Cough History: History Taking and Differential Diagnoses

History Taking

Overview

With each symptom, always (if relevant) ask about:

• When did it start?
• Did it come on suddenly or gradually?
• Is it continuous or intermittent?
• Has this ever happened before?

Cough

• Onset:
  • How did it start?
  • Did it suddenly come on?
• Character:
  • Dry or productive?
  • What are they coughing up?
    • Blood?
      • Fresh/bright red blood?
      • Dark clots or ground-up coffee?
    • What is the sputum like?
      • Offensive smell?
      • Colour? – may be white, yellow, green, or pink
• Timeline:
  • How long has it been ongoing?
• Exacerbating/alleviating factors:
  • What makes it better or worse?
    • Is it worse at home or at work?
    • Is it worse in the winter (COPD) or the summer (allergic asthma)?
    • Is it worse when lying down?
    • Is it worth with exercise?
• Severity – how much are they coughing?
• Variability:
  • Diurnal variation – is it worse at night or early in the morning?
  • Is it continuous or intermittent?
  • Does it change in different environments? (e.g. work, indoors, or outdoors)
• Have they noticed anything else?
• Has this ever happened before?
• Have they been ill recently?

Review of systems

• Screen for other respiratory symptoms:
  • Shortness of breath, orthopnoea, paroxysmal nocturnal dyspnoea
  • Sputum – as above
  • Wheezing
  • Chest pain – use SOCRATES
  • Peripheral oedema
• Screen for features of infection:
  • Fever
  • Productive cough
• Screen for red flags:
  • Haemoptysis
  • Unexplained weight loss
  • Night sweats
  • Hoarse voice
• Screen for gastro-oesophageal reflux disease (GORD):
  • Heartburn, regurgitation
• Screen for ENT symptoms:
  • Runny nose, nasal drip, itching
  • Sore throat

Past Medical History

Questions include:

• Do they have any other medical conditions?
• Have they ever had any previous surgery?
• Do they take any regular medications?
• Do they take any over-the-counter medications, herbal remedies, or supplements?

Family History

• Is there any family history of anything similar?

Allergy History

• Are they allergic to anything?
  • What happens during the allergic reaction?

Social History

• Do they smoke?
  • If so, how much and how long?
• Do they drink alcohol?
  • If so, how much and how long?
• Do they use any illicit drugs?
  • If so, how much and how long?
• Do they have any pets?
• What is their occupation?
  • Are they exposed to dust?
  • Are they exposed to asbestos?
• Who’s at home?
  • What support do they have?
• How has this impacted their activities of daily living?
• Has there been any recent foreign travel?

Investigations

Overview

When suggesting investigations in an OSCE, the BOXES (Blood tests, orifice tests, x-rays, ECGs, special tests) mnemonic is useful for deciding the order of investigations:

• Blood tests:
  • Full blood count:
    • Anaemia may be seen in malignancy
    • Leukocytosis suggests an infection
  • Urea and electrolyte (U&Es) and calcium:
    • Hyponatraemia may be seen in Legionella pneumonia and small-cell lung cancer
    • Hypercalcaemia may be seen in squamous cell lung cancer
• Orifice tests:
  • Sputum microscopy, culture, and sensitivity:
    • To identify the underlying cause of a chest infection
  • Sputum cytology:
    • If lung cancer suspected
• X-rays:
  • Chest x-ray:
    • May show abnormal opacification and areas of consolidation
• ECGs:
  • ECG:
    • If a cardiac cause (e.g. heart failure) is suspected
• Special tests:
  • Spirometry and bronchodilator reversibility:
    • For asthma/COPD
  • High-resolution CT scan:
    • For lung cancer, pulmonary fibrosis, and bronchiectasis
  • Bronchoscopy:
    • Obtain a biopsy to diagnose lung cancer
  • Echocardiogram:
    • If a cardiac cause (e.g. heart failure) is suspected
  • Nasoendoscopy:
    • For ENT-related causes
  • 24-hour pH manometry:
    • For GORD

Differential Diagnoses

Asthma

• A history may reveal:
  • Wheezing, cough, chest tightness
  • Increased use of reliever inhaler
  • History of atopy (e.g. eczema/hayfever)
• A physical exam may reveal:
  • Wheezing, tachycardia, tachypnoea, difficulty completing sentences, cyanosis, accessory muscle use, altered consciousness, coma depending on severity
• Investigations may reveal:
  • Peak expiratory flow rate (PEFR):
    • Decreased compared to best or predicted
  • Spirometry with bronchodilator reversibility:
    • FEV1/FVC ratio 0.7 or less with reversibility
  • Fractional exhaled nitric oxide test (FeNO):
    • Increased

COPD

• A history may reveal:
  • Shortness of breath, cough, and wheezing
  • Sputum production
  • A history of smoking
• A physical exam may reveal:
  • Fever, crackles, wheezing, hypoxaemia
  • Cyanosis, chest hyper-expansion, facial plethora
• Investigations may reveal:
  • Spirometry with bronchodilator reversibility:
    • FEV1/FVC ratio 0.7 or less without reversibility

Bronchiectasis

• A history may reveal:
  • Chronic cough productive of foul, offensive, copious amounts of sputum
  • Shortness of breath
  • Recurrent infection
  • Severe infection in childhood
• A physical exam may reveal:
  • Crackles, wheezing, clubbing
• Investigations may reveal:
  • Chest x-ray:
    • Thickened airways
  • High-resolution CT chest:
    • Tram-tracking and bronchial dilation

