Clerking cough

History

In clerking cough, a detailed history is more likely to influence the clinician’s impression as to which (if any) of the commonest causes of cough are most likely. Physical examination does more of early detection of the rarer and possibly more serious causes of cough such as interstitial lung diseases and malignancies.

Obtain the patient’s biodata, taking note of the age and occupation especially.

A proper characterisation of the cough is done in the body of the history, with attention to the following:

  • Onset of the cough; whether sudden or gradual
  • Timing; whether worse at any fixed time of the day, continuously present, or intermittently with cough-free periods in between.
  • Sputum production; and nature of sputum
  • Associated symptoms like fever, chest pain
  • Exacerbating and relieving factors
  • Prior history suggestive of atopy

More specific questions may then be asked as follows depending on the possible differentials already generated after characterising the cough. 

Common differentials:

  • Upper airway cough syndrome (postnasal drip): 

frequent throat clearing, postnasal drip, nasal discharge, nasal obstruction or sneezing typical, halitosis

  • Asthma:

wheezing, chest tightness, dyspnoea, symptom variability, strong FHx of asthma/atopic disease, cough, paroxysms, exacerbation by irritants or seasonal exposures; cough may sometimes be the sole symptom (cough-variant asthma)

  • Gastro-oesophageal reflux disease (GORD):

heartburn, dysphagia, acid regurgitation, association of cough with slouched posture, phonation, rising from bed, or eating suggest reflux disease; may be silent

  • Non-asthmatic eosinophilic bronchitis:

chronic non-productive cough; no differentiating features on hx

  • Chronic bronchitis:

hx of smoking may be present; cough may produce sputum; dyspnoea, especially exertional, may accompany the cough

  • Angiotensin-converting enzyme inhibitor:

dry cough, typically associated with tickling or scratching sensation in the throat; cough may begin within days or months of onset of ACE inhibitor therapy

  • Pneumonia:

fever, malaise, cough, usually productive of sputum, chest pain

  • Tuberculosis:

residence in/visit to high-prevalence area, close contact with active TB; hx of anorexia, malaise, weight loss, fever, or night sweats; chronic cough productive of sputum, occasionally associated with haemoptysis; immunosuppressed status, especially AIDS

  • Post-infectious cough:

cough of duration between 3 and 8 weeks following symptoms of acute respiratory infection; nasal/sinus congestion, non-purulent nasal discharge, sore throat

  • Bordetella pertussis infection:

paroxysms of cough, post-tussive vomiting, or inspiratory whooping sound; more likely if local epidemiology suggests increased prevalence

Uncommon

  • Lung cancer:

hx of tobacco smoking, change in character of chronic cough, haemoptysis, hoarseness, chest pain, weight loss, superior vena cava syndrome (localised oedema of face and upper extremities, facial plethora, distended neck and chest veins), symptoms related to distant metastases and advanced stages of cancer

  • Bronchiectasis and chronic suppurative lung disease: 

cough productive of large amounts of mucopurulent sputum, diurnal variation (e.g., worse in the morning), positional worsening; dyspnoea, wheezing, haemoptysis; paroxysmal cough non-productive of sputum may sometimes be present

  • Interstitial pulmonary fibrosis:

dyspnoea of sub-acute onset dominates the clinical picture; cough typically dry

  • Sarcoidosis:

most patients asymptomatic; symptomatic patients: shortness of breath, dyspnoea on exertion, and chest pain are present in minority of patients; low-grade fever; other symptoms reflect involvement of various organs

  • Zenker’s diverticulum:

dysphagia present in 98% of patients; regurgitation of bland undigested food; frequent aspiration; noisy deglutition (gurgling); halitosis; voice changes

  • Thoracic aortic aneurysm:

most patients have no symptoms attributable to TAA at the time of diagnosis; most common initial symptom is vague pain, which can occur in the chest, back, flank, or abdomen; hoarseness due to stretching or compression of left recurrent laryngeal nerve; tracheal deviation, persistent cough, or other respiratory symptoms such as shortness of breath or chest pain; dysphagia (uncommon) due to compression of the oesophagus by the aneurysm; sudden and catastrophic haemoptysis or haematemesis; neurological deficits including paraplegia

  • Foreign body:

abrupt onset, more common in young children

  • Hypersensitivity pneumonitis:

occupational/environmental exposure to allergens (e.g., farmers, bird breeders), progressive dyspnoea, fatigue, and weight loss

