How should I approach a patient presenting with fever and cough?

Approach to a Patient with Fever and Cough

The most effective approach to a patient presenting with fever and cough is to first determine the duration of symptoms, assess severity, and perform targeted diagnostic testing based on clinical findings to guide appropriate management.

Initial Assessment

• Classify cough duration as acute (<3 weeks), subacute (3-8 weeks), or chronic (>8 weeks) to guide your diagnostic approach 1, 2
• Assess for signs of respiratory distress including increased respiratory rate, grunting, intercostal recession, breathlessness with chest signs, cyanosis, altered consciousness, or complicated seizures 2
• Evaluate for risk factors for complications including comorbidities, frailty, impaired immunity, or reduced ability to cough and clear secretions 2
• Implement respiratory hygiene/cough etiquette measures immediately:
  • Provide tissues for the patient to contain respiratory secretions 1
  • Ensure hand hygiene after contact with respiratory secretions 1
  • Consider providing a mask for the patient if tolerated 1
  • Maintain at least 3 feet of separation between symptomatic patients and others in waiting areas 1

Diagnostic Approach

History and Physical Examination

• Obtain focused history including:
  • Duration and characteristics of cough (paroxysmal, productive) 1
  • Presence of posttussive vomiting or inspiratory whooping 1
  • Presence or absence of fever 1, 2
  • Recent travel history or exposure to infectious individuals 1
  • Medication history, particularly ACE inhibitors 2
  • Smoking status 2

Diagnostic Testing

• Obtain a chest radiograph if pneumonia is suspected based on clinical findings such as tachypnea, tachycardia, dyspnea, or abnormal lung findings 2, 3
• Consider measuring C-reactive protein (CRP) - pneumonia can be ruled out in patients with CRP values below 10 μg/ml or in patients with CRP between 11-50 μg/ml without dyspnea and daily fever 4
• Perform pulse oximetry to assess for hypoxemia 3
• Consider microbiological studies (sputum Gram stain and culture) if bacterial infection is suspected 3

Management Based on Duration and Severity

Acute Cough (<3 weeks)

Mild Symptoms (Low-grade fever, no respiratory distress)

• Recommend adequate fluid intake to avoid dehydration 2
• Consider honey for cough suppression in patients over 1 year of age 2
• Advise paracetamol for fever management 2
• For cough associated with common cold, consider a first-generation antihistamine/decongestant combination 1

Moderate to Severe Symptoms

• If bacterial infection is suspected (high fever >38.5°C, productive cough, abnormal lung findings), consider empiric antibiotic therapy 1, 2
• For suspected influenza with severe symptoms, consider antiviral therapy if within 48 hours of symptom onset 1
• For patients with signs of pneumonia, initiate appropriate antibiotic therapy based on likely pathogens 2, 3

Subacute Cough (3-8 weeks)

• Determine if cough is postinfectious or not 1
• If postinfectious, consider:
  • First-generation antihistamine/decongestant for postnasal drip 1
  • Inhaled bronchodilators if bronchial hyperresponsiveness is suspected 1, 2
• If not postinfectious, evaluate and manage as chronic cough 1

Chronic Cough (>8 weeks)

• Use sequential and additive approach as multiple causes may be present 1
• Consider the most common causes: upper airway cough syndrome, asthma, and gastroesophageal reflux disease 5, 6
• Discontinue ACE inhibitors if applicable 2, 6
• Counsel and assist with smoking cessation 2

Special Considerations

Immunocompromised Patients

• Follow the same initial diagnostic algorithm but consider an expanded list of differential diagnoses 2
• Use CD4+ lymphocyte counts to guide differential diagnosis in HIV-infected patients 2
• Consider high-resolution CT scan and bronchoscopic evaluation for uncommon causes if cough persists despite appropriate evaluation and treatment 2

Suspected Highly Contagious Respiratory Infections

• Implement appropriate isolation precautions 1
• For suspected SARS or similar highly contagious infections:
  • Place patient in a negative pressure isolation room if available 1
  • Ensure healthcare workers use appropriate personal protective equipment 1
  • Maintain a list of all staff who have contact with the patient 1

Common Pitfalls to Avoid

• Do not rely solely on cough characteristics for diagnosis, as they have limited diagnostic value 2
• Avoid treating only one potential cause of chronic cough, as multiple factors often contribute 2
• Do not use newer generation non-sedating antihistamines for cough associated with common cold as they are ineffective 2
• Avoid using antipyretics with the sole aim of reducing body temperature without addressing other symptoms 2
• Do not forget to consider uncommon causes when cough persists despite appropriate evaluation and treatment 2