Acute Cough

Age: ‍ years old

Gender: ‍malefemale



HISTORY:

Presents with a ‍-‍day history of cough

Described as ‍dryproductive, with ‍clearwhiteyellowgreen sputum

Severity is ‍mildmoderatesevere

Pattern ‍persistentintermittent, worse during the ‍day

Worsening factors: ‍none

Alleviating factors: ‍none, ‍effectiveineffective



Associated symptoms: *Try using right-click for negatives*

‍rhinorrhea, ‍clearcolored

‍nasal congestion

‍post-nasal drip

‍shortness of breath

‍wheezing

‍chest tightness

‍chest pain, ‍retrosternal, ‍aching, ‍on exertionat restwith deep breath, ‍mild

‍hemoptysis

‍sore throat

‍hoarsness

‍fever, up to ‍°, over ‍ ‍hoursdays

‍chills

‍fatigue



Contributing factors:

‍smokingpast smoking

‍similar symptoms in close contacts

no history of: ‍asthma, ‍COPD, ‍pneumonia, ‍allergic rhinitis, ‍recent upper respiratory infection, ‍recent Covid-19





EXAM:

General appearance: ‍well-appearing, ‍apparent distress

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Ears: tympanic membranes ‍normal ‍, auditory canal ‍ on ‍rightleft, hearing ‍intact

Nose: ‍clear, discharge ‍clear, ‍

Throat: ‍normal, ‍erythema, ‍exudate, ‍

Neck: ‍normal, ‍lymphadenopathy, ‍, c-spine ‍

Heart: ‍RRR, ‍MRG, ‍normal S1 and S2

Lungs: ‍clear bilaterally, ‍abnormal sounds, ‍retractions

Abdomen: ‍soft, ‍non-tender ‍, ‍non-distended, ‍

Skin: ‍rashlesions on ‍

Extremities: ‍warm, ‍dry, cap refill ‍< 3> 3 sec, pulses ‍intact, ‍edema ‍bilaterally, ‍





ASSESSMENT:

‍Upper respiratory infection ‍likelysuspectedpossible

DDx: upper respiratory infection, viral URI, post-nasal drip, acute sinusitis, bronchitis, asthma, GERD, pneumonia, COPD, allergic rhinitis, pertussis, influenza, COVID-19, foreign body aspiration





PLAN:

Investigations:

- Chest X-ray

- Covid test, Influenza test

- Blood work: ‍CBC, ‍electrolytes, ‍creatinine, ‍CRP, ‍LFTs, ‍blood culture

Treatments:

- Saline nasal irrigation

- ‍Nasal Steroids

- ‍Cough suppressants

- ‍Expectorants

- ‍Antibiotics

- ‍Inhalers

- Smoking cessation counseling

Further care:

- Follow-up in ‍ ‍daysweeks

- Return if cough persists for more than 3 weeks, if new symptoms develop, or if condition worsens