1. 🧼 Opening the Consultation

• Wash or sanitise hands
• Introduce yourself: "Hi, my name is (Name), one of the physician associates"
• Confirm the patient's full name and date of birth
• Gain consent: "Would it be okay if I asked you some questions about your cough?"
• Establish whether the patient appears acutely unwell, significantly breathless or unable to speak comfortably

2. ❓ Presenting Complaint

• Begin openly:
  • "What brought you in today?"
  • "Can you tell me about the cough you've been experiencing?"
• Clarify whether this is:
  • A new cough
  • A persistent cough
  • A recurrent cough
  • A change in a longstanding cough
• If the patient says…	You should consider…
  "It started after a cold"	Viral upper respiratory infection or acute bronchitis
  "I wheeze and cough more at night"	Asthma
  "I bring up phlegm every morning"	COPD, chronic airway disease or bronchiectasis
  "I cough after I lie down"	Reflux, upper airway symptoms or cardiac causes depending on associated features
  "Talking, perfume or cold air sets it off"	Cough hypersensitivity or laryngeal dysfunction
  "I coughed up blood"	Haemoptysis – investigate the cause and assess urgently where indicated
  "I've had a cough for months and I'm getting more breathless"	COPD, asthma, interstitial lung disease, bronchiectasis, malignancy or another chronic respiratory condition

3. 🩺 History of Presenting Complaint

• Onset: "When did the cough first start?"
  Sudden onset may suggest aspiration, infection, pulmonary embolism or an inhaled irritant. Gradual or persistent symptoms broaden the differential towards asthma, COPD, reflux, malignancy and other chronic causes.

• Duration: "How long have you been coughing for?"
  Acute cough is commonly infective and often settles within 3 to 4 weeks. A cough lasting more than 8 weeks is generally considered chronic in adults and requires a structured assessment.

• Dry or productive: "Is it a dry cough, or are you bringing anything up?"
  A dry cough may occur with asthma, ACE inhibitors, interstitial lung disease, reflux or cough hypersensitivity. A persistent productive cough suggests airway disease or infection and should prompt further assessment.

• Sputum: "If you're bringing up phlegm, what does it look like and roughly how much are you producing?"
  • Clear or white?
  • Yellow or green?
  • Thick or thin?
  • Foul smelling?
  • Small or large volume?
  • Any blood?
  Large volume or persistently purulent sputum may suggest bronchiectasis or chronic airway infection. Sputum colour alone does not determine whether antibiotics are required.

• Haemoptysis: "Have you noticed any blood when you cough?"
  • Blood streaks?
  • Clots?
  • How much?
  • How often?
  Haemoptysis can occur with infection, bronchiectasis, pulmonary embolism, tuberculosis and malignancy. Unexplained haemoptysis in someone aged 40 or over is particularly important.

• Timing: "Is there a particular time of day when the cough is worse?"
  • Night-time?
  • Early morning?
  • After eating?
  • When lying down?
  • At work?
  Nocturnal symptoms may suggest asthma. Morning productive cough can occur with chronic airway disease. Work-related symptoms raise the possibility of occupational exposure.

• Triggers: "Have you noticed anything that brings the cough on?"
  • Exercise
  • Cold air
  • Talking or laughing
  • Perfume or aerosols
  • Dust
  • Animals
  • Food or eating
  • Lying flat
• Paroxysms: "Do you get sudden uncontrollable coughing fits?"
  Prolonged coughing bouts associated with an inspiratory whoop or vomiting after coughing may suggest pertussis.

• Progression: "Is the cough getting better, worse or staying about the same?"
  A progressively worsening or unexplained persistent cough deserves further assessment, particularly when accompanied by other concerning symptoms.

• Previous episodes: "Have you had anything like this before?"
• Impact: "How is the cough affecting you?"
  • Sleep
  • Work or study
  • Exercise
  • Speaking
  • Eating
  • Urinary leakage
  • Chest or abdominal discomfort from coughing
• Cough syncope: "Have you ever become very light-headed or passed out during a coughing episode?"
  Loss of consciousness associated with coughing is clinically important and requires further assessment.

4. 🫁 Associated Symptoms

• Respiratory symptoms:
  • Shortness of breath
  • Wheeze
  • Chest tightness
  • Pleuritic chest pain
  • Stridor
  • Haemoptysis
• Infection symptoms:
  • Fever
  • Chills or rigors
  • Feeling systemically unwell
  • Sputum production
  • Recent cold or respiratory infection
• Upper airway symptoms:
  • Blocked nose
  • Runny nose
  • Sneezing
  • Throat clearing
  • Hoarse voice
  • Facial pressure
• Asthma features:
  • Variable wheeze
  • Chest tightness
  • Night-time symptoms
  • Exercise-triggered symptoms
  • Symptoms triggered by cold air, pollen, dust or animals
  • Personal history of eczema or allergic rhinitis
• Reflux symptoms:
  • Heartburn
  • Acid regurgitation
  • Sour taste
  • Symptoms after meals
  Reflux should be considered when typical symptoms are present. Do not automatically assume an otherwise unexplained chronic cough is caused by reflux.

• Cardiac symptoms:
  • Orthopnoea
  • Paroxysmal nocturnal dyspnoea
  • Ankle swelling
  • Chest pain
  • Palpitations
  Cough associated with orthopnoea, nocturnal breathlessness and peripheral oedema should prompt consideration of heart failure.

