🩺 Mock Patient Scripts – Cough
“Why won’t this cough go away?”
Cough is one of the most common complaints in outpatient settings. It can be acute, subacute, or chronic—with diverse causes such as infection, reflux, asthma, and medication. In this article, we present three practical cases to help you simulate clinical reasoning in English interviews.
👉 For systematic workup and differential diagnosis, see our Symptom-Based Approach: Cough.
Case 1: Long-standing Productive Cough
Case 2: No Heartburn, Just a Cough
Case 3: Is It the Medication?
📚 Summary & Differentials
💡 Clinical Pearls
❓ Challenging Questions
🩺 Case 1 – Long-standing Productive Cough
“My cough just won’t go away—it’s been months now.”
Doorway Information
- 45-year-old male
- Chief Complaint: Persistent cough for 3 months
- Vital Signs: T 36.8°C, HR 76, BP 132/84, RR 18, SpO₂ 97%
Shoreline
He reports a daily productive cough that started around three months ago. He finally came in because it’s interfering with his work and sleep.
Structured History
- Opening: “It just keeps coming back. Every morning I cough up yellow phlegm.”
- Onset & Course: Gradual onset, worse in the mornings
- Associated Symptoms: Mild dyspnea, chronic nasal congestion
- Mood / Function / Appetite / Sleep: Tired due to poor sleep
- Medical History / Medication: Chronic sinusitis. No current meds
- PAM HITS FOSS: Ex-smoker (10 pack-years), delivery driver. No allergies or surgeries.
- Concerns & Questions: “Could this be asthma or something serious?”
Physical Examination
- Positive findings: Bilateral crackles at bases, postnasal drip
- Negative findings: No wheezing, no clubbing, no fever
❓ Challenging Questions
Q1: “Is this something serious like lung cancer?”
- A: “That’s a reasonable concern. Right now, you don’t have signs that would strongly suggest cancer, like weight loss or bloody sputum. Still, we’ll get a chest scan to be thorough. Let’s rule things out one step at a time.”
Q2: “Will this cough ever go away?”
- A: “Chronic cough can take time to improve, especially if related to sinus or airway inflammation. But with the right treatment, many patients see good results. We’ll tailor the plan based on what we find and follow you closely.”
Differential Diagnosis
- Most likely: Sinobronchial syndrome / DPB
- Supporting: Sinusitis, productive cough, nasal drip, crackles
- Against: No hemoptysis, no systemic signs
- Chronic bronchitis
- Supporting: Cough >3 months, smoker
- Against: Quit smoking years ago, non-progressive
- Asthma / GERD
- Supporting: Common chronic cough causes
- Against: No wheeze, no heartburn
Clinical Reflection
Classic features of sinobronchial syndrome, especially in the Japanese population. Time to confirm with imaging and initiate therapy.
📝 SOAP Note
S: 45M with 3-month productive cough and nasal symptoms. No fever or weight loss.
O: T 36.8°C. Coarse crackles bilaterally. PND noted.
A:
# Chronic productive cough
# History of chronic sinusitis
# Likely SBS / DPB
ddx): chronic bronchitis, asthma, GERD
r/o): pneumonia, TB, malignancy (no red flags)
→ Sinobronchial syndrome likely. Will order CT and consider macrolide therapy.
P:
- Sinus + chest CT
- Sputum culture, CBC
- Macrolide trial (azithromycin)
- Smoking cessation counseling
- Re-evaluate in 2 weeks
🩺 Case 2 – No Heartburn, Just a Cough
“I don’t have heartburn, just this annoying cough at night.”
Doorway Information
- 38-year-old female
- Chief Complaint: Dry cough for 6 weeks
- Vital Signs: T 36.6°C, HR 70, BP 120/78, RR 16, SpO₂ 99%
Shoreline
She reports a persistent dry cough, mostly nocturnal. No signs of asthma, allergies, or infection.
Structured History
- Opening: “It’s driving me crazy. I can’t sleep.”
- Onset & Course: Gradual onset, worse after meals and at night
- Associated Symptoms: None—no PND, dyspnea, or acid reflux
- Mood / Function / Appetite / Sleep: Sleep disturbance only
- Medical History / Medication: Healthy, no regular meds
- PAM HITS FOSS: Non-smoker, high-stress desk job. No allergies.
- Concerns & Questions: “Is this something serious?”
Physical Examination
- Positive findings: None
- Negative findings: Normal lungs, ENT, no wheezing or PND
❓ Challenging Questions
Q1: “But I don’t feel any acid—how can it be reflux?”
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- A: “That’s a great question. Some people have what’s called ‘silent reflux’—it affects the throat without the typical burning sensation. A short trial of acid blockers can help us see if it’s playing a role. We’ll monitor how your symptoms respond.”
Q2: “Could it be something in my lungs?”
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- A: “It’s understandable to worry about that. Your lungs sound clear and your chest X-ray looks normal, which is reassuring. We’ll focus on likely causes like reflux for now, but we’ll keep an open mind if things don’t improve.”
Differential Diagnosis
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- Most likely: GERD-related cough
- Supporting: Nocturnal pattern, after meals
- Against: No reflux symptoms
- UACS (postnasal drip)
- Supporting: Common cause
- Against: No nasal symptoms
- Cough-variant asthma
- Supporting: Dry, nocturnal cough
- Against: No response to bronchodilator
- Most likely: GERD-related cough
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Clinical Reflection
GERD is often silent. A therapeutic PPI trial can be both diagnostic and curative.
