A 43-year-old man comes to the office due to a cough. The patient started with symptoms of nasal congestion, sore throat, and cough about 10 days ago, and most of the symptoms have since improved. However, the cough is persistent throughout the day and is productive of yellow sputum. He has no fever, chills, weight loss, or night sweats. The patient has had no prior respiratory problems, shortness of breath, sick contacts, or recent travel. He has taken lisinopril for hypertension and metformin for type 2 diabetes mellitus for the past 5 years. His last hemoglobin A1c was 6.6%. The patient has smoked half a pack of cigarettes daily for 5 years and is currently trying to quit. He drinks 1 or 2 cans of beer daily but does not use illicit drugs. Family history includes diabetes in multiple family members. Temperature is 36.1 C (97 F), blood pressure is 130/80 mm Hg, pulse is 65/min, and respirations are 14/min. The patient's pulse oximetry shows 99% on room air. On examination, the patient is in no apparent distress and appears his stated age. Mucous membranes are moist, and no lymphadenopathy or jugular venous distension is present. Heart rate is regular with normal S1 and S2. Bilateral scattered rhonchi are auscultated, which clear after expectoration. No crackles, wheezing, or rubs are heard. Percussion is resonant throughout, and normal tactile fremitus is observed. Which of the following is the most appropriate next step in management of this patient?

Question

A 43-year-old man comes to the office due to a cough.  The patient started with symptoms of nasal congestion, sore throat, and cough about 10 days ago, and most of the symptoms have since improved.  However, the cough is persistent throughout the day and is productive of yellow sputum.  He has no fever, chills, weight loss, or night sweats.  The patient has had no prior respiratory problems, shortness of breath, sick contacts, or recent travel.  He has taken lisinopril for hypertension and metformin for type 2 diabetes mellitus for the past 5 years.  His last hemoglobin A1c was 6.6%.  The patient has smoked half a pack of cigarettes daily for 5 years and is currently trying to quit.  He drinks 1 or 2 cans of beer daily but does not use illicit drugs.  Family history includes diabetes in multiple family members.  Temperature is 36.1 C (97 F), blood pressure is 130/80 mm Hg, pulse is 65/min, and respirations are 14/min.  The patient's pulse oximetry shows 99% on room air.  On examination, the patient is in no apparent distress and appears his stated age.  Mucous membranes are moist, and no lymphadenopathy or jugular venous distension is present.  Heart rate is regular with normal S1 and S2.  Bilateral scattered rhonchi are auscultated, which clear after expectoration.  No crackles, wheezing, or rubs are heard.  Percussion is resonant throughout, and normal tactile fremitus is observed.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c06b_bf9a_8f63_bd7821ad6de1_MD0005_00 This patient most likely has acute bronchitis, which is characterized by cough lasting >5 days and up to 3 weeks. The vast majority of cases are due to a viral respiratory infection, and presentation is often with several days of viral upper respiratory symptoms (eg, sore throat, nasal congestion) that give way to cough as the predominant symptom. Purulent yellow or green sputum is commonly present due to epithelial sloughing and is not a sign of bacterial infection. Patients may also have mild dyspnea and chest wall discomfort (from coughing) as well as crackles that clear with cough, suggesting secretions that are easily mobilized (unlike in pneumonia). Fever is not typical and, when present, should raise suspicion for bacterial pneumonia or acute bronchitis due to influenza. The course of acute bronchitis is self-limited, and most of the time only symptomatic treatment (eg, nonprescription pain relievers, bronchodilators) is indicated. Except for acute bronchitis due to Bordetella pertussis (whooping cough), which represents 1% of cases and is suggested by infected contacts or a prolonged course, antibiotics provide no benefit; they are associated with adverse effects and increased bacterial resistance and should be avoided. (Choice A) ACE inhibitors (eg, lisinopril) can cause a cough due to increased bradykinin levels. However, this patient's cough in the setting of upper respiratory infection is more likely due to acute bronchitis. (Choices B and C) A course of either azithromycin or moxifloxacin is appropriate for the outpatient treatment of community-acquired pneumonia (CAP); however, the diagnosis is highly unlikely given this patient's lack of fever and absence of evidence of consolidation (eg, crackles, focal increased breath sounds) on lung auscultation. Mycoplasma pneumoniae and Chlamydia pneumoniae are rare but potential causes of acute bronchitis; however, there is no evidence that antibiotics provide benefit over supportive care even in patients who test positive for these organisms. (Choice D) Pulmonary function testing is indicated for the evaluation of chronic bronchitis, which is defined as cough for >3 months in 2 consecutive years. Although smoking increases the risk of chronic bronchitis, this patient has no previous lung problems and his cough in the setting of an upper respiratory infection is consistent with acute bronchitis. Educational objective: Acute bronchitis is typically a self-limited bronchial inflammation characterized by cough lasting >5 days and up to 3 weeks. The vast majority of cases are due to a viral respiratory infection, and only symptomatic treatment is needed. Antibiotics are rarely indicated and should be avoided. References: Diagnosis and treatment of acute bronchitis. (http://www.ncbi.nlm.nih.gov/pubmed/21121518) Evidence-based acute bronchitis therapy. (http://www.ncbi.nlm.nih.gov/pubmed/23076965)

A 43-Year-Old Man Comes to the Office Due to a Cough