Acute Bronchitis

HISTORY:

‍CoughChest congestion for ‍ ‍hoursdays

‍cough, ‍non-productiveproductive

‍sputum, ‍clearcolored

‍sore throat

‍nasal congestion

‍chest congestion

‍shortness of breath

‍wheezing

‍chest pain, ‍retrosternal, ‍on exertionat restwith deep breath

‍fever, up to ‍°, over ‍ ‍hoursdays

‍fatigue

‍headache, ‍diffuse, ‍persistentintermittent, ‍pressurethrobbing, ‍mild

Worsening factors: ‍none

Treatments tried: ‍none, ‍effectiveineffective



EXAM:

General appearance: ‍well-appearing

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Ears: -R: ‍normal, -L: ‍normal

Nose: ‍normal

Throat: ‍normalrednessexudate

Neck: ‍normallymphadenopathy

Heart: ‍RRR, ‍normal S1 and S2

Lungs: ‍clearabnormal sounds, ‍retractions

Skin: ‍no rash

Extremities: ‍edema, ‍warm, cap refill ‍< 3 sec> 3 sec, pulses ‍normal, ‍



ASSESSMENT:

‍Acute Bronchitis ‍likelysuspectedpossible

DDx: ‍



PLAN:

- Chest X-ray if symptoms persist after 3 weeks or if severe symptoms

- Sputum culture

- Blood work: ‍CBC, ‍CRP, ‍electrolytes, ‍creatinine

- ‍Antibiotics

- ‍Bronchodilators

- ‍Cough suppressants

- ‍Analgesics

- Hydration and rest

- Smoking cessation counseling

- Follow-up in ‍ ‍daysweeks

- Return if symptoms worsen or if new symptoms develop

- Go to ER if severe chest pain, severe shortness of breath, or fever occurs