What is the assessment and treatment approach for an 18-year-old male presenting with cough with wheeze, hematemesis (coughing up vomit), headache, and random vomiting?

Assessment and Management of Cough with Wheeze, Vomiting, and Headache in an 18-Year-Old Male

This presentation requires immediate assessment for serious conditions including pneumonia, pulmonary embolism, or intracranial pathology, followed by systematic evaluation for the most common causes: asthma, post-nasal drip syndrome, and gastroesophageal reflux disease. 1

Immediate Red Flag Assessment

First, determine if this requires urgent intervention by checking for:

• Respiratory distress, abnormal vital signs (tachypnea, tachycardia, fever, hypoxia), or systemic illness appearance 1
• Hematemesis vs. hemoptysis clarification - "coughing up vomit" needs clarification; true hemoptysis (blood) is a red flag requiring immediate chest X-ray, while vomiting from forceful coughing is less concerning 2, 1
• Headache characteristics - sudden onset, severe intensity, or associated with neck stiffness could indicate serious intracranial pathology 3
• Weight loss, night sweats, or history of immunosuppression - these high-risk features mandate chest X-ray 1

If any red flags are present, obtain chest X-ray immediately and consider hospitalization 1, 4.

Focused History Elements

Obtain specific details about:

• Medication review - particularly ACE inhibitors which cause chronic cough 2
• Smoking status and environmental exposures 2, 1
• Timing and triggers - cough worse at night, with exercise, cold air, or laughing suggests asthma; cough with meals or lying down suggests GERD 2
• Associated symptoms - nasal congestion/post-nasal drip, heartburn, throat clearing 2, 5
• Vomiting pattern - is it from forceful coughing (common with severe cough) or independent episodes? 2
• Duration - acute (<3 weeks), subacute (3-8 weeks), or chronic (>8 weeks) guides differential 2, 6

Physical Examination Priorities

Perform targeted examination focusing on:

• Vital signs - fever, tachypnea, oxygen saturation, blood pressure 1
• Lung auscultation - wheezing, prolonged expiratory phase, crackles, or focal findings 2, 1
• Upper airway - nasal mucosal swelling, secretions, polyps suggesting post-nasal drip 2
• Chest wall - use of accessory muscles, hyperexpansion suggesting air trapping 2
• Skin - atopic dermatitis or eczema suggesting allergic diathesis 2

Diagnostic Testing Strategy

If examination is normal and no red flags:

Spirometry is essential to objectively assess for airflow obstruction and reversibility, as history and physical examination alone are unreliable 2. Peak flow meters are inadequate for diagnosis 2.

If spirometry shows obstruction with reversibility:

• Diagnose asthma and initiate treatment with inhaled bronchodilators and corticosteroids 2, 4

If spirometry is normal but asthma suspected:

• Consider methacholine challenge testing to detect airway hyperresponsiveness 2

If initial evaluation is unrevealing:

• Empiric trial approach - treat sequentially for the most common causes since cough may be the only manifestation 2, 5:
  • Post-nasal drip: first-generation antihistamine/decongestant combination 1, 6
  • Asthma: inhaled corticosteroids and bronchodilators even with normal spirometry 2
  • GERD: proton pump inhibitor therapy for 8-12 weeks 2

Initial Treatment Recommendations

For presumed viral upper respiratory infection with post-viral cough:

• First-generation antihistamine plus decongestant combination to address post-nasal drip 1, 6
• Naproxen which may favorably affect cough 1, 6
• Honey for cough suppression (proven effective) 1, 6
• Adequate hydration and warm fluids 6
• Acetaminophen for headache 1

For suspected asthma exacerbation:

• Inhaled short-acting beta-agonists (albuterol) for immediate bronchodilation 4
• Systemic corticosteroids if moderate-severe exacerbation 4
• Initiate or optimize inhaled corticosteroid controller therapy 2

Critical Management Pitfalls

• Do not prescribe antibiotics unless there is clinical evidence of bacterial pneumonia (fever, focal consolidation, infiltrate on X-ray) - colored sputum alone does not indicate bacterial infection 6, 4
• Do not rely on peak flow meters for diagnosis - they are monitoring tools, not diagnostic 2
• Do not assume normal examination rules out asthma - findings may be absent between episodes 2
• Recognize that multiple causes often coexist - sequential and additive therapy may be necessary 2, 5

Follow-Up and Safety Net Instructions

Return immediately or call if:

• Breathing difficulty develops 1, 4
• True hemoptysis (blood) occurs 4
• Fever develops or persists 4
• Severe headache with neck stiffness develops 3

Schedule follow-up if:

• Cough persists beyond 3 weeks despite treatment (transitions to subacute cough requiring systematic evaluation) 6, 4
• Cough persists beyond 8 weeks (meets criteria for chronic cough requiring comprehensive workup including possible HRCT and bronchoscopy) 2, 6
• No improvement after 7-10 days of appropriate empiric therapy 1

Advanced Evaluation if Initial Approach Fails

If symptoms persist despite adequate trials of therapy:

• HRCT scan to evaluate for bronchiectasis or interstitial lung disease 2
• 24-hour esophageal pH monitoring if GERD suspected but not responding to PPI therapy 2
• Bronchoscopy to evaluate for occult airway disease, eosinophilic bronchitis, or endobronchial lesions 2
• Consider referral to cough specialist before labeling as unexplained cough 2