What is the appropriate evaluation and treatment for a patient (Pt) with a cough, chest pain, and headache for 3 days?

Evaluation and Management of Acute Cough with Chest Pain and Headache

For a patient with cough, chest pain, and headache for 3 days, the primary goal is to rule out pneumonia through focused clinical assessment, and if pneumonia is excluded, provide symptomatic management without antibiotics as this represents acute bronchitis which is viral in over 90% of cases. 1

Immediate Clinical Assessment

Check vital signs and perform focused lung examination to identify patients requiring chest radiography. 1

Key findings that indicate need for chest X-ray include:

• Vital sign abnormalities: Heart rate ≥100 bpm, respiratory rate ≥24 breaths/min, or temperature ≥38°C 1, 2
• Asymmetrical lung sounds or focal consolidation on auscultation 1
• Absence of all vital sign abnormalities AND normal lung examination substantially reduces the likelihood of pneumonia, making chest radiography unnecessary 1, 2

Rule Out Pneumonia

In healthy, nonelderly adults with normal vital signs and symmetrical lung sounds, pneumonia is uncommon and chest radiography is usually not indicated. 1

If pneumonia is suspected based on abnormal findings:

• Order chest radiography to confirm diagnosis 1
• Consider measuring C-reactive protein (CRP) if available, as CRP ≥30 mg/L combined with fever, chest pain, and dyspnea increases likelihood of pneumonia 1
• If pneumonia is confirmed radiographically, initiate appropriate antibiotic therapy per local guidelines 1

Consider Influenza

If influenza is suspected (during flu season or known outbreak), initiate antiviral treatment with oseltamivir within 48 hours of symptom onset, as this may decrease antibiotic usage, hospitalization, and improve outcomes. 1, 3

Common influenza features include:

• Acute onset fever with cough 1
• Myalgia and headache 1
• Seasonal timing 1

Rule Out Pertussis

If the patient has paroxysmal coughing fits, post-tussive vomiting, or inspiratory whooping sound, treat immediately for pertussis with azithromycin 500 mg once daily for 3-5 days without waiting for laboratory confirmation. 4, 5, 6

Management of Uncomplicated Acute Bronchitis

If pneumonia and pertussis are excluded, this represents acute bronchitis which requires symptomatic management only—do NOT prescribe antibiotics. 1, 5

The evidence is clear:

• Acute bronchitis is viral in >90% of cases and self-limited 5
• Routine antibiotic treatment is not recommended regardless of cough duration (up to 3 weeks) 1
• Multiple randomized controlled trials showed no significant difference in cough duration, purulent sputum resolution, or days of missed work when comparing antibiotics to placebo 5

Symptomatic Treatment Options

• Antitussive agents (such as dextromethorphan) can be offered for short-term symptomatic relief of coughing 5
• Analgesics (acetaminophen or NSAIDs) for chest pain and headache (general medical knowledge)
• Adequate hydration and rest (general medical knowledge)

Common Pitfalls to Avoid

• Do not prescribe antibiotics based on sputum color alone, as purulent sputum in acute bronchitis does not indicate bacterial infection 5
• Do not assume chest pain equals cardiac disease in this context—musculoskeletal chest pain from coughing is common in acute bronchitis (general medical knowledge)
• Do not miss pertussis—ask specifically about paroxysms and post-tussive vomiting 4, 5

When to Escalate or Follow Up

Arrange follow-up if:

• Cough persists beyond 3 weeks, at which point chest radiography may be warranted and treatment for post-infectious cough should be considered 1, 4
• Fever >39.5°C, hemoptysis, constitutional symptoms, respiratory distress, or hypoxemia develop, requiring chest X-ray to exclude pneumonia 5
• Symptoms worsen or new concerning features develop 1