From the Guidelines
The patient is a 65-year-old male with a history of coronary artery disease (CAD), congestive heart failure (CHF), and asthma who presents with persistent cough and shortness of breath for 2 weeks. The cough is productive with yellowish sputum, worse in the mornings, and exacerbated by cold air and physical activity. The patient reports fever, fatigue, chest tightness, and wheezing. They deny hemoptysis, chest pain, orthopnea, or lower extremity edema.
Past Medical History
- Past medical history is significant for CAD with previous myocardial infarction, CHF with reduced ejection fraction of 40%, and moderate persistent asthma.
- The patient denies diabetes, hypertension, or COPD.
Family History
- Family history includes father with CAD and mother with asthma.
Past Surgical History
- Past surgical history includes coronary artery bypass grafting 5 years ago.
Social History
- The patient is a former smoker who quit 10 years ago after a 20 pack-year history, drinks alcohol occasionally, and denies illicit drug use.
Occupational History
- No significant occupational history.
Allergies
- No known allergies.
Medications
- The patient is currently taking aspirin, beta-blockers, ACE inhibitors, and inhaled corticosteroids.
Review of Systems
- Positive review of systems includes cough, shortness of breath, fever, fatigue, chest tightness, and wheezing.
- Negative review of systems includes hemoptysis, chest pain, orthopnea, or lower extremity edema.
Acute bronchitis is an inflammation of the bronchial tubes typically caused by viral infections (90% of cases), with rhinovirus, influenza, and adenovirus being common culprits 1.
Signs and Symptoms
- Symptoms include persistent cough lasting 1-3 weeks, which may be productive with clear, yellow, or green sputum.
- Patients often experience low-grade fever, fatigue, chest discomfort, and wheezing.
Clinical Findings
- Physical examination typically reveals normal vital signs or low-grade fever, occasional rhonchi and wheezing on auscultation, and normal oxygen saturation unless complicated by underlying conditions.
- In patients with comorbidities like CAD, CHF, and asthma, symptoms may be more pronounced with increased risk of complications.
Laboratory Results
- Chest X-ray is usually normal without infiltrates, distinguishing it from pneumonia.
- Complete blood count may show normal or slightly elevated white blood cell count.
- Pulmonary function tests may show transient airflow obstruction.
Physical Exam Findings
- Normal vital signs or low-grade fever.
- Occasional rhonchi and wheezing on auscultation.
- Normal oxygen saturation unless complicated by underlying conditions.
Treatment and Management
- Treatment focuses on symptomatic relief with adequate hydration, rest, and antipyretics for fever.
- Short-acting bronchodilators may help with wheezing, particularly in patients with underlying asthma.
- Antibiotics are generally not recommended unless bacterial infection is suspected (persistent symptoms >10-14 days, purulent sputum, or high fever) 1.
- For this patient with multiple comorbidities, close monitoring is essential to prevent exacerbation of underlying conditions, with consideration of a short course of oral corticosteroids if asthma symptoms worsen.
- Follow-up should be arranged within 1-2 weeks to ensure resolution of symptoms and to adjust management of underlying conditions as needed.
From the Research
History of Present Illness (HPI)
- The patient presents with a persistent cough and shortness of breath (SOB), with a history of Coronary Artery Disease (CAD), Congestive Heart Failure (CHF), and Asthma.
- Old charts: The patient has a history of respiratory problems, including asthma and COPD exacerbations.
- Review of Systems (ROS):
- Positive: cough, SOB, wheezing
- Negative: chest pain, palpitations, fever
- Past Medical History (PMH):
- Positive: CAD, CHF, Asthma, COPD
- Negative: none
- Family History (FH): none
- Personal and Social History (PSH): none
- Occupational History (OH): none
Acute Bronchitis
Signs and Symptoms
- Cough, often productive of mucus
- SOB
- Wheezing
- Chest discomfort or tightness
- Fatigue
- Headache
- Sore throat
- Runny nose
- Sneezing 2, 3
Clinical Findings
- Physical exam: wheezing, crackles, or rhonchi on lung exam
- Laboratory results: complete blood count (CBC), blood cultures, and arterial blood gas (ABG) may be ordered to rule out other conditions 3, 4
- Chest X-ray: may show increased bronchial markings or patchy infiltrates
CAR and ALB Results
- Complete Blood Count (CBC): may show elevated white blood cell count
- Arterial Blood Gas (ABG): may show hypoxemia or hypercapnia
- Albumin (ALB) levels: may be decreased in severe cases
Physical Exam Findings
- Wheezing or crackles on lung exam
- Rhonchi or bronchial breath sounds
- Decreased lung sounds or dullness to percussion
Treatment and Management
- Supportive care: rest, hydration, and humidification
- Bronchodilators: such as beta-agonists or anticholinergics to relieve bronchospasm
- Expectorants: such as guaifenesin to thin mucus
- Cough suppressants: such as codeine or dextromethorphan to relieve cough
- Antibiotics: only if bacterial infection is suspected or confirmed 3, 5
- Inhaled corticosteroids: may be used to reduce inflammation in patients with underlying asthma or COPD 2, 4, 5