PANCE Blueprint Pulmonary (9%)

26 y/o female with acute onset of cough and dyspnea during pregnancy

Patient will present as → a 45-year-old female presents to the clinic with a 5-day history of cough and feeling generally unwell. She reports the cough started as a dry, irritating cough but has since progressed to a productive cough with yellowish sputum. She denies any shortness of breath or wheezing but mentions mild chest discomfort with coughing. She also reports a low-grade fever and malaise. On examination, her temperature is 37.8°C (100.4°F), her respiratory rate is 18 breaths per minute, and her oxygen saturation is 98% on room air. Scattered rhonchi are heard throughout all lung fields. A diagnosis of acute bronchitis is made. The patient is advised about the viral nature of most acute bronchitis cases, meaning antibiotics are not indicated. She is counseled on symptomatic management, including increased fluid intake, rest, and over-the-counter cough suppressants and analgesics as needed for comfort. She is advised to return if symptoms worsen or if she develops shortness of breath, high fever, or persistent symptoms beyond a few weeks. A follow-up phone call in a week is scheduled to assess her progress.

Acute bronchitis is an inflammation of the bronchial tubes (the airways that carry air to the lungs)

• It typically develops from a cold or other respiratory infection and is characterized by the production of mucus (sputum), coughing, and sometimes shortness of breath and wheezing
• Symptoms include persistent cough (lasting more than 5 days, up to 3 weeks) that may be productive (yellow sputum), white nasal discharge, sore throat, and fatigue
• Auscultation of the lungs may reveal scattered rhonchi or wheezing, which often clears with coughing
• A low-grade fever is common - but a high fever is unusual in acute bronchitis. If your patient has a fever, consider pneumonia
• Most cases (over 90%) of acute bronchitis are viral (e.g., influenza, rhinovirus, coronavirus)
• Bacteria, such as Mycoplasma pneumoniae, Bordetella pertussis, and Chlamydia pneumoniae, cause less than 10% of cases and sometimes occur in outbreaks

Chest X-ray if the diagnosis is uncertain or symptoms have persisted despite conservative treatment

Since most cases (over 90%) are viral, symptomatic treatment is the cornerstone of management:

• Supportive measures include hydration, expectorants, analgesics, β2-agonists, and cough suppressants as needed (not recommended for children)
• For patients who desire medication for cough, offer over-the-counter medications such as dextromethorphan or guaifenesin rather than other medications
  • Reserve use of inhaled beta-agonists, such as albuterol, for patients with wheezing and underlying pulmonary disease
• Antibiotics are not recommended for acute bronchitis. Purulent (yellow or green) sputum does not predict a bacterial infection or a response to antibiotics
• Reserve antimicrobials for a specific suspected or confirmed pathogen: pertussis (a macrolide such as azithromycin is first-line) or influenza in a high-risk patient (oseltamivir)
• Fever above 38°C (100.4°F), other abnormal vital signs, or focal lung findings suggest pneumonia: obtain a chest x-ray
• Acute exacerbations of chronic bronchitis (COPD) are a different condition and are managed separately