11/13/24, 8\:08 PM Guide | Cough history

Cough history

Table of contents

Background

Cough is a re
When a patient reports a cough, it is important to distinguish it from retching or gagging, which indicates nausea and
regurgitation of food secondary to dysphagia. These symptoms have di

Causes of cough

The causes of cough can be organised according to the surgical sieve.
Infective
Upper respiratory tract infection (usually viral, including COVID-19)
Laryngitis (usually viral)
Acute bronchitis and acute tracheitis (viral or bacterial)
Chronic bronchitis, as part of chronic obstructive pulmonary disease (COPD)
B o r d e t e l l a p e r t u s s i s (whooping cough)
Pneumonia, including aspiration pneumonia
Pulmonary tuberculosis
Fungal infections, such as allergic bronchopulmonary aspergillosis (ABPA), which is a hypersensitivity reaction to A .
f u m i g a t u s and is usually associated with asthma
Neoplastic
Laryngeal or pharyngeal carcinoma
Bronchial (lung) carcinoma
Pleural carcinoma
Vascular
Pulmonary embolism
Pulmonary oedema secondary to cardiac failure
In
Post-infectious cough
Upper airway cough syndrome (UACS, also known as post-nasal drip)\: mucous from the nasal passages and/or sinuses,
secondary to infection or allergy, causes pharyngo-laryngeal irritation
Gastro-oesophageal re
Smoking-related cough
Asthma, including cough-variant asthma (in which cough is the main, or only, symptom) and eosinophilic bronchitis
Chronic obstructive pulmonary disease (COPD)
Bronchiectasis (incystic ,
and connective tissue disorders such as rheumatoid arthritis)
Pulmonary
Sarcoidosis
Hypersensitivity pneumonitis secondary to exposure to allergens (e.g. bird feathers); examples include farmer's lung and
bird fancier's lung
silicosis and asbestosis
Occupational lung disease secondary to exposure to inorganic dusts; examples include coal workers' pneumoconiosis,
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Traumatic
Inhaled foreign body
Pneumothorax/tension pneumothorax
Endocrine/degenerative/metabolic
N/A
Drugs
Angiotensin-converting enzyme inhibitor (ACE-i) induced cough
Sitagliptin-induced cough
Congenital
N/A (cystic and ciliary dysfunction syndromes are causes of bronchiectasis, which is considered in the
in
When other diagnoses have been excluded, somatic cough syndrome should be considered. This is also known as
psychogenic cough and is a diagnosis of exclusion when no organic cause can be found.

Opening the consultation

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient, including your name and role.
Con
Explain that you’d like to take a history from the patient.
Gain consent to proceed with history taking.
General communication skills
It is important you do not forget the general communication skills which are relevant to all patient encounters.
Demonstrating these skills will ensure your consultation remains patient-centred and not checklist-like (just because
you’re running through a checklist in your head doesn’t mean this has to be obvious to the patient).
Some general communication skills which apply to all patient consultations include\:
Demonstrating empathy in response to patient cues\: both verbal and non-verbal.
Active listening\: through body language and your verbal responses to what the patient has said.
An appropriate level of eye contact throughout the consultation.
Open, relaxed, yet professional body language (e.g. uncrossed legs and arms, leaning slightly forward in the chair).
Making sure not to interrupt the patient throughout the consultation.
Establishing rapport (e.g. asking the patient how they are and o
Signposting\: this involves explaining to the patient what you have discussed so far and what you plan to discuss next.
Summarising at regular intervals.

Presenting complaint

Use open questioning to explore the patient’s presenting complaint\:
“ W h a t’ s b r o u g h t y o u i n t o s e e m e t o d a y ?”
“ T e l l m e a b o u t t h e i s s u e s y o u’ v e b e e n e x p e r i e n c i n g.”
Provide the patient with enough time to answer and avoid interrupting them.
Facilitate the patient to expand on their presenting complaint if required\:
“ O k , c a n y o u t e l l m e m o r e a b o u t t h e c o u gh ?”
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Open vs closed questions
History taking typically involves a combination of open and closed questions. Open questions are e
consultations, allowing the patient to tell you what has happened in their own words. Closed questions can allow you to
explore the symptoms mentioned by the patient in more detail to gain a better understanding of their presentation.
Closed questions can also be used to identify relevant risk factors and narrow the di

History of presenting complaint

Gather further details about the patient’s cough using the SOCRATES acronym.

