Department of General Practice RCSI Medical School Dublin

Acute cough
Senior Cycle 1 General Practice
1
Department of General Practice RCSI Medical School Dublin
Format of module
1 Acute cough
2 Format of module
3 Structure of eLearning modules
4 Learning outcomes
5 Patient scenario
6 Epidemiology
7 Aetiology
8 Diagnosis
9 Investigation & referral
10 Prognosis
11 Children: duration of cough
12 Children: repeat consultations
13 Children: antibiotic resolution
14 Children: antibiotic complications
15 Children: antibiotic side effects
16 Adults: antibiotic resolution
17 Adults: antibiotic duration
18 Adults: side effects
19 Adults: OTC treatments
20 Antibiotics
21 Management strategies
22 Delayed v immediate treatment
23 Patient information leaflets/ weblinks
24 Patient scenario revisited
25 References & sources
26 Post-test MCQ/ Evaluation reminder
2
Department of General Practice RCSI Medical School Dublin
Structure of eLearning modules
1 Pre-test MCQ attempt to assess prior knowledge
2 eLearning module + references
3 Post-test MCQ to assess new learning
4 Self-directed learning from resources provided
5 Repeat post-test MCQ attempts
6 eModule overall evaluation
3
Department of General Practice RCSI Medical School Dublin
Learning outcomes
At the end of the module you should be able to:
1 Describe the clinical features of acute cough in children & adults
2 Outline the benefits & harms of common treatment options
3 Discuss how to manage a patient with acute cough
4
Department of General Practice RCSI Medical School Dublin
Patient scenario
History
40 year old man
7 day history of mild shortness of breath and cough.
Productive of purulent sputum.
No relevant past history.
Smokes 10 day.
Works as insurance agent.


Examination
Vital signs normal.
Auscultation: scattered wheeze.


Consultation
Requests antibiotic as last doctor prescribed it for me
What is the likely cause of his symptoms?


What is the likely duration of illness?


What treatment would you recommend?


How would you deal with his request for antibiotics?
5
Department of General Practice RCSI Medical School Dublin
Epidemiology
Adults
US: affects 5% adults
90% seek medical attention
UK: consultation rate 77.2 /1000 person years at risk

Children
UK consultation rate 310/1000 person years at risk 0-4 years
100/1000 person years at risk 5-15 years
6
Department of General Practice RCSI Medical School Dublin
Diagnosis
Adults
Diagnosis on clinical grounds
Absence of vital sign abnormality &
abnormal findings on
Chest auscultation rules out
pneumonia

Children
Preceding coryza
Some valuei
n clinical findings of fever or chest signs
Children: re-consultation probability
Post-test probabilities
-------------------------------------------------------------------------
Category of interest Post-test probability
(% who have sign) % (95% CI)
-------------------------------------------------------------------------
Neither sign (71) 6.5 (3.1 to 11.7)
Chest signs only (21) 18.2 (6.9 to 35)
Fever only (11) 27.8 (9.6 to 53)
Both signs (3) 40.0 (5.2 to 85)
7
Department of General Practice RCSI Medical School Dublin
Aetiology
Viral 50-80%
Influenza
Parainfluenza
Respiratory syncitial virus (RSV)
Pertussis

Bacterial 20% adults, <10% children
Typical
Strep pneumoniae
Haemophilus influenzae

Atypical
Mycoplasma
Bordetella
8
Department of General Practice RCSI Medical School Dublin
Investigation & referral
Diagnostic tests
Sputum seldom indicated
A normal CRP is of prognostic value to rule out community acquired pneumonia
Chest X ray rarely indicated (unless other features suggest it)

Referral
1 to 5% referred to hospital
Sick child
Vulnerable adults:

Elderly
Co-morbidity
Institutionalised

9
Department of General Practice RCSI Medical School Dublin
Prognosis
Adults
Initial consult 7-10 days duration
Subsequent duration 10-14 days
Re-consultation 15-20%

Children
Duration of illness similar to adults
Parents expectations
10
Department of General Practice RCSI Medical School Dublin
Duration of cough in pre-school children
11
Department of General Practice RCSI Medical School Dublin
Therapy
Antibiotics
Over the counter (OTC) preparations

SUMMARY
Worldwide, it is estimated that half of all medicines are inappropriately prescribed, dispensed or sold, and that half of all
patients fail to take their medicine properly.

