Cough History Taking - OSCE Guide | Geeky Medics (2024)

Taking a comprehensivecough history is an important skill often assessed in OSCEs. This guide provides a structured framework for taking a history from a patient with a cough in an OSCE setting.

Background

Cough is a reflex response to stimulation of sensory nerves in the mucosa of the respiratory tract.

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 different aetiology from true cough.

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)
• Bordetella pertussis (whooping cough)
• Pneumonia, including aspiration pneumonia
• Pulmonary tuberculosis
• Fungal infections, such as allergic bronchopulmonary aspergillosis (ABPA), which is a hypersensitivity reaction to A. fumigatus 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

Inflammatory/autoimmune

• 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 reflux disease (GORD): aspiration of acid from the stomach causes pharyngo-laryngeal irritation
• 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 (inflammatory damage to the airways with multiple causes, including previous severe infection, cystic fibrosis, and connective tissue disorders such as rheumatoid arthritis)
• Pulmonary fibrosis
• Sarcoidosis
• Hypersensitivity pneumonitis secondary to exposure to allergens (e.g. bird feathers); examples include farmer’s lung and bird fancier’s lung
• Occupational lung disease secondary to exposure to inorganic dusts; examples include coal workers’ pneumoconiosis, silicosis and asbestosis

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 fibrosis and ciliary dysfunction syndromes are causesof bronchiectasis, which is considered in the inflammatory/autoimmune section above)

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.

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Opening the consultation

Wash your handsanddon PPEif appropriate.

Introduce yourself to the patient, including your nameandrole.

Confirm the patient’snameanddate of birth.

Explainthat you’d like to take a history from the patient.

Gain consentto proceed with history taking.

Presenting complaint

Useopen questioningto explore the patient’spresentingcomplaint:

• “What’s brought you in to see me today?”
• “Tell me about the issues you’ve been experiencing.”

Provide the patient with enoughtimeto answer and avoid interrupting them.

Facilitate the patient toexpandon theirpresentingcomplaintif required:

• “Ok, can you tell me more about the cough?”

History of presenting complaint

Gather further details about the patient’s cough using the SOCRATESacronym.

SOCRATES

TheSOCRATESacronym 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:

• “Where do you feel as though the cough is coming from?”

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:

• “When did the cough start?”
• “How long has the cough been going on for?”

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 (defined as acute in this context) is most likely to suggest an infective cause, including 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 toeight weeks. The most common cause of this is a post-infectious cough, but it can be seen with Bordetella pertussis 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), inflammatory/autoimmune causes, drugs and chronic cardiac failure

Character

Ask about thespecificcharacteristics of the cough:

• “Can you describe the cough?”
• “Is the cough wet (productive of sputum) or dry?”

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 byStrep. pneumoniae 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.

A chronic dry cough is seen in smoker’s cough, UACS, asthma, GORD, lung cancer, and inflammatory conditions such as sarcoidosis, fibrosis and hypersensitivity pneumonitis. It is also seen with drug-induced coughs and in the early stages of pulmonary tuberculosis.

Directly ask about haemoptysis:

• “Have you coughed up any blood?”

Haemoptysis is seen with upper respiratory tract infections, bronchitis and pneumonia. It is also a red-flag symptom of pulmonary embolism, bronchial carcinoma, bronchiectasis, and pulmonary tuberculosis.

Directly ask about coughing paroxysms:

• Do you get bursts (paroxysms) of coughing?

In the second stage of whooping cough (after the first 1 – 2 weeks of the illness), patients experience paroxysms of coughing, 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:

• Is this cough the same as your usual exacerbations, or is there anything different this time?

If the patient reports a difference, ask them how it differs (e.g. duration, severity, sputum colour or quantity).

Radiation

N/A

Associated symptoms

Ask if there are other symptoms which areassociated with the cough

• “Are there any other symptoms associated with the cough?”

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 flushing (whooping cough)

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

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

Inflammatory/autoimmune causes may be associated with:

• Nasal obstruction and/or rhinorrhoea/sneezing (UACS)
• Wheeze and chest tightness (asthma, COPD)
• Shortness of breath (asthma, COPD, bronchiectasis, pulmonary fibrosis, sarcoidosis, hypersensitivity pneumonitis, occupational lung disease)
• Dyspepsia (GORD)
• Recurrent pleurisy (bronchiectasis)
• Weight loss (bronchiectasis, sarcoidosis, pulmonary fibrosis, hypersensitivity pneumonitis)
• Fatigue (sarcoidosis, pulmonary fibrosis, hypersensitivity pneumonitis)
• 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 changesovertime:

• “Is the cough there all the time, or does it come and go?”

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:

• Have you been experiencing repeated episodes of cough?

A recurrent infective cough may indicate underlying immunosuppression, recurrent aspiration, bronchiectasis, or lung cancer.

Exacerbating or relieving factors

Ask if anything makes the cough worseorbetter:

• “Does anything make the cough worse?”
• “Does anything make the cough better?”

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.

Certainmedicationscan worsen cough (see drug history section).

