Cough

1. Overview

Cough is a protective respiratory reflex that clears airway secretions, irritants and foreign material. In an OSCE, the main task is to determine the duration, character, triggers, associated symptoms and red flags, then decide whether the cough is likely acute, subacute or chronic.

Acute cough is commonly due to viral upper respiratory tract infection or acute bronchitis, but pneumonia, asthma exacerbation, COPD exacerbation, pulmonary embolism and heart failure must be considered when red flags are present. Chronic cough commonly relates to asthma, upper airway cough syndrome, gastro-oesophageal reflux disease, smoking, COPD, bronchiectasis, ACE inhibitor use or more serious pathology.

Key OSCE priorities

• Clarify duration: acute, subacute or chronic.
• Ask whether the cough is dry or productive.
• Ask about sputum colour, amount and blood.
• Screen for red flags such as haemoptysis, weight loss, fever, chest pain and severe breathlessness.
• Ask about infective symptoms and contact history.
• Ask about asthma, COPD, reflux, postnasal drip and smoking.
• Ask about ACE inhibitor use.
• Assess for tuberculosis and lung cancer risk when appropriate.
• Perform a full respiratory examination.
• State that chest X-ray is important when red flags or chronic cough are present.

Important causes

• Viral upper respiratory tract infection.
• Acute bronchitis.
• Pneumonia.
• Asthma.
• COPD.
• Bronchiectasis.
• Upper airway cough syndrome or postnasal drip.
• Gastro-oesophageal reflux disease.
• ACE inhibitor-related cough.
• Tuberculosis.
• Lung cancer.
• Pulmonary embolism.
• Heart failure.
• Interstitial lung disease.

Red flag features

• Haemoptysis.
• Unexplained weight loss.
• Persistent fever or night sweats.
• Prominent breathlessness, especially at rest.
• Chest pain.
• Hoarseness.
• Recurrent pneumonia.
• Persistent cough in a smoker.
• New cough in an older patient.
• Immunosuppression.
• Abnormal chest signs.
• Cyanosis or oxygen desaturation.

2. History Taking

Opening

• Wash hands.
• Introduce yourself.
• Confirm patient identity.
• Explain that you would like to ask about the cough.
• Gain consent.
• Check whether the patient currently has severe breathlessness, chest pain, haemoptysis or feels acutely unwell.
• If acutely unwell, state that you would assess using ABCDE and call for senior help.

Presenting complaint

• Ask when the cough started.
• Ask whether it started suddenly or gradually.
• Ask whether it is improving, worsening or persistent.
• Ask whether it is dry or productive.
• Ask whether the cough occurs during the day, night or both.
• Ask whether it is continuous or episodic.
• Ask whether there are specific triggers.
• Ask whether the patient has had similar episodes before.

Duration of cough

• Acute cough: usually less than 3 weeks.
• Subacute cough: usually 3 to 8 weeks.
• Chronic cough: usually more than 8 weeks.
• A prolonged cough after infection may occur, but red flags still need assessment.
• Persistent unexplained cough requires further evaluation.

Character of cough

• Dry cough.
• Productive cough.
• Barking cough.
• Paroxysmal cough.
• Nocturnal cough.
• Cough worse after meals or lying flat.
• Cough triggered by cold air, exercise or allergens.
• Cough associated with wheeze.
• Cough associated with choking or aspiration.

Sputum history

• Ask whether sputum is present.
• Ask about sputum colour: clear, white, yellow, green or rusty.
• Ask about sputum volume.
• Ask whether sputum is foul-smelling.
• Ask whether sputum is difficult to clear.
• Ask about chronic daily sputum production.
• Ask about large-volume sputum, which may suggest bronchiectasis.
• Ask about blood-stained sputum or frank haemoptysis.

