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onthewebonthewebonthewebonthewebonthewebonthewebonthewebonthewebonthewebDiagnosis ChallengePhysicians are often called upon to diagnose a wide range of symptoms andconditions. In this section, we offer our readers the chance to follow a physicianthrough the diagnosis process. What diagnosis would you make?The Patient with theCan’t-Stop CoughGary* was exhausted. He could barely keep his eyes on theroad. Not even the strongest cup of coffee could perk himup. Several times during the drive to work he caught himselfveering off the road, jerking the wheel in the other direction toget his car back on the highway.For weeks he had been suffering severe and repetitivecoughing fits. His sleep was constantly being interrupted byspasms of coughing. Midnight. 2 a.m. 4 a.m. He had hackingbouts during the day, too, often ducking out of meetings toavoid the annoyed stares of his boss and co-workers.Gary assumed it was nothing more than a cold, writing offhis symptoms as a typical winter-weather bug. But after threeweeks of excusing himself from the table at restaurants, suppressingcoughing fits in public, and waking up with chokingepisodes so violent he sometimes gagged, he decided a visitto the doctor was in order.The Office VisitCleveland Clinic physician Camille Sabella,M.D., listened to Gary explain his symptoms:several weeks of violent coughing, sometimesto the point of vomiting, and feelings of dehydration.Gary didn’t experience sinus-relatedproblems - no stuffy head or trouble breathing- other than when he couldn’t catch hisCamille Sabella, M.D.breath during a coughing fit.Gary has no history of asthma or respiratory infections,and he has no fever or abnormal temperature. Dr. Sabellainquired about Gary’s lifestyle and discovered that he isnot a smoker and maintains a fairly healthy diet, avoidinglate-night dinners or excessive alcohol consumption. Gary ismarried, without children, and his wife has not developed acough or similar symptoms. A thorough physical examinationof Gary was completely normal.Based on the described symptoms, Dr. Sabella formed afew theories about what Gary’s condition might be:Bronchitis – Gary’s cough alerted Dr. Sabella to the possibilityof this common breathing condition in which the bronchialtree inside the lungs becomes infected by a virus. Symptomsof bronchitis come on quickly and can persist for weeks.Common Cold – Winter weather and an office atmosphereharbor a slew of common cold viruses. Gary might havepicked up a virus from a co-worker. Fatigue and stress cancause colds to linger.Gastroesophageal Reflux – Characterized by a backwash ofstomach contents and acid into the airway, symptoms of thiscondition include coughing, gagging and vomiting. Also, it iscommon for these symptoms to occur at night.Pertussis (Whooping Cough) – Pertussis is a highly contagiousbacterial disease that affects the respiratory system. It producesspasms of coughing that may end in a high-pitched, deep inhalationin children, although the “whoop” is rare in adults.Asthma – With asthma, inflammation of the airways causesairflow into and out of the lungs to be restricted, producingthe characteristic wheezing sound. Mucus production also isincreased.As a next step, Dr. Sabella ordered a test for whoopingcough bacteria from the back of Gary’s nose to culture in thelaboratory. In addition, he ordered a chest X-ray.Dr. Sabella then continued with his assessment. After acareful history and physical examination, Dr. Sabella determinedthat Gary did not have bronchitis. Although bronchitissymptoms can last for a couple of weeks, Gary’s symptomswere too severe and prolonged for bronchitis.A cold was the least likely conclusion. Gary didn’t displayrelated complications, such as a stuffy or runny nose, sore throator fever. Also, colds generally run their course in two weeks.Because Gary is careful not to eat late or consume excessiveamounts of alcohol, the likelihood of gastroesophagealreflux was minimal. Reflux is common following meals, andGary experiences coughing symptoms most of the time.In addition, asthma seemed unlikely since Gary has nopast history of asthma, no history of wheezing or shortness ofbreath, and his physical examination was normal.Gary’s chest X-ray was normal and the nasal culture cameback negative for the whooping cough bacteria, meaning Dr.Sabella did not find anything in the culture that alerted himto pertussis.So, what could be the cause of Gary’s condition?For Dr. Sabella’s diagnosis, go to our Web site atwww.clevelandclinic.org/clevelandclinicmagazineYou can also send us an email atclevelandclinicmagazine@ccf.org and we will emailyou the diagnosis.*The patient and history presented in “Diagnosis Challenge” are fictional.8 cleveland clinic magazine