Acute Cough, PLUS Upper Respiratory Symptoms, but No shortness of breath (& Normal lung exam)

Here the cough is clearly coming from the Upper Respiratory Tract.  Possible causes include:

Covid-19 — We’ve noted how anyone with Covid symptoms needs a Covid Test; “cough” for under 10 days surely counts. If they’re not very sick, meaning no shortness of breath nor a significant fever, we probably tell them to isolate at home while the test is pending. If the test is negative but the cough had just begun a few days ago, they need a repeat test.

The rest of this discussion assumes the patient does not have Covid-19.

Common Cold  —  This is the most likely diagnosis for a cough with nasal symptoms, provided itโ€™s been going on less than 2 weeks.  Itโ€™s due to a Virus, and none of the many viruses around last longer, or if they do, theyโ€™re clearly on their way to getting better (see Differences Among Germs).  For viruses, antibiotics never help at all, just cause problems.

Thereโ€™s no treatment for a Common Cold; no proof that any of the countless over-the-counter remedies work any better than placebo.  Sorry.

Allergic Rhinitis (โ€œAllergiesโ€; โ€œHay Feverโ€)  —  Once a Cough with upper respiratory symptoms has been going on over 2 weeks without improvement, Allergies become our leading diagnosis.  But since every disease has its โ€œDay #1,โ€ it doesnโ€™t mean we have to wait.  Whereas there’s not really any good medicine available for the Common Cold (due to a virus), thereโ€™s excellent treatment available for Allergies.  I happily diagnose Allergies right away if any of the following are noteworthy:

  • Sneezing is a very prominent symptom, especially if also watery / itchy eyes
  • The person has had recurrent episodes, over & over.  Kids might get up to eight Colds a year, but adults shouldnโ€™t get over 2 or 3.
  • The person had similar episodes in the past that were prolonged [over 1 month].  Any illness that long couldnโ€™t have been a virus, so if that time was allergic, this one may well be also.
  • Exam is obvious for very pale/gray and boggy nasal passages (looking inside the nostrils), darkened lower eye lids (almost like โ€œblack eyesโ€), or a horizontal crease across the tip of the nose.

Sinusitis  —  Caused by bacteria, treated with antibiotics, this is much less common than the other two conditions.  Most people who complain that their โ€œsinuses keep acting upโ€ actually have Allergic Rhinitis.  They need decent allergy treatment, and NOT antibiotics.

When do I diagnose Sinusitis as a cause of Cough (& no fever)?  Only in two circumstances:

  • Nasal congestion, & with facial / forehead pressure & tenderness going on 10 days without starting to improve.  This is pretty rare.
  • Symptoms began as a Cold or Allergies, but changed & worsened 7-10 days into the illness, with more nasal congestion and facial pressure.

Green nasal discharge only impresses me if it persists constantly throughout the day.  If congestion & facial pressure are on just one side, the more convincing [odds are that bacteria just happened to invade a single sinus].  Tapping on the upper teeth may cause pain in the same cheek.

I’m much more willing to diagnose Sinusitis in immunocompromised patients (with other diseases that cause weak immune systems), because bad things can happen.ย  Of course, anyone with symptoms of sinusitis whoโ€™s also mentally confused, or has neurologic symptoms like major changes in vision, needs to go right to an E.R. for a CT Scan to rule out spread of infection to the brain or eye.

Why not simply give antibiotics to everyone, just in case?  Because the more antibiotics get prescribed, the more our bacteria will develop resistance to the drugs.  Then, when we really need them (like for life-threatening infections), they won’t work.  Over-prescribing antibiotics is the hallmark of the lazy clinician, eager to hurry through patients, unwilling to spend time taking a medical history and thinking through a best diagnosis.


This sub-topic of “Acute Cough PLUS Upper Respiratory Symptoms & No SOB” assumes that the lung exam is normal when we listen with a stethoscope.  If we hear abnormal sounds, then we focus our thought process on Lung Diseases; see Acute Cough — PLUS Some SOB, but NO Fever

See also Acute Cough for the clinicianโ€™s condensed thought-process when face-to-face with a patient.

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