SOCRATES

The SOCRATES acronym is a useful tool for exploring each of the patient’s presenting symptoms in more detail. It is most
commonly used to explore pain but can be applied to other symptoms, although some of the elements of SOCRATES may not
be relevant to all symptoms.
Site
The patient may not be aware of where the cough originates, but in some cases, they may be able to localise it\:
" W h e r e d o y o u f e e l a s t h o u g h t h e c o u g h i s c o m i n g f r o m ?"
Irritation in the throat suggests an upper respiratory tract infection, laryngitis, GORD, UACS. or ACE-i induced cough.
Cough associated with tightness in the upper chest suggests bronchitis or asthma.
Onset
Clarify when the cough developed\:
" W h e n d i d t h e c o u g h s t a r t ?"
" H o w l o n g h a s t h e c o u g h b e e n g o i n g o n f o r ?"
It is important to remember that all coughs have a short history at the outset, but the point at which the patient presents
relative to the onset of the cough can help determine the cause\:
Presentation within hours of the onset of cough alone would be unusual, however when cough is accompanied by other
alarm symptoms (e.g. pain and/or acute shortness of breath), this would be consistent with inhaled foreign body,
pneumothorax, pulmonary embolus, acute asthma or acute pulmonary oedema.
A cough of less than three weeks (de
UACS secondary to infective sinusitis. It could also be seen with a pulmonary embolus which was not causing severe pain or
shortness of breath.
A sub-acute cough is one which has lasted for three to eight weeks. The most common cause of this is a post-infectious
cough, but it can be seen with B o r d e t e l l a p e r t u s s i s infection (whooping cough).
A chronic cough is one which has persisted for over eight weeks, and at this stage, it is important to consider neoplastic
causes (e.g. lung cancer), inchronic cardiac failure
Character
Ask about the speci
" C a n y o u d e s c r i b e t h e c o u g h ?"
" I s t h e c o u g h w e t ( p r o d u c t i v e o f s p u t u m ) o r d r y ?"
An acute productive cough suggests an infective cause, particularly bronchitis or pneumonia. Purulent, coloured sputum
(yellow, green or brown) may indicate a bacterial infection. In pneumonia caused by S t r e p . p n e u m o n i a e the sputum may be
rust-coloured. White or clear sputum is more suggestive of a viral infection.
An acute dry cough is also seen in infections, such as viral upper respiratory tract infections (including COVID-19) and
bronchitis. A post-infectious cough is also typically dry.
A chronic productive cough is seen in COPD, bronchiectasis, and pulmonary tuberculosis. In pulmonary oedema, patients may
experience a cough productive of frothy white or pink sputum. In ABPA, the cough may be productive of bronchial casts.
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A chronic dry cough is seen in smoker's cough, UACS, asthma, GORD, lung cancer, and in
sarcoidosis,
pulmonary tuberculosis.
Directly ask about haemoptysis\:
" H a v e y o u c o u g h e d u p a n y b l o o d ?"
Haemoptysis is seen with upper respiratory tract infections, bronchitis and pneumonia. It is also a red-
pulmonary embolism, bronchial carcinoma, bronchiectasis, and pulmonary tuberculosis.
Directly ask about coughing paroxysms\:
D o y o u g e t b u r s t s ( p a r o x y s m s ) o f c o u gh i n g ?
In the second stage of whooping cough (after the
possibly followed by an inspiratory ‘whoop’
. However, this is less common in adults than in children.
If the patient is known to have a chronic respiratory condition, such as asthma, COPD or bronchiectasis, it is important not to
assume that a new cough is due to an exacerbation of this condition, as doing so could delay the diagnosis of a serious cause
(e.g. lung cancer). Therefore, asking them to compare their current cough to their usual experience of an exacerbation is
essential\:
I s t h i s c o u g h t h e s a m e a s y o u r u s u a l e x a c e r b a t i o n s , o r i s t h e r e a n y t h i n g d i
If the patient reports a di
Radiation
N/A
Associated symptoms
Ask if there are other symptoms which are associated with the cough
“ A r e t h e r e a n y o t h e r s y m p t o m s a s s o c i a t e d w i t h t h e c o u gh ?”
