Assessment and Plan
Primary Assessment: Post-Infectious Cough with Left-Sided Pneumonia
This patient requires immediate chest radiography and empiric antibiotic therapy for community-acquired pneumonia, followed by treatment of post-infectious cough once bacterial infection is controlled.
The 3-day history of fever (now resolved), dry cough with post-tussive vomiting, and new focal crackles in the left lung strongly suggest community-acquired pneumonia rather than simple viral upper respiratory infection. The presence of focal auscultatory abnormalities raises the probability of pneumonia to approximately 39% 1. The combination of productive cough lasting >3 days, new focal chest signs (left-sided crackles), and recent fever meets diagnostic criteria requiring radiographic confirmation 2.
Immediate Diagnostic Workup
- Chest X-ray (PA and lateral) – mandatory to confirm pneumonia versus post-infectious bronchitis 2, 3
- Complete blood count with differential – assess for leukocytosis and lymphopenia patterns 1
- Basic metabolic panel – evaluate electrolytes given vomiting history
- Oxygen saturation monitoring – current SpO2 94% on room air is borderline and requires trending 1
Antibiotic Therapy (if pneumonia confirmed)
First-line regimen: Amoxicillin 1000 mg PO three times daily for 5-7 days 2. Tetracycline is an alternative first-line option 2.
Alternative if β-lactam allergy: Azithromycin 500 mg PO day 1, then 250 mg daily for days 2-5, or clarithromycin 500 mg PO twice daily for 7 days 2. These macrolides are appropriate only in regions with low pneumococcal resistance 2.
Critical Rule-Out: Pertussis
The post-tussive vomiting and 3-day cough history warrant consideration of pertussis, which should be suspected when cough lasts ≥2 weeks with paroxysms, post-tussive vomiting, or inspiratory whoop 2, 3. If cough persists beyond 2 weeks with continued paroxysmal features, obtain nasopharyngeal PCR for Bordetella pertussis and initiate azithromycin 500 mg daily for 5 days with 5-day isolation 2.
Secondary Assessment: Rotatory Dizziness
The rotatory dizziness in the context of recent viral illness most likely represents vestibular neuritis or benign paroxysmal positional vertigo (BPPV) triggered by the upper respiratory infection. The absence of focal neurological deficits, normal cranial nerve examination, and lack of nystagmus on current exam make central causes (posterior circulation stroke, cerebellar pathology) less likely.
Diagnostic Maneuvers
- Dix-Hallpike maneuver – perform bilaterally to assess for BPPV
- Head impulse test – evaluate vestibulo-ocular reflex if peripheral vertigo suspected
- Gait assessment – already documented as normal cerebellar function, but observe for ataxia
Management of Peripheral Vertigo
- Meclizine 25 mg PO three times daily as needed for acute vertigo symptoms
- Vestibular rehabilitation exercises if symptoms persist beyond 48-72 hours
- Safety precautions: avoid driving, use assistive device if gait instability develops
Red flags requiring urgent imaging (MRI brain): new-onset severe headache, diplopia, dysarthria, limb ataxia, or Horner syndrome [@general medicine knowledge@].
Tertiary Assessment: Difficulty Speaking
The 1-day history of difficulty speaking requires clarification of whether this represents:
- Dysphonia (voice quality change from laryngitis/vocal cord inflammation)
- Dysarthria (motor speech disorder)
- Aphasia (language disorder suggesting CNS pathology)
Given the concurrent sore throat and recent URI, acute laryngitis is most probable. However, the neurological examination documented normal cranial nerve XII (tongue midline), normal facial symmetry (CN VII), and normal palatal movement (CN IX, X), making structural neurological causes unlikely.
