A 34-year-old woman comes to the urgent care clinic due to a cough. Her symptoms began 5 days ago with nasal congestion, rhinorrhea, and subjective fever, followed 2 days later by a cough. The initial symptoms resolved, but the patient continues to have a lingering cough with clear sputum. Medical history is unremarkable; she takes no medications and has no medication allergies. Vital signs are normal. Examination of the ears, nose, and throat shows only mild pharyngeal erythema. Lung examination shows no crackles, dullness, or egophony. The patient states, "Every year I get these same symptoms, and every year my doctor tells me it's bronchitis. It goes away when she gives me azithromycin. She doesn't take my insurance anymore, so I'm hoping you can prescribe it for me." Which of the following is the most appropriate response to this patient's request?

Question

A 34-year-old woman comes to the urgent care clinic due to a cough.  Her symptoms began 5 days ago with nasal congestion, rhinorrhea, and subjective fever, followed 2 days later by a cough.  The initial symptoms resolved, but the patient continues to have a lingering cough with clear sputum.  Medical history is unremarkable; she takes no medications and has no medication allergies.  Vital signs are normal.  Examination of the ears, nose, and throat shows only mild pharyngeal erythema.  Lung examination shows no crackles, dullness, or egophony.  The patient states, "Every year I get these same symptoms, and every year my doctor tells me it's bronchitis.  It goes away when she gives me azithromycin.  She doesn't take my insurance anymore, so I'm hoping you can prescribe it for me."  Which of the following is the most appropriate response to this patient's request?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d2ce_120a_bc81_4b7229a7940f_MD0003_00 In the setting of upper respiratory infection (eg, rhinitis, pharyngitis), cough is common and can be caused by postnasal drip, pharyngeal irritation, or extension of infection into the lower respiratory tract (ie, acute bronchitis). In the absence of manifestations of pneumonia (eg, focal lung findings, egophony, tachycardia, fever), this is not a concerning symptom and may linger for days to weeks. Upper respiratory infection and bronchitis are self-limited conditions usually caused by viruses (eg, parainfluenza, rhinovirus). Antibiotics do not reduce the duration or severity of symptoms. Nevertheless, patients frequently erroneously receive antibiotics (eg, azithromycin), a pattern reinforced by the observation that symptoms improve after taking them (as would be expected regardless). Several communication strategies can reduce antibiotic prescriptions for viral infections: The clinician should express awareness of the patients' symptoms and concern for their well-being. The clinician should also probe patients' understanding of the illness and its self-limited nature, providing specific education. Referring to acute bronchitis as a "cold" or "chest cold" can sometimes alleviate concern about having an infection requiring antibiotics. The clinician should also clarify that antibiotics have risks and adverse effects. (Choice A) This statement may be taken as patronizing, especially in the absence of meaningful action or education. The patient's comments show that specific education is needed. (Choice B) This statement evades discussions about the lack of utility of antibiotics in viral bronchitis and is likely to lead to confusion regarding which infections require antibiotics (eg, pneumonia) and which do not (eg, bronchitis). Although the physician does not have prior medical records, it is unlikely that the patient's prior episodes of bronchitis truly required antibiotics. (Choice C) This statement could be taken as denigrating the prior provider; such statements are rarely helpful and promote distrust of all providers. In addition, this response concludes with a reference to expert opinion, which is less effective than an educational approach. (Choice D) Sputum color (eg, green, yellow, gray) suggests respiratory epithelial cell desquamation but does not specifically indicate a bacterial pathogen. Conversely, no specific conclusions can be drawn regarding etiology in a patient with clear sputum. This statement may lead to further patient misunderstanding. Educational objective: Several communication strategies can reduce antibiotic use in acute bronchitis. The clinician should express awareness of patients' symptoms and concern for their well-being and probe their understanding of the illness and the self-limited nature of the infection. Referring to the illness as a "chest cold" may alleviate patients' anxiety that their infection requires antibiotics. The clinician should also discuss the risks and adverse effects of antibiotics. References: Acute bronchitis. (http://www.ncbi.nlm.nih.gov/pubmed/27929206)

A 34-Year-Old Woman Comes to the Urgent Care Clinic Due