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Approach to a patient with cough
1. Patient Demographics and Presenting Complaint
Begin with the patient’s age, gender, and main complaint: “What brings you in today?”
Confirm and clarify the symptom: “Can you tell me more about your cough?”
2. History of Presenting Illness
Onset: When did the cough start? Was the onset sudden or gradual?
Duration: How long have you had the cough (acute: <3 weeks, subacute: 3-8 weeks, chronic: >8 weeks)?
Character: Is it dry or productive? If productive, describe the sputum (color, amount, odor, presence of blood).
Timing: Is the cough worse at any particular time (e.g., night, early morning)?
Pattern/Progression: Has it changed over time or remained the same?
Aggravating/Relieving Factors: What makes it worse or better (e.g., lying down, exposure to dust, exertion)?
Associated Symptoms: Ask about fever, breathlessness, chest pain, wheeze, hemoptysis, nasal symptoms, heartburn, weight loss, night sweats.
Review of Systems
Systematically ask about symptoms in other systems to rule out extrapulmonary causes (e.g., reflux, cardiac symptoms, systemic features like weight loss or night sweats).
3. Past Medical History
Ask about previous respiratory illnesses (asthma, COPD, tuberculosis, pneumonia, bronchiectasis).
Inquire about other chronic illnesses (diabetes, heart disease, GERD, immunosuppression).
4. Family History
Inquire about family history of respiratory diseases (asthma, tuberculosis, lung cancer), autoimmune diseases, or other
6. Personal History
Smoking: Type, amount, duration (calculate pack-years).
Alcohol and Substance Use: Frequency and type.
Occupation: Exposure to dust, chemicals, animals, asbestos, or infectious diseases.
Travel/Recent Contacts: Exposure to tuberculosis or other infectious diseases.
Allergy History
Ask about known allergies and reactions, especially to drugs or environmental triggers.
relevant conditions.
Drug History
List all current medications, including over-the-counter and herbal remedies.
Specifically ask about ACE inhibitors, beta-blockers, and other drugs known to cause cough or pulmonary side effects.
Any recent medication changes
7. Socioeconomic History
Living Conditions: Crowding, exposure to allergens, pets, passive smoking, use of biomass fuels.
Now, let’s explore a case presented in the structured format outlined above
Name: Mr. Ramesh Kumar
Age: 52 years
Occupation: Shopkeeper
Presenting Complaint:
Mr. Kumar presents with a complaint of cough for the past 3 weeks.
History of Present Illness:
The cough began insidiously and has gradually worsened over the past three weeks. It is present throughout the day and disturbs his sleep at night. The cough is productive, with yellowish sputum, about a teaspoonful each time, and occasionally streaked with blood. He denies any foul odor. He also reports low-grade fever, malaise, and loss of appetite. There is no history of breathlessness, chest pain, or wheezing. He denies any recent travel or contact with tuberculosis patients.
Aggravating and Relieving Factors:
The cough worsens in the early morning and after exposure to dust in his shop. It is not relieved by over-the-counter cough syrups.
Associated Symptoms:
He has experienced mild weight loss and night sweats over the past month. No history of heartburn, nasal congestion, or postnasal drip.
Past Medical History:
No history of asthma, COPD, or previous tuberculosis. No known diabetes or hypertension. No previous hospitalizations or surgeries.
Family History:
No family history of asthma, tuberculosis, or lung cancer. Father was hypertensive, mother is healthy.
Personal HIstory
He has been smoking 10 cigarettes per day for the past 25 years (12.5 pack-years). No alcohol or illicit drug use. Works in a dusty environment as a shopkeeper.
Drug History:
Not on any regular medications. No recent use of ACE inhibitors or other drugs known to cause cough. No known drug allergies.
Socioeconomic History
Lives with his wife and two children in a well-ventilated house. No pets at home.
Summary:
Mr. Ramesh Kumar, a 52-year-old shopkeeper and chronic smoker, presents with a subacute productive cough, low-grade fever, mild hemoptysis, weight loss, and night sweats. The history raises suspicion for pulmonary tuberculosis or a chronic respiratory infection, and further evaluation is warranted
Here are some commonly asked viva questions based on the above topic.
1. How do you define acute, subacute, and chronic cough?
Acute cough lasts less than 3 weeks, subacute cough lasts 3–8 weeks, and chronic cough persists for more than 8 weeks.
2. What are the key points to elicit in the history of a patient with cough?
Onset, duration, character (dry or productive), sputum details (color, quantity, odor, blood), aggravating and relieving factors, associated symptoms (fever, breathlessness, chest pain, hemoptysis, weight loss, night sweats), past medical history, drug history, family history, smoking, and occupational exposure.
3. What are the common causes of chronic cough?
Chronic bronchitis (COPD), bronchiectasis, pulmonary tuberculosis, asthma, postnasal drip, gastroesophageal reflux disease (GERD), lung cancer, and drug-induced cough (e.g., ACE inhibitors).
4. What is the significance of hemoptysis in a patient with cough?
Hemoptysis is a red flag symptom and may indicate serious conditions like pulmonary tuberculosis, bronchiectasis, or lung cancer.
5. How does the character and color of sputum help in diagnosis?
Purulent, colored sputum suggests bacterial infection; blood-stained sputum may indicate tuberculosis or malignancy; foul-smelling sputum suggests anaerobic infection.
6. What are the red flag symptoms associated with cough?
Hemoptysis, significant weight loss, night sweats, persistent fever, and severe breathlessness.
7. What initial investigations would you order for a patient with chronic productive cough?
Sputum examination (for AFB, culture), chest X-ray, complete blood count, ESR/CRP, and, if indicated, CT chest.
8. How does smoking contribute to chronic cough?
Smoking damages the respiratory epithelium, impairs mucociliary clearance, increases mucus production, and predisposes to infections, COPD, and malignancy.
9. What is the physiological basis of cough?
Cough is a protective reflex triggered by stimulation of sensory receptors in the respiratory tract, leading to forceful expulsion of air to clear irritants, mucus, or pathogens.
10. How would you approach the management of a patient with suspected pulmonary tuberculosis?
Isolate the patient, confirm diagnosis with sputum AFB and chest X-ray, start anti-tubercular therapy, notify public health authorities, and counsel on infection control.