Why Cough History Appears in OSCEs
Cough is one of the most common presenting complaints in primary and secondary care, and examiners use it to test breadth of diagnostic thinking. A good candidate will move fluently from common causes (URTI, asthma) to serious differentials (malignancy, TB, PE) without missing medication side-effects or atypical presentations. The station rewards a structured framework, targeted closed questions, and confident red flag identification.
Opening the Consultation
Introduce yourself, confirm patient details, and establish rapport. Begin with an open question: "Can you tell me a bit more about your cough?" Then allow the patient to speak uninterrupted for 30–60 seconds. This generates a rich history and scores marks for active listening.
Systematic History Framework
Character of the Cough
Ask about onset (acute vs. chronic — >8 weeks is chronic), duration, progression, and whether it is constant or intermittent. Character matters: a dry, irritating cough suggests ACE inhibitor side-effect or ILD; a productive cough with purulent sputum points to infection or bronchiectasis; a barking cough in a child raises croup.
Sputum
Explore colour (clear, yellow/green, rusty, pink), volume, consistency (watery vs. thick), and any blood (haemoptysis). Frothy pink sputum is a hallmark of acute pulmonary oedema. Rust-coloured sputum is classical for pneumococcal pneumonia. Haemoptysis always demands urgent investigation for malignancy, TB, and PE.
Associated Symptoms
Use a structured checklist:
| Symptom | Likely Differential |
|---|---|
| Wheeze, nocturnal symptoms, triggers | Asthma |
| Heartburn, regurgitation, worse lying flat | GORD |
| Fever, myalgia, coryzal symptoms | Respiratory infection |
| Weight loss, anorexia, night sweats | Malignancy, TB |
| Dyspnoea, orthopnoea, ankle swelling | Cardiac failure |
| Pleuritic chest pain, haemoptysis, leg swelling | Pulmonary embolism |
| Dry cough on ACE inhibitor | Drug-induced (bradykinin) |
| Occupational exposure, progressive dyspnoea | ILD, occupational lung disease |
Timing and Triggers
Ask about diurnal variation (asthma is often worse at night and early morning), post-exercise cough (asthma, VCD), post-infectious cough (>3 weeks after URTI — pertussis, post-viral), and positional changes (GORD worse lying down; cardiac failure worse lying flat).
Red Flags — Never Miss These
⚠️ Red Flag
Red flags requiring urgent investigation: haemoptysis, weight loss >5% in 3 months, persistent hoarseness, dysphagia, lymphadenopathy, age >40 with new cough and smoking history, or night sweats. These mandate same-day referral or urgent chest X-ray.
Drug History
Always ask specifically about ACE inhibitors (ramipril, lisinopril, perindopril). ACE inhibitor cough affects up to 15% of patients, is non-productive, and often missed because it was prescribed months or years ago. The fix is switching to an ARB.
Social and Exposure History
Screen for smoking (pack-year history), occupational exposures (asbestos, silica, grain dust — relevant to ILD and mesothelioma), travel history (TB endemic areas, fungal infections), TB contacts, and pet exposure (psittacosis, bird fancier's lung).
Closing the History
Summarise back, check ICE (Ideas, Concerns, Expectations), and propose a management plan. Typical investigations to mention: chest X-ray, spirometry ± reversibility, sputum culture and MC&S, peak flow diary, CT chest if red flags. Offer safety-netting: "If you cough up blood or feel significantly worse, please attend A&E."
Mark-Scheme Checklist
💡 Tip
Examiners credit: open opener → sputum character → haemoptysis → weight loss/night sweats → wheeze/dyspnoea → GORD symptoms → drug history (ACE inhibitors) → occupational/travel/TB exposure → smoking history → ICE → safety-net.
Frequently Asked Questions
"What are the main differentials for a chronic cough lasting more than 8 weeks?"
