What is the appropriate approach to taking a complete history for a patient presenting with cough?

Complete History for a Patient with Cough

A detailed, systematic history should begin by establishing cough duration to classify it as acute (<3 weeks), subacute (3-8 weeks), or chronic (≥8 weeks), as this fundamentally determines the diagnostic approach and most likely etiologies. 1

Essential Initial Questions

Duration and Temporal Characteristics

• Establish exact duration in weeks - this is the single most important historical element as it determines whether you're dealing with acute, subacute, or chronic cough 1, 2
• Ask about onset: sudden versus gradual, and whether symptoms are worsening, stable, or improving 2
• Determine timing patterns: nocturnal (suggests asthma or GERD), morning (suggests chronic bronchitis), or constant 1
• Ask about paroxysmal nature of the cough 1

Red Flag Symptoms (Must Ask Immediately)

• Hemoptysis - requires urgent investigation for malignancy or tuberculosis 1, 2
• Unintentional weight loss - suggests malignancy or tuberculosis 2
• Fever or prominent systemic illness - indicates need for immediate evaluation 1
• Suspicion of inhaled foreign body - particularly with sudden onset 1

Sputum Production

• Quantify daily sputum production - significant sputum usually indicates primary lung pathology and requires a different diagnostic approach than dry cough 1, 2
• Ask if productive cough occurs most days for ≥3 months over ≥2 consecutive years, which defines chronic bronchitis 2
• Describe sputum color, consistency, and volume 3

Medication History

ACE Inhibitors (Critical to Address Early)

• Ask specifically about ACE inhibitor use - this is a common, easily reversible cause that should be identified immediately 1, 4
• ACE inhibitor-associated cough can occur within hours to over a year after starting treatment, affects up to 16% of patients, and typically resolves within 26 days (though may take up to 40 weeks) after discontinuation 1
• Risk factors include smoking, East Asian ethnicity, and previous ACE inhibitor-associated cough 1
• Review all other medications that might cause or potentiate cough 1

Occupational and Environmental Exposures

Workplace and Home Environment

• Obtain thorough occupational history including current and past jobs, specific tasks, and duration of exposure 1, 2
• Ask about exposure to dust, chemicals, fumes, hot acidic conditions, or respiratory irritants 1, 2
• Inquire about hobbies that involve chemical or dust exposure 1
• Ask about pets and home environment 1

Smoking History

• Quantify tobacco use - smoking is responsible for 85-90% of chronic bronchitis cases and is dose-related 2
• Document current smoking status, pack-years, and years since quitting if former smoker 2
• Ask about exposure to secondhand smoke 1

Associated Symptoms by System

Upper Airway Symptoms (Upper Airway Cough Syndrome/UACS)

• Postnasal drip sensation or feeling of something dripping down the throat 2
• Frequent throat clearing 2
• Nasal discharge, congestion, or rhinorrhea 2
• Facial pain or pressure suggesting rhinosinusitis 1

Lower Airway Symptoms (Asthma/Eosinophilic Bronchitis)

• Wheezing or chest tightness 2
• Dyspnea or shortness of breath 2
• Nocturnal symptoms or awakening from sleep 2
• Exercise-induced symptoms 1

Gastrointestinal Symptoms (GERD)

• Heartburn or acid regurgitation 2
• Dysphagia or difficulty swallowing 2
• Sour taste in mouth 1
• Note that GERD can cause cough without typical reflux symptoms 4

Past Medical History

Respiratory Conditions

• History of asthma, COPD, or bronchiectasis - these commonly present with or are exacerbated by cough 1
• Previous pneumonia, tuberculosis, or pertussis infection 1
• History of lung cancer or treatment for malignancy 1

Atopic Disease

• Personal history of allergic rhinitis, eczema, or food allergies - atopic individuals have increased respiratory symptoms 1
• Family history of atopy or asthma 1

Other Relevant Conditions

• Immunodeficiency or HIV status 3
• Gastroesophageal reflux disease 4
• Cardiovascular disease 1

Impact Assessment

Quality of Life and Severity

• Use validated cough severity assessment tools - either cough-specific quality of life questionnaires or visual analogue scales (0-10 ladder) 1, 2
• Assess impact on sleep quality and frequency of nocturnal awakening 2
• Determine effect on work productivity and social activities 2
• The decrement in quality of life from chronic cough is comparable to severe COPD 1

Common Pitfalls to Avoid

• Don't assume sputum production indicates bacterial infection - the most common causes of chronic productive cough (UACS, asthma, GERD) are the same as dry cough 3, 5
• Don't rely on cough character alone for diagnosis - the character, timing, and complications of cough have poor predictive value for determining specific causes 5
• Don't overlook pertussis - 10% of chronic cough cases may be related to Bordetella pertussis infection 1
• Don't forget that multiple simultaneous causes are common - 59% of chronic cough cases have multiple contributing factors 5