How do I take a comprehensive cough history?

How to Take a Comprehensive Cough History

Begin by establishing the duration of cough—acute (<3 weeks), subacute (3-8 weeks), or chronic (>8 weeks)—as this single piece of information immediately narrows your differential diagnosis and determines your entire management pathway. 1

Essential Initial Questions

Duration and Timing

• Ask the exact number of weeks the cough has been present, as this is the most critical piece of information for diagnosis 1
• Determine if there is diurnal variation—cough that abates overnight may indicate gastroesophageal reflux disease, while nocturnal cough suggests asthma, infection, or heart failure 1
• Inquire whether cough occurs predominantly after meals (suggests GERD) or with exercise/cold air exposure (suggests asthma) 1

Red-Flag Symptoms (Require Immediate Investigation)

• Hemoptysis—any blood in sputum mandates urgent evaluation for malignancy, tuberculosis, bronchiectasis, or pulmonary embolism 1, 2
• Unintentional weight loss—suggests malignancy, tuberculosis, or chronic infection 1, 2
• Fever or night sweats—indicates active infection or systemic disease 1, 2
• Significant dyspnea at rest or nocturnal dyspnea—may signal severe cardiopulmonary disease 1, 2
• Hoarseness—raises concern for laryngeal pathology or recurrent laryngeal nerve involvement 1, 2
• Recurrent pneumonia—suggests structural lung disease, immunodeficiency, or aspiration 1, 2

Medication History

• ACE inhibitor use—this is a common, reversible cause of chronic cough that typically resolves within a median of 26 days (range up to 40 weeks) after discontinuation 1, 2, 3
• Sitagliptin use—this DPP-4 inhibitor can provoke cough and should be discontinued if suspected 1, 2
• Document all medications that may aggravate reflux: bisphosphonates, nitrates, calcium-channel blockers, theophylline, and progesterone 2

Smoking History

• Quantify pack-years and current smoking status—smoking is one of the most common causes of chronic productive cough and typically resolves within 4 weeks of cessation 1, 2, 3
• In patients ≥45 years with new cough or those aged 55-80 with ≥30 pack-years, maintain high suspicion for lung cancer 2

Occupational and Environmental Exposures

• Systematically assess for workplace irritants, dusts, fumes, or chemicals that may trigger cough 1, 2, 3
• Ask about home exposures including mold, dust mites, pets, and indoor air quality 1
• Inquire about outdoor pollutants such as traffic exhaust, ozone, and particulate matter 1

Symptom Characterization

Sputum Production

• Ask about daily sputum volume and color—chronic mucopurulent sputum raises concern for bronchiectasis regardless of obvious risk factors 2
• Note that the character and quantity of sputum have limited diagnostic value, as gastroesophageal reflux disease, postnasal drip syndrome, and asthma can all cause productive or nonproductive cough 4, 5

Associated Upper Airway Symptoms

• Inquire about frequent throat clearing, sensation of postnasal drip, nasal congestion, or chronic rhinitis—these suggest upper airway cough syndrome, which accounts for 18.6%-81.8% of chronic cough cases 1, 2
• Ask about sinus pressure, facial pain, or purulent nasal discharge 1

Gastroesophageal Symptoms

• Ask about heartburn, regurgitation, sour taste, or dysphagia—however, recognize that GERD-related cough often occurs without typical gastrointestinal symptoms 1, 2
• Determine if cough worsens after meals or when lying down 1

Respiratory Symptoms

• Ask about wheezing, chest tightness, or shortness of breath—these suggest asthma, which accounts for 14.6%-41.3% of chronic cough 1, 2
• Inquire whether symptoms worsen with exercise, cold air, or allergen exposure 1

Pertussis-Specific Features (for Subacute Cough)

• Ask about paroxysmal coughing fits, post-tussive vomiting, or inspiratory "whoop"—these are highly specific for Bordetella pertussis and require immediate macrolide therapy 1, 6

Quality of Life Impact

Functional Impairment

• Ask about stress incontinence in women—this is a common and distressing complication of chronic cough 1
• Inquire about sleep disruption, work absenteeism, and social embarrassment 1
• Document impact on daily activities and psychological well-being 1

Physical Examination Focus

General Inspection

• Look for digital clubbing—this finding with productive cough mandates evaluation for bronchiectasis, interstitial lung disease, or malignancy 2
• Assess for peripheral edema and weight gain, which suggest heart failure 1, 2

Upper Airway Examination

• Inspect the nasal mucosa for congestion, polyps, or purulent discharge 1
• Examine the oropharynx for cobblestoning or mucus in the posterior pharynx 1

Chest Auscultation

• Listen for wheezes—those appearing only on forced expiration or immediately after coughing are characteristic of cough-variant asthma 2
• Note any crackles, which may indicate interstitial lung disease, bronchiectasis, or heart failure 1

Common Pitfalls to Avoid

• Do not assume a single etiology—up to 67% of chronic cough patients have multiple concurrent causes (UACS, asthma, and GERD), and cough will not resolve until all contributing factors are treated 1, 2
• Do not rely on cough characteristics for diagnosis—the timing, character, and complications of cough lack both diagnostic sensitivity and specificity 1, 4
• Do not overlook GERD in the absence of gastrointestinal symptoms—reflux-associated cough frequently occurs without heartburn or regurgitation 1, 2
• Do not assume normal spirometry excludes asthma—cough-variant asthma commonly presents with normal baseline pulmonary function tests 1, 2, 3
• Do not forget to quantify cough severity—use visual analog scales or validated quality-of-life questionnaires to objectively monitor treatment response 1, 2, 3