Infective causes of cough may be associated with\:
Fever (+/- rigors)
Shortness of breath
Nasal blockage/rhinorrhoea and sore throat (upper respiratory tract infection)
Anosmia (upper respiratory tract infection, particularly COVID-19)
Tender, enlarged cervical lymph nodes (upper respiratory tract infection)
Hoarseness (laryngitis)
Wheeze and chest tightness (bronchitis)
Pain on coughing (tracheitis)
Pleuritic chest pain (pneumonia)\: occasionally, patients with lower lobe pneumonia may also report upper abdominal pain
Night sweats (pulmonary tuberculosis)
Weight loss (pulmonary tuberculosis)
Haemoptysis
Vomiting after a paroxysm of coughing and/or sweating/facial
Neoplastic causes of cough may be associated with\:
Weight loss
Appetite loss
Fatigue
Night sweats
Hoarseness (laryngeal carcinoma or bronchial carcinoma)
Shortness of breath (bronchial or pleural carcinoma)
Chest wall pain (bronchial or pleural carcinoma)
Pain in the shoulder and inner aspect of the arm (known as Pancoast's syndrome and caused by bronchial carcinoma)
Wheeze (bronchial carcinoma)
Enlarged cervical or supraclavicular lymph nodes
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A pulmonary embolus may be associated with\:
Shortness of breath
Pleuritic chest pain
Current or recent symptoms of deep vein thrombosis (unilateral leg pain, swelling and erythema)
Pulmonary oedema may be associated with\:
Shortness of breath
Bilateral leg oedema
Orthopnoea
In
Nasal obstruction and/or rhinorrhoea/sneezing (UACS)
Wheeze and chest tightness (asthma, COPD)
Shortness of breath (asthma, COPD, bronchiectasis, pulmonary
occupational lung disease)
Dyspepsia (GORD)
Recurrent pleurisy (bronchiectasis)
Weight loss (bronchiectasis, sarcoidosis, pulmonary
Fatigue (sarcoidosis, pulmonary
Headache (hypersensitivity pneumonitis)
Myalgia (hypersensitivity pneumonitis)
Traumatic causes may be associated with\:
Wheeze and/or stridor (inhaled foreign body)
Shortness of breath and/or pleuritic chest pain (pneumothorax)
A sitagliptin-induced cough may be associated with rhinorrhoea, dyspnoea and fatigue.
Time course
Clarify how the cough changes over time\:
" I s t h e c o u g h t h e r e a l l t h e t i m e , o r d o e s i t c o m e a n d g o ?"
Diurnal variation, with symptoms worse at night and in the morning, suggests asthma. A smoking-related cough is typically
worse in the mornings.
Paroxysms of coughing in whooping cough are worse at night.
Ask about repeated episodes of cough\:
H a v e y o u b e e n e x p e r i e n c i n g r e p e a t e d e p i s o d e s o f c o u g h ?
A recurrent infective cough may indicate underlying immunosuppression, recurrent aspiration, bronchiectasis, or lung cancer.
Exacerbating or relieving factors
Ask if anything makes the cough worse or better\:
“ D o e s a n y t h i n g m a k e t h e c o u g h w o r s e ?”
“ D o e s a n y t h i n g m a k e t h e c o u g h b e t t e r ?”
Positional variation in cough, with symptoms worse when supine, suggests cardiac failure or GORD. In GORD, the cough may
worsen after eating or bending forwards. In bronchiectasis, cough may be triggered by a change in posture.
A worsening cough when the patient is in certain places suggests an environmental trigger. For example, the cough associated
with occupational lung disease may improve during holidays from work, whilst an asthmatic cough triggered by exposure to
animal dander may be worse in the home if the patient has pets.
A recurrent cough whilst eating with repeated episodes of pneumonia may suggest recurrent aspiration pneumonia.
Cough which worsens during exercise may occur in asthma.
Certain medications can worsen cough (see drug history section).
Severity
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N/A
Lung cancer red
Unexplained haemoptysis is a red
haemoptysis should be referred urgently (urgent suspected cancer referral).
NICE advise an urgent chest X-ray (within two weeks) in patients aged 40 years and over with two or more of the
following unexplained symptoms\:
Cough
Fatigue
Shortness of breath
Chest pain
Weight loss
Appetite loss
needed.
If they have ever smoked or been exposed to asbestos, then only one unexplained symptom from the list above is

