Family Medicine · Year 3 · from Family Medicine

Case 2: The Persistent Cough - Acute Bronchitis

Patient Demographics

• Age: 42 years old
• Sex: Male
• Occupation: High school teacher

Chief Complaint

"I've had this cough for almost 2 weeks and it won't go away. I need something stronger."

History of Present Illness

Mr. Robert Chen is a 42-year-old man presenting with cough for 12 days. The illness started with nasal congestion, sore throat, and low-grade fever. Those symptoms resolved after 4-5 days, but the cough persists. The cough is sometimes productive of clear-to-yellow mucus, worse at night, and occasionally triggers gagging. He reports fatigue and chest discomfort from coughing.

He has tried over-the-counter cough suppressants with minimal relief. He states, "My neighbor had the same thing and got a Z-pack and felt better. Can I have one?"

Review of Systems

• Positive: Cough (productive), chest soreness from coughing, fatigue
• Negative: No fever currently, no shortness of breath at rest, no wheezing, no hemoptysis, no night sweats, no weight loss

Past Medical History

• No chronic conditions
• No asthma or COPD
• Non-smoker (never)
• No allergies

Physical Examination

• Vital Signs: Temp 98.4F, HR 76, BP 124/78, RR 14, SpO2 98% on room air
• General: Well-appearing, occasional coughing during exam
• HEENT: Oropharynx clear, no exudates, no postnasal drip visible
• Neck: No lymphadenopathy
• Lungs: Clear to auscultation bilaterally, no wheezes, no crackles, no rhonchi
• Cardiovascular: Regular rate and rhythm

Clinical Assessment

Does this patient need a chest X-ray?

Conclusion: No red flags for pneumonia; chest X-ray not indicated.

Assessment

1. Acute bronchitis - Viral illness with expected prolonged cough

Management Plan

Antibiotics: NOT INDICATED

Patient Education (Key Conversation Points): "I understand the cough is frustrating and affecting your daily life. Let me explain what's happening:

This is acute bronchitis - a viral infection that has inflamed your airways. The cough is your body's way of clearing the irritation. Here's the important part: antibiotics don't help because this is caused by a virus, not bacteria. Multiple studies involving thousands of patients show that antibiotics don't make the cough go away faster but do cause side effects like diarrhea and allergic reactions, and contribute to antibiotic resistance.

The cough typically lasts 2-3 weeks total, sometimes longer. I know that sounds discouraging when you're at 12 days, but you should notice gradual improvement."

Symptomatic Treatment:

• Honey (1-2 teaspoons) for cough, especially before bed
• Dextromethorphan (OTC cough suppressant) for nighttime symptom relief
• Ibuprofen or acetaminophen for chest discomfort
• Adequate hydration
• Humidifier at night

Return Precautions:

• New or worsening fever
• Shortness of breath
• Cough lasting > 3 weeks without improvement
• Hemoptysis (coughing blood)
• Worsening symptoms after initial improvement ("double sickening")

Follow-Up

• No routine follow-up needed if symptoms resolve
• Return in 1-2 weeks if cough not improving

Teaching Points

1. Antibiotic stewardship: Acute bronchitis is one of the most common conditions for inappropriate antibiotic prescribing. Clear communication about why antibiotics won't help is essential.

1. Setting expectations: Educating patients that cough from bronchitis typically lasts 2-3 weeks helps prevent return visits and antibiotic requests.

1. Distinguishing bronchitis from pneumonia: Clinical assessment without red flags allows confident diagnosis of bronchitis without chest X-ray.

1. Symptomatic treatment: Offering alternative treatments (honey, OTC medications) demonstrates concern for patient comfort while appropriately withholding antibiotics.

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