What is the appropriate evaluation and management, including need for antibiotics and a short‑term medical certificate, for an adult who quit smoking five weeks ago and now has a two‑week productive cough with yellow sputum that disrupts sleep but no fever, dyspnea, chest pain, or other systemic signs?

Management of Post-Smoking-Cessation Productive Cough

This patient requires reassurance, symptomatic management, and a short-term medical certificate—but not antibiotics—because his two-week productive cough with yellow sputum and no systemic signs represents a self-limited post-cessation airway clearance phenomenon that typically resolves within 4 weeks of quitting smoking. 1

Immediate Clinical Assessment

Exclude Red-Flag Features

• Verify the absence of hemoptysis, unintentional weight loss, fever, night sweats, significant dyspnea at rest, or recurrent pneumonia—all of which would mandate urgent investigation for malignancy, tuberculosis, or serious infection. 1, 2
• In this patient, the lack of fever, chest pain, dyspnea, and systemic symptoms effectively rules out pneumonia, pulmonary embolism, and acute bacterial infection. 1

Confirm Smoking History and Cessation Timeline

• Cough attributable to smoking typically resolves within 4 weeks after cessation in the majority of patients; approximately 90–100% experience resolution or marked improvement within this timeframe. 1, 3
• This patient quit 5 weeks ago and has had cough for 2 weeks, placing him well within the expected window for post-cessation airway inflammation and mucus clearance. 1, 3

Review Medications

• Discontinue any ACE inhibitor immediately, as these drugs cause chronic cough in 5–50% of patients and symptoms resolve within a median of 26 days (range up to 40 weeks) after stopping. 1, 2, 3
• This patient is not on any medications, so drug-induced cough is excluded. 2

Diagnostic Evaluation

Chest Radiograph Is Not Routinely Indicated

• Chest radiography is recommended only when red-flag features are present (e.g., hemoptysis, systemic illness, suspicion of foreign body, or concern for malignancy). 1
• In an otherwise healthy adult with a 2-week productive cough, no fever, no dyspnea, and recent smoking cessation, the pre-test probability of serious pathology is extremely low. 1
• Acute cough (<3 weeks) associated with viral upper respiratory infection is the predominant cause and usually resolves without specific therapy. 1, 2

Spirometry and Advanced Testing Are Not Required at This Stage

• Spirometry with bronchodilator testing is mandatory for chronic cough (>8 weeks) to detect airflow obstruction and assess reversibility, but this patient's cough has lasted only 2 weeks. 2
• If cough persists beyond 8 weeks, obtain chest radiograph and spirometry to evaluate for chronic bronchitis, COPD, asthma, or bronchiectasis. 1, 2

Management Strategy

No Antibiotics Are Indicated

• Routine antibiotic treatment of uncomplicated acute bronchitis is not recommended, regardless of duration of cough. 1
• Yellow or green sputum does not reliably distinguish bacterial from viral infection and should not trigger empiric antibiotic therapy in the absence of systemic signs (fever, tachycardia, hypoxia) or radiographic pneumonia. 1
• There is insufficient evidence to recommend routine use of any pharmacologic treatments (antibiotics, bronchodilators, mucolytics) for cough relief in stable chronic bronchitis. 1

Symptomatic Relief and Reassurance

• Supportive care with over-the-counter remedies (e.g., honey-lemon mixtures, steam inhalation) is appropriate for symptom relief while the post-cessation airway inflammation resolves. 1
• The patient has already tried steam inhalation and honey with occasional relief; continue these measures. 1
• Explain that post-cessation cough is a normal physiological response as ciliary function recovers and the airways clear accumulated mucus; most patients improve within 4 weeks. 1, 3

Medical Certificate

• Provide a short-term medical certificate (e.g., 3–5 days) to allow adequate rest and sleep, given that the cough is disrupting his sleep and affecting his quality of life. 1, 2
• Chronic cough significantly impairs quality of life, including sleep disruption, work absenteeism, and social embarrassment. 1

Follow-Up and Safety-Netting

Schedule Re-Evaluation at 4 Weeks

• If cough persists beyond 4 weeks after smoking cessation, obtain chest radiograph and spirometry to evaluate for chronic bronchitis, COPD, or other structural lung disease. 1, 2, 3
• In former smokers aged 55–80 years with ≥30 pack-year history, maintain a low threshold for imaging when the character of cough changes or persists, as this population meets lung-cancer screening criteria. 2, 3

Systematic Evaluation for Chronic Cough (If Cough Persists >8 Weeks)

• For cough lasting >8 weeks, systematically evaluate and treat the most common causes in sequential and additive steps: upper airway cough syndrome (UACS), asthma, non-asthmatic eosinophilic bronchitis (NAEB), and gastroesophageal reflux disease (GERD). 2, 3
• Up to 67% of chronic cough patients have multiple simultaneous causes, so therapy must be given in additive steps rather than stopping after identifying one potential cause. 2, 3

Common Pitfalls to Avoid

• Do not prescribe antibiotics for yellow sputum alone in the absence of fever, dyspnea, or radiographic pneumonia; this practice drives antimicrobial resistance without clinical benefit. 1
• Do not assume that post-cessation cough will resolve immediately; some patients require up to 4 weeks, and those with severe COPD may have persistent cough. 1, 3
• Do not overlook the possibility of lung cancer in older former smokers; if cough persists or changes character, obtain chest imaging. 2, 3