Ideas, concerns and expectations

A key component of history taking involves exploring a patient’s ideas, concerns, and expectations (often referred to as ICE) to
gain insight into how a patient currently perceives their situation, what they are worried about and what they expect from the
consultation.
The exploration of ideas, concerns and expectations should be
This will help ensure your consultation is more natural, patient-centred, and not overly formulaic.
It can be challenging to use the ICE structure in a way that sounds natural in your consultation, but we have provided several
examples for each of the three areas below.
Ideas
Explore the patient’s ideas about the current issue\:
“ W h a t d o y o u t h i n k t h e p r o b l e m i s ?”
“ W h a t a r e y o u r t h o u g h t s a b o u t w h a t i s h a p p e n i n g ?”
“ I t’ s c l e a r t h a t y o u’ v e g i v e n t h i s a l o t o f t h o u gh t a n d i t w o u l d b e h e l p f u l t o h e a r w h a t y o u t h i n k m i gh t b e go i n g o n .
”
Concerns
Explore the patient’s current concerns\:
“ I s t h e r e a n y t h i n g , i n p a r t i c u l a r , t h a t’ s w o r r y i n g y o u ?”
“ W h a t’ s y o u r n u m b e r o n e c o n c e r n r e g a r d i n g t h i s p r o b l e m a t t h e m o m e n t ?”
“ W h a t’ s t h e w o r s t t h i n g y o u w e r e t h i n k i n g i t m i g h t b e ?”
Expectations
Ask what the patient hopes to gain from the consultation\:
“ W h a t w e r e y o u h o p i n g I’ d b e a b l e t o d o f o r y o u t o d a y ?”
“ W h a t w o u l d i d e a l l y n e e d t o h a p p e n f o r y o u t o f e e l t o d a y’ s c o n s u l t a t i o n w a s a s u c c e s s ?”
“ W h a t d o y o u t h i n k m i g h t b e t h e b e s t p l a n o f a c t i o n ?

Summarising

Summarise what the patient has told you about their presenting complaint. This allows you to check your understanding of
the patient’s history and provides an opportunity for the patient to correct any inaccurate information.
Once you have summarised, ask the patient if there’s anything else that you’ve overlooked. Continue to periodically
summarise as you move through the rest of the history.
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Signposting

Signposting, in a history taking context, involves explicitly stating what you have discussed so far and what you plan to
discuss next. Signposting can be a useful tool when transitioning between di
provides the patient with time to prepare for what is coming next.
Signposting examples
Explain what you have covered so far\:
a c h i e v e t o d a y .
”
“ O k , s o w e’ v e t a l k e d a b o u t y o u r s y m p t o m s , y o u r c o n c e r n s a n d w h a t y o u’ r e h o p i n g w e
What you plan to cover next\:
h i s t o r y .
”
“ N e x t I’ d l i k e t o q u i c k l y s c r e e n f o r a n y o t h e r s y m p t o m s a n d t h e n t a l k a b o u t y o u r p a s t m e d i c a l