  • Bronchiolitis:

age <1 year, cough, wheeze, and dyspnoea, hx of prematurity, underlying cardiopulmonary disease or immunodeficiency

  • Recurrent aspiration: 

dysphagia, association of cough with eating/drinking, fear of choking with eating/drinking; may have hx of neurological disease including stroke, multiple sclerosis, Parkinson’s disease

  • Tropical filarial pulmonary eosinophilia:

travel to endemic area (sub-Saharan Africa, Indian subcontinent, southeast Asia, Oceania); dry, paroxysmal cough, frequently nocturnal

  • Psychogenic cough:

extensive evaluation has ruled out other causes

Past medical/surgical history should focus on previous hospital admissions, operations, medication use, immunisations, allergies, and current comorbidities.

Family history further probes risk factors for possible genetic or familial aetiologies.

Social history looks for occupational and lifestyle contributions (especially smoking) to the disease process.

Drug and allergy history explores current drug use and previous allergies to any known drug.

Review of other systems not covered in the body of the history.

Physical examination

  • Upper airway cough syndrome (postnasal drip): 

mucopurulent secretions in the nasopharynx and oropharynx or cobblestone appearance of posterior oropharynx

  • Asthma:

wheezing and prolonged expiratory phase on pulmonary examination

  • Gastro-oesophageal reflux disease (GORD):

no differentiating features on examination

  • Non-asthmatic eosinophilic bronchitis:

no differentiating features on examination

  • Chronic bronchitis:

mild cases: most respiratory examinations are normal, may show quiet breath sounds, prolonged expiratory phase, rhonchi, or wheezes; advanced cases: cyanosis, barrel chest, use of accessory muscles of inspiration, increased S2 over left sternal border, or peripheral oedema

  • Angiotensin-converting enzyme inhibitor:

no specific examination findings

  • Pneumonia:

dullness to percussion, decreased breath sounds, and presence of rales

  • Post-infectious cough:

diagnosis is clinical and one of exclusion

  • Bordetella pertussis infection:

petechiae and conjunctival haemorrhages may result from cough paroxysms; lung examination is typically normal

  • Lung cancer:

central lung cancers may cause unilateral localised wheezing; superior vena cava syndrome; cachexia and symptoms related to distant metastases (e.g., bone pain) are late symptoms

  • Bronchiectasis and chronic suppurative lung disease: 

crackles and wheezing, predominantly over lower lobes; clubbing in a minority of patients

  • Interstitial pulmonary fibrosis:

dry, crackles, typically over lung bases; clubbing may be present

  • Sarcoidosis:

most often normal; skin lesions (erythema nodosum and maculopapular skin lesions), enlargement of lacrimal glands, lymphadenopathy in cervical, supraclavicular, or axillary areas; redness of eye, tearing, and photophobia may represent uveitis

  • Tuberculosis:

fever, cachexia, tachycardia; asymmetry in chest movement and dullness to percussion due to pleural effusion, bronchial breathing, crackles, rales due to an infiltrate or rhonchi in presence of significant bronchial purulence; palpable extra-thoracic lymphadenopathy is uncommon

  • Zenker’s diverticulum:

halitosis, voice changes

  • Thoracic aortic aneurysm:

generally no obvious physical findings in chest area unless tracheal deviation is present; patients with an abdominal component may have a pulsatile abdominal mass similar to pure abdominal aortic aneurysms; signs of arterial perfusion differentials in both upper and lower extremities; evidence of visceral ischaemia; focal neurological deficits; murmur of aortic regurgitation; bruits

  • Foreign body:

may be asymptomatic or show signs of airways obstruction, including cough, wheeze, decreased breath sounds, dyspnoea, or fever

  • Hypersensitivity pneumonitis:

clubbing, increased respiratory rate, inspiratory crackles over lower lung fields

  • Bronchiolitis:

high respiratory rate, accessory muscle use, retractions, wheezes, crackles, purulent secretions on bronchoscopy

  • Recurrent aspiration: 

signs of neurological disease such as stroke, multiple sclerosis, Parkinson’s disease

  • Tropical filarial pulmonary eosinophilia:

frequently normal; wheezing, rhonchi, crackles may be present on lung exam; some patients develop hepatosplenomegaly

  • Psychogenic cough:

no significant finding

Appropriate lab investigations may then be requested to strengthen clinical impression made at the end of history and examination.