# A cough for six weeks with weight loss in a 34-year-old: a case to work up

> A respiratory case for medical students: a 34-year-old with six weeks of cough, evening fevers, night sweats and weight loss. What to ask, red flags, first tests and the differential.

- Respiratory Medicine · Intermediate · about 20 minutes
- Web page: https://www.medikarya.in/case-studies/34-year-old-man-with-a-cough-for-six-weeks-and-weight-loss
- Work up this patient: https://www.medikarya.in/case-studies/34-year-old-man-with-a-cough-for-six-weeks-and-weight-loss

## How the patient presents

An auto-rickshaw driver has had a cough for six weeks, evening fevers and night sweats, and has lost 6 kg. A course of antibiotics from a local clinic did not help, and last week he saw streaks of blood in his phlegm.

## Why a long cough with weight loss matters

In India, a long cough with fever, night sweats or weight loss must be tested for tuberculosis, and other causes, including cancer, kept in mind. The history also tells you about drug resistance, HIV and the people he lives with.

## What to ask in the history

- How long the cough has lasted, sputum, blood in it
- Fever pattern, night sweats, weight loss, appetite
- Contact with anyone with tuberculosis; previous tuberculosis treatment
- HIV risk, diabetes
- Smoking, dust or fumes at work
- Which antibiotics he has already had
- Breathlessness, chest pain
- Who lives with him

## Red flags

- Coughing up a large amount of blood
- Breathless at rest, low oxygen saturation
- Previous tuberculosis treatment
- HIV
- Severe weight loss

## What to examine

- Weight, temperature
- Lymph nodes
- Clubbing
- Chest: crackles, bronchial breathing, signs of fluid
- Liver and spleen

## First investigations

- Sputum for a rapid molecular test and smear
- Chest X-ray
- HIV test, glucose
- Full blood count, ESR
- Liver and kidney function before any treatment
- CT or bronchoscopy if sputum tests are negative and suspicion stays high

## Differential diagnosis of a long cough with weight loss

Grouped, not ranked. Which one fits this patient is for you to work out in the case.

### Infection

- Tuberculosis
- Pneumonia that has not settled
- Lung abscess
- Fungal infection

### Cancer

- Lung cancer
- Lymphoma

### Other

- Bronchiectasis
- Sarcoidosis
- HIV-related lung disease

## Common mistakes

- Giving course after course of antibiotics instead of testing.
- Not testing for HIV and diabetes.
- Forgetting the people he lives with.

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A study guide for medical students, not medical advice. Follow your institution's protocols in practice.