Immediate Assessment
- Direct laryngoscopy – visualize vocal cords for erythema, edema, or nodules
- Detailed speech assessment – distinguish dysphonia from dysarthria/aphasia
- If true dysarthria or aphasia: urgent non-contrast CT head followed by MRI brain with diffusion-weighted imaging to exclude stroke
Management of Presumed Laryngitis
- Voice rest – minimize speaking for 48-72 hours
- Humidification – steam inhalation or cool-mist humidifier
- Adequate hydration – 2-3 liters daily
- Avoid irritants – no whispering (increases vocal cord strain)
Post-Infectious Cough Management (After Pneumonia Treatment)
Once pneumonia is treated and chest X-ray clears, the patient will likely experience post-infectious cough lasting 3-8 weeks 2. This is driven by ongoing airway inflammation and bronchial hyperresponsiveness, not persistent infection 2.
First-Line Therapy (Weeks 1-3)
Inhaled ipratropium bromide 2-3 puffs (17-34 mcg per puff) four times daily – this has the strongest evidence for attenuating post-infectious cough, with clinical response expected within 1-2 weeks 2, 3.
Supportive measures:
- Guaifenesin 200-400 mg PO every 4 hours (maximum 6 times daily) to thin secretions 2
- Honey and lemon for symptomatic relief 2
- Adequate hydration and rest 2
Second-Line Therapy (If Cough Persists Beyond 3 Weeks)
Add inhaled corticosteroid if quality of life remains impaired despite ipratropium:
- Fluticasone 220 mcg inhaled twice daily, OR
- Budesonide 360 mcg inhaled twice daily 2
Allow up to 8 weeks for full therapeutic response 2.
Third-Line Therapy (Severe Paroxysms Only)
Oral prednisone 30-40 mg daily for 5-10 days – reserved exclusively for severe, quality-of-life-impairing cough after ruling out upper airway cough syndrome, asthma, and GERD 2, 3.
What NOT to Do
Antibiotics are explicitly contraindicated for post-infectious cough unless there is documented bacterial sinusitis or confirmed pertussis 2, 3. They provide no benefit, contribute to antimicrobial resistance, and cause unnecessary adverse effects 2.
Cardiovascular Risk Management
Hypertension
The patient stopped amlodipine 2 years ago but presents with BP 133/75 mmHg. While not acutely hypertensive, her history of hypertension and current dyslipidemia place her at elevated cardiovascular risk.
Restart antihypertensive therapy:
- Amlodipine 5 mg PO daily – resume previous effective therapy 4, 5
- Titrate to 10 mg daily if BP remains >130/80 mmHg at 2-week follow-up
- Target BP <130/80 mmHg given dyslipidemia and cardiovascular risk factors
Dyslipidemia
Continue atorvastatin at current dose. Consider checking fasting lipid panel at follow-up to ensure LDL-C goal achievement (<100 mg/dL for moderate risk, <70 mg/dL if high risk) 4, 5.
Follow-Up Plan
Immediate (24-48 hours)
- Review chest X-ray results
- Reassess respiratory status and oxygen saturation
- Confirm antibiotic tolerance if pneumonia diagnosed
- Re-evaluate speech difficulty and vertigo symptoms
Short-term (1 week)
- Repeat chest X-ray if initial showed pneumonia (to document improvement)
- Assess cough trajectory and initiate ipratropium if persistent
- Blood pressure recheck after restarting amlodipine
Medium-term (3-4 weeks)
- If cough persists, advance to inhaled corticosteroids
- Consider pertussis testing if paroxysmal features develop
- Fasting lipid panel
Long-term (8 weeks)
If cough persists beyond 8 weeks, reclassify as chronic cough and systematically evaluate for 2:
- Upper airway cough syndrome (UACS) – treat with first-generation antihistamine/decongestant combination plus intranasal corticosteroid
- Asthma – perform spirometry with bronchodilator response; if normal but suspicion high, bronchoprovocation challenge
- GERD – initiate high-dose PPI (omeprazole 40 mg twice daily) with dietary modifications
Red Flags Requiring Immediate Re-Evaluation
- Fever recurrence or development of new fever
- Hemoptysis (any amount)
- Worsening dyspnea or oxygen desaturation <90%
- New neurological symptoms (true aphasia, limb weakness, severe headache)
- Chest pain or palpitations
- Weight loss or night sweats