What is the diagnosis and recommended treatment for a 58-year-old female patient presenting with cough and difficulty expelling mucus?

Medical Assessment and Treatment Plan

Diagnosis

Acute Upper Respiratory Tract Infection with Productive Cough (Acute Bronchitis)

This 58-year-old female presents with occasional cough, difficulty expectorating phlegm, and throat irritation consistent with acute bronchitis—a self-limiting viral infection of the large airways 1, 2. The symptom duration appears acute (<3 weeks), and there are no clinical features suggesting pneumonia (no fever, tachypnea, or focal lung findings mentioned) 1.

Treatment Recommendations

Medication Plan (PhilHealth Konsulta Formulary)

Dextromethorphan 15mg/5mL syrup

• Dosing: 10mL (30mg) every 6-8 hours as needed for cough
• Dispense: 120mL bottle
• Duration: 7 days
• Cost estimate: ₱80-120

3, 4

Cetirizine 10mg tablet (first-generation antihistamine alternative if unavailable: Chlorpheniramine 4mg)

• Dosing: 1 tablet once daily at bedtime
• Dispense: 7 tablets
• Duration: 7 days
• Cost estimate: ₱35-70

1, 3

Total estimated cost: ₱115-190

Why These Medications

• Dextromethorphan is specifically recommended for dry, bothersome cough that disrupts daily activities and sleep 3, 4
• Antihistamines address the upper airway irritation (throat itching) and post-nasal drip contributing to cough 1, 3
• Antibiotics are NOT indicated because acute bronchitis is viral in >90% of cases, and antibiotics provide minimal benefit (only 0.5 day reduction in cough) while causing adverse effects 1, 2, 5

Non-Pharmacologic Measures

• Adequate hydration (8-10 glasses water daily)
• Avoid irritants (smoke, strong odors)
• Honey for throat soothing (if not diabetic)
• Rest as needed

2, 5

Expected Course and Follow-Up

Expected duration: Cough typically lasts 2-3 weeks even with treatment 2, 5, 6. This is important patient education to prevent unnecessary antibiotic requests.

Return immediately if:

• Fever >38°C develops
• Breathing difficulty or chest pain occurs
• Cough persists beyond 3 weeks
• Blood in sputum

1

Routine follow-up: Only if symptoms worsen or persist beyond 3 weeks 2, 5

Medical Certificate

This certifies that the patient has been seen and examined today with the diagnosis of: Acute Upper Respiratory Tract Infection (Acute Bronchitis)

Recommendation: Symptomatic treatment with oral medications as prescribed. Patient is fit to return to work with the above medications for symptom relief. Expected recovery within 2-3 weeks.

Certificate issued for: Return to work clearance

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Patient Education Points

Your cough is caused by a viral infection of your airways (chest cold), not a bacterial infection 2, 5. This means:

• Antibiotics will not help and may cause side effects like diarrhea or allergic reactions 1, 2
• The cough medicine will help suppress the irritating cough 3, 4
• The antihistamine will reduce throat irritation and help you sleep 1, 3
• Complete recovery takes 2-3 weeks even with proper treatment—this is normal 2, 5

Return immediately if you develop high fever, difficulty breathing, or cough up blood 1.