What is the next step in evaluating and treating a patient with a chronic cough, scratchy throat, and headache, who has tested negative for COVID-19 (Coronavirus Disease 2019), strep (Streptococcal) throat, flu (Influenza), and RSV (Respiratory Syncytial Virus)?

Chronic Cough with Scratchy Throat and Headache: Next Steps After Negative Viral Testing

This is most likely an acute viral upper respiratory tract infection (URI) that will resolve on its own with symptomatic treatment, and you should focus on managing symptoms while monitoring for red flags that would indicate a more serious condition. 1

Immediate Clinical Assessment

The American Academy of Family Physicians states that approximately 70% of adults presenting with acute cough have an upper respiratory tract infection, making this the most likely diagnosis even with negative viral panels. 1 The key question is whether this represents simple acute bronchitis/URI versus something requiring further workup.

You need to specifically assess for signs of pneumonia: fever persisting >4 days, new focal chest signs on examination, dyspnea, tachypnea, or abnormal vital signs (respiratory rate ≥30/min, oxygen saturation ≤93%). 1 The European Respiratory Society notes that the absence of these findings makes pneumonia unlikely and chest X-ray unnecessary. 1

Duration Matters: Acute vs. Chronic Cough

• If symptoms have been present <3 weeks: This is acute bronchitis/URI, not chronic cough. 2, 1
• If symptoms persist >3 weeks (or >8 weeks by some definitions): You need to consider the differential diagnosis for chronic cough. 3, 4

Symptomatic Management for Acute Viral URI

First-line treatment includes: 1

• Analgesics (acetaminophen preferred over NSAIDs for viral illness) 5
• Throat lozenges for scratchy throat 1
• Nasal decongestant if nasal congestion present 1
• Inhaled ipratropium bromide as first-line cough suppressant (Grade A recommendation from American College of Chest Physicians) 1
• Honey for cough (if patient >1 year old) 2

Do NOT prescribe antibiotics - multiple randomized controlled trials consistently demonstrate that antibiotics do not reduce symptom duration or severity in uncomplicated acute bronchitis. 2, 1

Consider Alternative Diagnoses

Acute Asthma Masquerading as Bronchitis

The American College of Chest Physicians notes that approximately one-third of patients presenting with acute cough are misdiagnosed with acute bronchitis when they actually have acute asthma, particularly if there have been at least two similar episodes in the past 5 years. 1

Assess for: 1

• History of wheezing
• Prolonged expiration on exam
• History of smoking
• Symptoms of allergy
• Previous similar episodes

If ≥2 of these are present, consider spirometry/lung function testing and empiric trial of inhaled bronchodilators. 1, 4

Post-Infectious Cough Hypersensitivity

Cough may persist for up to 3 weeks after viral URI as post-infectious cough, which is normal and expected. 1 This represents temporary airway hyperresponsiveness following the infection. 6

If Symptoms Persist >3 Weeks: Chronic Cough Workup

The four most common causes accounting for >90% of chronic cough are: 3, 4

1. Upper airway cough syndrome (post-nasal drip) - Trial of first-generation antihistamine plus decongestant 4
2. Asthma - Confirm with spirometry and trial of inhaled bronchodilators/corticosteroids 4
3. Gastroesophageal reflux disease (GERD) - Empiric trial of proton pump inhibitor 4
4. Nonasthmatic eosinophilic bronchitis - Requires induced sputum analysis 3

Note: Up to 25% of patients have multiple contributing causes. 6

Red Flags Requiring Urgent Re-evaluation

The patient should return immediately if: 1, 5

• Respiratory rate ≥30/min 5
• Oxygen saturation ≤93% 5
• Development of dyspnea or significant shortness of breath 5
• High fever persisting >4 days 1
• Development of focal chest findings 1
• Symptoms worsen after initial improvement 1
• Altered mental status or severe headache 5
• Inability to maintain oral hydration 5

Expected Timeline and Follow-up

Symptoms typically peak at days 3-6 and should begin improving thereafter. Most uncomplicated viral URIs resolve within 5-7 days, though cough may persist for up to 3 weeks. 1

Schedule follow-up if: 1

• Symptoms persist >10 days without improvement
• No improvement after 3 weeks (transition to chronic cough evaluation)
• Any red flag symptoms develop

Common Pitfalls to Avoid

• Don't prescribe antibiotics for uncomplicated acute bronchitis - this is almost certainly viral and antibiotics provide no benefit. 2, 1
• Don't order chest X-ray unless pneumonia is suspected based on the specific criteria above (fever >4 days, focal findings, dyspnea, abnormal vitals). 1
• Don't miss asthma - consider this diagnosis if patient has had similar episodes before or has wheezing/prolonged expiration. 1
• Don't ignore the possibility of multiple causes if symptoms persist beyond 3 weeks. 6