• Tuberculosis features:
  • Persistent cough
  • Haemoptysis
  • Fever
  • Night sweats
  • Unexplained weight loss
  • Known TB contact
• Possible malignancy features:
  • Persistent unexplained cough
  • Haemoptysis
  • Unexplained shortness of breath
  • Persistent or recurrent chest infection
  • Unexplained chest pain
  • Persistent hoarseness
  • Unexplained weight loss
  • Reduced appetite
  • Unexplained fatigue

5. 🚩 Red Flag Cough Screen

6. 🧠 Recognising Common Cough Patterns

7. 📋 Past Medical History

• Asthma
• COPD
• Bronchiectasis
• Previous pneumonia or recurrent chest infections
• Tuberculosis
• Interstitial lung disease
• Previous pulmonary embolism or DVT
• Heart failure or other cardiovascular disease
• Gastro-oesophageal reflux disease
• Chronic rhinitis or sinus disease
• Previous malignancy
• Immunosuppression
• Previous thoracic surgery or radiotherapy where relevant

8. 💊 Drug History & Allergies

• "What medications are you currently taking, including anything you've bought yourself?"
• ACE inhibitors: "Have you recently started medication such as ramipril, lisinopril or another ACE inhibitor?"
  ACE inhibitors are an important reversible cause of persistent dry cough.

• Ask about:
  • Inhalers
  • Recent antibiotics
  • Immunosuppressive treatment
  • Anticoagulants if haemoptysis is present
• For patients using inhalers:
  • Adherence
  • Inhaler technique
  • Frequency of reliever use
• Allergies: medication + reaction

9. 👨‍👩‍👧‍👦 Family History

• Asthma or atopy
• Chronic respiratory disease
• Bronchiectasis where relevant
• Interstitial lung disease
• Lung cancer
• Inherited respiratory conditions where clinically relevant

10. 🏠 Social & Exposure History

• Smoking:
  • Current, previous or never smoked
  • Cigarettes per day
  • Number of years smoked
  • When they stopped
  Quantify exposure in pack-years where appropriate. Smoking history is particularly important when considering COPD and lung malignancy.

• Vaping: "Do you vape or use electronic cigarettes?"
• Recreational inhaled substances: cannabis or other substances where relevant
• Occupation: "What do you do for work, and does the cough change when you're away from work?"
  Improvement away from work may suggest occupational asthma or another workplace respiratory exposure.

• Occupational exposures:
  • Asbestos
  • Silica or stone dust
  • Wood dust
  • Flour
  • Chemicals or fumes
  • Paint sprays
  • Animals
• Home/environment:
  • Damp or mould
  • Pets
  • Smoke exposure
  • Poor ventilation
• TB risk:
  • Known TB contact
  • Previous TB
  • Recent or previous residence in an area with high TB prevalence
  • Immunosuppression
• Travel: recent travel where relevant to the clinical presentation
• Functional impact:
  • Work
  • Exercise
  • Sleep
  • Social activity

11. 💬 ICE – Ideas, Concerns & Expectations

• "Do you have any thoughts about what might be causing the cough?"
• "Is there anything in particular you're worried this could be?"
• "What were you hoping we could help you with today?"

12. 🧾 Summarise & Explain Next Steps

"So, you've had a (dry/productive) cough for around (duration). It is worse (timing/trigger) and you are producing (sputum description) with (associated symptoms). You have/have not had haemoptysis, significant breathlessness, chest pain or other concerning symptoms. Relevant background includes (PMH, smoking or exposure history)".

"I'd like to examine your chest and check your observations. What we do next will depend on the duration of the cough, your examination findings and whether there are features suggesting infection, airway disease or another underlying cause".

13. 🔬 Investigations - Think Targeted

• Short uncomplicated acute cough: investigations are often unnecessary when the patient is clinically well and there are no concerning features.
• Suspected pneumonia: assess observations, clinical severity and need for chest imaging or further acute assessment.
• Chronic cough lasting more than 8 weeks: consider chest X-ray and spirometry with reversibility testing as part of the initial assessment.
• Possible eosinophilic airway disease: fractional exhaled nitric oxide and blood eosinophils may help identify an eosinophilic or type 2 airway pattern where available.
• Productive cough or suspected infection: consider sputum microscopy, culture and sensitivity where clinically indicated.
• Possible tuberculosis: arrange appropriate TB investigations according to the presentation and local pathway.
• Possible asthma or COPD: spirometry and objective airway assessment are important once clinically appropriate.
• Possible malignancy: follow the appropriate urgent chest X-ray or suspected cancer referral pathway according to the clinical features.
• Possible cardiac cause: ECG, natriuretic peptide testing, echocardiography or other cardiovascular investigations may be appropriate depending on the history and examination.
• CT chest: should not routinely be used for every chronic cough. Consider it when there is a specific clinical indication such as suspected bronchiectasis, interstitial lung disease or malignancy.

🎓 Present Back to Examiner (PA Format)

"This is a (age)-year-old (man/woman) presenting with a (duration) history of a (dry/productive) cough. The cough is predominantly worse (timing/trigger) and is associated with (relevant symptoms). Sputum is described as (description), with no (key red flags such as haemoptysis, significant breathlessness or chest pain). Relevant background includes (PMH), with a smoking history of (smoking history) and occupational exposure to (exposure if relevant). My leading differential is (diagnosis), with (diagnosis 2) and (diagnosis 3) also considered. I would perform full observations and a respiratory examination, followed by targeted investigations based on the duration, examination findings and suspected underlying cause".

📚 Key References

• NICE NG120 - Cough (acute): antimicrobial prescribing.
• NICE NG12 - Suspected cancer: recognition and referral. Updated 2026.
• British Thoracic Society - Clinical Statement on Chronic Cough in Adults.
• NICE NG250 - Pneumonia: diagnosis and management.