Medically Fit For Exams
Medically Fit For Exams

Cough history taking

 

  • Wash hands and introduce yourself

Differential diagnoses

Asthma

Chest infection/post-nasal drip

Pneumonia

Lung cancer

COPD

Bronchiectasis

GORD

ACE inhibitors

TB

  • Check the patient’s name and DOB
  • Ask if the patient minds talking to you before they see the doctor

 

History of presenting complaint

  • Ask what has brought the patient in today
  • Ask them to tell you more about the cough
  • Onset
    • When did they first notice it?
      • Recent (URTI, post-nasal drip, ACE inhibitors, pneumonia)
      • Ongoing/gradual onset (asthma, cancer, COPD, bronchiectasis, GORD)
  • Progression
    • Has it been getting any worse?
    • Has it changed?
  • Timings
    • Is it there all the time?
    • Worse on exercise? (asthma)
    • Worse in the night/first thing in morning? (asthma)
    • Vary with the weather (asthma)
  • Triggers
    • Is there anything that sets it off? (asthma)
    • Big meals, lying flat (GORD)
  • Sputum/blood
    • How much?
    • Colour
      • Clear (asthma)
      • White/grey (COPD)
      • Yellow/green (pneumonia, URTI)
      • Pink, frothy (heart failure)
      • Brown (pneumonia, bronchiectasis, cancer)
      • Red/blood (PE, cancer, TB)
  • Wheeze
    • Audible expiration (asthma)
    • Morning? Exercise? (asthma)
    • Stridor? (inhaled foreign body, cancer)
  • Breathlessness
    • How much can you do before getting breathless?
      • Not usually exercise related (PE)
      • Exercise related, may be at rest (Pneumonia, bronchiectasis, asthma, COPD)
  • Chest pain
    • SOCRATES
    • Think: PE, tumour invasion, GORD, angina
  • Malaise/fever
    • (Pneumonia, URTI, TB)
    • Night sweats (TB)
  • Weight loss
    • Amount, over how low (TB, cancer)
  • Reflux (GORD)
  • Infection
    • Cold/runny nose/headache, worse on bending forward or pressing face (URTI)
    • Recently recovered from these symptoms (post-nasal drip)
  • ICE
    • Is there anything in particular that you are concerned about?
    • Is there anything that you thought might be causing your cough?
  • Summarise and check what the patient has told you
  • Systems enquiry if necessary
    • Headache, faint, fits
    • Changes in vision or sensation
    • Abdominal pain
    • Changes in bowel or waterworks
    • Aches and pains

 

Past medical history

  • Ask if the patient has any current or past medical problems
    • Hayfever
    • Eczema
  • Ask if they have had problems with a cough before
  • Ask about childhood asthma
  • Check about COPD
  • Ask if they have had recent surgery (PE)

 

Drug history

  • Ask what medications they are taking, and any recent changes
    • ACE inhibitors eg Ramipril, enalapril
  • Ask about over the counter medications
  • Ask about supplements

 

Allergies

  • Ask if they have any allergies
  • Ask what happens

 

Family history

  • Ask if anyone in the family has had:
    • Asthma
    • Allergies
    • Lung cancer
  • Ask if any other conditions run in their family

 

Social history

  • Ask about smoking and pack years
  • Ask about drinking and weekly units
  • Ask about recent travel abroad, and whether they had their vaccinations, including BCG
  • Ask about occupation
    • Asbestos exposure
    • Particulate exposure (paint, dust, powder)
  • Ask about home situation, mould etc

 

Summary

  • Ask if the patient has any questions or other concerns
  • Ask if they think you have missed anything out
  • Summarise again if necessary/time
  • Thank the patient for talking to you

 

Asthma

Cough, worse in the night/morning, on exercise, cold air, after triggers

Associated SOB and wheeze/chest tightness

Possibly history of asthma as child, hayfever, eczema, family history

URTI/post-nasal drip

Fever, malaise, greeny-yellow sputum, runny nose, possible sinusitis headache (facial, worse when lean forwards or press on face)

Recent onset

Pneumonia

Fever, malaise, SOB, sputum production (green, yellow, rusty, possibly occasional blood), pleuritic chest pain

Possible background of COPD or bronchiectasis

COPD

Cough with white/grey sputum

Associated SOB, worse on exertion, history of infective exacerbation

History of smoking

Progressive

Bronchiectasis

Large amounts of sputum ‘cupfulls’ of varying colour

Frequent infective exacerbation

May have breathlessness and haemoptysis

May have cystic fibrosis

Lung cancer

History of cough with haemoptysis, possible chest pain, weight loss, fatigue, malaise, hoarse voice, stridor, dysphagia

Progressive

Smoking or asbestos exposure history

TB

Cough with haemoptysis, weight loss, low-grade fever and night sweats, may have SOB

Travel history, living in London/Birmingham

GORD

Retrosternal burning pain, worse after eating, when lying down, relieved by sitting forwards and by antacids

History of reflux

Hoarse voice in morning, or after clearing throat

ACE inhibitors

Dry cough, recently started on ACE inhibitors, around 15% get cough

 

 

 

Next steps

In all cases

Respiratory exam, peak-flow, pulse oximetry, FBC, CXR to rule out cancer

Asthma

Peak flow diary, spirometry with reversibility, trial of salbutamol, monteleukast in children

URTI/post-nasal drip

Antibiotics if appropriate, review in 2 weeks, rest, antihistamines, decongestants

Pneumonia

CRP, blood cultures, U&Es, temperature, CXR, admit using CURB 65 (confusion, urea (BUN >19), RR>30, BP< 90/60, age >65, 1 point each, consider admitting if 2, consider ICU if 3)

COPD

CT scan to check for cancer, CRP, stop smoking, bronchodilators, rehab/breathe easy classes, antibiotic prophylaxis, possible bronchoscopy

Bronchiectasis

CT scan, bronchoscopy

TB

Mantoux test, bronchoscopy and ziehl-nielsen, blood cultures

Lung cancer

2 week CXR, CT scan

GORD

CXR, gastroscopy, PPIs, rule out pericarditis (ECG, blood cultures, echo)

ACE inhibitors

Switch to angiontensin receptor inhibitor, eg losartan, candesartan

 

 

Cough history taking.docx
Microsoft Word document [18.9 KB]

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