What is the appropriate treatment for a patient with a dry cough, running nose, and low-grade fever, considering potential underlying conditions such as hypertension, diabetes, or impaired renal function?

Treatment for Dry Cough, Running Nose, and Low-Grade Fever

For a patient presenting with dry cough, running nose, and low-grade fever—consistent with a viral upper respiratory tract infection—first-line treatment should be a first-generation antihistamine/decongestant combination (such as brompheniramine with pseudoephedrine) plus an NSAID like naproxen 500 mg twice daily or acetaminophen for fever relief. 1, 2

Initial Assessment and Diagnosis

Before initiating treatment, confirm this is an uncomplicated viral upper respiratory infection by verifying:

• Absence of pneumonia indicators: No focal chest signs, tachypnea (>30 breaths/min), hypoxemia (SpO2 <90%), or dyspnea 3
• Fever pattern: Low-grade fever without prolonged duration (>4 days suggests bacterial infection) 3
• No red flags: Absence of hemoptysis, severe breathlessness, or worsening symptoms after initial improvement 3, 2

The presence of green or colored sputum does not indicate bacterial infection—most viral infections produce colored phlegm 3, 2. This is a common cold/viral upper respiratory infection, not acute bronchitis (which is overdiagnosed and leads to inappropriate antibiotic use in 65-80% of cases) 3, 1.

Recommended First-Line Pharmacological Treatment

For Nasal Congestion and Cough

Prescribe a first-generation antihistamine/decongestant combination as the primary treatment:

• Brompheniramine or dexbrompheniramine with pseudoephedrine 3, 1
• This provides substantial benefit for nasal congestion, postnasal drainage, sneezing, and cough 1

For Cough Suppression

Add dextromethorphan for bothersome dry cough:

• Effective dose: 60 mg for maximum cough reflex suppression 3, 4, 5
• Standard over-the-counter doses are often subtherapeutic 4
• Codeine is not recommended due to side effects without superior efficacy 3, 4

For Fever and Malaise

NSAIDs or acetaminophen:

• Naproxen 500 mg twice daily specifically reduces cough associated with the common cold 3, 1
• Alternatively, acetaminophen or ibuprofen for fever, headache, and myalgia 1

Special Considerations for Comorbidities

Hypertension

• Use decongestants cautiously as pseudoephedrine may elevate blood pressure 1
• Monitor blood pressure during treatment
• Consider avoiding decongestants if hypertension is poorly controlled

Diabetes

• Continue current insulin regimen without modification 1
• Monitor blood glucose more frequently during acute illness 1
• Pseudoephedrine may elevate blood glucose—use cautiously 1

Impaired Renal Function

• Avoid or reduce NSAID doses due to risk of further renal impairment 3
• Acetaminophen is safer for fever control in renal impairment
• Many medications are renally excreted—adjust doses accordingly 4

Treatments to Explicitly Avoid

Do NOT prescribe:

• Antibiotics: Provide no benefit for uncomplicated viral infections and contribute to resistance 3, 1, 2
• Newer-generation nonsedating antihistamines (loratadine, cetirizine, fexofenadine): Completely ineffective for common cold symptoms 3, 1
• Expectorants, mucolytics, or bronchodilators: Not effective in acute viral LRTI in primary care 3

Adjunctive Non-Pharmacological Measures

• Home remedies: Honey and lemon may provide symptomatic relief 3, 2
• Hand hygiene: Emphasize frequent handwashing to prevent transmission 2
• Smoking cessation: If applicable, as smoking worsens respiratory symptoms 2

Expected Clinical Course and When to Reassess

Typical timeline:

• Symptoms should improve within 3 days of starting treatment 3
• Cough may persist for up to 3 weeks even with appropriate treatment 3, 2
• Most patients will have resolution within 1-2 weeks 3

Instruct the patient to return if:

• Fever persists beyond 48 hours or exceeds 4 days total 3, 1
• Cough worsens after initial improvement (biphasic course suggests bacterial superinfection) 3, 1
• Development of dyspnea, tachypnea, or hypoxemia 1, 2
• Hemoptysis occurs 2, 4
• Symptoms persist beyond 3 weeks 3, 2

Common Pitfalls to Avoid

• Do not diagnose acute bronchitis unless the common cold has been definitively excluded—this leads to inappropriate antibiotic prescribing 3, 1
• Do not prescribe antibiotics based on colored sputum alone—this is not indicative of bacterial infection 2
• Do not use combination over-the-counter cold medications unless they contain first-generation antihistamine/decongestant ingredients 3
• In elderly patients (>75 years), consider cardiac failure as a potential cause of cough, especially with orthopnea or history of myocardial infarction 3, 4