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(This is not a 'seeking medical advice thread' either).
Just working on a vignette.
Just working on a vignette.
What can be in the differentials for a dry cough that causes pain in the chest?
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Good list. However, I'd take off PE (never seen one with a cough and I've seen a ton of these), CHF (no pain), PAH (haven't seen this with pain or cough, more of a right sided CHF picture when it exacerbates, but aska pulmonologist). GERD is interesting in that it can cause chest pain, or it can cause a cough, but usually it's gonna be one or the other you get.
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Bad way to approach medicine. You never pigeon hole diagnosis base on every single complaint. ANYBODY WITH CHEST PAIN (especially older patients) will automatically need to be ruled out for PE, MI, pneumothorax, and aortic dissection. It doesnt matter if they have dry cough or no cough. Imagine being in a court room trying to say that you didnt consider PE in a 60 year old with chest pain because they had a cough. Medicine is way to complex...the patient could be having a PE, but also a concurrent pneumonia. They could be having a PE but no SOB, they could be having a PE but no chest pain...
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Are you really saying that everyone w/ pneumonia needs a CTA to r/o a PE?
That's nice and all, especially since that is what I specialize in and already do, but that has nothing to do with what I said. PE is in the differential for chest pain. It is not in the differential for chest pain with non-productive cough. If the patient ends up with a PE, then chest pain with non-productive cough was the wrong differential to use and the provider commited an anchoring error in sticking with the cough as being a primary marker of the disease process.
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no...it will depend on the overall clinical picture...but PE should be on the differential on anyone with chest pain and you start ruling out base on further questioning and history, physical exam, and then labs/imaging. But you should not take PE out of the differential just because the patient has a cough. What if they are having pneumonia and a PE, what if they have a chronic cough and now they have a PE...etc.
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So...a 60 year old presents with a cc of a cough and upon further questioning he then mentions some acute chest pain and PE would not be on the differential???...Sorry but a patient can come in to the ER with a complaint of diarrhea and then lightly mentions that they have been having chest pains for the past 2 days and things like MI and PE would quickly climb up the differential until I can start ruling it out base on further history and labs/imaging. I understand what your saying, in a academic/theorical sense (yes...PE should not present with a cough) but practically it makes no sense. You cant rule out things like a PE or MI just because the patient also has a cough. I think our argument here is base solely on academic/theoritical vs. practical/real world perspective. In the real world...someone with chest pain, cough or no cough you slap on an ECG no matter what. If they have very bad risk factors for MI or PE with new chest pain, you probably will need to investigate with further imaging or labs no matter if the presenting symptom was cough or a cut on their leg.
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He's asking for the differential diagnosis of a dry cough and wants to whittle that differential down for those things within the differential that cause pain. He is not asking for the workup of undifferentiated chest pain in a 60 year old, which I could spend 5 pages writing about. If for some reason you want to discuss the workup of undifferentiated chest pain either broadly, or in finer detail, please make a topic and I'd be happy to contribute. But don't create an argument that doesn't exist just to get there. It's annoying to be "educated" on a position I don't have, particularly when acute undifferentiated chest pain is a major part of my specialty.
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I know you're a resident and may feel confident in your knowledge base, but there are more credible sources out there that disagree. Aside from diagnosticpro, my phone app, and an nih site I was looking at earlier, one of my clinical science bibles also says PE may suddenly produces dry cough and dyspnea w/ pleuritic or anginal pain, but the cough is often also accompanied by bloody sputum. I'm more inclined to believe them than you, no offense.
hemoptysis =/= dry cough. what is it with everyone trying to show off how smart they are today?
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All that... and the final clue is the give away.
PE:
1. pleuritic chest pain
2. dyspnea
3. tachypnea
4. tachycardia
5. HD unstability
6. possible cyanosis
7. possible hemoptysis
Essentially, you would be able to differentiate a PE from a HDS pt w/ CP and unproductive cough.
Of course, pt > 45, cardiac risk factors, etc... rule out MI. Do a cardiac workup.
Order a CXR, if there's consolidation, edema, effusion, etc. treat accordingly.
If the pt begins to become tachycardic/HD unstable w/ pleuritic CP, then consider workup for PE.
