A 72-year-old man presents to urgent care with 10 days of cough, initially dry but now productive of yellow sputum. He reports mild fatigue and intermittent wheezing but denies chest pain, hemoptysis, or syncope. He has had no high fevers. He is currently taking tiotropium daily for his chronic obstructive pulmonary disease (COPD), lisinopril for hypertension, and metformin for treatment of type 2 diabetes.
His vital signs are: temperature, 37.6°C; blood pressure, 138/82 mm Hg; heart rate, 94 beats/min; respiratory rate, 18 breaths/min; and O₂ saturation, 96% on room air. On physical examination, he has mild bilateral wheezing and rhonchi that improve with coughing, and no focal crackles, egophony, or signs of consolidation.
Which of the following is the most appropriate next step in management for this patient?
- Prescribe azithromycin due to productive sputum
- Order chest x-ray to evaluate for pneumonia
- Start oral corticosteroids for acute bronchitis
- Provide supportive care and prescribe albuterol for wheezing
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Correct answer: d. Provide supportive care and prescribe albuterol for wheezing
The patient had classic features of acute bronchitis with normal vital signs and no signs of pneumonia (eg, fever, tachypnea, hypoxia). His lung examination showed wheezing that improved with coughing, which supported a diagnosis of bronchitis rather than pneumonia, as did the absence of focal findings such as crackles or consolidation. Chest imaging is not required for this patient, and prescribing a short-acting bronchodilator for his wheezing is appropriate, given his history of COPD.
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Tracey Davidoff, MD, FACP, FCUCM, has practiced Urgent Care Medicine for more than 15 years. She is Board Certified in Internal Medicine. Dr. Davidoff is a member of the Board of Directors of the Urgent Care Association and serves as Co-Editor-in-Chief of the College of Urgent Care Medicine’s “Urgent Caring” publication. She is also the Vice President of the Southeast Regional Urgent Care Association and a member of the editorial board of the Journal of Urgent Care Medicine. At EB Medicine, Dr Davidoff is Editor-In-Chief of Evidence-Based Urgent Care, and co-host of the Urgentology podcast.
