A 25-year-old man comes to the office due to a dry cough that has persisted since he contracted an upper respiratory tract infection 10 days ago. The cough is worse at night and is not associated with nasal congestion, facial pressure, sore throat, abdominal discomfort, or vomiting. Medical history is notable only for childhood asthma, which the patient reports he "outgrew." All recommended vaccinations are up to date. The patient is afebrile, and other vital signs are normal. Nasal and pharyngeal examinations are unremarkable. Scattered wheezes are heard on lung auscultation. There are no heart murmurs. Which of the following is the best next step in management of this patient?

Question

A 25-year-old man comes to the office due to a dry cough that has persisted since he contracted an upper respiratory tract infection 10 days ago.  The cough is worse at night and is not associated with nasal congestion, facial pressure, sore throat, abdominal discomfort, or vomiting.  Medical history is notable only for childhood asthma, which the patient reports he "outgrew."  All recommended vaccinations are up to date.  The patient is afebrile, and other vital signs are normal.  Nasal and pharyngeal examinations are unremarkable.  Scattered wheezes are heard on lung auscultation.  There are no heart murmurs.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d134_ad46_bc81_efec7bec4b02_MD0003_00 This patient has a persistent, dry cough following an acute upper respiratory infection. He has mild wheezing on examination, but clinical findings are otherwise unremarkable. This presentation is consistent with acute bronchitis. Acute bronchitis is a self-limited infection that can last for 3-4 weeks. More than 90% of cases are caused by viruses (eg, rhinovirus, coronavirus, influenza); purulent yellow or green sputum can occur due to epithelial sloughing and is not a sign of bacterial infection. Patients may also have mild dyspnea and chest wall discomfort (from coughing). Crackles from airway secretions may be audible but typically clear with cough (unlike in pneumonia). Fever is not typical and should raise suspicion for bacterial pneumonia. Treatment of acute bronchitis is primarily supportive and may include throat lozenges and over-the-counter cough suppressants (eg, dextromethorphan/guaifenesin). Patients with associated wheezing in the setting of underlying pulmonary disease (eg, asthma) may benefit from inhaled bronchodilators (eg, albuterol); otherwise, these medications are not generally recommended. Oral corticosteroids are not indicated. (Choice A) Chest x-ray to rule out pneumonia is indicated for patients with acute cough associated with high fever, tachycardia, tachypnea, or signs of lung consolidation on examination (eg, crackles, dullness). It should be considered for elderly patients, in whom clinical signs of pneumonia may be subtle, and those with advanced lung disease (eg, chronic obstructive pulmonary disease). However, minor wheezing in a young patient who is otherwise clinically stable does not warrant chest imaging. (Choice C) Macrolide antibiotics (eg, azithromycin) are indicated for treatment of community-acquired pneumonia (eg, fever, tachypnea, lung crackles) or pertussis (eg, paroxysmal bouts of coughing, posttussive emesis). Although macrolide-sensitive species (eg, Mycoplasma) are responsible for a minority of acute bronchitis cases, treatment with antibiotics does not improve outcomes. (Choice D) Penicillin antibiotics (eg, amoxicillin/clavulanate) are indicated for acute bacterial sinusitis that fails to improve with symptomatic treatment. However, sinusitis is typically associated with nasal congestion, sinus tenderness, and fever. (Choice E) First-generation antihistamines (eg, diphenhydramine) are useful in combination with nasal decongestants for acute upper respiratory symptoms, although they are associated with significant side effects (eg, sedation). Second-generation antihistamines (eg, loratadine) alone are less effective for upper respiratory symptoms and are not indicated for acute bronchitis. Educational objective: Acute bronchitis is a self-limited illness usually caused by a viral infection. Treatment is supportive, although patients with associated wheezing due to underlying asthma may benefit from an inhaled bronchodilator (eg, albuterol). Antibiotics are not helpful and should be avoided. References: Beta2-agonists for acute cough or a clinical diagnosis of acute bronchitis. (http://www.ncbi.nlm.nih.gov/pubmed/26333656)

A 25-Year-Old Man Comes to the Office Due to a Dry