Systemic enquiry

A systemic enquiry involves performing a brief screen for symptoms in other body systems which may or may not be relevant
to the primary presenting complaint. A systemic enquiry may also identify symptoms that the patient has forgotten to mention
in the presenting complaint.
Deciding on which symptoms to ask about depends on the presenting complaint and your level of experience.
Some examples of symptoms you could screen for in each system include\:
Systemic\: fever, night sweats, unintentional weight loss
Cardiovascular\: chest pain, leg swelling
Respiratory\: shortness of breath, pleuritic chest pain
Gastrointestinal\: dyspepsia
ENT\: rhinorrhoea, nasal obstruction, anosmia
Skin\: eczema (associated with asthma and allergic rhinitis)
Rheumatological\: joint pain/swelling (rheumatoid arthritis is associated with pulmonary
Neurological\: dysphagia

Past medical history

Ask if the patient has any medical conditions\:
“ D o y o u h a v e a n y m e d i c a l c o n d i t i o n s ?”
“ A r e y o u c u r r e n t l y s e e i n g a d o c t o r o r s p e c i a l i s t r e gu l a r l y ?”
Ask if the patient has previously undergone any surgery (e.g. thoracic surgery, ENT surgery)\:
“ H a v e y o u e v e r p r e v i o u s l y u n d e r g o n e a n y o p e r a t i o n s o r p r o c e d u r e s ?”
“ W h e n w a s t h e o p e r a t i o n / p r o c e d u r e , a n d w h y w a s i t p e r f o r m e d ?”
If the patient does have a medical condition, you should gather more details to assess how well controlled the disease is and
what treatment(s) the patient is receiving. It is also important to ask about any complications associated with the condition
including hospital admissions.
Examples of relevant medical conditions
Relevant medical conditions in the context of cough include\:
For infective causes\:
Conditions which cause immunosuppression\: diabetes mellitus, HIV, end-stage renal failure, haematological
malignancies and malnutrition
Neurological disorders which cause dysphagia and increase the risk of aspiration pneumonia\: Parkinson’s disease,
stroke and motor neurone disease
For neoplastic causes\:
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Primary malignancies which metastasise to the lungs\: adenocarcinomas of the colon/breast/kidney/testicle,
melanoma, thyroid carcinoma, oesophageal cancer and sarcomas
For vascular causes\:
Conditions which increase the risk of pulmonary embolus\: previous venous thromboembolism, current or recent
pregnancy, recent surgery, leg fractures, malignancy, or any condition which has caused signi
Conditions which increase the risk of cardiac failure\: ischaemic heart disease, atrial
For in
Eczema and allergic rhinitis (associated with asthma)
Hiatus hernia (associated with GORD)
Other autoimmune conditions, such as rheumatoid arthritis and systemic lupus erythematosus (SLE)
Allergies
anaphylaxis).
Ask if the patient has any allergies and if so, clarify what kind of reaction they had to the substance (e.g. mild rash vs

Drug history

Ask if the patient is currently taking any prescribed medications or over-the-counter remedies\:
“ A r e y o u c u r r e n t l y t a k i n g a n y p r e s c r i b e d m e d i c a t i o n s o r o v e r-t h e-c o u n t e r t r e a t m e n t s ?”
If the patient is taking prescribed or over the counter
medications, document the medication name, dose, frequency, form and route.
Ask the patient if they’re currently experiencing any side e
“ H a v e y o u n o t i c e d a n y s i d e e
“ D o y o u t h i n k y o u r c o u g h s t a r t e d a f t e r y o u b e g a n t a k i n g a n y o f y o u r c u r r e n t m e d i c a t i o n s ?”
Medication examples
ACE inhibitors (e.g. ramipril lisinopril, perindopril and enalapril) cause a dry cough in some patients, which is associated
with irritation in the throat. Its onset can be days to months after initiation of the medication. These drugs are commonly
prescribed for hypertension, heart failure, and following myocardial infarction.
Sitagliptin, used to treat type II diabetes mellitus, can cause a cough associated with dyspnoea, rhinorrhoea and fatigue.
Beta-blockers, such as propranolol, can precipitate asthma, as can aspirin and non-steroidal anti-in
(NSAIDs), such as ibuprofen and naproxen.
Drugs which cause pulmonary

