Cough
Respiratory
Introduction
Author: Sarosh Ibrahim
Taking a comprehensive history from a patient presenting with a cough involves exploring its duration, onset, and characteristics (e.g., dry or productive), as well as associated symptoms such as fever, shortness of breath, or wheezing. Key principles include understanding the context, such as recent infections, exposure to irritants, smoking, or occupational risks, and identifying any exacerbating or alleviating factors. It's crucial to inquire about past medical history, allergies, medications, and family history of respiratory diseases. Additionally, understanding the psychosocial impact of the cough can help tailor management and address patient concerns.
WIPER
W – Wash/sanitise hands
I – Introduce yourself (name and title)
P – Permission, take consent
E – Expose the patient (if necessary)
R – Reposition the patient (if needed)
Presenting Complaint
1. Onset:
When did the cough begin?
Was the onset sudden or gradual?
2. Duration and frequency
How long has the cough been present (acute: <3 weeks,
subacute: 3–8 weeks, chronic: >8 weeks)?
Is it constant or intermittent?
3. Character of the cough:
Is it dry or productive?
If productive, describe the sputum (colour, volume,
consistency, odour).
Is there haemoptysis (blood-streaked or frank blood)?
4. Triggers:
Are there any known triggers? (e.g., allergens, smoke, cold
air, exercise, lying down).
5. Associated Symptoms:
Respiratory:
Shortness of breath, wheezing, chest pain, fever, night
sweats.
Gastrointestinal:
Heartburn, regurgitation, dysphagia.
ENT:
Sore throat, nasal congestion, postnasal drip, hoarseness.
Systemic:
Fatigue, weight loss, loss of appetite.
6. Pattern:
Is the cough worse at any specific time of day (e.g., nocturnal,
early morning)?
Seasonal variations? Does cold weather make it bad?
7. Exacerbating Factors:
What makes the cough worse? (e.g., exertion, lying flat, cold
weather
8. Relieving Factors:
Does anything improve the symptom? (e.g., rest, sitting upright, inhalers, oxygen therapy)
9. Impact:
What alleviates the cough? (e.g., sitting up, hydration,
medication)
10. Severity:
How troublesome is the cough on a scale (e.g., mild, moderate,
severe)? Ask to rate between 1 (least) to 10 (most)
ICE: Ideas, Concerns, Expectations
Ideas: Does the patient think it’s an infection, allergy, or
something serious (e.g., cancer)?
Concerns: Are they worried about the duration or possible
complications?
Expectations: Do they hope for reassurance, antibiotics, or
further investigations?
Past Medical History
W – Wash/sanitise hands
I – Introduce yourself (name and title)
P – Permission, take consent
E – Expose the patient (if necessary)
R – Reposition the patient (if needed)
Medications
Current medications and recent changes including over the counter drugs.
ACE inhibitors, beta-blockers, or recent antibiotic use.
Over-the-counter remedies for cough.
Recreational drug use (e.g., smoking, vaping)
Family History
Family history of asthma, atopy, or other respiratory conditions.
Social History
Smoking History: Calculate pack-years history
Alcohol Consumption: How many units per week?
Occupation: Exposure to allergens, dust, or chemicals
Recreational Drugs: Especially cocaine
Lifestyle: Living conditions (e.g., damp housing), pets (potential
allergens)
Differential Diagnosis
Cough (acute, subacute or chronic) can be caused by the following causes:
Respiratory Causes:
Acute: Infections (e.g. viral URTI, pneumonia), exacerbation of asthma/COPD
Chronic: Asthma, COPD, bronchiectasis, interstitial lung disease, tuberculosis, malignancy
Cardiac Causes:
Heart failure, pulmonary oedema.
Gastrointestinal Causes
GORD with chronic aspiration.
ENT Causes:
Postnasal drip, chronic sinusitis, laryngitis.
Medication-Induced Causes:
ACE inhibitors..
Management
Bedside:
Physical examination to check for
Inspect for signs of respiratory distress (e.g., use of accessory
muscles)
Palpate for tenderness or deformities in the chest wall.
Auscultate for wheezing, crackles, or reduced air entry.
Laboratory:
Blood Tests:
Full blood count (FBC) – anaemia or infection
C-reactive protein (CRP)/Erythrocyte sedimentation rate (ESR) – inflammation or infection.
IgE levels – allergies or atopy.
Arterial blood gases (ABG) – assess oxygenation and acid-base status.
Imaging and Special Tests:
Chest X-ray – rule out pneumonia, tuberculosis, or malignancy.
Spirometry – for asthma or COPD.
Peak expiratory flow rate – asthma monitoring.
Sputum culture – for bacterial or fungal infections.
Special Tests:
CT scan – for suspected malignancy or bronchiectasis.
Bronchoscopy – if malignancy suspected.
Management Plan
Tailor based on underlying cause:
Tailor based on underlying cause (e.g., antibiotics for infection,
inhalers for asthma).
Lifestyle modifications (e.g., smoking cessation,
allergen avoidance).
Provide reassurance for acute conditions (e.g., post-viral
cough).
Referral to specialists (e.g., pulmonologist, gastroenterologist
if needed)