Pneumonia

• A history may reveal:
  • Subacute onset of fever, cough, shortness of breath, pleuritic chest pain
  • Cough may be productive
• A physical exam may reveal:
  • Fever, tachycardia, crackles
  • Focal consolidation and dullness of percussion
• Investigations may reveal:
  • Full blood count:
    • May show leukocytosis
  • Legionella urinary antigen:
    • For Legionella pneumonia
  • Blood cultures:
    • Identifies likely pathogen
  • Urea and electrolytes (U&Es):
    • Prognosis is worse if urea is elevated (CURB-65)
  • Chest x-ray:
    • Shows opacification

Acute bronchitis

• A history may reveal:
  • >2 weeks of cough which may or may not be productive, may be associated with a runny nose and sore throat
  • Symptoms are less severe than that of pneumonia
• A physical exam may reveal:
  • Low-grade fever
  • No dullness to percussion, no crackles 
• Investigations may reveal:

Post-nasal drip

• A history may reveal:
  • Frequent throat clearing, a ‘dripping’ or ‘trickling’ sensation down the back of the throat, nasal discharge, nasal congestion, sneezing, halitosis
• A physical exam may reveal:
  • Mucus secretions in the nasopharynx/oropharynx
• Investigations may reveal:
  • Clinical diagnosis

Gastro-oesophageal reflux disease (GORD)

• A history may reveal:
  • Epigastric burning pain, regurgitation, trigger foods that may worsen symptoms
  • Associated with posture such as lying down
• A physical exam may reveal:
  • n/a
• Investigations may reveal:
  • Therapeutic trial of proton pump inhibitor:
    • Relieves symptoms
  • 24-hour oesophageal pH monitoring:
    • Diagnostic

Drug-induced cough

• A history may reveal:
  • The use of angiotensin-converting enzyme inhibitors (ACE inhibitors) associated with a tickly, dry cough
• A physical exam may reveal:
  • n/a
• Investigations may reveal:
  • Stopping ACE inhibitor resolves cough

Pulmonary tuberculosis (TB)

• A history may reveal:
  • Cough, fever, weight loss, night sweats, haemoptysis
  • HIV/immunosuppression
  • Travel to an endemic area
• A physical exam may reveal:
  • Fever, tachypnoea
• Investigations may reveal:
  • Chest x-ray:
    • May show bilateral hilar lymphadenopathy, may show upper lobe cavitation
  • Sputum culture:
    • Diagnostic

Whooping cough (pertussis)

• A history may reveal:
  • Paroxysms of cough followed by inspiratory whoop that may lead to post-tussive vomiting
• A physical exam may reveal:
  • Subconjunctival haemorrhages
• Investigations may reveal:
  • Nasopharyngeal culture or PCR:
    • Identifies Bordetella pertussis

Lung cancer

• A history may reveal:
  • Cough, haemoptysis, unexplained weight loss, hoarseness, chest pain
  • Features of paraneoplastic syndromes
• A physical exam may reveal:
  • Focal wheezing, dullness, decreased breath sounds
• Investigations may reveal:
  • Chest x-ray:
    • Mass present
  • CT chest:
    • Mass present
  • Biopsy:
    • Histologically confirms lung cancer

Laryngeal cancer

• A history may reveal:
  • A persistent hoarse voice, a lump in the neck, sore throat or feeling something is stuck in the throat, stridor
• Investigations may reveal:
  • Refer to ENT
  • CT with contrast of neck and chest:
    • Identifies tumour
  • Fine-needle aspiration:
    • Allows for histological diagnosis

Foreign body aspiration

• A history may reveal:
  • Coughing and choking, ingestion of food
  • Recurrent pneumonia
• A physical exam may reveal:
  • Unilateral wheezing, stridor, focal dullness to percussion
• Investigations may reveal:
  • Chest x-ray:
    • May identify object

Interstitial lung disease (including idiopathic pulmonary fibrosis)

• A history may reveal:
  • Slow, progressive shortness of breath and dry cough
  • There may be a history of exposure to chemicals, radiotherapy, chemotherapy, some drugs (e.g. nitrofurantoin, methotrexate, amiodarone), asbestos, tuberculosis, ankylosing spondylitis, silicosis, sarcoidosis
• A physical exam may reveal:
  • Dry crackles, clubbing
• Investigations may reveal:
  • Pulmonary function tests:
    • Shows restrictive pattern
  • High-resolution CT scan:
    • Ground glass appearance

Hypersensitivity pneumonitis

• A history may reveal:
  • May present acutely within 4-8 hours after exposure with fever, chills, cough (may be productive)
  • May present more slowly weeks-months after exposure with lethargy, productive cough, weight loss
  • A causative trigger many be identified such as pet birds
• A physical exam may reveal:
  • Crackles
• Investigations may reveal:
  • Chest x-ray:
    • May show fibrosis
  • CT chest:
    • May show fibrosis

Sarcoidosis

• A history may reveal:
  • Fever, arthritis, erythema nodosum, weight loss, malaise
• A physical exam may reveal:
  • Wheezing, dry crackles
• Investigations may reveal:
  • Chest x-ray:
    • Bilateral hilar lymphadenopathy
  • Serum ACE:
    • Elevated
  • Serum calcium:
    • Elevated
  • Lung biopsy:
    • Non-caseating granuloma

Pharyngeal pouch (Zenker’s diverticulum)

• A history may reveal:
  • Usually seen in older men
  • Regurgitation of undigested food, gurgling, halitosis, aspiration
• A physical exam may reveal:
  • Halitosis, gurgling neck swelling
• Investigations may reveal:
  • Barium swallow with fluoroscopy:
    • Identifies pharyngeal pouch