Haemoptysis assessment

• Ask whether the blood is streaking, clots or large-volume bleeding.
• Ask how often it occurs.
• Ask whether it is mixed with sputum.
• Ask whether there is epistaxis or vomiting blood as an alternative source.
• Ask about weight loss, smoking and malignancy risk.
• Ask about fever, night sweats and TB exposure.
• Ask about pleuritic chest pain and PE risk factors.
• Large-volume haemoptysis is an emergency.

Associated respiratory symptoms

• Shortness of breath.
• Wheeze.
• Chest tightness.
• Pleuritic chest pain.
• Sore throat.
• Runny nose or nasal congestion.
• Postnasal drip.
• Hoarseness.
• Fever or rigors.
• Night sweats.
• Recurrent chest infections.

Symptoms suggesting pneumonia or infection

• Fever.
• Rigors.
• Purulent sputum.
• Pleuritic chest pain.
• Breathlessness.
• Confusion in older patients.
• Reduced oral intake.
• Recent sick contacts.
• Recent travel.
• Immunosuppression.

Symptoms suggesting asthma

• Episodic cough.
• Wheeze.
• Chest tightness.
• Shortness of breath.
• Symptoms worse at night or early morning.
• Symptoms triggered by exercise, cold air, dust, pollen or animals.
• Personal or family history of atopy.
• Improvement with inhalers.

Symptoms suggesting COPD

• Chronic cough.
• Chronic sputum production.
• Progressive exertional dyspnoea.
• Smoking history.
• Frequent winter bronchitis.
• Recurrent exacerbations.
• Wheeze.
• Reduced exercise tolerance.

Symptoms suggesting reflux-related cough

• Heartburn.
• Acid regurgitation.
• Sour taste in the mouth.
• Cough worse after meals.
• Cough worse when lying flat.
• Hoarseness.
• Throat clearing.
• Globus sensation.

Symptoms suggesting upper airway cough syndrome

• Nasal congestion.
• Runny nose.
• Sneezing.
• Postnasal drip.
• Frequent throat clearing.
• Cough worse when lying down.
• History of allergic rhinitis or sinusitis.
• Facial pain or pressure if sinusitis is suspected.

Symptoms suggesting tuberculosis

• Persistent cough.
• Haemoptysis.
• Fever.
• Night sweats.
• Weight loss.
• Loss of appetite.
• Fatigue.
• Previous TB.
• Close contact with TB.
• Travel or residence in a high TB prevalence area.
• Immunosuppression or HIV risk.

Symptoms suggesting lung cancer

• Persistent cough.
• Change in chronic smoker's cough.
• Haemoptysis.
• Unexplained weight loss.
• Loss of appetite.
• Chest pain.
• Hoarseness.
• Recurrent chest infections.
• Finger clubbing.
• Smoking history.
• Occupational exposure such as asbestos.

Pulmonary embolism screen

• Sudden breathlessness.
• Pleuritic chest pain.
• Haemoptysis.
• Syncope or collapse.
• Unilateral leg swelling or pain.
• Recent surgery or immobility.
• Long-haul travel.
• Active cancer.
• Previous DVT or PE.
• Pregnancy or postpartum state.
• Oestrogen therapy.

Heart failure screen

• Breathlessness on exertion.
• Orthopnoea.
• Paroxysmal nocturnal dyspnoea.
• Ankle swelling.
• Rapid weight gain.
• Nocturnal cough.
• Pink frothy sputum in acute pulmonary oedema.
• Known ischaemic heart disease, hypertension or valve disease.

Past medical history

• Asthma.
• COPD.
• Bronchiectasis.
• Previous pneumonia.
• Tuberculosis.
• Lung cancer.
• Interstitial lung disease.
• Heart failure.
• Gastro-oesophageal reflux disease.
• Allergic rhinitis or sinusitis.
• Immunosuppression.
• HIV or other chronic infection risk.
• Diabetes mellitus.

