An Adult With a 10 Day History of Cough

A 28‑year‑old male non‑smoker with no chronic health problems presents with a 10‑day history of persistent cough that's worse at night, stating, "I started with a head cold about two weeks ago. The cold moved into my chest." He reports mild chest discomfort with deep cough, rare production of small amounts of clear to white sputum, and feels tired because, "the cough keeps waking me up." He denies sore throat, fever, ear pain, shortness of breath, or GI symptoms. Objective temp 97.6, heart rate 72, respiratory rate 18, BP 112 over 68, SpO2 is 99%, no acute distress, mild pharyngeal redness, no lymphadenopathy, chest without crackles, occasional dry cough, abdominal exam is within normal limits. 

Which of the following is the most appropriate next step?

A. Prescribe one week of oral amoxicillin.

B. Order a chest x-ray

C. Prescribe a five-day course of azithromycin

D. Provide advice about symptomatic care

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Transcript

Voiceover: Welcome to NP Certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question so you can better understand how to arrive at the correct test answer. So, if you're ready, let's jump right in.

Margaret Fitzgerald: A 28‑year‑old male non‑smoker with no chronic health problems presents with a 10‑day history of persistent cough that's worse at night, stating, "I started with a head cold about two weeks ago. The cold moved into my chest." He reports mild chest discomfort with deep cough, rare production of small amounts of clear to white sputum, and feels tired because, "the cough keeps waking me up." He denies sore throat, fever, ear pain, shortness of breath, or GI symptoms. Objective temp 97.6, heart rate 72, respiratory rate 18, BP 112 over 68, SpO2 is 99%, no acute distress, mild pharyngeal redness, no lymphadenopathy, chest without crackles, occasional dry cough, abdominal exam is within normal limits. 

Which of the following is the most appropriate next step? 

A. Prescribe one week of oral amoxicillin

B. Order a chest x-ray 

C. Prescribe a five-day course of azithromycin 

D. Provide advice about symptomatic care

The correct answer is D. Provide advice about symptomatic care.

Where should you start with this question? First, as we've done with all the other questions, let's determine what kind of a question it is. The format of this question is a bit different and that many questions we've looked at we could clearly say it's a plan question, it's assessment question or whatever. But here you'll notice that option B is actually an assessment answer. The others are all plan/intervention answers. 

So let me expand on that a little bit. You might wonder, how could a question that's considered to be valid on boards have both an assessment answer and a treatment/plan/intervention answer and put that out to you and say figure it out. Remember, the NP boards are geared for you to demonstrate that you will be a safe entry-level NP in whatever your focus of study is. And most of you are family and adult gero primary care NPs and therefore your focus of study has been primary care practice that will include a fair chunk of same day urgent care, and this kind of question absolutely could be on your boards. And in this case since the correct answer is focused on treatment. This is what we need to walk away from this question with. You need to know that you can make the diagnosis off the information provided. And that's exactly what's happened here. What's the diagnosis? Acute bronchitis. What is it? It's a clinical diagnosis. As a reminder, what is a clinical diagnosis? It's one that's made off the history and physical exam. No additional information is needed. for example, no imaging, no lab testing, nothing along those lines are necessary to make this diagnosis.

So, a bit of background information on acute bronchitis. It is one of those diseases that really kind of defines itself. It's a condition of lower airway inflammation that is self-limited, meaning it resolves on its own, usually caused by viral infection, and it can persist for up to 3 weeks or occasionally as long as four to six weeks. This person's 10 days into it. The diagnosis is usually limited to those without chronic airway disease, and we're told that about this patient. Otherwise, well, there's no asthma, no COPD. Now, one of the things is then if this is acute bronchitis, how come I just wouldn't say it's a viral URI or something like that? Well, part of this is acute bronchitis can be differentiated from the common cold, which usually lasts 7 to 10 days. But with the common cold, you're going to have nasal congestion, rhinorrhea, a sore throat, that type of thing. This person has none of that. Now, the other big differential, of course, is pneumonia. How do you differentiate acute bronchitis from pneumonia? With pneumonia, you're going to have the presence of fever, tachypnea, perhaps tachycardia, and clinical lung findings such as crackles, bronci that do not clear with cough and the like. Acute bronchitis, what's the causative pathogen? Nearly always viral. And the culprits can be adenovirus, coronavirus, influenza A or B, RSV, SARS Kovv2. A variety of viruses can cause acute bronchitis.

When bacterial infection is implicated in acute bronchitis which is rare less than 5% of the time and it usually will resolve without any antimicrobial, but two bugs do on rare occasion. Did you hear me say rare occasion? That would be C pneumonia and M pneumonia. In other words, atypical pathogens. 

So, what's why do people with acute bronchitis come in? Here's the reason why. Listen to him. He's tired. He's coughing at night. He can't get any sleep. The problematic cough is usually what brings people in. And they're complaining of disordered sleep, fatigue caused by this cough. That's why he's in your exam room today. And typically the cough with acute bronchitis it persists beyond the average 7 to 10 days of the typical viral URI. If there is sputum production it is scant. It is more likely absent and the color of the sputum can go from clear to white to as much as yellow or green. Contrary to color common belief, colored sputum does not represent bacterial infection but is rather evidence of the presence of leucocytes mobilized by the body to counter the infecting agents. And that often happens with somebody who has green nasal discharge, too. They're convinced they've got a bacterial sinusitis because their nasal discharge is green. And what it means is lots of white blood cells went to the nose and sinuses tinged the nasal discharge a different color. And I discuss with patients that that's actually a really really good finding because it means the body is fighting the infection off.