Severity

N/A

Ideas, concerns and expectations

A key component of history taking involves exploring a patient’sideas,concerns, andexpectations(often referred to asICE) 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 befluidthroughout the consultation inresponse to patient cues. This will help ensure your consultation is morenatural,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’sideasabout the current issue:

• “What do you think the problem is?”
• “What are your thoughts about what is happening?”
• “It’s clear that you’ve given this a lot of thought and it would be helpful to hear what you think might be going on.”

Concerns

Explore the patient’s currentconcerns:

• “Is there anything, in particular, that’s worrying you?”
• “What’s your number one concern regarding this problem at the moment?”
• “What’s the worst thing you were thinking it might be?”

Expectations

Ask what the patient hopes togainfrom the consultation:

• “What were you hoping I’d be able to do for you today?”
• “What would ideally need to happen for you to feel today’s consultation was a success?”
• “What do you think might be the best plan of action?

Summarising

Summarisewhat the patient has told you about theirpresenting complaint. This allows you tocheck your understandingof the patient’s history and provides an opportunity for the patient tocorrectanyinaccurate information.

Once you havesummarised, ask the patient if there’s anything else that you’veoverlooked. Continue toperiodically summariseas you move through the rest of the history.

Signposting

Signposting, in a history taking context, involves explicitly statingwhat you have discussed so farandwhat you plan to discuss next. Signposting can be a useful tool whentransitioningbetween different parts of the patient’s history and it provides the patient with time topreparefor what is coming next.

Signposting examples

Explain what you have covered so far:“Ok, so we’ve talked about your symptoms, your concerns and what you’re hoping we achieve today.”

What you plan to cover next:“Next I’d like to quickly screen for any other symptoms and then talk about your past medical history.”

Systemic enquiry

Asystemicenquiryinvolves 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 ofsymptomsyou couldscreen forin eachsysteminclude:

• 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 fibrosis)
• Neurological: dysphagia

Past medical history

Ask if the patient has anymedicalconditions:

• “Do you have any medical conditions?”
• “Are you currently seeing a doctor or specialist regularly?”

Ask if the patient has previously undergone anysurgery(e.g. thoracic surgery, ENT surgery):

• “Have you ever previously undergone any operations or procedures?”
• “When was the operation/procedure, and why was it performed?”

If the patient does have a medical condition, you should gather more details to assesshowwellcontrolledthe disease is and whattreatment(s)the patient is receiving. It is also important to ask about anycomplicationsassociated with the condition includinghospitaladmissions.

Allergies

Ask if the patient has anyallergiesand if so, clarifywhat kind of reactionthey had to the substance (e.g. mild rash vs anaphylaxis).

Drug history

Ask if the patient is currently taking anyprescribedmedicationsorover-the-counterremedies:

• “Are you currently taking any prescribed medications or over-the-counter treatments?”

If the patient is taking prescribed or over the counter medications,documentthemedicationname,dose,frequency,formandroute.

Ask the patient if they’re currently experiencing anysideeffectsfrom their medication:

• “Have you noticed any side effects from the medication you currently take?”
• “Do you think your cough started after you began taking any of your current medications?”

Family history

Ask the patient if there is any family history of lung disease, cardiovascular disease, thromboembolic disease, autoimmune disease or malignancy.

• “Do any of your parents or siblings have any medical conditions?”

Clarify at whatagethe diseasedeveloped(disease developing at a younger age is more likely to be associated with genetic factors).

If one of the patient’s close relatives aredeceased, sensitively determine theage at which they diedand thecause of death:

• “I’m really sorry to hear that, do you mind me asking how old your dad was when he died?”
• “Do you remember what medical condition was felt to have caused his death?”

Social history

General social context

Explore the patient’sgeneral social contextincluding:

• 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’ssmokinghistory, including the type and amount of tobacco used.

Calculate the number of ‘pack-years’ the patient has smoked for to determine their cardiovascular risk profile:

• pack-years = [number of years smoked] x [average number of packs smoked per day]
• one pack is equal to 20 cigarettes

See oursmoking cessation guidefor 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 thefrequency,typeandvolumeofalcoholconsumed on a weekly basis.

See ouralcohol history taking guidefor more information.

Excessive alcohol use is a risk factor for tuberculosis.

Recreational drug use

Ask the patient if they userecreationaldrugsand if so, determine the type of drugs used and their frequency of use. Intravenous drug use is a risk factor fortuberculosis.

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 infectiveaetiology, 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 toLegionellacan 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.

Closing the consultation

Summarisethekeypointsback to the patient.

Ask the patient if they have anyquestionsorconcernsthat have not been addressed.

Thank the patientfor their time.

Dispose of PPEappropriately andwash your hands.

References

• Barraclough, K. Chronic cough in adults. BMJ 2009; 338
• Boon, NA. Colledge, NR, Walker, BR (eds). Davidson’s Principles & Practice of Medicine 20^th Ed. Churchill Livingstone Elsevier, 2006
• BMJ Best Practice. Assessment of chronic cough. Available from: [LINK]
• NICE CKS. Cough. Available from: [LINK]