Drug history and allergies

• Current regular medications.
• ACE inhibitor use, such as ramipril, lisinopril or enalapril.
• Inhalers and adherence.
• Recent antibiotics.
• Steroid use.
• Immunosuppressive medication.
• Anticoagulants if haemoptysis is present.
• Over-the-counter cough medicines.
• Recent medication changes.
• Drug allergies and reaction.

Family history

• Asthma or atopy.
• COPD.
• Bronchiectasis.
• Lung cancer.
• Tuberculosis exposure in household.
• Cystic fibrosis or inherited lung disease if relevant.

Social history

• Smoking status and pack-year history.
• Vaping.
• Alcohol intake.
• Recreational drug use.
• Occupation and dust, chemical or asbestos exposure.
• Pets, birds or mould exposure.
• Recent travel.
• TB contact or high-risk living environment.
• Living situation and support.
• Impact on sleep, work and daily activities.

Ideas, concerns and expectations

• Ask what the patient thinks is causing the cough.
• Ask what they are most worried about.
• Ask whether they are worried about pneumonia, TB, cancer or asthma.
• Ask what they were hoping would happen today.

Red flags

• Haemoptysis.
• Unexplained weight loss.
• Persistent fever or night sweats.
• Severe breathlessness.
• Chest pain.
• Hoarseness.
• Recurrent pneumonia.
• Cough in an immunosuppressed patient.
• Cyanosis or oxygen desaturation.
• Confusion or sepsis features.
• New cough in a heavy smoker.
• Abnormal chest examination.

Closing the history

• Summarise the key points back to the patient.
• Ask if they would like to add anything else.
• Thank the patient.
• State that you would examine the respiratory system, check observations and arrange investigations depending on severity and red flags.

3. Physical Examination

The examination should assess severity, respiratory compromise, infective signs, airway disease, consolidation, effusion, wheeze, cardiac causes and systemic red flags.

Before starting the examination

• Wash hands or use alcohol gel.
• Introduce yourself with name and role.
• Confirm the patient's identity.
• Explain the examination clearly.
• Gain consent.
• Ask if the patient has chest pain, severe breathlessness or feels faint.
• Position the patient sitting upright or at 45 degrees.
• Expose the chest appropriately while maintaining dignity.
• Ask for a chaperone if appropriate.

Initial assessment

• Look from the end of the bed.
• Assess whether the patient is comfortable, breathless, cyanosed, pale or sweaty.
• Assess whether the patient can speak in full sentences.
• Look for use of accessory muscles.
• Look for oxygen therapy, nebulisers, inhalers, sputum pot or tissues with blood.
• If acutely unwell, perform ABCDE assessment and call for senior help.

Vital signs

• Respiratory rate.
• Oxygen saturation.
• Heart rate.
• Blood pressure.
• Temperature.
• Level of consciousness.
• Peak expiratory flow if asthma is suspected and the patient can perform it safely.

Hands

• Check for peripheral cyanosis.
• Assess capillary refill time.
• Look for finger clubbing.
• Look for nicotine staining.
• Look for tar staining.
• Look for tremor suggesting beta-agonist use or anxiety.
• Look for palmar erythema if chronic liver disease is relevant.
• Check for asterixis if CO2 retention is suspected.

Pulse and blood pressure

• Assess pulse rate.
• Assess pulse rhythm.
• Tachycardia may suggest infection, hypoxia, PE or beta-agonist use.
• Irregular rhythm may suggest atrial fibrillation.
• Measure blood pressure.
• Hypotension with cough and infection suggests possible sepsis.

Face, mouth and neck

• Look for central cyanosis.
• Look for conjunctival pallor.
• Look for cachexia or weight loss.
• Inspect the mouth and throat if upper airway symptoms are present.
• Look for nasal congestion or allergic features.
• Assess cervical and supraclavicular lymph nodes.
• Assess tracheal position.
• Look for raised JVP suggesting heart failure.

