Chronic Cough Evaluation Note (Pediatric Algorithm)

Date/Time: [Encounter date and time]

Setting: [clinic / urgent care / ED / other]

Historian: [patient / caregiver / both] (Include reliability statement if applicable; specify caregiver relationship.)

Interpreter: [not used / used – language: ___; modality: in-person / phone / video]

Referral Source: [self / primary care / ED / specialist / school / other]

Chief Complaint

[Chief complaint in patient/caregiver words]

Reason for Visit

[Statement confirming daily cough exceeding 4 weeks and visit goals] (Explicitly state that cough is daily and >4 weeks, therefore qualifying for chronic cough evaluation. Outline goals: red flag screening, initial testing, and determining wet vs dry pathway.)

History of Present Illness

[Narrative timeline] (Onset date or best estimate; clarify daily vs episodic; course and progression; note last period with no cough.)

Cough Characterization: [wet/productive / dry / mixed / uncertain] (Document caregiver report and clinician impression if observed.)

• Pattern: [daytime predominant / nighttime predominant / both / no clear pattern]; [school / home / both]; [seasonal / year-round]; [exercise-related: yes / no]
• Triggers: [exertion / cold air / allergens / lying flat / feeding / laughter or crying / none identified] (List only those explicitly reported.)
• Qualitative descriptors: [barky / brassy / paroxysmal / whoop / post-tussive emesis / staccato / none] (Include only if diagnostically relevant.)
• Productive features (if wet): [sputum color / volume / ability to expectorate]
• Impact: [sleep disruption / school absence / chest pain / abdominal pain / activity limitation]

Associated Symptoms: (List positives first, then pertinent negatives.)

• Respiratory: [wheeze / dyspnea / exercise intolerance / chest tightness / none]
• ENT: [nasal congestion / rhinorrhea / throat clearing / sinus symptoms / none]
• Constitutional: [fever / weight loss / fatigue / growth concerns / none]
• Feeding/Aspiration: [cough with feeds / gagging / choking / vomiting / reflux symptoms / none]

Red Flags and Specific Cough Pointers

(Explicitly attest to each item as Present, Absent, or Unknown with reason if not assessed. This section should rarely be omitted.)

• Dyspnea [Present / Absent / Unknown – reason: ___] (If present, specify at rest, exertion, or both.)
• Recurrent pneumonia [Present / Absent / Unknown – reason: ___]
• Hemoptysis [Present / Absent / Unknown – reason: ___]
• Chest pain [Present / Absent / Unknown – reason: ___]
• Systemic symptoms (persistent fever, weight loss, growth failure) [Present / Absent / Unknown – reason: ___]
• Neurodevelopmental abnormality affecting airway protection [Present / Absent / Unknown – reason: ___]
• Feeding difficulties (choking, vomiting, cough with feeds) [Present / Absent / Unknown – reason: ___]
• Stridor or other abnormal respiratory noises [Present / Absent / Unknown – reason: ___]
• Abnormal prior exam findings (crackles, clubbing, caregiver-reported cyanosis) [Present / Absent / Unknown – reason: ___]
• Abnormal prior chest radiograph or lung function testing [Present / Absent / Unknown – reason: ___]
• Known or suspected immunodeficiency or significant comorbidity [Present / Absent / Unknown – reason: ___]

Prior Evaluations and Treatment Response:

• Prior clinician visits: [dates / settings / key impressions]
• Imaging: [CXR / other] [date] [key findings]
• Spirometry: [date] [pre/post bronchodilator: yes / no] [key values and interpretation]
• Laboratory tests: [test] [date] [result] [interpretation]
• Medication trials (agent, duration, adherence, response):
  • Antibiotics: [agent] [duration] [adherence] [response]
  • Bronchodilators: [agent] [device/spacer] [schedule] [response]
  • Inhaled corticosteroids: [agent] [dose] [duration] [adherence] [response]
  • Antihistamines/intranasal steroids: [agent] [duration] [response]
  • Acid suppression: [agent] [duration] [GI features present: yes / no] [response]
  • OTC products: [agent] [duration] [response]

