1. History
a. Onset?
b. Associated symptoms suggestive of infection?
c. Wheeze?
d. Associated symptoms suggestive of:
i. Post nasal drip syndrome (PNDS)
ii. GERD
e. Associated with fever and sputum?
f. Risk factor?
i. Smoking
ii. Environment
iii. HIV
g. Medication = ACE inhibitor


Cough Ix
1. CXR
2. ENT Ex
3. Lung Function Test
4. Barium Esophagography
5. CT scan
6. V/Q scans
7. fibreoptic bronchoscopy
8. ECG
9. Psychiatric appraisal



Evaluating Chronic Cough


Lung CA Ix
1. Chest radiograph
• Non-diagnostic
• Just to screen possibilities of infection, tumour, pleural effusion.
• If a mass is observed than send for CT.

2. Sputum cytology
a. By fibreopticbronchoscopy (or transtracheal aspiration)
• the reason to do a transtracheal aspiration is to collect sputum arising from deep regions of the lung (inc alveolus). In doing so, the bronchials are stimulated to produce a cough reflex. Sputum will be cough out from the deep region and can be collected. The procedure is done after doing at CT scan showing that there are abnormalities of the peripheral region. A fibreoptic bronchoscopy will not be able to collect sputum within the alveoli.
• Transtracheal aspiration brings extra advantage when required to investigate on lower respiratory infection. Normal sputum collection (by patient coughing it out) will be contaminated with other organism at URT.


3. High Resolution CT Scan
• Look for local spread of tumour
• Can have a 3D view so that we know the amount of lung area affected
• But cannot see nodes involvement


4. Positron Emission Tomography (PET)
• Fluorodeoxyglucose
• detect abnormalities not demonstrated on CT scans.
• Differentiate between benign and malignant
• Not usually done (limited to certain places e.g. Putrajaya
• Risky because the whole body is radiated
• But the procedure allows us to see any distant metastasis
o Bone marrow scan is usually done instead of PET to investigate marrow involvement.

5. Biopsy
• Fibreoptic bronchoscopy
i. Used to define bronchial anatomy and take biopsy
1. viewing possibility of resection
2. if more than 2cm of tumour (from carina), than cannot undergo surgery
**. concept = avascular area will not heal and leads to fibrous tissue. Thus brings more complication

• Mediastinoscopy and scalene node biopsy
i. Carcinoma of bronchus
ii. Involves inspection of the mediastinal structures using a mediastinoscope inserted by blunt dissection downwards from behind the proximal end of the clavicle
iii. Biopsy of enlarge lymph node taken

• Fine Needle Aspiration
i. Biopsy of peripheral lung
ii. Under appropriate CT guidance