Chest inspection

• Inspect chest shape.
• Look for hyperinflation or barrel chest.
• Look for asymmetrical chest movement.
• Look for scars.
• Look for deformity such as kyphoscoliosis.
• Look for use of accessory muscles.
• Look for intercostal recession.
• Observe respiratory pattern.

Palpation

• Assess chest expansion with both hands.
• Compare expansion bilaterally.
• Assess tactile vocal fremitus if consolidation or effusion is suspected.
• Palpate for tenderness if chest wall pain is present.
• Confirm tracheal position.

Percussion

• Percuss symmetrical areas of the chest.
• Dullness may suggest consolidation, pleural effusion or collapse.
• Hyperresonance may suggest pneumothorax or hyperinflation.
• Stony dullness at the base may suggest pleural effusion.
• Compare side to side.

Auscultation

• Auscultate symmetrical areas of the chest.
• Assess air entry.
• Listen for wheeze.
• Listen for crackles.
• Listen for bronchial breathing.
• Listen for pleural rub.
• Assess vocal resonance if consolidation or effusion is suspected.
• Ask the patient to cough and reassess if crackles may be due to secretions.

Expected respiratory findings

• Wheeze may suggest asthma or COPD.
• Coarse crackles may suggest secretions, bronchiectasis or infection.
• Fine inspiratory crackles may suggest interstitial lung disease or pulmonary oedema.
• Bronchial breathing with dull percussion may suggest consolidation.
• Reduced breath sounds with stony dullness may suggest pleural effusion.
• Reduced breath sounds with hyperresonance may suggest pneumothorax.

Cardiovascular examination

• Assess JVP.
• Auscultate heart sounds.
• Listen for murmurs.
• Look for signs of heart failure.
• Check for peripheral oedema.
• Cardiac cough may occur with pulmonary oedema or heart failure.

Abdominal and peripheral examination

• Assess for hepatomegaly if right heart failure is suspected.
• Assess for ascites if systemic disease is suspected.
• Check calves for unilateral swelling or tenderness if PE is suspected.
• Look for peripheral oedema.
• Assess for lymphadenopathy if malignancy or TB is suspected.

Specific findings to mention in cough OSCE

• Fever, tachypnoea and focal crackles suggest pneumonia.
• Wheeze suggests asthma or COPD.
• Clubbing suggests chronic suppurative lung disease, lung cancer or interstitial lung disease.
• Weight loss and lymphadenopathy raise concern for malignancy or TB.
• Raised JVP, crackles and oedema suggest heart failure.
• Normal examination does not exclude asthma, early pneumonia, PE or lung cancer.

To complete the examination

To complete my examination, I would review observations, check oxygen saturation, consider peak flow, perform a chest X-ray if indicated, and arrange further investigations such as blood tests, sputum studies, spirometry, CT chest or referral depending on the clinical picture and red flags.

4. Differential Diagnosis

Acute cough

• Viral upper respiratory tract infection.
• Acute bronchitis.
• Pneumonia.
• COVID-19 or influenza depending on local epidemiology.
• Asthma exacerbation.
• COPD exacerbation.
• Pulmonary embolism.
• Heart failure.
• Aspiration.

Chronic cough

• Asthma or cough-variant asthma.
• Upper airway cough syndrome.
• Gastro-oesophageal reflux disease.
• ACE inhibitor-related cough.
• Smoking-related chronic bronchitis.
• COPD.
• Bronchiectasis.
• Tuberculosis.
• Lung cancer.
• Interstitial lung disease.

Productive cough causes

• Pneumonia.
• COPD.
• Bronchiectasis.
• Chronic bronchitis.
• Lung abscess.
• Tuberculosis.
• Cystic fibrosis if clinically relevant.

Dry cough causes

• Viral infection.
• Asthma.
• ACE inhibitor use.
• Gastro-oesophageal reflux disease.
• Upper airway cough syndrome.
• Interstitial lung disease.
• Pulmonary embolism.
• Lung cancer.

