What is the recommended treatment for a 60-year-old patient with a history of diabetes (DM), hypertension (HTN), and hyperlipidemia, presenting with symptoms of cough with yellow sputum, chest pain, and shortness of breath (SOB) on exertion, who is a current smoker and has poor medication compliance?

Acute Lower Respiratory Tract Infection with Possible Bacterial Exacerbation

This patient requires immediate smoking cessation counseling, chest X-ray to rule out pneumonia and lung cancer, and consideration of antibiotic therapy given the productive cough with yellow sputum, chest pain, and significant smoking history with multiple comorbidities.

Immediate Diagnostic Priorities

Rule Out Serious Pathology

• Chest X-ray is mandatory in this heavy smoker with new respiratory symptoms to exclude lung cancer, pneumonia, heart failure, or emphysema 1, 2
• The productive cough with yellow sputum and chest pain raises concern for bacterial lower respiratory tract infection, particularly given the patient's smoking history and comorbidities 3
• Heavy smokers with persistent cough (>1 week) warrant chest imaging as cough is present in >65% of lung cancer patients at diagnosis 1

COVID/Influenza Testing

• The offered COVID/Influenza swab should be performed to guide specific antiviral therapy if positive and to inform infection control measures 3

Treatment Approach

Antibiotic Therapy Consideration

Given the productive cough with yellow (purulent) sputum, chest pain, and high-risk comorbidities (diabetes, hypertension, smoking), antibiotic therapy is warranted 3, 4

• The presence of purulent sputum production suggests bacterial infection requiring antibiotic treatment 4
• Amoxicillin-clavulanate 875mg twice daily for 5-7 days is appropriate first-line therapy for acute exacerbation with purulent sputum 4
• Alternative: Extended-release clarithromycin 1000mg once daily for 7 days shows equivalent efficacy with better gastrointestinal tolerability 4

Important caveat: While one study showed amoxicillin provides little benefit when pneumonia is not suspected 5, that study excluded patients with purulent sputum and comorbidities like this patient has. The presence of yellow sputum, chest pain, and multiple risk factors justifies antibiotic use here.

Bronchodilator Therapy

• Initiate short-acting bronchodilator (salbutamol inhaler 2 puffs every 4-6 hours as needed) for the wheeze noted on examination and SOB on exertion 3
• The wheeze on examination suggests bronchospasm that will respond to bronchodilator therapy 3
• Consider adding ipratropium bromide if inadequate response to beta-agonist alone 3

Smoking Cessation - Critical Priority

Smoking cessation is the single most important intervention for both immediate symptom relief and long-term mortality reduction 1, 2

• 90% of smokers with chronic cough experience resolution with smoking cessation 2
• Initiate nicotine replacement therapy combined with behavioral counseling immediately 1
• This addresses both the acute presentation and reduces lung cancer risk, which is significantly elevated in this patient 1, 2

Chronic Disease Management - Urgent Issue

Poor Medication Compliance

This patient's last prescription was filled 10/06/2025, indicating 5+ months of non-compliance with diabetes, hypertension, and hyperlipidemia medications - this represents a critical mortality risk 6, 7

• Blood pressure of 148/87 mmHg indicates uncontrolled hypertension 7
• Restart all chronic medications immediately: Metformin 500mg BD, Candesartan 16mg OD, Atorvastatin OD 6, 7
• Cardiovascular disease is the leading cause of death in type 2 diabetes patients, making aggressive management of all three conditions essential 8, 7
• Schedule close follow-up (within 1-2 weeks) to assess compliance and consider medication intensification if targets not met 6, 7

Follow-Up Strategy

Short-Term (48-72 hours)

• Review chest X-ray results urgently - if abnormal findings suggestive of mass, nodule, or infiltrate, refer immediately to pulmonology 1, 2
• Assess response to antibiotics and bronchodilators 3
• Monitor for red flags: hemoptysis, worsening dyspnea, fever, or constitutional symptoms requiring immediate re-evaluation 1, 2

Medium-Term (2-4 weeks)

• Spirometry with bronchodilator response is essential to objectively confirm or exclude COPD given the smoking history, wheeze, and SOB 1, 2
• Re-evaluate cough persistence - if cough continues despite smoking cessation and normal workup, refer to pulmonology 2
• Verify medication compliance and check HbA1c, lipid panel, and blood pressure control 6, 7

Critical Pitfalls to Avoid

• Do not dismiss this as simple "smoker's cough" - the acute change in symptoms, purulent sputum, and chest pain require investigation 1, 2
• Do not delay chest X-ray - lung cancer must be excluded in any heavy smoker with new or changed respiratory symptoms 1, 2
• Do not ignore the medication non-compliance - this patient is at extremely high cardiovascular risk with uncontrolled diabetes, hypertension, and hyperlipidemia 8, 7
• Do not prescribe chronic cough suppressants (codeine, dextromethorphan) until serious pathology is excluded - these are only for short-term symptomatic relief 3