A 44-year-old otherwise healthy woman comes to the office due to a cough that has lasted 3 weeks. She had rhinorrhea with clear discharge, sore throat, and mild myalgias for 2-3 days before the cough started. Initially, she coughed up thick, yellow sputum in small amounts, but now she is coughing up small amounts of whitish grey sputum. The cough is worse when she exercises, and it often awakens her from sleep between 1:00 AM and 3:00 AM. The patient has no fevers, chills, vomiting, or chest pain. She takes no medications and does not use tobacco. Her immunizations are up to date. There is no family history of asthma.
Vital signs are within normal limits. Pulse oximetry shows an oxygen saturation of 97% on room air. The nasal mucosa is not congested and there is no evidence of post-nasal drip. Scattered wheezes and rhonchi are present at both lung bases; rhonchi clear when the patient coughs. The remainder of the physical examination is within normal limits.
Which of the following is the most appropriate next step in management of this patient?

Question

A 44-year-old otherwise healthy woman comes to the office due to a cough that has lasted 3 weeks.  She had rhinorrhea with clear discharge, sore throat, and mild myalgias for 2-3 days before the cough started.  Initially, she coughed up thick, yellow sputum in small amounts, but now she is coughing up small amounts of whitish grey sputum.  The cough is worse when she exercises, and it often awakens her from sleep between 1:00 AM and 3:00 AM.  The patient has no fevers, chills, vomiting, or chest pain.  She takes no medications and does not use tobacco.  Her immunizations are up to date.  There is no family history of asthma.
Vital signs are within normal limits.  Pulse oximetry shows an oxygen saturation of 97% on room air.  The nasal mucosa is not congested and there is no evidence of post-nasal drip.  Scattered wheezes and rhonchi are present at both lung bases; rhonchi clear when the patient coughs.  The remainder of the physical examination is within normal limits.
Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_98ce_30ee_853d_afbc3c51ae0b_MD0002_00 This patient likely has hyperreactive airways following acute bronchitis. Acute bronchitis is most often due to lower respiratory involvement following a viral upper respiratory infection (URI); patients have improvement of their original URI symptoms but develop persistent cough lasting >5 days up to 3 weeks. In addition, transient hyperreactive airways, with cough and obstructive evidence on pulmonary function testing, may occur and last up to 5-6 weeks. Patients with significant symptoms (eg, nagging cough, shortness of breath) and wheezing on examination may be treated with an inhaled beta-2 adrenergic agonist to help improve obstruction and provide symptomatic relief. Other causes of subacute (3-8 weeks) or chronic (>8 weeks) cough should be considered in patients with cough that fails to resolve. Other causes (Choices A and D) With acute bronchitis, routine use of antibiotics is not recommended and purulent sputum production has not been shown to reflect bacterial infection. Even among those patients who test positive for atypical bacterial respiratory pathogens (eg, Mycoplasma pneumoniae, Chlamydia pneumoniae), there is no evidence that antibiotics provide benefit over supportive care. Azithromycin is indicated for pertussis (mainly to decrease risk of transmission); however, pertussis is rare overall and is unlikely in patients with up-to-date immunizations and no paroxysms of coughing, inspiratory whoop, or posttussive emesis. (Choice B) Chest x-ray is unlikely to change management in patients whose presentation is consistent with acute bronchitis. It is indicated only for those with clinical suggestion of pneumonia (eg, abnormal vital signs, hypoxemia, evidence of lung consolidation on examination). (Choice E) Collection of sputum cultures is rarely helpful as antibiotics are not needed for acute bronchitis. Pertussis testing (eg, sputum culture, serology) can be considered in appropriate cases. Educational objective: Acute bronchitis is usually viral in origin and does not require antibiotics. Many patients develop a persistent cough due to bronchospasm with transient airway obstruction. Inhaled beta-2 adrenergic agonists can relieve the obstruction and provide symptomatic relief in those with significant symptoms. __________ References: Beta2-agonists for acute bronchitis. (http://www.ncbi.nlm.nih.gov/pubmed/21735384) Principles of appropriate antibiotic use for treatment of uncomplicated acute bronchitis: background. (http://www.ncbi.nlm.nih.gov/pubmed/11255532)

A 44-Year-Old Otherwise Healthy Woman Comes to the Office Due