What to assess and ask when evaluating a patient with cough and congestion?

Evaluating Cough and Congestion: Essential Assessment Framework

Begin with a focused medical history and physical examination to determine if the cough represents a life-threatening condition versus a common self-limited illness, while specifically identifying medication use (particularly ACE inhibitors), smoking status, and duration of symptoms to guide your diagnostic approach. 1

Critical Initial Questions to Ask

Duration and Severity Classification

• Acute cough (<3 weeks): First rule out serious illness such as pneumonia or pulmonary embolism versus typical viral upper respiratory infection 1, 2
• Subacute cough (3-8 weeks): Consider post-infectious causes, including pertussis if cough persists >2 weeks with paroxysms, post-tussive vomiting, or inspiratory whooping 3, 2, 4
• Chronic cough (>8 weeks in adults, >4 weeks in children): Focus on the "big four" causes: upper airway cough syndrome, asthma, gastroesophageal reflux disease, and nonasthmatic eosinophilic bronchitis 5, 6, 7

Medication History

• Ask specifically about ACE inhibitor use - this is a common and reversible cause that should be addressed immediately by switching to another drug class 1, 5
• Inquire about β-adrenergic blocking medications that may exacerbate asthma 1
• Evaluate for any other drugs that could induce cough 1

Smoking and Environmental Exposures

• Document current or past tobacco use 1
• Ask about occupational or environmental exposures to noxious or irritating agents 1
• Assess for triggers including changes in air temperature, scents, aerosols, or exercise 8

Associated Symptoms That Change Management

Red flags requiring urgent evaluation:

• Hemoptysis (especially in smokers with risk factors for lung cancer) 1, 8
• Fever, weight loss, or thrush (particularly in immunocompromised patients) 1
• Prominent systemic illness 8
• Dyspnea, tachypnea, or tachycardia suggesting pneumonia or pulmonary embolism 8, 4

Aspiration risk factors:

• Coughing specifically while eating or drinking 1
• Fear of choking during meals 1
• History of stroke, neurological conditions, or developmental problems associated with dysphagia 1
• Unexplained dehydration, malnutrition, or unintentional weight loss 1

Cardiac considerations:

• Lightheadedness with coughing or laughing (suggests possible hyperventilation syndrome or cardiac arrhythmia) 8
• Chest discomfort, palpitations, or irregular heartbeat 8

Immunocompromised Patients

• Obtain CD4+ lymphocyte counts in HIV-infected patients to guide differential diagnosis 1
• If CD4+ <200 cells/μL or >200 with unexplained fever/weight loss/thrush, suspect Pneumocystis pneumonia, tuberculosis, or other opportunistic infections 1

Physical Examination Priorities

Vital Signs and General Assessment

• Measure respiratory rate, heart rate, oxygen saturation, and blood pressure 8
• Respiratory rate >35 breaths/min is a contraindication for swallowing evaluation and suggests severe respiratory compromise 1
• Assess level of consciousness (reduced consciousness indicates high aspiration risk) 1

Cardiopulmonary Examination

• Auscultate for abnormal heart sounds, murmurs, or lung findings suggestive of pneumonia 8, 4
• Look for signs of pulmonary edema in patients on peritoneal dialysis 1

Upper Airway and Swallowing Assessment

• Examine oropharynx for signs of inflammation or irritation 8
• Assess for dysarthria, dysphonia, or weak voluntary cough 1
• In alert patients at high risk for aspiration, observe them drinking 3 oz of water - if they cough or show clinical signs of aspiration, refer for detailed swallowing evaluation by a speech-language pathologist 1
• Look for drooling, nasal regurgitation, or need for frequent oral/pharyngeal suctioning 1

Signs of Hyperventilation or Dysfunctional Breathing

• Evaluate breathing patterns during normal respiration and during symptomatic episodes 8
• Assess for hyperventilation syndrome if lightheadedness occurs with coughing 8

Initial Diagnostic Testing

Essential First-Line Tests

• Chest radiograph to rule out pneumonia, malignancy, structural abnormalities, or infiltrates 1, 5, 7
• Spirometry with bronchodilator testing to assess for asthma or obstructive lung disease 8, 5, 7
• ECG if lightheadedness or cardiac symptoms are present 8
• Consider exhaled nitric oxide and blood eosinophil count for chronic cough evaluation 7

Additional Testing for Specific Scenarios

• Chest CT scan and bronchoscopy if cough persists after evaluation for common causes, or if smoker with hemoptysis even with normal chest radiograph 1
• Nutritional assessment in patients with conditions associated with aspiration 1
• Swallowing evaluation (videofluoroscopic or fiberoptic endoscopic) for patients with dysphagia symptoms, conditions predisposing to aspiration, or recurrent pneumonia/bronchitis 1

Common Pitfalls to Avoid

• Do not rely on cough timing and characteristics alone - these have little diagnostic value 1
• Do not diagnose unexplained/idiopathic cough prematurely - this is a diagnosis of exclusion only after thorough evaluation, empiric treatment trials, and ruling out uncommon causes 1
• Do not feed patients orally if they have reduced level of consciousness - they are at extremely high risk for aspiration 1
• Do not assume acute cough is benign - always first rule out serious conditions like pneumonia or pulmonary embolism 1
• Do not forget to consider foreign body aspiration in patients with abrupt onset of cough 1
• Do not overlook pertussis in patients with cough >2 weeks, especially with paroxysms or post-tussive vomiting 3, 4

Special Population Considerations

Peritoneal Dialysis Patients

Evaluate for GERD, ACE inhibitors, pulmonary edema, asthma exacerbated by β-blockers, and infection 1

Patients with Lung Cancer Risk

Obtain chest radiograph if risk factors present or known cancer elsewhere that could metastasize to lungs 1

Geographic and Immune Status Factors

Consider expanded differential diagnosis based on type and severity of immune defect and geographic location 1