What is the appropriate evaluation and management for a patient with a persistent sore throat and chronic cough who has had multiple urgent‑care visits?

Chronic Sore Throat and Cough with Recurrent Urgent Care Visits

This patient requires a systematic algorithmic evaluation for chronic cough starting with medication review, chest radiography, and sequential empiric treatment for the three most common causes: upper airway cough syndrome (UACS), asthma, and gastroesophageal reflux disease (GERD), because multiple causes frequently coexist and must be addressed in additive steps. 1

Immediate Assessment and Red Flag Exclusion

Before proceeding with chronic cough evaluation, you must first exclude serious conditions:

• Check vital signs immediately: Heart rate >100 bpm, respiratory rate >24 breaths/min, or temperature >38°C warrant urgent chest radiography to rule out pneumonia 2
• Measure oxygen saturation: SpO₂ <90% indicates hypoxic respiratory failure requiring immediate oxygen therapy 3
• Obtain chest X-ray to exclude pneumonia, malignancy, tuberculosis, interstitial lung disease, and structural abnormalities 1, 2
• Screen for tuberculosis risk factors: Weight loss, night sweats, or high TB prevalence area require sputum cultures for acid-fast bacilli even with negative PPD 4, 2

Critical Medication Review

Stop ACE inhibitors immediately if the patient is taking one, regardless of when the cough started, as this is the only uniformly effective treatment for ACE inhibitor-induced cough 1. The cough typically resolves within 1-4 weeks but may take up to 3 months in some patients 1. This single intervention can resolve the entire problem and must be addressed first 1.

Sequential Algorithmic Approach for Chronic Cough

The ACCP guidelines provide clear evidence that chronic cough requires sequential and additive empiric treatment because more than one cause is present in the majority of cases 1. Treating only one condition and stopping is a common pitfall 3.

Step 1: Treat Upper Airway Cough Syndrome (UACS) First

• Begin with a first-generation oral antihistamine/decongestant combination as initial empiric therapy 1
• Treat for 4-6 weeks before concluding UACS is not contributing 5
• UACS (formerly postnasal drip) accounts for >80% of chronic cough cases when combined with asthma and GERD 6

Step 2: Evaluate and Treat Asthma

If cough persists after UACS treatment:

• Obtain spirometry with bronchodilator testing to assess for reversible airflow obstruction 3, 5
• Measure exhaled nitric oxide and blood eosinophil count to identify eosinophilic inflammation 5
• If spirometry is normal, perform bronchoprovocation challenge (BPC) to diagnose cough-variant asthma, as medical history alone is unreliable 1
• If BPC is unavailable, initiate an empiric trial of inhaled corticosteroids plus bronchodilators 1
• Consider oral leukotriene inhibitors as part of combination therapy 1

Step 3: Add Treatment for Nonasthmatic Eosinophilic Bronchitis (NAEB)

If cough persists despite UACS and asthma treatment:

• Obtain induced sputum for eosinophil count if available 1
• If testing unavailable, proceed with empiric trial of inhaled or oral corticosteroids 1

Step 4: Treat Gastroesophageal Reflux Disease (GERD)

When cough responds only partially or not at all to respiratory treatments:

• Institute empiric GERD therapy with proton pump inhibitors 1
• GERD treatment should be added even without typical reflux symptoms, as silent reflux commonly causes chronic cough 1

Additional Diagnostic Considerations

When to Obtain High-Resolution CT (HRCT)

• Suspect bronchiectasis if the patient produces >30 mL of sputum daily with recurrent hemoptysis and prior pneumonia episodes 2
• HRCT showing airway dilation is the definitive test for bronchiectasis 2
• Physical examination findings (crackles, rhonchi) are unreliable and may be absent 2

Smoking Cessation

• All patients who smoke must be counseled and assisted with smoking cessation as an essential component of chronic cough management 1

Measuring Treatment Success

• Use validated cough severity and quality-of-life instruments to objectively track improvement 5, 7
• Document both frequency and severity of coughing episodes 7
• Treatment trials should last 4-6 weeks before concluding a specific cause is not contributing 5

Management of Refractory Cough

If the systematic approach fails after 4-6 weeks of sequential treatment:

• Low-dose morphine is the preferred agent for refractory chronic cough 5
• Alternative options include gabapentin or pregabalin 5
• Newer P2X3 receptor antagonists (gefapixant, camlipixant) are under investigation 5

Critical Pitfalls to Avoid

• Never assume a single cause: Multiple etiologies coexist in most chronic cough patients, requiring additive rather than sequential-only treatment 1, 3
• Never rely on history alone to diagnose or exclude asthma: Objective testing with spirometry or BPC is essential 1
• Never delay chest imaging in patients with constitutional symptoms (weight loss, fever, night sweats) even if initial evaluation seems benign 4, 2
• Never diagnose "habit cough" or "psychogenic cough" until after extensive evidence-based evaluation and failure of specific therapies 1

Why Recurrent Urgent Care Visits Fail

The fragmented urgent care approach typically treats acute exacerbations without addressing underlying causes systematically 7. Only 37% of chronic cough patients receive systematic dedicated workup in community settings 7. This patient needs comprehensive sequential evaluation and treatment, not episodic symptom management 1.