Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with a chronic, non-productive, dry cough persisting for >8 weeks. Symptoms are predominantly nocturnal, triggered by cold air, exercise, or viral upper respiratory infections. Denies dyspnea, wheezing, or chest tightness. No history of GERD, post-nasal drip, or ACE-inhibitor use. Cough severity is rated [X/10], significantly impacting sleep quality.
Clinical Examination Findings
General: Patient in no acute distress. HEENT: Oropharynx clear, no cobblestoning. Lungs: Auscultation reveals clear breath fields bilaterally; no wheezing, rhonchi, or crackles detected during quiet breathing or forced expiration. Cardiac: Regular rate and rhythm, no murmurs. Extremities: No peripheral edema or cyanosis.
Treatment Protocol
Initiate inhaled corticosteroid (ICS) therapy: [Medication Name/Dosage] twice daily. PRN short-acting beta-agonist (SABA) for breakthrough symptoms. Schedule follow-up in 4 weeks to assess cough frequency and response to therapy. Consider pulmonary function testing (PFT) with methacholine challenge if symptoms persist.