A 35-year-old man comes to the physician with a 3-week history of hacking, nonproductive cough that occurs more frequently at night. He also has a sensation of liquid dripping into the back of the throat. He had an upper respiratory infection 4 weeks ago that resolved, except for the cough. He has no runny nose, chest pain, heartburn, difficulty breathing, or wheezing. The patient's past medical history is unremarkable, and he takes no medications. He is a lifetime nonsmoker. His father died at age 72 from lung cancer due to smoking. His vital signs are normal and physical examination is unremarkable. Which of the following is the best initial management for this patient?

Question

A 35-year-old man comes to the physician with a 3-week history of hacking, nonproductive cough that occurs more frequently at night.  He also has a sensation of liquid dripping into the back of the throat.  He had an upper respiratory infection 4 weeks ago that resolved, except for the cough.  He has no runny nose, chest pain, heartburn, difficulty breathing, or wheezing.  The patient's past medical history is unremarkable, and he takes no medications.  He is a lifetime nonsmoker.  His father died at age 72 from lung cancer due to smoking.  His vital signs are normal and physical examination is unremarkable.  Which of the following is the best initial management for this patient?

Quizplus · Accepted Answer

11ec25c8_d4ab_0f7f_bc81_412d717de256_MD0003_00 Subacute (3-8 weeks) and chronic (>8 weeks) cough is seen frequently in adults. Upper-airway cough syndrome (UACS) (eg, postnasal drip), gastroesophageal reflux disease (GERD), and asthma cause >90% of chronic cough in nonsmokers without pulmonary disease. A thorough history and examination can identify the important causes in most patients. Patients with clear history of UACS, asthma, or GERD should be treated accordingly; those taking ACE inhibitors should discontinue the drug. important causes This patient's cough started after a recent upper respiratory infection, occurs primarily at night, and is without expectoration. For cough following upper respiratory infection (which can be due to UACS or effects of the virus), the best approach is to treat empirically with an oral first-generation antihistamine (eg, chlorpheniramine) or combined antihistamine-decongestant (eg, brompheniramine and pseudoephedrine). Despite their sedating effects, first-generation antihistamines are used because they are more effective. This approach differs from that used for symptoms thought to be due to rhinitis, in which intranasal glucocorticoids are first-line. Patients who do not respond after 2-3 weeks may require further investigation (eg, sinus imaging, pulmonary function tests, high-resolution CT scan of the chest) or empiric sequential therapy for GERD, cough-variant asthma, chronic sinusitis, and non-asthmatic eosinophilic bronchitis (Choices B, D, and E). (Choice A) Chest x-ray is indicated in patients without a clear etiology or with possible pulmonary parenchymal disease, immunocompromised condition, purulent sputum, or smoking history. This patient is young, a nonsmoker, and afebrile; has only nocturnal cough with classic postnasal drip; has no expectoration; and has clear lungs, making pneumonia or malignancy very unlikely. Educational objective: Postnasal drip, gastroesophageal reflux disease, and asthma account for >90% of chronic cough in nonsmokers who do not have pulmonary disease. For patients with cough following upper respiratory infection, initial empiric treatment includes oral first-generation antihistamine (eg, chlorpheniramine) or combined antihistamine-decongestant (eg, brompheniramine and pseudoephedrine). References: Evaluation of the patient with chronic cough. (http://www.ncbi.nlm.nih.gov/pubmed/22010767)

A 35-Year-Old Man Comes to the Physician with a 3-Week