For a 32‑year‑old man with hypertension treated with Twynsta (telmisartan/amlodipine) and bisoprolol, and bipolar disorder treated with aripiprazole, who presents with a 4‑day history of cough, generalized weakness, dry heaving, neck pain and chills but no fever, chest pain, dyspnea, palpitations, or other red‑flag symptoms, what is the appropriate emergency department assessment and management plan?

Emergency Department Assessment and Plan

This is a 4-day subacute post-infectious cough following an upper respiratory infection in a stable, immunocompetent patient who requires supportive care and reassurance, not antibiotics or extensive workup at this time. 1, 2

Clinical Assessment

Diagnosis: Post-Infectious Cough (Subacute Phase)

The clinical presentation—cough, generalized weakness, dry heaving, neck pain, and chills beginning 4 days ago without fever, dyspnea, chest pain, or focal lung findings—is consistent with post-infectious cough in the acute-to-subacute phase (< 3 weeks duration). 1, 2 The absence of fever, tachypnea, focal crackles, or systemic toxicity makes bacterial pneumonia highly unlikely. 3, 1

Key supporting features:

• No fever documented despite subjective chills, which commonly accompany viral upper respiratory infections without indicating bacterial superinfection 3, 2
• Clear breath sounds bilaterally with no focal consolidation, making pneumonia probability < 10% 3, 1
• Stable vital signs with GCS 15, pink conjunctivae, and no respiratory distress 3, 1
• Dry heaving and neck pain are consistent with paroxysmal cough-induced musculoskeletal strain and post-tussive emesis, not red-flag symptoms 2

Critical Exclusions Completed

• Pneumonia ruled out clinically: No fever > 4 days, no focal chest signs, no dyspnea, no tachypnea 3, 1
• No indication for chest radiograph at this visit: The American Thoracic Society recommends chest X-ray for chronic cough (> 8 weeks) or when red-flag features are present; this patient has neither 3, 1
• Medication-induced cough excluded: Patient is not on an ACE inhibitor; his antihypertensive regimen (telmisartan/amlodipine plus bisoprolol) does not cause cough 3, 1

Emergency Department Management Plan

1. Reassurance and Education

Provide explicit reassurance that this is a self-limited viral illness requiring 10–14 days for resolution from today's visit. 3, 2 Explain that the cough reflects ongoing airway inflammation and hyperresponsiveness—not ongoing infection—and that antibiotics provide no benefit and contribute to resistance. 3, 2

Set realistic expectations: Most patients experience complete resolution within 3–8 weeks from symptom onset; cough at day 4 is expected and does not indicate treatment failure. 1, 2

2. Symptomatic Treatment (First-Line)

Prescribe supportive care with guaifenesin 200–400 mg every 4 hours (maximum 6 times daily) to help loosen secretions. 2 This is FDA-approved for productive cough and aligns with the self-limited nature of his illness. 2

Recommend honey and lemon for symptomatic relief through central modulation of the cough reflex. 2

Advise adequate hydration, rest, warm facial packs, steamy showers, and sleeping with the head of bed elevated. 2

3. Medications to AVOID

Do NOT prescribe antibiotics. The American College of Chest Physicians explicitly contraindicates antibiotics for post-infectious cough; they provide no clinical benefit, contribute to antimicrobial resistance, and add adverse-effect risk. 3, 2

Do NOT prescribe prednisone at this stage. Oral corticosteroids are reserved for severe paroxysms that significantly impair quality of life after 1–2 weeks of first-line therapy and only after ruling out other causes. 1, 2

4. Continuation of Maintenance Medications

Continue all current medications without modification:

• Twynsta (telmisartan/amlodipine): Well-tolerated combination for hypertension; does not cause cough 4, 5, 6
• Bisoprolol: Stable beta-blocker therapy; no contraindication in this clinical scenario 1
• Aripiprazole: Continue for bipolar disorder management; no interaction with respiratory symptoms 1

5. Safety-Net Instructions and Follow-Up

Instruct the patient to return immediately if any of the following develop:

• Fever (temperature > 38°C) 2
• Hemoptysis (any blood in sputum) 1, 2
• Worsening dyspnea or chest pain 1, 2
• Inability to tolerate oral intake due to vomiting 2

Arrange outpatient follow-up in 1–2 weeks if symptoms persist or worsen despite supportive care. At that visit, consider escalation to inhaled ipratropium bromide (2–3 puffs four times daily), which has the strongest evidence for attenuating post-infectious cough. 1, 2

If cough persists beyond 8 weeks, reclassify as chronic cough and initiate systematic evaluation for upper airway cough syndrome (UACS), asthma, and gastroesophageal reflux disease (GERD). 3, 1

Common Pitfalls to Avoid

Do not diagnose "acute bronchitis" and prescribe antibiotics. This leads to inappropriate antibiotic use; the American Academy of Family Physicians states that routine antibiotic treatment of uncomplicated acute bronchitis is not recommended regardless of cough duration. 3

Do not assume purulent sputum (if it develops) indicates bacterial infection. Colored phlegm commonly occurs with viral infections due to neutrophil influx and does not warrant antibiotics. 2

Do not order a chest X-ray in the ED for this stable patient with a 4-day cough and normal examination. Chest radiography is indicated for chronic cough (> 8 weeks), red-flag symptoms, or clinical suspicion of pneumonia—none of which are present. 3, 1

Disposition

Discharge home with symptomatic treatment, safety-net instructions, and outpatient follow-up as needed. 2