Haemoptysis causes

• Acute bronchitis.
• Pneumonia.
• Bronchiectasis.
• Tuberculosis.
• Lung cancer.
• Pulmonary embolism.
• Pulmonary oedema.
• Anticoagulation-related bleeding.
• Vasculitis.

5. Investigations

Bedside tests

• Full observations.
• Oxygen saturation.
• Peak expiratory flow if asthma is suspected.
• Capillary blood glucose if acutely unwell or diabetic.
• Urine dip if systemic illness is suspected.
• Pregnancy test in women of reproductive age when relevant.

Blood tests

• Full blood count.
• CRP.
• Urea and electrolytes.
• Liver function tests if systemic illness or malignancy is suspected.
• Blood cultures if sepsis or severe pneumonia is suspected.
• D-dimer only if PE is possible and clinical probability supports testing.
• HIV test if TB, recurrent infection or immunosuppression is suspected and consent is obtained.

Microbiology

• Sputum culture if productive cough with suspected bacterial infection or bronchiectasis.
• Sputum acid-fast bacilli testing if TB is suspected.
• Viral swabs depending on local policy and epidemiology.
• Blood cultures before antibiotics if severe infection or sepsis is suspected.

Imaging

• Chest X-ray if pneumonia, malignancy, TB, heart failure or chronic cough is suspected.
• Chest X-ray if red flags are present.
• CT chest if chest X-ray is abnormal or suspicion remains high.
• CT pulmonary angiography if PE is suspected and imaging is indicated.
• Sinus imaging is not routine but may be considered in selected ENT cases.

Lung function and specialist tests

• Spirometry with bronchodilator reversibility if asthma or COPD is suspected.
• Peak flow diary if asthma variability is suspected.
• FeNO may support eosinophilic airway inflammation where available.
• Bronchial challenge testing may be used in selected chronic cough cases.
• Bronchoscopy may be required for haemoptysis, suspected malignancy or foreign body.
• Echocardiography if heart failure is suspected.

Important investigation points

• A normal chest examination does not exclude serious disease.
• Chest X-ray is important in chronic cough or red flags.
• Spirometry is useful for asthma and COPD assessment.
• Haemoptysis requires careful assessment and may need urgent imaging or referral.
• Investigations should be guided by severity, duration, risk factors and red flags.

6. Management

Management depends on severity, duration, likely cause and red flags. In OSCEs, always identify whether the patient is acutely unwell before discussing outpatient management.

Immediate approach if acutely unwell

1. Assess ABCDE.
2. Call for senior help if severe breathlessness, hypoxia, haemoptysis, chest pain, confusion or sepsis features are present.
3. Sit the patient upright.
4. Give oxygen if hypoxaemic according to local oxygen target protocol.
5. Check observations and attach monitoring if unstable.
6. Obtain IV access if clinically indicated.
7. Perform chest X-ray and blood tests depending on the clinical picture.
8. Treat the likely emergency cause according to local protocol.

General management principles

• Treat the underlying cause.
• Provide safety-net advice.
• Advise smoking cessation where relevant.
• Review medications, especially ACE inhibitors.
• Avoid unnecessary antibiotics for likely viral cough unless bacterial infection is suspected.
• Encourage adequate hydration.
• Advise rest if acutely unwell.
• Review if symptoms persist or worsen.

If viral upper respiratory infection is likely

• Explain that cough can persist after viral infection.
• Advise fluids and rest.
• Consider simple symptomatic relief where appropriate.
• Avoid antibiotics unless bacterial infection is suspected.
• Safety-net for breathlessness, chest pain, haemoptysis, persistent fever or worsening symptoms.

If pneumonia is suspected

• Assess severity using clinical judgement and local pneumonia scoring where used.
• Check oxygen saturation and observations.
• Arrange chest X-ray if indicated.
• Start antibiotics according to local antimicrobial guidance.
• Consider hospital admission if hypoxic, confused, hypotensive, severely breathless or high risk.
• Provide safety-net and follow-up.