That's just my line of reasoning. Rendar knows better since he has more experience in this stuff. Feel free to comment, Rendar, either way. I'm about to start intern year, so I want to make sure I have this right.
That's definitely pretty dead on. There are some more atypical presentations of PE such as shoulder pain, flank pain, altered mental status (from poor peripheral perfusion. Now if the PE leads to pulmonary infarct, then you're going to have a rather different presentation, but that is not something I have much clinical experience with.
Just a few notes on my own line of reasoning. as mentioned before by Pansit, nearly every adult with acute chest pain should still be getting an EKG. Generally, it's the young pt with a good story/negative EKG/CXR, or the elderly patient, or the patient with known heart disease who gets further studies. Risk factors should not play a role in this, believe it or not. Surprisingly, if you look at the literature cardiac risk factors do not really affect how likely chest pain is due to an MI. Very low likelihood ratios. They only really tell you if you're at increased risk of developing CAD in 20-30 years. I wouldn't expect anyone to believe me on that without reading the literature, though. esp. since we are always taught to ask about them
For PE, the real goal is trying to figure if they're null, low, medium, or high risk based on H&P. Sometimes just tachycardia and a cancer history is enough to throw them into a higher risk category. You can look up some criteria like the Well's criteria which are pretty popular for stratification, but honestly there's a few out there and none are perfect (the risks and benefits of the different ones is a bit beyond me honestly). If it's not on your differential at all then you're done. but if it does show up on your differential, you'll either need to use a d-dimer and/or a CT to rule it in/out. What would keep it off my differential? Completely normal vitals, no risk factors (the textbooks are often wrong on them, but I'm no better, so if I've heard it as a risk factor, I usually include it), and I deeply considered having it on my differential. Gotta be wary of anchoring bias as Pantis was pointing out in his way.
I'm sure there are other good ways to go about it, that's just my own, and it's a relatively common one in my specialty.
BTW, good luck with your intern year. Don't worry, know one expects you to know that much yet. Just go in with an open mind, and you'll be fine.
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Thanks for the input.
For purposes of "reading up" on patients... what do you recommend?
I love eMedicine. I have Washington Manual (required text via school) and Step Up to Medicine. Not a fan of UpToDate's format. Do you also believe finding review articles on disease states to be very beneficial? Or, would the above 3 be more than sufficient to be very successful as an intern? I'm not going to be doing IM, but my intern year is medicine heavy. Also, I want to be really good at medicine since I'm going to be going into a field that requires sound medical knowledge (anesthesia).
For purposes of "reading up" on patients... what do you recommend?
I love eMedicine. I have Washington Manual (required text via school) and Step Up to Medicine. Not a fan of UpToDate's format. Do you also believe finding review articles on disease states to be very beneficial? Or, would the above 3 be more than sufficient to be very successful as an intern? I'm not going to be doing IM, but my intern year is medicine heavy. Also, I want to be really good at medicine since I'm going to be going into a field that requires sound medical knowledge (anesthesia).
well, uptodate is my personal favorite, but that's cause i'm used to its format. I will tell you that you can pay attention to society guidelines like the american thoracic society. The one nice benefit of those resources is that they typically give you evidence levels and are usually a bit more upfront about what is supposition and what is well-established fact. Cochrane reviews are usually very good. Another good evidence site is thennt.com. If you're going to be using reviews and textbooks though, please track down the references if you're doubting something. You'd be surprised how often the references just link you to review articles that link you to review articles that link you to really poor evidence from 60 years ago. Lastly, run a google search for "pubmed AND PICO" It should provide you with a link to a page that lets you track down clinical articles based on a PICO style question.
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Thanks for the input. 👍
You seem to have completely missed the point. PE may most often present with hemoptysis, but since it could produce a dry cough according to many credible sources, you can't say listing PE on an exhaustive ddx list is incorrect just because you've personally "never seen one with a cough".
No offense, but you haven't used particularly credible sources. I don't really care if you believe me or not. You'll realize when you start doing clinical work that iphones and textbooks, while helpful guides, are often wrong.
If textbooks and such aren't credible sources, what exactly is, a resident who's personally just "never seen one with a cough"?
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I agree with the resident this time, but do you realize that the difference between a med student and a resident can be less than a year of training depending on the time of the year.
