Navigating coughs—from common colds to serious causes
Description
Cough is one of the most common chief complaints in primary care and emergency settings. From viral infections to life-threatening diseases like lung cancer, it spans a wide spectrum of etiologies. This mock case script is designed to help learners navigate through various presentations of cough and sputum, enhancing their skills in clinical reasoning, patient interviewing, and communication in English.
🔎 Jump to Section
- Case 1: “I’ve had this dry cough for a week now.”
- Case 2: “Every morning I wake up coughing up yellow stuff.”
- Case 3: “I can’t stop coughing and I’m coughing up blood now.”
- Case 4: “My cough hasn’t gone away for more than 8 weeks.”
- Useful Expressions
- Layman’s Terms
- Glossary
- Related Articles / References / Recommended Resources
Description
Cough is one of the most common chief complaints in primary care and emergency settings. From viral infections to life-threatening diseases like lung cancer, it spans a wide spectrum of etiologies. This mock case script is designed to help learners navigate through various presentations of cough and sputum, enhancing their skills in clinical reasoning, patient interviewing, and communication in English.
🧑⚕️ Case 1: “I’ve had this dry cough for a week now.”
Doorway Information
- Age / Gender: 24-year-old female
- Chief Complaint: Dry cough for 7 days
- Vital Signs: T 37.4°C, HR 78, BP 112/68, RR 14, SpO₂ 98%
Structured History
- Opening: “I just can’t seem to shake this dry cough.”
- Shoreline: “It started about a week ago. No phlegm, but it’s annoying.”
- Onset & Course: Gradual after being caught in the rain; worse at night.
- Associated Symptoms: Mild nasal congestion, scratchy throat. No fever, no sputum, no SOB.
- Mood / Function / Appetite / Sleep: Fine during the day; poor sleep due to nighttime cough. Normal appetite and activity.
- Medical History / Medications: No chronic illness. Occasionally uses OTC syrup.
- Allergy: None known.
- Hospitalization / Injury / Trauma / Surgery: None.
- Family History: Mother has seasonal allergies.
- OBGYN / Sexual History: Regular menses, sexually active with one partner.
- Social History: Non-smoker, no alcohol/drug use. University student, 5–6 hr sleep, exam stress.
- Concerns & Questions: “Is it something serious? Do I need antibiotics?”
Physical Examination
- General: Well-nourished, no distress
- HEENT: Mild pharyngeal erythema, slight nasal mucosal edema
- Chest: Clear breath sounds, no wheezes/rales/rhonchi
- Abdomen: Soft, non-tender
- Neuro: Normal
- Skin: No rash
- Other: No cervical lymphadenopathy
Differential Diagnosis
- Viral URI
Supporting: Gradual onset, dry cough, nasal congestion, pharyngeal erythema, afebrile
Against: None significant - Allergic rhinitis / postnasal drip
Supporting: Family history, nasal symptoms
Against: No allergen trigger, acute onset - Cough-variant asthma
Supporting: Nighttime cough
Against: No wheeze, no asthma history
Clinical Reflection
Even for something that seems like a simple cold, I always want to be sure there’s no hidden red flag. A detailed history and auscultation are key to avoid missing something serious when the only complaint is a “cough.”
Clinical Tips
- Post-viral cough may persist up to 2 weeks.
- Dry cough at night can suggest asthma or reflux.
- OTC meds help symptomatically, not curatively.
- Antibiotics are not needed for uncomplicated viral URIs.
Challenging Questions
Q: “Do I need antibiotics?”
A: “Right now, it seems like a common viral cold. Antibiotics don’t help with viruses, and using them unnecessarily can lead to resistance. Let’s focus on rest, hydration, and symptom relief. If things change, we’ll reassess.”
Q: “Why is it worse at night?”
A: “That’s actually quite common. When you lie down, postnasal drip or throat sensitivity can increase. I’ll give you some tips to reduce nighttime coughing and keep an eye on it.”
📝 SOAP Note
S: 24-year-old female presents with a 7-day history of dry cough. No fever, sputum, or dyspnea. Mild nasal congestion and throat irritation. No smoking or medication use. Nighttime worsening noted. O: T 37.4°C, HR 78, RR 14, BP 112/68, SpO₂ 98%. Mild pharyngeal erythema, nasal edema. Lungs clear to auscultation. No rales, wheezing, or lymphadenopathy. A: # Dry cough, 7 days # Nasal congestion and sore throat # Normal vital signs and lung exam ddx): Viral URI, allergic rhinitis, cough-variant asthma r/o): Pneumonia (no fever, clear lungs), sinusitis (no facial pain or purulent discharge) → Most likely viral URI. Supportive care and close monitoring. P: * Reassurance and education * Symptomatic treatment (lozenges, warm fluids, optional OTC syrup) * No antibiotics needed * Return if worsening, fever develops, or new symptoms appear
🥶 Case 2: “Every morning I wake up coughing up yellow stuff.”
