What is the diagnosis and recommended treatment for a 63-year-old male with a 3-day history of cough and colds, producing white phlegm, who has CKD stage 5 and asthma, considering a budget of 300 pesos and the PhilHealth formulary?

Medical Assessment for PhilHealth Encoding

Diagnosis

Acute Upper Respiratory Tract Infection (Acute Viral Bronchitis) with Acute Exacerbation of Asthma in a patient with CKD Stage 5

The 3-day history of cough with white phlegm and colds is consistent with acute viral bronchitis, which typically lasts up to 3 weeks and is self-limited 1. Given the patient's known asthma, this acute respiratory infection has likely triggered bronchospasm, requiring treatment for both the viral syndrome and asthma exacerbation 1.

Clinical Assessment

Key Diagnostic Considerations

• Acute bronchitis is the primary diagnosis based on the short 3-day duration of productive cough with white phlegm, which is characteristic of viral upper respiratory infection 1, 2.

• Asthma exacerbation must be addressed as respiratory infections are common triggers for bronchospasm in asthmatic patients, and cough in asthma requires standard antiasthmatic therapy with inhaled bronchodilators and corticosteroids 1.

• CKD Stage 5 significantly limits medication options - avoid NSAIDs, adjust doses for renal function, and avoid nephrotoxic agents 1.

• Antibiotics are NOT indicated as routine antibiotic treatment for acute bronchitis is not justified and should not be offered 1.

Treatment Plan

Medications (Within 300 Peso Budget - PhilHealth Formulary)

1. Salbutamol (Albuterol) Inhaler 100 mcg/puff

• Dose: 2 puffs every 4-6 hours as needed for wheezing/dyspnea
• Dispense: 1 inhaler (200 doses)
• Duration: 7-14 days or until symptoms resolve
• Rationale: First-line bronchodilator for acute asthma exacerbation, safe in CKD 1

2. Cetirizine 10 mg tablets

• Dose: 5 mg once daily (reduced dose for CKD Stage 5)
• Dispense: 7 tablets
• Duration: 7 days
• Rationale: First-generation antihistamines with decongestants are effective for acute cough associated with upper respiratory tract infection 1

3. Paracetamol 500 mg tablets

• Dose: 500 mg every 6 hours as needed for fever/discomfort (maximum 2 grams/day in CKD)
• Dispense: 14 tablets
• Duration: 7 days as needed
• Rationale: Safe antipyretic in renal disease when dose-adjusted; avoid NSAIDs like naproxen due to CKD Stage 5

Non-Pharmacologic Measures

• Adequate hydration (monitor fluid status given CKD Stage 5)
• Rest and avoidance of triggers
• Proper inhaler technique education

Recommendations

• Return to work/school: Patient may return to work/school after 48 hours if fever-free and symptoms improving
• Follow-up: Return in 3-5 days if symptoms worsen or do not improve
• Reassessment needed if: Fever persists beyond 72 hours, development of dyspnea at rest, hemoptysis, or chest pain worsens 3

Red Flags Requiring Immediate Re-evaluation

• Respiratory distress or severe dyspnea 4
• Persistent fever >5 days 4
• Hemoptysis 3
• Worsening chest pain 3
• Signs of fluid overload (given CKD Stage 5)

---

Medical Certificate

This certifies that the patient has been seen and examined today with the diagnosis of:

Acute Upper Respiratory Tract Infection (Acute Viral Bronchitis) with Acute Exacerbation of Asthma

Recommendation:

Patient is advised home rest for 2 days with prescribed medications. May return to work/school after 48 hours if fever-free and symptoms are improving. Follow-up consultation if symptoms persist beyond 5 days or worsen.

This medical certificate is issued upon the request of the patient for: return to work after medical leave due to illness.