Yes it happens that sometimes what the 4th year med student is saying is right, and the intern is just plain wrong.
Just saying it happens.
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It seems that some of the med students here would like to scan everyone.
Use the modified well's criteria if you have doubts.
No they wont.
To try and call out a resident that he is not speaking from practical/real world perspective and you as a med student (who no offense but obviously has no idea what he is talking about) knows more is completely laughable.
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Are you really a resident??...because any resident would know that anyone with chest pain would need to be ruled out for things like an MI or PE..that includes an ECG and asking for focused and specific questions on history and physical exam. If you want to sit in court and try to explain why you did not do an ECG on a patient with chest pain who turned out to have an STEMI...good luck. If you have ever rotated at an ED, it is pretty much malpractice to not r/o an MI in someone with chest pain. And YES...as a medical student I have called out residents on a lot of things...For example...I did a whole month of electrophysiology...guess what...my next rotation I was still fresh enough from my old one to call out the residents in differentiating between an SVT with aberrancy vs. V-tach, and yes...they were asking me questions on other arrythmias. There have been NUMEROUS instances as a 4th year where I would ask an attending or resident...why not this? why not that? can we do this?...and yes...once in a while they would agree with me.
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You know what...looking back at the original post, you are right. I thought he was asking for the differential in someone with chest pain who also happens to have a cough, not just a cough that causes chest pain. But still, in real world medicine when are you ever for certain that someone's chest pain is caused purely by their coughing??? You still need to do a focused history and exam for MI and PE, you still need to do an ECG at the least, you might want to do cardiac enzymes. I guess this is just some of my frustration in how they teach medicine vs. how it is actually practiced. I think I would have been better prepared for 3rd year if I was given the Uptodate workup for chest pain vs. reading pages of differentials.
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Nobody's questioning CP r/o MI, that's automatically done in the ED.
They're questioning the PE. Sure, all you have to do is look at the pt clinically, look at their vitals, h/p, etc. to determine if they're heading in that direction. Their point is you don't need to scan every elderly pt that comes in w/ CP and dry cough.
the literature. If you look in the literature at various studies, while some will cite cough in the introduction sections, dry cough doesn't appear in any of the various clinical prediction or risk stratification rules, I decided to look and couldn't find any reported likelihood ratios for dry cough symptom in predicting PE, although I would bet that it is somewhere near 1 or it's confidence intervals overlap 1 (meaning having dry cough doesn't increase the likelihood that you have a PE). And there was no mention of it in Jama's Rational Clinical Exam series, either.
You'll find lots of credible sources saying lots of untrue things if you go back and read the lit (kayexalate being an example I just learned about).
Since you have made me do a literatue search, I did come across an abstract from 1981 Cardiology Journal that cited cough directly, but don't have access to the actual article yet. The problems there are 1. doesn't pass the sniff test. if 50% present with cough, it doesn't make sense to not have it as a prominent part of the typical presentation, let alone an atypical one. 2. It's 1981. The diagnosis and workup of it has drastically changed with the introduction of CTA, and multiple studies and clinical prediction rules. we catch tons more than we used to. The ones that used to be caught were much sicker generally with a good portion p/w pulmonary infarcts, effusions, etc, all of which present in their own way (and all of which are in the differential of dry cough). 3. Without being able to access it online, it's unclear if this is a retrospective study and what the methods were. There's potentially a large recall bias or other explanations of cough appearing in the abstract. So you do have hope of it being correct but I still doubt it with no present-day studies citing it as a prognostic factor.
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Yeah I'm a resident.
1) MI does NOT have to be ruled out for everyone with chest pain unless you consider looking at an EKG and talking to a patient "ruling out" an MI. You'll realize that once you see about 500 non-cardiac chest pains during your intern year. MI is all about the story. STEMIs are not even close to subtle. Nor are NSTEMIs (not demand ischemia) nor is ACS.
2) Every patient who comes to medicine gets an EKG. Every EKG gets looked at overnight and then again on rounds by the whole team where I am.
3) Any medicine resident who cannot distinguish SVT c aberrancy from V-tach is a *****.
4) I am a resident at a small, relatively obscure hospital in Baltimore called Johns Hopkins.
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