Doorway Information
- Age / Gender: 59-year-old male
- Chief Complaint: Morning productive cough for 2 months
- Vital Signs: T 36.8°C, HR 82, BP 132/76, RR 16, SpO₂ 97%
Structured History
- Opening: “I’ve been coughing up yellow mucus every morning lately.”
- Shoreline: “It’s been going on for a couple of months now, mostly first thing in the morning.”
- Onset & Course: Gradual onset, daily pattern, worse in the morning.
- Associated Symptoms: No fever or chest pain. Mild exertional dyspnea. No hemoptysis.
- Mood / Function / Appetite / Sleep: Still working, mornings are rough. Sleep mildly disturbed. Appetite normal.
- Medical History / Medications: Hypertension (on amlodipine 5mg daily)
- Allergy: None known
- Hospitalization / Injury / Trauma / Surgery: Appendectomy in 20s
- Family History: Father had COPD
- OBGYN / Sexual History: N/A
- Social History: Ex-smoker (35 pack-years, quit 1 year ago), drinks beer on weekends, no drug use
- Concerns & Questions: “Am I developing COPD like my dad? Do I need inhalers or something?”
Physical Examination
- General: Well-appearing, no acute distress
- HEENT: Oral mucosa moist, no tonsillar exudate
- Chest: Mild expiratory wheezing bilaterally, no crackles or dullness
- Abdomen: Soft, non-tender
- Neuro: No focal deficits
- Extremities: No cyanosis or edema
- Skin: No clubbing
Differential Diagnosis
- Chronic bronchitis (COPD subtype)
Supporting: Productive cough >3 months, smoking history, morning symptoms, family history
Against: No dyspnea at rest - Postnasal drip / Upper airway cough syndrome
Supporting: Morning symptoms
Against: No nasal symptoms or throat clearing - Bronchiectasis
Supporting: Daily productive cough
Against: No recurrent infections or clubbing
Clinical Reflection
Cough in former smokers always raises concern. While this sounds like chronic bronchitis, I want to make sure there’s no early COPD progression or bronchiectasis lurking. Spirometry will help clarify.
Clinical Tips
- Morning productive cough is classic for chronic bronchitis
- Don’t forget to ask about smoking cessation history
- Former smokers may still have active airway inflammation
- Physical exam in early COPD can be normal
- Rule out red flags: hemoptysis, weight loss, infections
Challenging Questions
Q: “So is this COPD?”
A: “It might be early-stage COPD, but we need more information. A lung function test called spirometry will help us understand how your airways are working. It’s good that you quit smoking— that’s the most important step.”
Q: “Why do I cough so much only in the morning?”
A: “At night, mucus tends to accumulate, and when you wake up, your body tries to clear it. That’s especially common in people with irritated or inflamed airways, like in chronic bronchitis.”
📝 SOAP Note
S: 59-year-old male with 2-month history of morning productive cough. Yellow sputum daily. No fever, weight loss, or hemoptysis. Smoked 1 pack/day for 35 years, quit 1 year ago. Mild exertional dyspnea. O: T 36.8°C, HR 82, BP 132/76, RR 16, SpO₂ 97%. Mild expiratory wheezing. Lungs otherwise clear. No edema, no clubbing. A: # Chronic productive cough in former smoker # Mild exertional dyspnea # Family history of COPD ddx): Chronic bronchitis (COPD), UACS (postnasal drip), bronchiectasis r/o): Lung cancer (no red flags), pneumonia (no fever, normal exam) → Chronic bronchitis most likely. Will confirm with spirometry. P: * Order spirometry to assess for airflow limitation * Recommend chest X-ray to rule out other pathology * Supportive care: hydration, monitor sputum color/volume * Reinforce smoking cessation benefits * Consider pulmonology referral if abnormal PFTs
⚠️ Case 3: “I can’t stop coughing and I’m coughing up blood now.”
Doorway Information
- Age / Gender: 67-year-old male
- Chief Complaint: Persistent cough and blood-streaked sputum
- Vital Signs: T 37.3°C, HR 88, BP 140/82, RR 18, SpO₂ 95%
Structured History
- Opening: “I was coughing as usual, then this morning I saw blood in it.”
- Shoreline: “I’ve had a cough for months, but the blood this morning really scared me.”
- Onset & Course: 4-5 months of chronic cough, recently worsened. Hemoptysis began this morning.
- Associated Symptoms: Fatigue, mild exertional dyspnea, 4-5 kg weight loss. No fever or night sweats.