Exposure and Risk History:

• Tobacco smoke or vaping exposure in household/car: [yes / no] (Detail sources and locations if present.)
• Daycare/school exposure: [attendance status / class size / frequency of viral illnesses]
• Sick contacts: [yes / no / unknown]
• Pets: [type / indoor or outdoor] or [none]
• Housing conditions: [mold / dampness / pests / none identified]
• TB exposure risk: [known contact / travel or residence in high-risk setting / none]
• Aspiration risk factors: [swallowing dysfunction / reflux symptoms / choking events / none]
• Foreign body risk: [witnessed choking episode / sudden onset without viral prodrome / none]

Caregiver Concerns and Goals: [Brief statement of concerns and goals]

Past Medical History

(Include relevant conditions with approximate dates or age at diagnosis. Do not omit critical comorbidities.)

• Asthma/reactive airway disease: [date/age]
• Atopy/eczema/allergic rhinitis: [date/age]
• Prematurity: [gestational age]; BPD/NICU history: [details]
• Recurrent infections/pneumonias: [frequency, dates]
• Chronic lung disease: [diagnosis, date]
• Cardiac disease: [diagnosis, date]
• Neuromuscular disease: [diagnosis, date]
• Swallowing disorders: [diagnosis, date]
• Immunodeficiency: [diagnosis, date]
• GERD: [diagnosis and basis]
• Birth history (for younger children): [gestational age / pregnancy complications / delivery]
• Developmental history (if aspiration risk relevant): [milestones / feeding skills]

Medications

• Active medications: [name] [dose] [route] [frequency]
• Inhaler devices/spacer use: [device type] [spacer/mask] [technique notes]
• Recent antibiotics (past 2–3 months): [agent] [dates] [indication]

Allergies

• Drug allergies: [agent] [reaction type/severity] (Note penicillin-class relevance given potential antibiotic treatment.)
• Environmental/food allergies: [agent] [reaction]

Family History

• Asthma/atopy/chronic cough: [relation(s)]
• Cystic fibrosis/bronchiectasis: [relation(s)]
• Immunodeficiency: [relation(s)]
• TB exposure in household: [yes / no]

Social and Environmental History

• Household composition: [members, caregivers]
• Housing conditions: [mold / dampness / pests / ventilation concerns / none]
• School/daycare attendance: [yes / no] [hours/days per week]
• Recent travel: [locations / dates / none]

Review of Systems

(Include only if it adds information beyond the HPI. May be omitted when HPI is comprehensive.)

• Respiratory: [positives], [pertinent negatives]
• ENT: [positives], [pertinent negatives]
• Constitutional: [positives], [pertinent negatives]
• GI: [positives], [pertinent negatives]
• Sleep: [positives], [pertinent negatives]

Objective

Vitals and Growth

• Temp: [value and units]
• HR: [value] bpm
• RR: [value] breaths/min
• BP: [value] mmHg
• SpO2: [value]% on [room air / supplemental oxygen]
• Weight: [value and units] ([percentile]%)
• Height/Length: [value and units] ([percentile]%)
• BMI: [value] ([percentile]%) [tracking appropriately / crossing percentiles – trend summary]

(If vitals not obtained, document the reason.)

Physical Examination

(Document only systems examined.)

• General: [appearance / work of breathing / hydration / distress level]
• HEENT: [nasal mucosa / turbinate swelling / postnasal drip / tonsils / sinus tenderness]
• Neck: [lymphadenopathy / masses]
• Respiratory: [symmetry / air movement / wheeze / crackles / rhonchi / prolonged expiratory phase / stridor / cough quality if observed]
• Cardiac: [rate and rhythm / murmurs / signs of heart failure]
• Skin: [eczema / cyanosis / clubbing]
• Neurologic: [tone / coordination / swallow function] (Include if aspiration risk is relevant.)

Data Reviewed and Diagnostics

Records Reviewed

[Outside records reviewed: source, date, key findings] (Omit section if no outside records.)

