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Difficulty: EasyPulmonary and Critical Care

A 34-year-old woman comes to the clinic reporting a persistent cough for the past 10 days. The cough is frequently productive of yellowish-green sputum. She states that she initially had a runny nose, mild sore throat, and low-grade fever that resolved after a few days, but the cough has persisted and occasionally interrupts her sleep. She has no past medical history, takes no medications, and does not smoke. Her temperature is 37.1°C (98.8°F), blood pressure is 118/76 mmHg, pulse is 78/min, and respiratory rate is 14/min. Pulse oximetry is 99% on room air. Pulmonary examination reveals normal vesicular breath sounds bilaterally with no wheezes, crackles, or rhonchi. Cardiac examination shows a regular rate and rhythm with no murmurs. There is no jugular venous distention or lower extremity edema. Which of the following is the most appropriate next step in management?

  1. Symptomatic treatment with an over-the-counter antitussiveAnswer
  2. B
    Prescription for a five-day course of oral azithromycin
  3. C
    Administration of intravenous furosemide
  4. D
    Measurement of arterial blood gases
  5. E
    Measurement of serum thyroid-stimulating hormone

Answer

Symptomatic treatment with an over-the-counter antitussive
The correct response is symptomatic treatment with an over-the-counter antitussive. This patient presents with a classic case of acute bronchitis, defined as a cough lasting greater than 5 days (typically 1 to 3 weeks) that frequently follows a viral upper respiratory tract infection. Over 90% of acute bronchitis cases in healthy adults are caused by viruses (e.g., rhinovirus, coronavirus, influenza, RSV). The presence of discolored or purulent sputum is very common and represents the shedding of epithelial cells and leukocytes; it does not reliably indicate a bacterial etiology. Because the patient has normal vital signs and a completely clear pulmonary examination, pneumonia is highly unlikely. The standard of care is reassurance and symptomatic management with antitussives (like dextromethorphan), expectorants, or bronchodilators if wheezing were present.

Step-by-Step Solution

1
Evaluate the timeline and sequence of the patient's symptoms.
The patient has a cough lasting 10 days that was preceded by classic viral upper respiratory infection (URI) symptoms.
Establishing the sequence helps differentiate acute bronchitis from chronic pulmonary diseases or acute bacterial pneumonia.
2
Analyze the physical examination findings and vital signs.
Vital signs are strictly normal (no fever, normal respiratory rate, normal oxygen saturation) and lung auscultation is clear.
Normal vitals and clear lungs essentially rule out pneumonia, heart failure, and severe asthma, confirming a diagnosis of uncomplicated acute bronchitis.
3
Determine the optimal management plan based on the diagnosis.
Since acute bronchitis is overwhelmingly viral, supportive care is the standard of practice.
Avoiding unnecessary antibiotics adheres to proper antimicrobial stewardship.

Key Concept

Diagnosis and management of acute bronchitis in an otherwise healthy adult.
Estimated Time:45s
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Topics

Pulmonary and Critical Care

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