Cough

First, ask open questions about the cough itself: • Acute or chronic? The British Thoracic Society (BTS) defines acute as <3 weeks and chronic as >8 weeks. Between 3 and 8 weeks the cough may be due to recovering acute illness or developing chronic illness. • Constant or intermittent? A cough that is intermittent may suggest an extrinsic trigger (e.g. if the patient only coughs at work there may be an allergy to something in the workplace). A cough that is constant suggests an intrinsic cause. • Productive or dry? The presence of sputum indicates inflammation and/or infection. Patients with chronic obstructive pulmonary disease (COPD) have chronically inflamed airways and often produce white or clear sputum. Patients with infection have yellow or green sputum. Particularly large volumes of sputum, often green or rusty coloured, may be coughed up in bronchiectasis and lung abscesses. • Blood? More specifically: ■ Blood-streaked sputum? Suggests infection or bronchiectasis. ■ Pink and frothy sputum? Suggests pulmonary oedema. ■ Frank blood (haemoptysis)? See Chapter 8. Suggests tuberculosis (TB), lung cancer, pulmonary embolus, bronchiectasis, or other rarer causes (e.g. granulomatosis with polyangiitis (GPA, formerly known as Wegener’s granulomatosis), or Goodpasture’s syndrome). • Timing? Asthma is classically worse at night and early hours of the morning. Pulmonary oedema or gastro-oesophageal reflux disease (GORD) can also be worse at night due to the positional effects of lying flat. Patients often report sleeping propped up on pillows to mitigate these effects. Trigger factors such as pets, cold weather, or exercise indicate asthma, as does a worsening in spring/summer. • Character? A wheezy cough suggests airway obstruction due to asthma or COPD. A bovine cough (breathy) is characteristic of vocal cord paralysis. A dry cough is suggestive of a bronchitis (usually viral) or interstitial lung disease. A gurgling/wet cough is suggestive of bronchiectasis. Pertussis infection causes a ‘whooping’ cough. Second, ask directed questions about factors that might be triggering the cough: • Environmental irritants: Smoking? Occupation? Pets? Change of house, office, etc? • Past medical history: Asthma? GORD? Rhinitis/sinusitis? Heart failure? Recent chest infection? • Drug history? Angiotensin-converting enzyme (ACE) inhibitors in particular can cause a cough.