Acute Bronchitis

Age: ‍ years old

Gender: ‍malefemale



HISTORY:

Presents with a ‍-‍day history of ‍coughchest congestion

Symptoms include:

‍cough, ‍non-productiveproductive of ‍clearcolored phlegm

‍sputum, ‍clearwhiteyellowgreen

‍sore throat

‍nasal congestion

‍chest congestion

‍shortness of breath

‍wheezing

‍chest pain, ‍retrosternal, ‍aching, ‍on exertionat restwith deep breath, ‍mild

‍fever, up to ‍°, over ‍ ‍hoursdays

‍fatigue

‍headache, ‍diffuse, ‍persistentintermittent, ‍pressurethrobbing, ‍mild



Worsening factors: ‍none

Alleviating factors: ‍none, ‍effectiveineffective



Contributing factors:

‍smoking

‍exposure to respiratory irritants

no history of: ‍asthma, ‍chronic obstructive pulmonary disease, ‍allergies





EXAM:

General appearance: ‍well-appearing, ‍apparent distress

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

Ears: tympanic membranes ‍normal ‍, auditory canal ‍ on ‍rightleft, hearing ‍intact

Nose: ‍clear, discharge ‍clear, ‍

Throat: ‍normal, ‍erythema, ‍exudate, ‍

Neck: ‍normal, ‍lymphadenopathy, ‍, c-spine ‍

Heart: ‍RRR, ‍MRG, ‍normal S1 and S2

Lungs: ‍clear bilaterally, ‍abnormal sounds, ‍retractions

Skin: ‍rashlesions on ‍

Extremities: ‍warm, ‍dry, cap refill ‍< 3> 3 sec, pulses ‍intact, ‍edema ‍bilaterally, ‍





ASSESSMENT:

‍Acute Bronchitis ‍likelysuspectedpossible

DDx: acute bronchitis, viral URI, asthma exacerbation, COPD exacerbation, pneumonia, COVID-19, pertussis, allergic rhinitis, sinusitis, tuberculosis, lung cancer, foreign body aspiration, environmental irritants, occupational lung diseases





PLAN:

Investigations:

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

- Sputum culture

- Blood work: ‍CBC, ‍CRP, ‍electrolytes, ‍creatinine

Treatments:

- ‍Antibiotics

- ‍Bronchodilators

- ‍Cough suppressants

- ‍Analgesics

- Hydration and rest

- Smoking cessation counseling

Further care:

- Follow-up in ‍ ‍daysweeks

- Return if symptoms worsen or if new symptoms develop

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