What is the appropriate management for a 16-year-old female presenting with a worsened cough, difficulty breathing, white phlegm, lower pelvic pain, and a history of chronic nausea, without fever, chest pain, or difficulty urinating?

Management of a 16-Year-Old Female with Worsening Cough, Dyspnea, and White Phlegm

This patient requires a chest radiograph and spirometry immediately to rule out pneumonia or other structural abnormalities, followed by a 2-week trial of antibiotics targeting common respiratory bacteria for suspected protracted bacterial bronchitis given the >2-week duration of wet/productive cough. 1, 2

Immediate Diagnostic Workup

Obtain a chest radiograph now to assess for pneumonia, given the progression from mild allergic symptoms to worsened cough with dyspnea and productive white phlegm over 2+ weeks, plus household exposure to bronchitis. 1, 2 The presence of difficulty breathing and productive cough warrants imaging regardless of fever absence. 2

Perform spirometry if available to assess for airway obstruction or reversibility, particularly given the dyspnea component. 1, 2 This helps differentiate between infectious bronchitis, asthma, or other causes of airway compromise. 2

Primary Diagnosis and Treatment

Protracted Bacterial Bronchitis (Most Likely)

Initiate a 2-week course of antibiotics targeting common respiratory bacteria (amoxicillin-clavulanate is typical first-line) given the wet/productive cough persisting >2 weeks without specific red flag features. 1 The white phlegm production, household contact with diagnosed bronchitis, and >2-week duration strongly suggest protracted bacterial bronchitis. 1

• If cough persists after 2 weeks of antibiotics, extend treatment for an additional 2 weeks before considering alternative diagnoses. 1
• If cough resolves with antibiotics, this confirms the diagnosis of protracted bacterial bronchitis. 1

Rule Out Asthma

Given the difficulty breathing and potential for post-viral bronchial hyperresponsiveness, assess for asthma features: nocturnal symptoms, exercise intolerance, or wheeze. 1, 2

• If spirometry shows reversible airflow obstruction, add inhaled bronchodilators (albuterol) and monitor response. 1, 2
• If spirometry is normal but asthma is suspected clinically, consider a trial of inhaled bronchodilators to assess response. 2
• The chronic anxiety and nausea history does not exclude asthma but suggests careful evaluation for multiple contributing factors. 3

Address the Pelvic Pain Separately

The lower pelvic cramping pain for 2 days is most likely dysmenorrhea given the moderate, intermittent, cramping quality in a 16-year-old female. 1 However, rule out pregnancy with a urine pregnancy test given the pelvic pain presentation, even with recent LMP documented. This is critical before prescribing antibiotics or other medications.

• The pelvic pain is unlikely related to the respiratory symptoms unless there is referred pain from severe coughing, but this would be musculoskeletal rather than true pelvic pain. 3

Environmental and Supportive Measures

Counsel on avoiding environmental tobacco smoke and other pollutants that may be exacerbating the cough. 3, 1 This is essential regardless of the underlying diagnosis. 3

Address the chronic nausea and Zofran use by ensuring it's not contributing to or masking other symptoms, though this is unlikely related to the acute respiratory presentation. 3

Critical Red Flags to Monitor

Do not dismiss this as simple post-viral cough given the progression and dyspnea. 2 Watch for:

• Hemoptysis (coughing blood) - requires immediate further evaluation 2, 4
• Persistent fever (though currently absent) 4
• Weight loss or night sweats - consider tuberculosis in endemic areas 3, 4
• Worsening dyspnea or respiratory distress - may require emergency evaluation 2

Follow-Up Timeline

Reassess in 2 weeks after initiating antibiotics to determine response. 1 If no improvement:

• Extend antibiotics for another 2 weeks 1
• Consider chest CT if chest radiograph was normal but symptoms persist to evaluate for bronchiectasis or other structural abnormalities 3
• Refer to pulmonology if symptoms persist beyond 4 weeks of appropriate treatment 2

What NOT to Do

Do not use over-the-counter cough suppressants or codeine-containing medications - these are ineffective and potentially harmful in adolescents. 1

Do not empirically treat for GERD, upper airway cough syndrome, or asthma without specific features suggesting these diagnoses. 3, 1 The productive cough and household exposure point toward infectious etiology first. 1

Do not delay antibiotics while waiting for test results if clinical suspicion for bacterial bronchitis is high based on the wet cough >2 weeks and household exposure. 1