- Mood / Function / Appetite / Sleep: Still working part-time. Appetite decreased. Sleep undisturbed.
- Medical History / Medications: Type 2 diabetes, hypertension (metformin, lisinopril)
- Allergy: NKDA
- Hospitalization / Injury / Trauma / Surgery: None recent
- Family History: Father died of colon cancer
- OBGYN / Sexual History: N/A
- Social History: 45 pack-year smoker, still smoking. Occasional alcohol. Retired electrician.
- Concerns & Questions: “Is this cancer? Should I be worried about tuberculosis or something like that?”
Physical Examination
- General: Appears fatigued, mild dyspnea
- HEENT: Pale conjunctiva, no oral lesions
- Chest: Decreased breath sounds in right upper lobe
- Abdomen: Soft, non-tender
- Neuro: Normal
- Skin: No clubbing or cyanosis
- Lymph Nodes: No cervical or supraclavicular nodes
Differential Diagnosis
- Lung cancer
Supporting: Chronic cough, hemoptysis, weight loss, smoking history, decreased breath sounds
Against: No lymphadenopathy or mass on exam - Lung abscess
Supporting: Chronic cough, foul sputum, fatigue
Against: No fever or foul odor, no clubbing - Tuberculosis
Supporting: Hemoptysis, weight loss, chronic symptoms
Against: No fever or TB contact
Clinical Reflection
In patients with hemoptysis and long-term cough, lung cancer must always be a top concern—especially with risk factors like smoking and weight loss. We need to act fast but also reassure the patient that we’ll investigate thoroughly.
Clinical Tips
- Hemoptysis should never be dismissed in older smokers
- Ask about systemic signs: weight loss, fever, night sweats
- Always consider TB in hemoptysis
- CT is more sensitive than CXR for lung masses
- Assess oxygenation and anemia risk
Challenging Questions
Q: “Is this lung cancer?”
A: “That is one of the possibilities we’re considering, but we can’t say for sure yet. Several other conditions can cause coughing up blood. We’ll order a chest scan and other tests to help us figure this out quickly. You’re not alone—we’ll go step by step.”
Q: “Should I be worried about TB?”
A: “Tuberculosis is one of the things we’ll check for, especially with the weight loss and cough. It’s important to test and rule it out, especially for your safety and others. We’ll include it in our workup today.”
📝 SOAP Note
S: 67-year-old male presents with 4–5 months of chronic cough, worsened recently, now with blood-streaked sputum. Fatigue and 4–5 kg weight loss. Mild dyspnea on exertion. Smoking 45 pack-years, still active. No fever or night sweats. O: T 37.3°C, HR 88, RR 18, BP 140/82, SpO₂ 95%. Decreased breath sounds RUL. No lymphadenopathy, no clubbing, normal abdomen. A: # Chronic cough with new-onset hemoptysis # Unintentional weight loss, fatigue # High-risk smoking history ddx): Lung cancer, lung abscess, tuberculosis r/o): Bronchitis (too chronic), pneumonia (no fever), PE (unlikely without acute dyspnea) → High suspicion for malignancy. Rule out TB. Proceed with urgent imaging and labs. P: * Chest CT (with contrast if possible) * CBC, CRP, ESR, sputum culture and AFB stain * Consider bronchoscopy referral * Counsel on smoking cessation * Monitor O₂ sat and symptoms closely
🤔 Case 4: “My cough hasn’t gone away for more than 8 weeks.”
Doorway Information
- Age / Gender: 38-year-old female
- Chief Complaint: Chronic dry cough for 2 months
- Vital Signs: T 36.9°C, HR 72, BP 118/76, RR 14, SpO₂ 99%
Structured History
- Opening: “I’ve been coughing for over two months and it just won’t stop.”
- Shoreline: “It started as a little tickle in my throat, but now it’s just constant.”
- Onset & Course: Gradual, persistent daily cough. Worsened post-meals and when lying down.
- Associated Symptoms: Burning sensation in throat/chest, bitter taste in mouth at night. No fever, weight loss, or SOB.
- Mood / Function / Appetite / Sleep: Cough affects social comfort and sleep. Uses extra pillows. Appetite fair but avoids spicy food.
- Medical History / Medications: Seasonal allergies, mild asthma. Prior azithromycin (no effect). Uses OTC antihistamines and rare albuterol.
- Allergy: Dust mites, pollen
- Hospitalization / Injury / Trauma / Surgery: None
- Family History: Mother with asthma, father with hypertension
- OBGYN / Sexual History: Regular menses, no STIs or pregnancies
- Social History: Non-smoker, minimal alcohol. Works late, eats late. Increased work stress.
- Concerns & Questions: “Could this be asthma again? Or do I need another antibiotic?”
