrhage risk
A 48-year-old homeless man presents with chronic cough, weight loss, night sweats, and intermittent hemoptysis. He has a history of incarceration. CXR shows upper lobe cavitary lesions. What is the next best step?
A. Start antibiotics
B. Sputum AFB smear and culture
C. Bronchoscopy
D. CT scan
E. Steroids
What is sputum AFB smear and culture?
Explanation:
Classic TB → confirm with AFB testing before treatment
A 6-month-old infant is brought to the emergency department with 2 days of cough, rhinorrhea, and poor feeding. Today, the parents noticed increased work of breathing. He was born full-term and has no prior medical history. On exam, he has nasal flaring, intercostal retractions, diffuse wheezing, and crackles. Oxygen saturation is 92% on room air. RSV testing is positive. What is the most appropriate management?
A. Albuterol nebulizer
B. Systemic corticosteroids
C. Supportive care with oxygen and hydration
D. Broad-spectrum antibiotics
E. Nebulized epinephrine
What is supportive care with oxygen and hydration?
Explanation:
This is bronchiolitis (RSV).
A patient taking amiodarone for atrial fibrillation presents with a chronic dry cough, progressive dyspnea, and fatigue. Chest X-ray shows diffuse interstitial infiltrates. What is the etiology of the cough?
Choices:
A. Pneumonia
B. Pulmonary fibrosis
C. Pulmonary embolism
D. Asthma
E. Tuberculosis
What is pulmonary fibrosis?
Explanation: Chronic amiodarone therapy, used for atrial fibrillation, is a known cause of pulmonary toxicity, leading to symptoms such as progressive dyspnea, a dry cough, fatigue and progress to interstitial lung disease and pulmonary fibrosis, presenting with chronic cough and dyspnea.
A 45-year-old nonsmoker presents with chronic cough for 3 months. CXR is normal. He is not taking ACE inhibitors. What is the most likely underlying cause?
A. Lung cancer
B. TB
C. Asthma, GERD, or upper airway cough syndrome
D. Pneumonia
E. PE
What is Asthma, GERD, or UACS?
Explanation:
Most common causes of chronic cough = think asthma, GERD, UACS [postnasal drip] first
A 45-year-old woman presents with chronic cough and hoarseness. Symptoms worsen at night and after meals. She denies wheezing. What is most likely diagnosis?
A. Asthma
B. GERD
C. TB
D. Pneumonia
E. COPD
What is GERD
Learning Objective: GERD can present with cough + hoarseness
A 60-year-old man presents with cough, fever, confusion, and diarrhea. Labs show hyponatremia. CXR shows patchy infiltrates. Which organism is most likely?
A. Streptococcus pneumoniae
B. Legionella pneumophila
C. Mycoplasma pneumoniae
D. Haemophilus influenzae
E. Klebsiella pneumoniae
What is Legionella pneumophila
Explanation:
GI symptoms + hyponatremia + atypical pneumonia = Legionella
A 2-year-old boy is brought to the clinic in the fall with a 2-day history of rhinorrhea and low-grade fever followed by a barking cough. His parents report that he has noisy breathing when crying but appears comfortable at rest. He is eating and drinking normally. On exam, he is afebrile, has mild inspiratory stridor only when agitated, and oxygen saturation is 99% on room air. No retractions are noted. What is the most appropriate next step in management?
A. Nebulized epinephrine
B. Oral dexamethasone
C. Albuterol nebulizer
D. Chest radiograph
E. Azithromycin
What is oral dexamethasone?
Explanation:
This is mild croup (viral laryngotracheitis). Key clue = stridor only with agitation.
A patient taking amiodarone for atrial fibrillation presents with a chronic dry cough, progressive dyspnea, and fatigue. Chest X-ray shows diffuse interstitial infiltrates. What is the diagnosis?
A. Pneumonia
B. Pulmonary fibrosis
C. Pulmonary embolism
D. Asthma
E. Tuberculosis
What is pulmonary fibrosis?