With acute bronchitis, fever is extraordinarily rare because let's just say we rewound the clock 10 days to the first day of his cold. He might have had a little bit of a fever that day or at least felt feverish, but he's telling us he's had no fever. We document he has no fever. If you have an acute bronchitis-like picture again this is usual person will be younger healthier no comorbidity and they actually do have a documented fever you should start thinking more of a diagnosis of influenza or pneumonia with acute bronchitis the lung exam is usually within normal limits as it is with this patient with the exception of the dry cough. As I had mentioned before we'd expect at this point with acute bronchitis no sore throat, earache or GI symptoms. Why is his pharynx a little bit red? It's red because he's coughing and that really irritates the pharynx, but it doesn't give him a sore throat. Treatment for acute bronchitis is largely supportive with little evidence that antimicrobial therapy is helpful. With that information in mind, let's take another look at the question. 

A 28-year-old male, non-smoker with no chronic health problems, presents with a 10-day history of persistent cough that's worth it worse at night, stating, “I started with a head cold about two weeks ago. The cold moved into my chest.” He reports mild chest discomfort with dis deep cough, rare production of small amounts of clear to white sputum and feels tired because “the cough keeps waking me up”. He denies sore throat, fever, ear pain, shortness of breath, or GI symptoms. Objective: temp 97.6, 6 heart rate 72 respiratory rate 18 BP 112 over 68 SPO2 is 99% no acute distress mild fair redness no lymphadenopathy chest without crackles occasional dry cough abdominal exam is within normal limits which of the following is the most appropriate next step? 

A. prescribe a one week of oral amoxicillin. This is of course incorrect. Cute bronchitis is nearly always viral in origin. My practice has been split into like 60% primary care, 40% same day urgent care for literally years. I cannot remember the last time I prescribed an antibiotic for acute bronchitis. One of the most common reasons for an unnecessary antimicrobial course is the treatment of acute bronchitis. We must all be sound stewards of antimicrobial therapy. Prescribe it when it's needed and don't prescribe it when it's not. 

B. Order a chest X-ray. Again, this is incorrect. Chest X-ray would be indicated if there was suspicion of pneumonia such as fever, difficulty breathing, increased sputum production, abnormal lung exam. None of those are present in this patient. 

C. Prescribe a 5-day course of azithromycin. Well, look back at option A. You know, if amox is no good, then azithromycin would be no good. But sadly, the practice of prescribing a Zpack in this clinical scenario is incredibly common, which doesn't mean it's acceptable practice. And you might say to yourself, "Yes, but I did a clinical rotation in an urgent care and they gave out a lot of Zpacks to patients like this." Okay, that's what they did. You shouldn't do that in practice. And if you answer a question on boards like this, there is a question you're going to get wrong just because of what you've seen in practice. 

Option D, of course, is the correct answer. Provide advice about symptomatic care. And in my practice, particularly when a patient has the expectation that they might get an antimicrobial, but I'm not going to prescribe one since it's not indicated. I approach my counsel like this. I start off with a lot of sympathy for the fact that the person hasn't felt well now for a number of days. Imagine that this person is sitting in your exam room and has a toddler, a 2-year-old, and a four-year-old with them. And I'll ask a little further, "Oh, have the kids been sick?" "Yeah, the kids were the ones that brought this cold into the house." I said, 'Oh, so you've been up off and on all night with the kids for the last couple of weeks, too. Yeah, but they're better now. I said, 'Oh, so you really went into this cold pretty run down, didn't you? Yeah, I did. I said, oh, this is one of the tough parts about raising kids, isn't it? So, I automatically do this big like, oh, this is tough. I'm so sorry you're feeling so poorly. They don't have kids? Okay, I'll cut that part out. I'll cut that part out right off the bat. Have you missed any days of work? Yeah, I I missed the day before yesterday. I was just so tired. I couldn't get out of bed. Okay, I'll write you a note. Will that be helpful? You know, right off the bat, I put myself in service to the patient. Okay. And let's say the person said, "No, I've been dragging myself to work every single day." And I will say, is there a possibility you can take even just one day off? I'll write you a note. 

Now, sometimes a lot of the patients I see, they don't get any paid time off. So, they'll tell me, "No, I'm going into work anyway." But some of them do, and they'll say, "Oh, yeah, they'd be great. I I'll just I'll take a day off and I'll sleep all day." Perfect. Okay. Yep. Here's your note. Here's your note. So really, really important to be empathetic to that. And again, if they've got kids at home and they need a little time away from the kids so that they can get in a nap, say, "Who could help you out? Who would take the kids for a while so that you could at least get a long nap one day?" Okay. And while I'm doing my physical exam, I also verbalize my findings to the patient as I start off. And so this sounds a lot better in real life than it does say giving you this condensed version. But I will do something along the lines of ears look clear, throat no evidence of strep, listening to your chest excellent, no pneumonia because people will be fearful of that. And I will say your body is doing a great job fighting off this infection which is from a virus. The good news is you don't need an antibiotic. But I'm going to give you advice on controlling the cough so that you can get some rest so you can finally start feeling better. And people are incredibly appreciative of this information. And it's a world of difference between the provider saying it's just a virus and you don't need an antibiotic. I'll go over what is best evidence for cough and cold remedies in a future podcast. 

Key takeaway, knowing when not to prescribe an antimicrobial is just as important as knowing when to prescribe an antimicrobial. The NP board content will be based on this principle.

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