An estimated two-thirds of global antibiotic sales occur without any prescription, and studies in Indonesia, Pakistan and
India show that over 70% of patients were prescribed antibiotics.

The great majority - up to 90% - are estimated to be unnecessary.

The inappropriate use of medicines is not only widespread, it is costly and extremely harmful both to the individual and the
population as a whole.

Adverse drug events rank among the top 10 causes of death in the USA and are estimated to cost that country between US$
30 and US$ 130 billion each year.

Growing resistance to antimicrobial medicines is a particularly serious challenge in countries at all economic levels, and
results largely from inappropriate prescribing and use. For the treatment of malaria, chloroquine resistance is now
established in 81 of the 92 countries in which the disease is endemic.

Much greater use of evidence-based diagnostic and treatment guidelines by health professionals is needed.

More effective monitoring and regulation of medicines, and public education and information are important components of
a strategy for increased rational use.
WHO http://apps.who.int/medicinedocs/fr/d/Js6160e/10.html
12
Department of General Practice RCSI Medical School Dublin
Antibiotic: choice of drug
Typical organisms
Aminopenicillin
Tetracycline
Macrolide

Atypical organisms
Tetracycline
Macrolide

Penicillin sensitive
Macrolide
Trimethoprim

13
Department of General Practice RCSI Medical School Dublin
Adults: antibiotics resolution
14
Department of General Practice RCSI Medical School Dublin
Adults: antibiotics duration
15
Department of General Practice RCSI Medical School Dublin
Adults: antibiotics side effects
16
Department of General Practice RCSI Medical School Dublin
Children: antibiotics resolution
17
Department of General Practice RCSI Medical School Dublin
Children: antibiotics complications
18
Department of General Practice RCSI Medical School Dublin
Children: antibiotics side effects
19
Department of General Practice RCSI Medical School Dublin
Antibiotics
Benefits
Duration of illness (adults)
Complications (children)


Risks
Side effects
Medicalisation
Resistance
Cost
20
Department of General Practice RCSI Medical School Dublin
Adults- over the counter medicines
21
Department of General Practice RCSI Medical School Dublin
Management strategies
Delayed prescribing

Patient Information Leaflet (PiL)
22
Department of General Practice RCSI Medical School Dublin
Duration of cough: delayed v immediate antibiotic
23
Department of General Practice RCSI Medical School Dublin
Patient Information Leaflet
24
Department of General Practice RCSI Medical School Dublin
Patient scenario (revisited)
History
40 year old man
7 day history of mild shortness of breath and cough.
Productive of purulent sputum.
No relevant past history.
Smokes 10 day.
Works as insurance agent.


Examination
Vital signs normal.
Auscultation: scattered wheeze.


Consultation
Requests antibiotic as last doctor prescribed it for me
What is the likely cause of his symptoms?


What is the likely duration of illness?


What treatment would you recommend?


How would you deal with his request for antibiotics?
25
Department of General Practice RCSI Medical School Dublin
Additional resources
Cochrane Review (adults)
http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD000245/frame.
html

Clinical Knowledge Summaries (CKS)
http://cks.library.nhs.uk/chest_infections/in_summary/acute_bronchitis

Patient UK
Adults http://www.patient.co.uk/pdf/pilsL520.pdf
Children http://www.patient.co.uk/pdf/pilsL43.pdf

OGPL (Oxford General Practice Library) Respiratory Problems
Lynch J & Simon C 1
st
edition (2007)

GP Notebook www.gpnotebook.co.uk

26
Department of General Practice RCSI Medical School Dublin
Post-test MCQ & Evaluation reminder
Now, please take your Post-test MCQ











Finally, remember to complete the eModule Evaluation. Thank you.
27