Family history

Ask the patient if there is any family history of lung disease, cardiovascular disease, thromboembolic disease, autoimmune
disease or malignancy.
“ D o a n y o f y o u r p a r e n t s o r s i b l i n g s h a v e a n y m e d i c a l c o n d i t i o n s ?”
Clarify at what age the disease developed (disease developing at a younger age is more likely to be associated with genetic
factors).
If one of the patient’s close relatives are deceased, sensitively determine the age at which they died and the cause of death\:
“ I’ m r e a l l y s o r r y t o h e a r t h a t , d o y o u m i n d m e a s k i n g h o w o l d y o u r d a d w a s w h e n h e d i e d ?”
“ D o y o u r e m e m b e r w h a t m e d i c a l c o n d i t i o n w a s f e l t t o h a v e c a u s e d h i s d e a t h ?”
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General social context
Explore the patient’s general social context including\:
the type of accommodation they currently reside in (e.g. house, bungalow) and if there are any adaptations to assist them
(e.g. stairlift)
who else the patient lives with and their personal support network
what tasks they are able to carry out independently and what they require assistance with (e.g. self-hygiene, housework,
food shopping)
if they have any carer input (e.g. twice daily carer visits)
It is important to ask about exposure to allergens, such as animal dander or bird feathers, in the home environment, and about
passive smoking.
Patients using homeless shelters or hostels are at increased risk of tuberculosis.
Smoking
Record the patient’s smoking history, including the type and amount of tobacco used.
Calculate the number of ‘pack-years’ the patient has smoked for to determine their cardiovascular risk pro
pack-years = [number of years smoked] x [average number of packs smoked per day]
one pack is equal to 20 cigarettes
See our smoking cessation guide for more details.
Patients who smoke may have a chronic, persistent cough which is benign and due to bronchial irritation. However, smoking is
also a major risk factor for developing COPD, malignancy and cardiovascular disease.
Alcohol
Record the frequency, type and volume of alcohol consumed on a weekly basis.
See our alcohol history taking guide for more information.
Excessive alcohol use is a risk factor for tuberculosis.
Recreational drug use
Ask the patient if they use recreational drugs and if so, determine the type of drugs used and their frequency of use.
Intravenous drug use is a risk factor for tuberculosis.
Occupation
A thorough occupational history (covering all jobs the patient has done throughout their working life) is essential when taking a
history from a patient with chronic cough.
Focus particularly on\:
Exposure to allergens, such as animal dander, pollen, dust
Exposure to asbestos
Exposure to infectious diseases, such as tuberculosis

Travel history

If the patient’s symptoms suggest an infective aetiology, take a travel history to assess exposure risk.
Ask about whether the patient was born outside of the UK and/or whether they have travelled outside of the UK. Countries
such as India, Pakistan, Romania, Bangladesh and Somalia have particularly high rates of tuberculosis. If a patient was born in,
or has travelled to, an area of high tuberculosis prevalence, ask about their vaccination status.
Pneumonia due to L e g i o n e l l a can also be associated with foreign travel, as it can be contracted through inhaling bacteria from
poorly-maintained plumbing systems, which may be found in hotels.
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Closing the consultation

Summarise the key points back to the patient.
Ask the patient if they have any questions or concerns that have not been addressed.
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.

References

Barraclough, K. C h r o n i c c o u g h i n a d u l t s . BMJ 2009; 338
t h
Boon, NA. Colledge, NR, Walker, BR (eds). D a v i d s o n’ s P r i n c i p l e s & P r a c t i c e o f M e d i c i n e 2 0 E d . Churchill Livingstone Elsevier,
2006
BMJ Best Practice. A s s e s s m e n t o f c h r o n i c c o u g h . Available from\: [LINK]
NICE CKS. C o u g h . Available from\: [LINK]
Source\: geekymedics.com
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