What is the treatment for a patient presenting with dry cough, sore throat, headache, and malaise?

Treatment of Dry Cough, Sore Throat, Headache, and Malaise

This symptom constellation represents a viral upper respiratory tract infection (common cold) that requires symptomatic treatment only—antibiotics are not indicated and cause more harm than benefit. 1, 2

Immediate Management Approach

First-Line Symptomatic Treatment

Start with a first-generation antihistamine/decongestant combination (such as brompheniramine with sustained-release pseudoephedrine) as this provides the most effective relief for upper airway symptoms including cough, sore throat, and nasal congestion. 1, 2

• Add naproxen or another NSAID for headache, malaise, and sore throat pain—this also helps reduce cough frequency 1
• Simple home remedies like honey and lemon are effective and should be recommended as initial therapy before or alongside pharmacological treatments 1, 2, 3

Cough-Specific Management

For persistent dry cough, use dextromethorphan at therapeutic doses of 60 mg (not the standard over-the-counter 15-30 mg dose which is subtherapeutic) for maximum cough reflex suppression 1, 3, 4

• Menthol inhalation (menthol crystals or proprietary capsules) provides acute but short-lived relief and can be used as needed 1, 3
• Avoid codeine or pholcodine—they have no greater efficacy than dextromethorphan but significantly more adverse effects including drowsiness, nausea, constipation, and dependence risk 1, 3

Additional Symptomatic Measures

• Intranasal saline irrigation helps with nasal congestion and may reduce viral load 1, 5
• If rhinorrhea persists beyond 3-5 days, add intranasal ipratropium bromide 2, 6
• If prominent upper airway symptoms persist beyond one week, add intranasal corticosteroids 2

Patient Education and Expectations

Reassure patients that symptoms typically last less than 1 week, though cough may persist for up to 3 weeks—this is normal and does not indicate bacterial infection. 2, 6

• Green or yellow sputum does NOT indicate bacterial infection and does not warrant antibiotics 2
• Emphasize hand hygiene as the best prevention method 2, 6
• Advise using tissues and washing hands to prevent transmission 2

Red Flags Requiring Re-evaluation

Return immediately or within 24-48 hours if any of the following develop:

• Fever >39°C (102.2°F) or fever persisting beyond 3 days 1, 2
• Shortness of breath or wheezing 2
• Hemoptysis (coughing blood) 2
• Symptoms worsen after initial improvement ("double sickening" pattern suggesting bacterial superinfection) 1
• Cough persists beyond 3 weeks (requires full diagnostic workup) 2, 3

Critical Pitfalls to Avoid

Do not prescribe antibiotics—they provide no benefit for viral upper respiratory infections and cause adverse effects in 1 out of 8 patients versus benefiting only 1 out of 18. 1

• Newer non-sedating antihistamines (like loratadine, cetirizine) are ineffective for acute viral cough and should not be used 1
• Do not use over-the-counter cough medications in children under 4 years of age 6
• Avoid combination products containing multiple active ingredients at higher doses of dextromethorphan, as they may contain paracetamol or other agents requiring dose adjustment 1, 3

Special Considerations

If the patient is on an ACE inhibitor, consider this as a potential cause of dry cough (though the acute onset with other viral symptoms makes this less likely in this scenario) 1

For patients with comorbid conditions like hypertension or diabetes, use decongestants cautiously as pseudoephedrine may affect blood pressure and blood glucose 3