What medication would you prescribe for a 49-year-old patient presenting with severe cold and cough symptoms?

Treatment for Severe Cold and Cough in a 49-Year-Old Patient

For a 49-year-old adult with severe cold and cough, prescribe a first-generation antihistamine/decongestant combination (such as diphenhydramine with pseudoephedrine or phenylephrine) plus dextromethorphan 60 mg for cough suppression, along with acetaminophen or naproxen for symptomatic relief. 1, 2, 3

Initial Assessment: Rule Out Serious Conditions

Before prescribing symptomatic treatment, exclude pneumonia by checking for:

• Heart rate >100 beats/min (tachycardia) 1, 3
• Respiratory rate >24 breaths/min (tachypnea) 1, 3
• Fever >38°C with systemic illness 1, 3
• Abnormal chest examination findings (rales, egophony, tactile fremitus, dullness to percussion, bronchial breathing, or crackles) 1, 3

If all four criteria are absent, pneumonia is unlikely and symptomatic treatment is appropriate. 1

First-Line Pharmacological Treatment Algorithm

For Nasal Congestion and Cold Symptoms

Prescribe a first-generation antihistamine/decongestant combination as the primary treatment. 1, 3 The American College of Physicians strongly recommends these combinations because they address multiple cold symptoms simultaneously and have proven efficacy. 1, 3

Important contraindications to screen for: 3

• Glaucoma
• Benign prostatic hypertrophy
• Uncontrolled hypertension
• Renal failure
• Congestive heart failure

Alternative option: Naproxen as monotherapy can be used instead of antihistamine/decongestant combinations if contraindications exist. 1, 3

For Severe Cough Suppression

Prescribe dextromethorphan 60 mg for maximum cough reflex suppression. 2, 3, 4 This is the preferred antitussive due to its superior safety profile compared to codeine-containing products. 2, 3 The dose-response relationship shows optimal effect at 60 mg, and lower doses are subtherapeutic. 2, 3

Critical warning: When using higher-dose dextromethorphan (60 mg), avoid combination products containing excessive acetaminophen or other active ingredients to prevent inadvertent overdose. 3

For Pain and Fever

Add acetaminophen 650 mg or naproxen for symptomatic relief of sore throat, body aches, and fever. 1, 5

Additional Symptomatic Options

For Nighttime Cough Disrupting Sleep

Consider adding a first-generation sedating antihistamine at bedtime (if not already using an antihistamine/decongestant combination during the day). 2, 3 These suppress cough through sedative properties and improve sleep quality. 2, 3

Adjunctive Non-Pharmacological Measures

Recommend honey and lemon mixtures as a cost-effective adjunct without adverse effects. 2, 3 Simple demulcents provide reasonable efficacy and can be used alongside pharmacological treatment. 2, 3

Menthol inhalation can provide acute but short-lived cough suppression and may be used as needed. 2, 3

Critical Pitfalls to Avoid

Do NOT prescribe antibiotics unless there is clear evidence of bacterial infection (symptoms persisting >10 days, high fever >39°C with purulent discharge for ≥3 consecutive days, or biphasic worsening after initial improvement). 1 Antibiotics are ineffective for viral upper respiratory infections and increase adverse effects. 1

Do NOT use newer-generation non-sedating antihistamines (like loratadine or cetirizine) as they are ineffective for cold symptoms. 3

Avoid codeine or other opioid antitussives as they have no greater efficacy than dextromethorphan but carry significantly more adverse effects. 2, 3

Do NOT use over-the-counter combination products unless they specifically contain older first-generation antihistamine/decongestant ingredients, as other combinations lack evidence of efficacy. 3

Expected Timeline and Follow-Up Instructions

Advise the patient that symptoms should gradually improve over 1-2 weeks. 1, 3 Cough is typically worst during the first few days. 3

Instruct the patient to return if: 1, 3

• Symptoms worsen after initial improvement (biphasic worsening suggesting bacterial superinfection)
• No improvement after 2-3 weeks
• Development of high fever, significant hemoptysis, progressive breathlessness, or voice changes

Reassess and discontinue symptomatic treatment if cough persists beyond 3 weeks, pursuing diagnostic workup rather than continued empiric suppression. 3

Monitoring for Adverse Effects

Monitor for common side effects from decongestants: 3

• Urinary retention (especially with underlying prostatic hypertrophy)
• Insomnia or jitteriness
• Tachycardia
• Worsening hypertension

Antihistamines may cause drowsiness, so warn patients about operating machinery or driving. 1