Explanation: Chronic amiodarone therapy, used for atrial fibrillation, is a known cause of pulmonary toxicity, leading to symptoms such as progressive dyspnea, a dry cough, fatigue and progress to interstitial lung disease and pulmonary fibrosis, presenting with chronic cough and dyspnea.
A 65-year-old smoker presents with chronic cough and 10-lb weight loss. He reports intermittent hemoptysis. What is the next best step?
A. Antibiotics
B. Chest X-ray
C. CT chest
D. Bronchoscopy
E. Steroids
What is chest X-ray
Explanation:
First step in evaluation of chronic cough with red flags is a CXR before proceeding to more advanced imaging including CT.
A 52-year-old woman presents with sudden onset cough, pleuritic chest pain, and dyspnea after a long flight. She is tachycardic. What is the next best step?
A. Chest X-ray
B. D-dimer
C. CT pulmonary angiography
D. Antibiotics
E. Steroids
What is CT pulmonary angiography?
Learning Objective: High suspicion PE → CT angio
A 16-year-old presents with 2 weeks of severe coughing fits followed by inspiratory “whoop” and post-tussive emesis. He is afebrile. Several classmates have similar symptoms. What is the MOST appropriate management?
A. Supportive care only
B. Start azithromycin
C. Start amoxicillin
D. Steroids
E. Bronchodilator
What is azithromycin?
Explanation:
Pertussis → treat with macrolide to reduce transmission
Learning Objective: Treat pertussis regardless of vaccination status
A 7-year-old girl is brought to the clinic with severe coughing fits for the past 2 weeks. The episodes are characterized by repetitive coughing followed by a “whooping” sound during inspiration and occasional post-tussive vomiting. She is fully vaccinated. She has no fever and appears well between episodes. Which of the following is the most appropriate next step in management?
A. Supportive care only
B. Start azithromycin
C. Start amoxicillin
D. Order chest x-ray
E. Start corticosteroids
What is start azithromycin?
Explanation:
This is pertussis despite vaccination (immunity wanes).
Treat suspected pertussis with macrolides regardless of vaccination status
A 65-year-old woman with Hodgkin lymphoma starts chemotherapy. Three weeks later, she develops a persistent dry cough and mild dyspnea. She denies fever, sputum production, or chest pain. Pulmonary exam reveals bibasilar inspiratory crackles. Chest X-ray shows patchy interstitial infiltrates. Which of the following medications is the most likely cause of her symptoms?
A) Bleomycin
B) Vincristine
C) Cyclophosphamide
D) Doxorubicin
What is Bleomycin?
Explanation: Bleomycin causes drug-induced pneumonitis with dry cough and interstitial infiltrates. Vincristine → neuropathy, Cyclophosphamide hemorrhagic cystitis, Doxorubicin → cardiotoxicity.
A 50-year-old man presents with chronic cough worse after meals and when lying down. He denies wheezing. CXR is normal. What is the best initial management?
A. Endoscopy
B. Start PPI trial
C. Bronchoscopy
D. Antibiotics
E. Steroids
What is start PPI trial?
Explanation:
GERD cough → empiric PPI trial
A 35-year-old African-American man presents with a 2-month history of dry cough and mild shortness of breath. He also notes intermittent red, tender nodules on his shins and mild eye redness. He denies fever, sputum production, or chest pain. On exam, he has bilateral cervical lymphadenopathy and inspiratory crackles at the lung apices. Chest X-ray shows bilateral hilar lymphadenopathy with upper-lobe interstitial infiltrates. Laboratory studies reveal mild hypercalcemia. Which of the following is the most likely cause of his cough?
A. Hypersensitivity pneumonitis
B. Sarcoidosis
C. Idiopathic pulmonary fibrosis
D. Granulomatosis with polyangiitis
E. Interstitial lung disease secondary to systemic sclerosis
What is sarcoidosis?
Explanation: Dry cough + upper-lobe infiltrates + bilateral hilar lymphadenopathy + erythema nodosum + hypercalcemia = sarcoidosis