Name: Cough / possible pneumonia — bulletproof documentation — ER Toolkit
Creator: Kim Trinh, MD

"Bronchitis, here's a Z-pack" is where cough goes wrong. The defensible chart shows pneumonia was assessed (and severity scored if present), and that the dangerous mimics — PE, heart failure, TB, and malignancy — were considered before a benign label and an antibiotic.

01What's at stake

Most acute cough is viral and self-limited, but the misses are consequential: a PE presenting as cough/dyspnea, decompensated heart failure mislabeled as a "chest cold," active TB sent home without isolation, and a smoker's persistent cough that is lung cancer. Antibiotics for simple acute bronchitis are usually unhelpful — the value is in the can't-miss assessment.

02Can't-miss differential

Pneumonia — focal findings, fever, hypoxia; score severity (CURB-65) for disposition.
Pulmonary embolism — cough/dyspnea with VTE risk; pretest probability.
Heart failure — orthopnea, edema, "cardiac" cough; BNP/CXR.
Tuberculosis — risk factors, weight loss, night sweats, hemoptysis → airborne isolation.
Malignancy — smoker, persistent cough, hemoptysis, weight loss → imaging/follow-up.
Pertussis, aspirated foreign body (esp. children), and the crashing asthma/COPD.

03History & exam

Fever, focal crackles, hypoxia, tachypnea? → pneumonia
Pleuritic pain, dyspnea, VTE risk, unilateral leg swelling? → PE
Orthopnea, PND, edema, cardiac history? → heart failure
TB risk/exposure, weight loss, night sweats, hemoptysis? → TB (isolate)
Smoker, >3 weeks, hemoptysis? → malignancy
Check vital signs including SpO₂; document the pulmonary exam.

Skip the typing

Work the case in the Cough / Possible Pneumonia Workup — it records the CURB-65, chest imaging, and oxygenation, and assembles an MDM that documents pneumonia severity and the dangerous mimics considered.

04Testing & management

Pneumonia: chest x-ray when suspected; CURB-65 (confusion, urea, RR ≥30, BP, age ≥65) to guide admission; treat per CAP guidelines; check oxygenation.
Targeted, not shotgun: PE assessment (pretest probability/d-dimer) when the story fits; BNP/echo for heart failure; airborne isolation + testing for possible TB; CT/pulmonology follow-up for a smoker's persistent cough.
Avoid antibiotics for simple acute bronchitis — symptomatic care and return precautions.
Children: consider foreign body (sudden onset/choking) and pertussis.

05What to document

▼ weak

"Cough and congestion, lungs clear-ish. Bronchitis, azithromycin, discharged."

▲ defensible

"Productive cough × 4 days; afebrile, SpO₂ 98%, no focal crackles or tachypnea — pneumonia unlikely (CXR not indicated by exam, or obtained and clear). PE considered (no pleuritic pain/VTE risk/leg swelling); heart failure (no orthopnea/edema) and TB (no risk factors/weight loss/night sweats) considered; non-smoker. Viral bronchitis; antibiotics not indicated. Return precautions for fever, dyspnea, chest pain, or hemoptysis; follow-up for cough >3 weeks."

06Where charts fail

Calling it "bronchitis" and prescribing antibiotics without assessing pneumonia or the mimics.
Missing PE or heart failure behind cough/dyspnea.
Not isolating/testing possible TB.
Dismissing a smoker's persistent cough/hemoptysis without imaging and follow-up.
No documented SpO₂/pulmonary exam, or no CURB-65 when pneumonia is diagnosed.

07Sources

Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia: ATS/IDSA clinical practice guideline. Am J Respir Crit Care Med. 2019;200(7):e45-e67.
Lim WS, van der Eerden MM, Laing R, et al. Defining community acquired pneumonia severity on presentation to hospital: the CURB-65 score. Thorax. 2003;58(5):377-382.
Smith SM, Fahey T, Smucny J, Becker LA. Antibiotics for acute bronchitis. Cochrane Database Syst Rev. 2017;(6):CD000245.
Irwin RS, French CL, Chang AB, et al. Classification of cough as a symptom in adults and management algorithms: CHEST guideline. Chest. 2018;153(1):196-209.

Cough & pneumonia: documentation that holds up