Diagnosis: Acute Viral Upper Respiratory Infection (Acute Bronchitis)
This is most likely an uncomplicated acute viral upper respiratory infection (URI) or acute bronchitis, given the presentation of cough, sore throat, and chest tightness in a young, otherwise healthy adult with a negative chest X-ray. 1
Clinical Reasoning
Why This is NOT Pneumonia
- The negative chest X-ray effectively rules out pneumonia, which is the most important serious diagnosis to exclude in patients presenting with acute cough illness. 1
- Pneumonia should be suspected only when acute cough is accompanied by new focal chest signs, dyspnea, tachypnea, or fever >4 days—and even then requires chest radiography for confirmation. 1
- In the absence of abnormal vital signs (heart rate ≥100 bpm, respiratory rate ≥24 breaths/min, temperature ≥38°C) and focal chest examination findings (rales, egophony, fremitus), the likelihood of pneumonia is sufficiently low that the negative X-ray confirms this. 1
Why This is Acute Bronchitis/URI
- Acute cough is defined as lasting <3 weeks, and this patient is in the early phase of illness. 1
- The combination of cough, sore throat, and chest tightness without focal findings is classic for acute bronchitis, which is predominantly viral in etiology. 1, 2
- Chest tightness in acute bronchitis results from transient bronchial hyperresponsiveness and airway inflammation, not bacterial infection. 1
- Approximately 70% of adults presenting with acute cough have an upper respiratory tract infection, making this the most likely diagnosis. 1
Evidence-Based Treatment Plan
Immediate Symptomatic Management (Days 1-5)
- Analgesics: Acetaminophen or ibuprofen for sore throat, chest discomfort, and any fever. 2, 3
- Throat lozenges for sore throat relief. 2
- Pseudoephedrine if nasal congestion is present (though not mentioned in this case). 2
- Adequate hydration and rest. 2
Cough Management
- DO NOT prescribe benzonatate or other peripheral/central cough suppressants (codeine, dextromethorphan) for URI-related cough—these have limited efficacy in acute viral infections. 1, 2
- If cough persists beyond 3-5 days and is bothersome, switch to inhaled ipratropium bromide as the first-line cough suppressant (Grade A recommendation). 1, 2
- Ipratropium bromide is the only inhaled anticholinergic agent recommended for cough due to URI or acute bronchitis. 1
What NOT to Do
- NO antibiotics: This is a viral infection, and antibiotics are not indicated for uncomplicated acute bronchitis. 1, 2
- Purulent sputum does NOT indicate bacterial infection and is not a reason to prescribe antibiotics—purulence results from inflammatory cells and can occur with viral infections. 1
- NO albuterol unless there is evidence of significant bronchospasm or underlying asthma. 1
Expected Clinical Course
- Symptoms typically peak at days 3-6 and should begin improving thereafter. 2
- Most uncomplicated viral URIs resolve within 5-7 days, though cough may persist for up to 3 weeks (post-infectious cough). 1, 2, 4
- Transient bronchial hyperresponsiveness can last 2-3 weeks, occasionally up to 2 months. 1
Red Flags Requiring Re-evaluation
The patient should return if any of the following develop: 2
- Symptoms persist >10 days without improvement
- Symptoms worsen after initial improvement (suggests bacterial superinfection)
- High fever with purulent discharge (suggests bacterial sinusitis)
- Development of focal chest findings or significant dyspnea (reconsider pneumonia)
Common Pitfalls to Avoid
- Do not diagnose asthma or cough-variant asthma in the setting of acute cough <2-3 weeks duration, as transient bronchial hyperresponsiveness is common in acute bronchitis and typically resolves. 1
- Do not prescribe antibiotics based on purulent sputum alone—this is a common misconception. 1
- Do not use over-the-counter combination cold medications for cough suppression, as evidence does not support their efficacy. 1