Assessment and Management of a 34-Year-Old Patient with Cough and Shortness of Breath
The initial assessment of a 34-year-old patient presenting with cough and shortness of breath should focus on identifying potentially serious conditions while following a systematic approach to determine the most likely diagnosis based on symptom duration, associated features, and risk factors.
Initial Assessment
Determine Duration of Symptoms
Red Flag Assessment (Requires Immediate Attention)
- Hemoptysis
- Significant dyspnea, especially at rest or at night
- Fever
- Weight loss
- Abnormal respiratory findings
- Hoarseness
- Smoker > 45 years with new cough or change in cough
- Peripheral edema with weight gain
- Trouble swallowing
- Vomiting
- Recurrent pneumonia 1, 2
Key History Elements
- Smoking status and pack-years
- Occupational exposures
- Medication review (particularly ACE inhibitors)
- History of asthma, COPD, GERD, or allergies
- Environmental exposures
- Travel history
- Timing and pattern of cough (day/night)
- Quality of cough (productive vs. non-productive)
- Associated symptoms 1, 2
Physical Examination Focus
- Vital signs (including oxygen saturation)
- General appearance
- HEENT examination (nasal passages, sinuses, throat)
- Respiratory examination (breath sounds, wheezing, crackles)
- Cardiovascular examination 2
Initial Diagnostic Testing
Essential Tests
Additional Tests Based on Clinical Suspicion
- Complete blood count (if infection suspected)
- Exhaled nitric oxide (FeNO) testing (if asthma suspected) 1
- Blood gas analysis (if moderate to severe respiratory distress) 1
Management Algorithm Based on Likely Diagnosis
1. Acute Cough (< 3 weeks)
Most commonly associated with viral upper respiratory tract infection 1
Management:
- Symptomatic treatment:
- Dextromethorphan for non-productive cough
- First-generation antihistamines for nocturnal cough 2
- Consider albuterol 2.5 mg via nebulizer 3-4 times daily if bronchospasm present 3
- Antibiotics generally not indicated for viral upper respiratory infections 2
- Patient education on respiratory hygiene and cough etiquette 2
2. If Asthma Suspected
Consider if:
- Episodic wheezing
- Nocturnal cough
- Exercise-induced symptoms
- Personal/family history of atopy
Management:
- Trial of inhaled corticosteroids and bronchodilators for 4 weeks 2
- Consider short course of oral corticosteroids if symptoms are severe 2
- FeNO testing may help identify steroid-responsive cough 1
3. If Upper Airway Cough Syndrome Suspected
Consider if:
- Postnasal drip
- Throat clearing
- Nasal congestion
Management:
- First-generation antihistamine/decongestant combination for 2-4 weeks 2
4. If GERD Suspected
Consider if:
- Heartburn
- Regurgitation
- Worse when lying down
- Note: Can occur without GI symptoms 1
Management:
- Proton pump inhibitor with lifestyle modifications for 4-8 weeks 2
- Intensive acid suppression with proton pump inhibitors and alginates for minimum 3 months if severe 1
5. If Post-infectious Cough Suspected
Consider if:
- Recent history of upper respiratory infection
- Cough persisting after other symptoms resolve
Management:
- Short course of inhaled corticosteroids if cough affects quality of life
- Inhaled ipratropium bromide may be considered as first-line therapy 2
Follow-up Recommendations
- Re-evaluate if cough persists beyond 4-6 weeks 2
- Consider specialist referral if:
- Cough persists despite appropriate treatment
- Suspected serious underlying pathology
- Significant impact on quality of life 2
Common Pitfalls to Avoid
- Premature diagnosis closure
- Unnecessary antibiotic use for viral infections
- Overlooking medication causes (especially ACE inhibitors)
- Delayed diagnosis of serious conditions
- Inadequate follow-up 2
- Failure to consider GORD as a cause for cough 1
Remember to assess cough severity or quality of life before and after treatment using validated tools such as a visual analog scale, and schedule routine follow-up 4-6 weeks after the initial visit to ensure resolution of symptoms. 1