What is the recommended management for a patient with a persistent daytime cough and mild dyspnea, with a history of recent upper respiratory symptoms and a negative SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2) PCR (Polymerase Chain Reaction) test?

Recommended Management for Post-Viral Persistent Cough

For this patient with a 2-week persistent daytime cough following upper respiratory symptoms, normal vital signs, clear chest examination, and negative SARS-CoV-2 testing, supportive care with a follow-up visit in 2 weeks is the most appropriate management. Additional testing including chest radiography, pertussis testing, or pulmonary function testing is not indicated at this time given the clinical presentation and timeframe.

Clinical Reasoning

Post-Viral Cough Characteristics

• This presentation is classic for post-viral cough syndrome, which commonly persists for 2-8 weeks following upper respiratory tract infections 1
• The daytime-only pattern (absent at night) and improvement of other cold symptoms with isolated cough persistence strongly suggests post-viral etiology rather than asthma, pertussis, or structural lung disease 1
• The 2-week duration falls within the expected timeframe for acute cough (less than 3 weeks), which typically resolves spontaneously 1

Why Imaging is Not Indicated

• Chest radiography is mandatory only for chronic cough (duration >3-8 weeks) or when clinical features suggest pneumonia, malignancy, or other structural disease 1
• The Fleischner Society guidelines specify that imaging is not indicated in patients with mild clinical features unless they are at risk for disease progression 1
• This patient has normal vital signs, good air entry, and only scattered rhonchi that clear with cough—findings inconsistent with pneumonia or significant parenchymal disease 1

Why Pertussis Testing is Not Indicated

• Bordetella pertussis typically presents with paroxysmal cough, inspiratory whoop, and post-tussive emesis—none of which are described in this patient 1
• The 2-week duration is too short to warrant pertussis investigation, which is typically considered when cough persists beyond 3 weeks with characteristic features 1
• The patient's cough is only occasionally productive of scant white phlegm, not the severe paroxysmal pattern typical of pertussis 1

Why Pulmonary Function Testing is Premature

• Spirometry and bronchial provocation testing should be performed in patients with chronic cough (>3-8 weeks) and normal chest radiography when referred to a respiratory physician 1
• Exercise challenge testing would be considered if asthma is suspected, but the daytime-only pattern and absence of nocturnal symptoms make asthma less likely 1
• Current evidence shows that pulmonary function tests are typically normal in children with post-viral respiratory symptoms, even when symptoms persist for months 2, 3

Appropriate Management Strategy

Immediate Supportive Care

• Reassurance that post-viral cough commonly persists for 2-8 weeks after resolution of other cold symptoms 1
• Symptomatic treatment with dextromethorphan as a cough suppressant if cough is significantly bothersome 4
• Adequate hydration and rest during recovery 5
• Avoidance of irritants (smoke, strong odors, cold air) that may trigger cough 1

Follow-Up Parameters

• Schedule reassessment in 2 weeks to evaluate cough resolution 1
• Instruct the patient to return immediately if red flag symptoms develop, including: dyspnea at rest, respiratory rate ≥30/min, oxygen saturation ≤93%, persistent high fever, chest pain, or hemoptysis 6, 5
• If cough persists beyond 3-4 weeks total duration, then proceed with chest radiography and spirometry as initial investigations 1

When to Escalate Investigation

• If cough becomes nocturnal or associated with wheezing, consider asthma and proceed with spirometry and bronchial provocation testing 1
• If constitutional symptoms develop (weight loss, night sweats, hemoptysis), obtain chest radiography immediately 1
• If cough becomes paroxysmal with inspiratory whoop, consider pertussis testing at that time 1

Common Pitfalls to Avoid

• Over-investigation of acute post-viral cough: The 2-week timeframe is too early for extensive workup, and most cases resolve spontaneously 1
• Premature use of chest radiography: This exposes the patient to unnecessary radiation when clinical examination is reassuring 1
• Misdiagnosing asthma: The absence of nocturnal symptoms and wheezing makes asthma unlikely; daytime-only cough is atypical for asthma 1
• Unnecessary antibiotic prescription: This patient has no fever, normal vital signs, and clear lungs—findings inconsistent with bacterial infection 1

The key is recognizing that this represents a typical post-viral cough trajectory with reassuring clinical findings, warranting watchful waiting rather than immediate investigation 1.