If asthma is suspected

• Assess severity and oxygen saturation.
• Check peak flow if safe.
• Treat acute exacerbation according to local asthma protocol.
• Arrange spirometry or objective testing when stable.
• Review inhaler technique and adherence.
• Discuss triggers and personalised asthma action plan.

If COPD is suspected

• Assess severity and oxygen saturation.
• Check smoking history.
• Arrange spirometry when stable.
• Treat exacerbation according to local COPD protocol.
• Review inhaler technique and adherence.
• Offer smoking cessation support.
• Consider pulmonary rehabilitation where appropriate.

If reflux-related cough is suspected

• Advise avoiding large late meals.
• Advise weight loss if overweight.
• Advise reducing alcohol, caffeine and trigger foods if relevant.
• Consider acid suppression trial according to local guidance if reflux symptoms are present.
• Review response and reconsider diagnosis if symptoms persist.

If upper airway cough syndrome is suspected

• Assess for rhinitis, sinusitis and postnasal drip.
• Consider nasal steroid or antihistamine treatment according to likely cause and local guidance.
• Advise saline nasal irrigation if appropriate.
• Refer to ENT if persistent, severe or associated with concerning features.

If ACE inhibitor cough is suspected

• Review timing between ACE inhibitor initiation and cough onset.
• Discuss switching to an alternative such as an ARB with the prescribing clinician.
• Do not stop essential medication without clinician review.
• Assess for other causes if cough persists after medication change.

If TB or malignancy is suspected

• Arrange urgent chest imaging.
• Use infection-control precautions if TB is possible.
• Send sputum for TB testing if appropriate.
• Refer urgently according to local respiratory, TB or cancer pathway.
• Assess close contacts if TB is confirmed according to public health protocol.

Safety-net advice

• Seek urgent help for coughing blood.
• Seek urgent help for severe or worsening breathlessness.
• Seek urgent help for chest pain.
• Seek urgent help for confusion, fainting or blue lips.
• Seek medical review for persistent fever.
• Seek review if cough persists, worsens or is associated with weight loss or night sweats.

7. Examiner Questions

1. How do you classify cough by duration?
2. What are common causes of acute cough?
3. What are common causes of chronic cough?
4. What red flags would you ask about?
5. What features suggest pneumonia?
6. What features suggest asthma?
7. What features suggest COPD?
8. What features suggest tuberculosis?
9. What features suggest lung cancer?
10. What medications can cause cough?
11. What investigations would you request?
12. When would you request a chest X-ray?
13. How would you manage a likely viral cough?
14. How would you manage suspected pneumonia?
15. What safety-net advice would you give?

Suggested short answers

8. OSCE Pearls

• Always ask duration first.
• Dry versus productive cough changes the differential.
• Always ask about haemoptysis.
• Always ask about smoking and occupational exposure.
• Ask about ACE inhibitor use.
• Ask about asthma symptoms: wheeze, chest tightness and triggers.
• Ask about reflux and postnasal drip in chronic cough.
• Ask about TB symptoms: fever, night sweats and weight loss.
• Ask about cancer red flags: haemoptysis, weight loss, hoarseness and smoker status.
• Check oxygen saturation.
• Wheeze suggests asthma or COPD but can also occur in heart failure.
• Clubbing is never an innocent finding in a cough OSCE.
• Normal chest examination does not exclude serious pathology.
• Give clear safety-net advice.

9. Example Presentation to Examiner

10. References

• NICE Clinical Knowledge Summary: Cough.
• British Thoracic Society Clinical Statement on chronic cough in adults.
• NICE NG12: Suspected cancer recognition and referral.
• Local respiratory, antimicrobial, TB and emergency medicine protocols.
• Standard undergraduate respiratory examination and OSCE teaching resources.