Physical Examination
- General: Tired appearance, no acute distress
- HEENT: Mild throat erythema, no lymphadenopathy
- Chest: Clear breath sounds, no wheezes or rales
- Abdomen: Mild epigastric tenderness
- Neuro: Normal
- Skin: No rash or cyanosis
Differential Diagnosis
- GERD (gastroesophageal reflux disease)
Supporting: Post-meal and nocturnal cough, sour taste, positional triggers
Against: No classic early heartburn - Cough-variant asthma
Supporting: History of asthma, night cough
Against: No response to inhalers, no wheezing - Postnasal drip (UACS)
Supporting: Allergy history
Against: No nasal drainage or throat clearing
Clinical Reflection
This case reminds me that GERD can present subtly. Many patients don’t complain of typical heartburn, yet the cough is persistent and often triggered by meals or lying flat. It’s essential to recognize extra-esophageal symptoms.
Clinical Tips
- GERD is a common cause of chronic cough, especially when physical exam and imaging are normal
- Ask about reflux indicators: bitter taste, nighttime symptoms, post-meal onset
- Empiric PPI therapy is often diagnostic
- Inhalers and antibiotics won’t help GERD-related cough
- Consider lifestyle triggers: caffeine, late meals, alcohol, stress
Challenging Questions
Q: “Do I have asthma again?”
A: “That’s a reasonable thought, especially with your history. But your current symptoms—especially how they worsen after meals or at night—make reflux more likely. We’ll still keep asthma in mind, but we might start with a treatment trial for acid reflux first.”
Q: “Why didn’t the antibiotic help me?”
A: “That’s a really important point. If the cough is caused by something like acid reflux or airway sensitivity, antibiotics won’t make a difference. The good news is we have other treatments that may work better for this kind of cough.”
📝 SOAP Note
S: 38-year-old female with 2-month history of dry, persistent cough. Worse after eating and when lying down. No fever, sputum, or weight loss. Sometimes wakes up with bitter taste. Previously tried antibiotics without improvement. History of asthma and seasonal allergies. O: T 36.9°C, HR 72, BP 118/76, RR 14, SpO₂ 99%. Mild throat erythema. Lungs clear. Mild epigastric tenderness. No wheezing or lymphadenopathy. A: # Chronic non-productive cough, 8+ weeks # Likely GERD-related based on timing and triggers # History of asthma, but no recent exacerbation signs ddx): GERD, cough-variant asthma, postnasal drip r/o): Pneumonia (no fever or infiltrates), ACEi-cough (no ACEi use), pertussis (no paroxysmal pattern) → GERD most likely. Begin empiric treatment and lifestyle adjustment. P: * Start PPI (e.g., omeprazole 20mg once daily before breakfast) * Counsel on reflux precautions: avoid late meals, elevate head of bed * Trial for 2–4 weeks and reassess * Avoid unnecessary antibiotic/inhaler use unless new findings * Consider ENT referral if symptoms persist
🔊 Useful Medical Expressions
- When did the cough start?
- Is it dry or productive?
- Have you had any fever, chills, or night sweats?
- Do you smoke? How much and for how long?
- Do you bring up any phlegm? What color is it?
- Have you noticed any blood in your sputum?
- Does anything trigger or relieve your cough?
- Have you tried any medications?
- Have you experienced weight loss or fatigue?
- Let me listen to your lungs.
🖊️ Layman’s Terms and Idioms
- “A nagging cough” = a persistent cough
- “Coughing my lungs out” = coughing severely
- “Bring up phlegm” = cough out mucus
- “Bloody sputum” = blood-streaked mucus
- “Smoker’s cough” = chronic cough in smokers
📖 Medical English Glossary
- Hemoptysis: coughing up blood
- Productive cough: cough that brings up mucus
- Rhonchi: low-pitched lung sounds, often from mucus
- Postnasal drip: mucus dripping down the throat from the nose
- GERD: gastroesophageal reflux disease, can cause chronic cough
🔗 Related Articles / References / Recommended Resources
✍️ Related Articles
- 😷Persistent Cough? A Step-by-Step Clinical Approach to Acute and Chronic Cough
- 🩺 Symptom-Based Clinical Reasoning
- 🩺 Mock Patient Scripts
📄 References
- BMJ Best Practice: Cough
- UpToDate: Evaluation of chronic cough
- GINA Guidelines (if asthma-related)
🎓 Recommended Resources
- First Aid for the USMLE Step 2 CS
- The Patient History: Evidence-Based Approach by Mark Henderson
- \u30c0\u30fb\u30f4\u30a3\u30f3\u30c1\u306e\u30ab\u30eb\u30c6 – Snap Diagnosisを鍛える99症例
- \u30c6\u30a3\u30a2\u30cb\u30fc先生の臨床入門
- 押味先生のブログ