The classic triad of chronic cough in a non-smoker is asthma, GORD, and upper airway cough syndrome (post-nasal drip). In smokers, COPD and malignancy must be excluded first with a chest X-ray. ACE inhibitor cough is the most commonly missed pharmacological cause and should always be asked about directly. Other causes to consider include ILD (especially if there is associated breathlessness), cardiac failure (especially if there is orthopnoea or ankle oedema), bronchiectasis (productive cough with recurrent infections), and pertussis (paroxysmal cough with an inspiratory whoop in unvaccinated adults). TB must be on the differential in patients from or who have visited endemic areas, those who are immunocompromised, or those with night sweats and weight loss.
"How do I ask about haemoptysis without alarming the patient?"
Use a gentle normalising approach: "Some patients with a cough notice they cough up a small amount of blood — has that happened to you at all?" This phrasing is non-threatening and avoids projecting alarm before you know the answer. If haemoptysis is confirmed, quantify it (streaks in sputum vs. frank blood), determine whether it is mixed with sputum or pure blood, and ask about associated features such as pleuritic chest pain (PE), weight loss (malignancy/TB), or fever (infection). Document it clearly and arrange urgent investigation — haemoptysis is a red flag until proven otherwise. Never reassure prematurely.
"What is the difference between cardiac and respiratory causes of cough?"
Cardiac causes of cough — particularly heart failure — produce a cough that is typically dry, worse at night, and accompanied by orthopnoea, paroxysmal nocturnal dyspnoea, and ankle swelling. Frothy pink sputum indicates acute pulmonary oedema. Respiratory causes (asthma, COPD, infection) are more often associated with sputum, wheeze, or preceding respiratory symptoms. ACE inhibitors prescribed for cardiac conditions (hypertension, heart failure, post-MI) add a pharmacological cough that is dry and irritating. In practice, disentangling these requires a full drug history, BNP, echo, and CXR. In the OSCE, demonstrate awareness of cardiac aetiology by asking about orthopnoea and ankle swelling in every chronic cough history.
"How does asthma present atypically and what questions identify it?"
Asthma can present with cough as the only symptom — this is called cough-variant asthma — without classical wheeze or breathlessness. Key clues are nocturnal wakening, morning cough, exercise-triggered symptoms, and seasonal variation. Directly ask about childhood asthma, eczema, hay fever (atopic triad), and family history of asthma. Ask whether symptoms improve with bronchodilators or worsen with NSAIDs or beta-blockers (aspirin-exacerbated respiratory disease). Occupational asthma is diagnosed by asking whether symptoms improve on days off work or holidays. Peak flow diary showing >20% diurnal variation supports the diagnosis; spirometry with reversibility (>12% and 200 mL improvement post-bronchodilator) confirms it.
"What are the key features that make me suspect lung cancer in a cough history?"
The highest-risk profile is a smoker aged over 40 with a new or changed cough lasting more than three weeks. Additional red flags include haemoptysis (even a single episode), unexplained weight loss, persistent hoarseness (recurrent laryngeal nerve involvement), dysphagia, superior vena cava obstruction (facial swelling, arm swelling), bone pain (metastases), and new-onset clubbing. The two-week wait (2WW) pathway is triggered by any of these features. In the OSCE, naming the 2WW referral pathway and suggesting urgent chest X-ray scores highly. Always check for a smoking history, including passive smoking and occupational exposures such as asbestos.
"What is TB cough and which questions does the mark scheme expect?"
TB cough is typically chronic (>3 weeks), productive, and accompanied by systemic features: drenching night sweats, weight loss, and low-grade fever. Ask specifically about: country of birth and recent travel to TB-endemic regions (South Asia, sub-Saharan Africa, Eastern Europe), close contact with a confirmed TB case, HIV status or other immunosuppression, history of previous TB or incomplete treatment, and homelessness or prison exposure. In the OSCE, completing a full TB exposure screen is often a specific mark. If TB is suspected, the patient should be isolated, sputum sent for AFB smear and culture (three early morning specimens), and referred urgently to the respiratory or infectious disease team.
Related guides: How to Take a Respiratory History OSCE · Acute Asthma Management OSCE · COPD Exacerbation OSCE · Chest X-Ray Interpretation OSCE · Pulmonary Embolism OSCE