Chief Complaint: Cough
a. History: Acute (< 3 weeks)
| Pivotal Assessment | Finding |
|---|---|
History |
High fever, dyspnea, hemoptysis, Immunocompromised, Normal pleuritic chest pain, weight elderly, abnormal lung vital signs loss, hypoxia, significant exam, or comorbid illness and physical exam smoking history? │ |
Patient presents with cough < 3 weeks
│
▼
❓ Are there Red Flag symptoms?
│
┌────────────────────────────────┼────────────────────────────────┐
│ │ │
▼ ▼ ▼
High fever, dyspnea, hemoptysis, Immunocompromised, Normal
pleuritic chest pain, weight elderly, abnormal lung vital signs
loss, hypoxia, significant exam, or comorbid illness and physical exam
smoking history? │
│ ▼
└──────────► Yes ❓ URI symptoms present?
│ (nasal congestion,
▼ sore throat, etc.)
❗ Further evaluation needed │
- Chest X-ray ▼
- CBC, +/- sputum testing ┌───────────┴────────────┐
- Consider pneumonia, PE, etc. Yes No
▼ ▼
Likely Viral URTI ❓ Cough with wheezing,
(most common) triggers, or at night?
→ Supportive care │
▼
Yes No
▼ ▼
→ Likely Asthma ❓ Cough with post-
→ Bronchodilator tussive vomiting?
trial, follow-up │
▼
Yes No
▼ ▼
→ Consider Pertussis → Consider:
(esp. if not - Postnasal drip
vaccinated) - Acute bronchitis
→ PCR, macrolide tx - GERD (less likely acutely)
Here's an algorithm for evaluating a cough <3 weeks (acute cough):
Patient presents with cough < 3 weeks │ ▼ ❓ Are there Red Flag symptoms? │ ┌────────────────────────────────┼────────────────────────────────┐ │ │ │ ▼ ▼ ▼ High fever, dyspnea, hemoptysis, Immunocompromised, Normal pleuritic chest pain, weight elderly, abnormal lung vital signs loss, hypoxia, significant exam, or comorbid illness and physical exam smoking history? │ │ ▼ └──────────► Yes ❓ URI symptoms present? │ (nasal congestion, ▼ sore throat, etc.) ❗ Further evaluation needed │ - Chest X-ray ▼ - CBC, +/- sputum testing ┌───────────┴────────────┐ - Consider pneumonia, PE, etc. Yes No ▼ ▼ Likely Viral URTI ❓ Cough with wheezing, (most common) triggers, or at night? → Supportive care │ ▼ Yes No ▼ ▼ → Likely Asthma ❓ Cough with post- → Bronchodilator tussive vomiting? trial, follow-up │ ▼ Yes No ▼ ▼ → Consider Pertussis → Consider: (esp. if not - Postnasal drip vaccinated) - Acute bronchitis → PCR, macrolide tx - GERD (less likely acutely)
Most common cause: Viral URTI
Avoid antibiotics unless pneumonia or bacterial infection is suspected.
Test for pertussis in prolonged cough with post-tussive vomiting or known exposure.
Chest X-ray is warranted only if:
Abnormal lung findings
Red flag symptoms
Immunocompromised or elderly
Let me know if you'd like this as a downloadable flowchart or in a visual format.
[ACE inhibitor therapy, (a dry cough develops in up to 20% of patients taking an ACE inhibitor, usually within 1–2 weeks of therapy initiation) as well as less common causes.
When community influenza-like illness activity levels are high, clinical diagnosis of influenza (cough, fever, chills with or without sweats, myalgias, and acute onset) has a positive predictive value of approximately 70%; this usually obviates the need for rapid diagnostic tests to guide isolation and empiric treatment decisions. The CDC’s FluView displays weekly updates of influenza surveillance data (https://www.cdc.gov/flu/weekly/index.htm).]
| Pivotal Assessment | Finding | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
Further History |
Ace Inhibitor, Takes | Chills | Congestion, Chest | Congestion, Nasal | Cough greater than 2 weeks | Fever | |||||
| Paroxysms of coughing, inspiratory whoop, or post-tussive emesis | Pertusssis outbreak or known close contact with a confirmed case, the presence of a cough lasting ≥2 weeks is sufficient | Runny Nose | Sore Throat | ||||||||
| Physical Exam | Heart rate greater than 100 beat per minute | Sputum, Present | |||||||||
Fever? → Consider infection
Sputum? Color/amount → Suggests bronchitis or pneumonia
Coryzal symptoms? (runny nose, sore throat, sneezing) → URTI/postnasal drip
Chest pain, dyspnea? → Pneumonia, pulmonary embolism
Wheezing? → Asthma, viral bronchitis
Sick contacts or recent travel? → Viral illness, pertussis
Smoking history
Medication use (especially ACE inhibitors)