A 38-year-old woman comes to the office with cough and blood-tinged sputum. She developed malaise, nasal congestion, sore throat, and dry cough 10 days ago. Most of her symptoms improved, but the cough persisted and became productive of yellowish sputum. For the past 2 days, she has had several episodes of blood-tinged sputum. The patient has no chest pain except the discomfort from coughing. Her appetite is normal, and she has no weight loss. She feels anxious as she has never had blood in the sputum before. She is a nonsmoker, has no other medical problems, and denies international travel. Her vaccinations are up to date. The patient's temperature is 36.7 C (98 F), blood pressure is 132/80 mm Hg, pulse is 82/min, and respirations are 18/min. Pulse oximetry is 98% on room air. Her BMI is 29 kg/m², and the oropharynx is clear. Scattered bilateral wheezes and crackles that clear with coughing are heard on chest auscultation. Chest x-ray reveals clear lung fields. Which of the following is the most appropriate next step in management of this patient?

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11ec25c8_d22c_05c3_bc81_07ade88b3fc8_MD0003_00 This nonsmoking patient with symptoms of recent upper respiratory infection (URI) and persistent cough productive of yellow, blood-tinged sputum likely has acute bronchitis. Cough lasting >5 days is characteristic of acute bronchitis, and a viral URI is the usual cause. Sputum production occurs in roughly half of patients; the typical yellow/purulent sputum is due to epithelial sloughing and is not a sign of bacterial infection. Small amounts of blood in the sputum can occur due to inflammation and epithelial damage. Mild dyspnea and chest wall discomfort are common, and physical examination often shows wheezing as well as crackles that clear with cough, suggesting that secretions are easily mobilized (unlike in pneumonia). Fever is not typical and, when present, should raise suspicion for bacterial pneumonia or influenza. The illness is self-limiting (although cough and airway hypersensitivity may persist for weeks), and only symptomatic treatment (eg, nonprescription pain relievers) is indicated. Antibiotics should generally be avoided as they provide no significant benefit (including in acute bronchitis due to Mycoplasma species) and are associated with adverse effects. (Choices A and B) Chest CT and flexible bronchoscopy can be useful in the diagnosis and treatment of recurrent or large-volume hemoptysis. This patient with small-volume hemoptysis in the setting of a URI, unremarkable chest x-ray, and no risk factors for malignancy (eg, smoking) or bronchiectasis (eg, recurrent infection) requires no further investigation. (Choice C) Patients with chronic cough may be evaluated with pulmonary function testing if asthma or chronic obstructive pulmonary disease is suspected. Cough due to acute bronchitis is usually self-limiting, and pulmonary function testing is not indicated. (Choice D) Sputum acid-fast stain is used to diagnose tuberculous infection in patients with chronic cough and constitutional symptoms such as weight loss or night sweats. An unremarkable chest x-ray and absence of risk factors (eg, international travel) make tuberculosis unlikely. (Choice E) Sputum cytology can occasionally help in the diagnosis of lung cancer, but sensitivity is poor. Lung cancer is very unlikely in this young patient with no smoking history. (Choice F) Most cases of acute bronchitis are viral, and sputum culture is not recommended unless pneumonia is suspected. The absence of fever and consolidation on chest x-ray makes pneumonia very unlikely. Educational objective: Acute bronchitis is a common cause of cough that may be productive of purulent, blood-tinged sputum. Upper respiratory viral infection is the typical etiology, and symptoms are usually self-limiting. Symptomatic treatment and close clinical follow-up are the best management strategies. References: Diagnosis and treatment of acute bronchitis. (http://www.ncbi.nlm.nih.gov/pubmed/21121518) Hemoptysis: diagnosis and management. (http://www.ncbi.nlm.nih.gov/pubmed/16225028)

A 38-Year-Old Woman Comes to the Office with Cough and Blood-Tinged