Key Questions for a 60-Year-Old Man with Chronic Cough
The most important questions to ask this patient focus on smoking cessation, evaluation for COPD, and ruling out other serious causes of chronic cough, as smoking cessation is the single most effective intervention that will improve his cough and prevent further deterioration of lung function.
Essential History Questions
Smoking History Details
- Exact smoking history (pack-years calculation: 3 packs × 40 years = 120 pack-years)
- Previous quit attempts and methods used
- Readiness to quit smoking now
- Exposure to secondhand smoke or occupational irritants
Cough Characteristics
- Pattern of cough (worse in mornings, after meals, at night)
- Changes in cough pattern or severity over the 20-year period
- Triggers that worsen the cough (cold air, exercise, talking, lying down)
- Impact on quality of life, sleep, and daily activities
Associated Respiratory Symptoms
- Degree of dyspnea (using mMRC scale)
- Exercise tolerance (how far can he walk before stopping?)
- Wheezing episodes or chest tightness
- History of respiratory infections and frequency
Sputum Assessment
- Daily volume of sputum production
- Changes in sputum color, consistency, or odor during exacerbations
- History of hemoptysis (even if currently denied)
Systemic Symptoms
- Unexplained weight loss
- Night sweats or fevers
- Chest pain (pleuritic or otherwise)
- History of recurrent pneumonia
Key Examination and Testing Questions
Prior Testing
- Previous pulmonary function tests or spirometry results
- Prior chest imaging results
- Previous treatments attempted and their effectiveness
- History of tuberculosis testing or exposure
Comorbidities
- History of allergies or atopy
- Gastroesophageal reflux symptoms
- Sinus disease or postnasal drip
- Cardiac history (heart failure can cause chronic cough)
Management-Related Questions
Medication History
- Current medications (especially ACE inhibitors)
- Previous use of inhalers or nebulizers
- Prior antibiotic courses for respiratory infections
- Use of over-the-counter medications besides cough suppressants
Environmental Factors
- Home environment (humidity, mold, pets)
- Occupational exposures to dusts, chemicals, or irritants
- Travel history to areas with endemic respiratory diseases
Diagnostic Algorithm
First priority: Smoking cessation counseling and support
Initial diagnostic testing:
- Spirometry with bronchodilator response
- Chest radiograph
- Complete blood count
If spirometry confirms COPD:
- Assess severity using GOLD criteria
- Evaluate for exacerbation vs. stable disease 1
If initial testing is inconclusive:
- Consider high-resolution CT chest
- Evaluate for other common causes (GERD, upper airway cough syndrome)
- Consider bronchial challenge testing for cough variant asthma 1
Treatment Approach Based on Findings
- For COPD with bronchospasm: Short-acting β-agonists and/or anticholinergic bronchodilators 1
- For chronic bronchitis component: Consider tiotropium to improve cough 1, 2
- For productive cough with thick secretions: Consider guaifenesin to loosen phlegm 3
- For acute exacerbation: Antibiotics if increased sputum purulence 1
Red Flags Requiring Urgent Evaluation
- Development of hemoptysis
- Significant weight loss
- New or worsening dyspnea
- Change in cough character after many years of stability
- Failure to improve with smoking cessation and appropriate therapy
Remember that smoking cessation is the cornerstone of treatment, with 90% of patients experiencing resolution of cough after quitting 1. The American College of Chest Physicians guidelines emphasize that avoidance of respiratory irritants is the most effective means to improve or eliminate cough of chronic bronchitis 1.