Approach to a Patient with Fever and Cough

Initial Assessment

Classify cough duration as acute (<3 weeks), subacute (3-8 weeks), or chronic (>8 weeks) to guide your diagnostic approach 1, 2, 3
Assess for signs of respiratory distress including increased respiratory rate, grunting, intercostal recession, breathlessness with chest signs, cyanosis, altered consciousness, or complicated seizures 3
Evaluate for risk factors for complications including comorbidities, frailty, impaired immunity, or reduced ability to cough and clear secretions 3
Implement respiratory hygiene/cough etiquette measures immediately, including providing tissues for the patient to contain respiratory secretions, ensuring hand hygiene after contact with respiratory secretions, considering providing a mask for the patient if tolerated, and maintaining at least 3 feet of separation between symptomatic patients and others in waiting areas 4

Obtain focused history including duration and characteristics of cough (paroxysmal, productive) 1, 2
Ask about presence of posttussive vomiting or inspiratory whooping 5
Inquire about presence or absence of fever 5, 3
Obtain recent travel history or exposure to infectious individuals 6
Ask about medication history, particularly ACE inhibitors 3
Inquire about smoking status 3

Obtain a chest radiograph if pneumonia is suspected based on clinical findings such as tachypnea, tachycardia, dyspnea, or abnormal lung findings 3, 7
Perform pulse oximetry to assess for hypoxemia 7
Consider microbiological studies (sputum Gram stain and culture) if bacterial infection is suspected 7

Recommend adequate fluid intake to avoid dehydration 3
Consider honey for cough suppression in patients over 1 year of age 3
Advise paracetamol for fever management 3
For cough associated with common cold, consider a first-generation antihistamine/decongestant combination 1, 2
If bacterial infection is suspected, consider empiric antibiotic therapy 6, 3
For suspected influenza with severe symptoms, consider antiviral therapy if within 48 hours of symptom onset 6, 8

Determine if cough is postinfectious or not 2
If postinfectious, consider first-generation antihistamine/decongestant for postnasal drip 2
If postinfectious, consider inhaled bronchodilators if bronchial hyperresponsiveness is suspected 2, 3
If not postinfectious, evaluate and manage as chronic cough 2

Follow the same initial diagnostic algorithm but consider an expanded list of differential diagnoses 3
Use CD4+ lymphocyte counts to guide differential diagnosis in HIV-infected patients 3
Consider high-resolution CT scan and bronchoscopic evaluation for uncommon causes if cough persists despite appropriate evaluation and treatment 3

Implement appropriate isolation precautions 4, 8
For suspected SARS or similar highly contagious infections, place patient in a negative pressure isolation room if available, ensure healthcare workers use appropriate personal protective equipment, and maintain a list of all staff who have contact with the patient 8