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Stem
A 28-year-old man presents to his general practitioner with a 5-day history of cough that began after a sore throat and runny nose. The cough is initially dry but is now producing yellow-green sputum. He has mild chest tightness but no shortness of breath. He is afebrile, respiratory rate 16/min, SpO2 99% on air, heart rate 78/min, BP 118/74 mmHg, and on examination the chest is clear apart from a few coarse crackles at both bases that clear on coughing. He has no past medical history, takes no regular medication, and smokes 10 cigarettes a day. He asks for a course of antibiotics because the sputum is green.
Questions
a) What is the most likely diagnosis, and give two bedside features that exclude pneumonia? (2 marks)
Acute bronchitis (acute viral tracheobronchitis). Pneumonia is excluded by (1) normal vital signs — no tachypnoea, no hypoxia, no high fever, no tachycardia — and (2) the absence of focal chest signs (no consolidation: no dullness to percussion, no bronchial breath sounds, no increased vocal resonance; the crackles clear on coughing).
b) Why are antibiotics not indicated here, and what is the key evidence? (2 marks)
Acute bronchitis is viral in over 90% of cases, and the green sputum reflects neutrophilic inflammation, not bacterial infection — it does not justify an antibiotic. The Cochrane review (Smith 2017, PMID 28626858) shows antibiotics provide only a small, clinically insignificant reduction in cough duration (less than a day) while significantly increasing adverse effects (nausea, vomiting, diarrhoea, rash); the ACP/ASIM principles of appropriate antibiotic use also advise against routine antibiotics.
c) Outline the symptomatic management with specific agents and doses. (3 marks)
- Reassurance and education — explain the illness is viral and self-limiting; the cough will last 1–3 weeks (sometimes up to 8); antibiotics will not help and may cause harm; offer a delayed (post-dated) prescription if desired.
- Antipyretic/analgesia: paracetamol 1 g orally every 6 hours (maximum 4 g/24 h) or ibuprofen 400 mg every 8 hours.
- Cough: honey 1–2 teaspoons (over 1 year) or an antitussive such as dextromethorphan 10–20 mg every 4 hours for a troublesome dry cough.
- Smoking cessation advice. Rest and adequate oral fluids.
d) Under what specific circumstance would you prescribe an antibiotic, and what would you give? (2 marks)
If the cough exceeded 3 weeks with paroxysms, an inspiratory whoop, or post-tussive vomiting (suggesting pertussis), or there were known exposure to pertussis — investigate with a nasopharyngeal swab for pertussis PCR and treat with a macrolide: azithromycin 500 mg on day 1 then 250 mg daily on days 2–5, with public-health notification and contact chemoprophylaxis.
e) Give two red flags that would prompt you to arrange a chest X-ray. (1 mark)
Any of: tachypnoea / hypoxia / high fever / tachycardia / hypotension, focal chest signs (consolidation or effusion), haemoptysis, diagnostic uncertainty, significant comorbidity (COPD, heart failure, immunocompromise), failure to improve or deterioration, or smokers over 50 with persistent cough.