Chest Radiograph

[ordered today / performed today / prior study reviewed / not ordered]

(Include date and views. Provide clinician interpretation and official report if available; note any discrepancies and actions taken. If not ordered, document rationale such as recent adequate study already reviewed. A CXR is expected for chronic cough evaluation unless a recent adequate study exists.)

Spirometry

[attempted / not attempted – reason: age / cooperation / equipment unavailability]

• Pre/post bronchodilator testing: [done / not done]
• Quality/acceptability: [acceptable / suboptimal / unacceptable] (Include reason if suboptimal.)
• Key values: FEV1 [value] % predicted; FVC [value] % predicted; FEV1/FVC [ratio]; FEF25–75 [value] % predicted
• Interpretation: [normal / obstructive / restrictive / mixed]; bronchodilator response: [yes / no]

(Spirometry is recommended when age-appropriate and the child can cooperate.)

Additional Testing

(Include only if ordered or reviewed; document indication for each.)

• [Test name]: [indication] [date] [result if known] [next step]

Assessment

[Synthesis paragraph] (Classify cough on two axes: wet vs dry, and specific cough with red flags/pointers present vs nonspecific cough. Summarize key history, exam elements, and initial test results supporting this classification.)

1. Chronic cough (>4 weeks): [classification and brief summary]
2. [Secondary problem]: [brief description]
3. [Additional problem]: [brief description]

Differential Diagnosis (prioritized):

• [Etiology 1]: [supporting reasoning]
• [Etiology 2]: [supporting reasoning]
• [Etiology 3]: [supporting reasoning]

(If red flags are present, explicitly note conditions not to miss: foreign body, aspiration, chronic infection including TB, bronchiectasis, interstitial lung disease, congenital airway abnormality. Clearly label inferences as such; definitive diagnoses require supporting objective evidence.)

Plan

Problem: Chronic Cough

(Select the applicable pathway based on findings.)

• If red flags/specific pointers present OR CXR/spirometry abnormal:
  • Escalation: [urgent / routine] referral to [pediatric pulmonology / ENT / emergency department]
  • Targeted diagnostics: [specific tests with rationale based on pointer identified]
  • Safety-net instructions: [warning signs warranting urgent reevaluation]
  • Follow-up: [timeframe] to review results and reassess
• If chronic wet cough, no red flags, normal initial evaluation (suspected protracted bacterial bronchitis):
  • Antibiotic: [agent] [dose] [frequency] for 2 weeks (Adjust selection if penicillin allergy.)
  • Adherence counseling: [instructions provided]
  • Reassessment at 2 weeks: document outcome as [resolved / improved / unchanged]
  • If persistent: [extend course / adjust agent]; consider referral if not improving after adequate therapy
  • Recurrence burden: [episodes per year]; referral threshold if >3 episodes/year
• If chronic dry cough, no red flags, normal initial evaluation:
  • Suspected post-infectious cough: watchful waiting with reassessment in [timeframe]
  • Suspected asthma: time-limited therapeutic trial with [medication, dose, duration] with explicit success criteria [expected improvement] and stop rules [discontinue if no benefit by specified timeframe]
  • Prolonged duration without resolution: referral trigger [criteria] and planned next steps
• Medication stewardship: (Document counseling provided: avoid empiric acid suppression without GI features; avoid sedating or narcotic antitussives in children; limited benefit of OTC cough medications.)

Additional Problems

• Allergic rhinitis: [intranasal steroid / antihistamine] [dose/duration]; environmental measures; ENT referral if refractory
• Smoke/vape exposure: [counseling provided]; [cessation resources offered to household]
• Suspected GERD with GI features: [evaluation/management plan] (If no GI features, document why empiric therapy not pursued.)
• School impact: [accommodations / documentation provided]

Follow-Up

• Return in: [2–4 weeks / sooner if red flags develop]
• Treatment failure criteria requiring escalation: [no improvement / recurrence / new red flag development]
• Missing information needed: [what is needed] and [how it will be obtained]

(Do not auto-populate negatives. Use explicit statements such as "unknown" or "not assessed" with reason when information is unavailable.)