In a 44‑year‑old woman with hypertension treated with telmisartan, who had a two‑month productive cough that resolved and now presents with morning‑predominant fever, chills, glabellar headache and watery nasal discharge, what is the most likely diagnosis and what are the appropriate next steps for work‑up and management?

Most Likely Diagnosis and Next Steps

This patient most likely has post-infectious cough (also called post-viral cough or upper airway cough syndrome) following two sequential viral upper respiratory infections, and the appropriate next step is to initiate inhaled ipratropium bromide 2-3 puffs four times daily as first-line therapy, combined with supportive care. 1

Clinical Reasoning for Post-Infectious Cough

The clinical timeline strongly supports post-infectious cough rather than bacterial infection:

• Initial illness 2 months ago: Productive cough with fever 38-39°C, body malaise, and diarrhea that completely resolved within 5 days with symptomatic treatment alone suggests viral upper respiratory infection 2
• Second illness 6 days ago: Morning-predominant fever 38.2°C with glabellar headache and watery nasal discharge represents a new viral URI episode 3
• Current presentation: The cough persisting after the second viral illness, now in the subacute phase (less than 8 weeks), fits the classic pattern of post-infectious cough 1, 4

Key features excluding bacterial sinusitis or pneumonia include: normal vital signs except mild hypertension (which is her baseline), normal lung examination, no lymphadenopathy on examination despite patient's report, resolution of fever with decongestants, and watery (not purulent) nasal discharge 1. The absence of persistent high fever, purulent discharge beyond 10 days, or severe unilateral facial pain argues strongly against acute bacterial rhinosinusitis 3.

Why Antibiotics Are Explicitly Contraindicated

Antibiotics have absolutely no role in post-infectious cough and should never be prescribed for this indication. 1, 4 The pathophysiology involves ongoing airway inflammation, bronchial hyperresponsiveness, mucus hypersecretion, and impaired mucociliary clearance—not bacterial infection 4. Prescribing antibiotics provides no benefit, contributes to antimicrobial resistance, and causes unnecessary adverse effects 1.

The diagnosis of acute bacterial sinusitis cannot be made accurately during the first week of viral symptoms, and even sinus imaging abnormalities (present in 87% of common colds) resolve spontaneously without antibiotics in 79% of cases 2.

Evidence-Based Treatment Algorithm

First-Line Therapy (Initiate Now)

Inhaled ipratropium bromide 2-3 puffs (17-34 mcg per puff) four times daily has the strongest evidence for attenuating post-infectious cough, with clinical response expected within 1-2 weeks 1, 4. This anticholinergic agent reduces mucus hypersecretion and airway inflammation 1.

Supportive care measures to recommend concurrently:

• Guaifenesin 200-400 mg every 4 hours (up to 6 times daily) to help loosen phlegm 1
• Adequate hydration, warm facial packs, steamy showers 3
• Sleeping with head of bed elevated 3
• Honey and lemon for symptomatic relief (avoid in infants under 1 year) 4

Second-Line Options (If No Improvement After 1-2 Weeks)

Add first-generation antihistamine-decongestant combination (e.g., brompheniramine/pseudoephedrine or chlorpheniramine/phenylephrine) to address upper airway cough syndrome component, with improvement typically within days to 1-2 weeks 2, 1. Newer non-sedating antihistamines like loratadine are ineffective and should not be used 2, 3.

Consider intranasal corticosteroid spray (fluticasone or mometasone) for persistent upper airway inflammation 1.

Third-Line (If Quality of Life Significantly Impaired After 2-3 Weeks)

Inhaled corticosteroids (fluticasone 220 mcg or budesonide 360 mcg twice daily) may be added if cough adversely affects quality of life despite ipratropium, allowing up to 8 weeks for full response 1, 4. This is particularly relevant given her history of possible myocardial bridging, as severe coughing paroxysms could theoretically stress coronary circulation.

Oral prednisone 30-40 mg daily for 5-10 days should be reserved only for severe paroxysms that significantly impair quality of life, and only after ruling out upper airway cough syndrome, asthma, and GERD 1, 4.

Critical Timeline for Re-evaluation

If cough persists beyond 8 weeks, it must be reclassified as chronic cough and systematically evaluated for:

• Upper airway cough syndrome (UACS)
• Asthma or cough-variant asthma
• Gastroesophageal reflux disease (GERD)

At that point, obtain chest radiograph and consider spirometry 1, 4.

Red Flags Requiring Immediate Re-assessment

Instruct the patient to return immediately if:

• Fever redevelops or persists beyond 3-5 days 3, 4
• Hemoptysis occurs 1, 4
• Symptoms worsen after initial improvement (suggests bacterial superinfection) 3
• Severe headache with neck stiffness, vision changes, or mental status changes 3
• Purulent nasal discharge develops and persists beyond 10 days without improvement (would then meet criteria for bacterial sinusitis requiring amoxicillin-clavulanate) 3

Special Consideration: Telmisartan and Cough

Telmisartan is an angiotensin II receptor blocker (ARB), not an ACE inhibitor, and is significantly less likely to cause persistent dry cough compared to ACE inhibitors like lisinopril 5, 6. Her current cough is productive and temporally related to viral infections, making drug-induced cough extremely unlikely. No medication change is needed. 1

Common Pitfalls to Avoid

• Do not assume green or yellow sputum indicates bacterial infection—colored phlegm is common in viral infections due to white blood cells and desquamated epithelium 3, 7
• Do not obtain sinus imaging during the first week of symptoms, as abnormalities are present in 87% of viral URIs and lack specificity for bacterial infection 2
• Do not prescribe antibiotics based on symptom duration alone without meeting all three criteria: symptoms >10 days without improvement, purulent discharge, and facial pain/pressure 3
• Do not overlook underlying asthma—if cough persists despite UACS treatment, consider bronchodilator trial and spirometry, especially given the morning-predominant symptoms 3
• Do not continue antitussive therapy beyond 3 weeks without reassessment 4

Addressing the Reported Lymph Nodes

The physical examination documented no lymph nodes palpated in the reported areas, which is reassuring. Transient lymphadenopathy can occur with viral infections but typically resolves. If lymphadenopathy were actually present and persistent beyond 4-6 weeks, or if constitutional symptoms (fever, night sweats, weight loss) develop, further workup including chest radiograph would be warranted 1.

Blood Pressure Management

Her blood pressure of 140/90 mmHg represents inadequate control on telmisartan 40 mg monotherapy. Once the acute respiratory symptoms resolve, consider uptitrating telmisartan to 80 mg daily or adding hydrochlorothiazide 12.5 mg, as combination therapy provides significantly greater blood pressure reduction than monotherapy 8, 6. However, this is not the immediate priority given her acute presentation.