📝 SOAP Note
S: 38F with dry cough for 6 weeks, worse at night and after meals. No heartburn.
O: Vitals normal. Exam unremarkable.
A:
# Chronic non-productive cough
# No ENT, pulmonary, or allergic signs
# Suspect GERD-induced cough
ddx): UACS, asthma, eosinophilic bronchitis
r/o): infection, medication side effects
→ Will initiate PPI trial and assess response.
P:
- Start omeprazole 20mg BID x2 weeks
- Lifestyle: avoid late meals, elevate head of bed
- Re-evaluate in 2–3 weeks
- Consider ENT/pulmo referral if no improvement
🩺 Case 3 – Is It the Medication?
“Ever since I started that new blood pressure pill, I’ve had this dry cough.”
Doorway Information
- 66-year-old male
- Chief Complaint: Dry cough for 4 weeks
- Vital Signs: T 36.4°C, HR 78, BP 132/82, RR 14, SpO₂ 98%
Shoreline
Dry cough started about a week after starting lisinopril. Denies fever, dyspnea, or GERD.
Structured History
- Opening: “It must be the blood pressure pill—I’ve never had this before.”
- Onset & Course: Subacute, 1–2 weeks post-medication
- Associated Symptoms: None
- Mood / Function / Appetite / Sleep: Mild discomfort, social embarrassment
- Medical History / Medication: HTN, dyslipidemia. Started lisinopril 5 weeks ago.
- PAM HITS FOSS: No smoking or lung disease. Retired, lives with wife.
- Concerns & Questions: “Can I switch to something else?”
Physical Examination
- Positive findings: None
- Negative findings: Normal lungs, ENT, no fever
❓ Challenging Questions
Q1: “Do I have to stop this blood pressure medicine?”
A: “It’s likely the cause of your cough, so stopping it is usually the best next step. Fortunately, there are alternative medications that work just as well without this side effect. We’ll switch you to another class and see if the cough improves. It should get better in about a week or two.”
Q2: “What if the cough doesn’t go away?”
A: “If the cough persists even after stopping the medication, we’ll explore other possible causes like reflux or asthma. But usually, ACE-I cough improves within a week or two. Let’s take it step by step and adjust based on your progress.”
Differential Diagnosis
- Most likely: ACE-I induced cough
- Supporting: Onset after medication, resolution upon withdrawal
- Against: None
- GERD, asthma
- Supporting: Age, common causes
- Against: Lacks typical features
Clinical Reflection
Always ask about new meds—ACE-I is a common but underappreciated cause of dry cough.
📝 SOAP Note
S: 66M with new dry cough. Began after starting lisinopril. No other changes or symptoms.
O: Vitals and exam normal. CXR clear.
A:
# Likely ACE-I induced cough
# No signs of infection or reflux
ddx): GERD, asthma, post-viral
→ Stop ACE-I and observe. Expect resolution in 1–2 weeks.
P:
- Discontinue lisinopril
- Start losartan as alternative
- Monitor symptom resolution
- Educate on medication side effects
- Follow-up in 10 days
📚 Summary & Differentials
Summary
Chronic cough often presents without alarming features, yet can significantly impair quality of life. In clinical practice, identifying the most likely cause—whether postnasal drip, asthma, GERD, or medication side effects—is crucial. These cases illustrate how careful history-taking and therapeutic trials (e.g., PPI, medication change) can serve both diagnostic and treatment purposes. Always consider local epidemiology (e.g., DPB in East Asia) and review medications early in your workup.
Key Differentials (VITAMIN CDE)
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- V: Vasculitis (e.g., GPA)
- I: Infection (TB, DPB, chronic sinusitis)
- T: Tumor (lung cancer, post-obstructive pneumonia)
- A: Allergy / Asthma / Atopic cough
- M: Medications (ACE-I)
- I: Iatrogenic (post-viral cough)
- N: Neurogenic cough (psychogenic)
- C: Cardiac (CHF, mitral stenosis)
- D: Digestive (GERD)
- E: Endocrine (thyroid mass, goiter)
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💡 Clinical Pearls
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- Chronic cough = >8 weeks. Think: UACS, asthma, GERD, ACE-I.
- SBS/DPB is an important endemic cause in East Asian countries.
- GERD-related cough can exist without heartburn.
- Always review medications—ACE-I is a frequent offender.
- Trial treatments (e.g., PPI, bronchodilator) can help diagnose.
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❓ Challenging Questions
Q: “Could this be lung cancer?”
A: “That’s a valid concern. You don’t currently have red flags like weight loss or bloody sputum, but we’ll do the right tests to rule it out carefully. You’re in good hands.”
Q: “Why didn’t my last doctor figure this out?”
A: “Chronic cough often overlaps with multiple causes. It can take time to work through them. Let’s build on what’s been tried and continue step by step.”
Q: “Do I need a bronchoscopy?”
A: “That’s not usually needed right away. We’ll start with less invasive tests and only proceed to bronchoscopy if something concerning turns up.”
📎 Related Articles
📚 References
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- UpToDate: Evaluation of chronic cough in adults. 2024.
- Mayo Clinic. Cough: Causes and Treatment. 2023.
- 日本呼吸器学会 慢性咳嗽診療ガイドライン2023
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📘 Recommended Resources
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- First Aid for the USMLE Step 2 CS
- ダ・ヴィンチのカルテ―SxDxを鍛える99症例
- ティアニー先生の診察入門
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