(ACUTE BROCHITIS) Follow the MRU Soap Note Rubric as a guide: Use APA format and must include mia minimum of 2 Scholarly Citations. Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program) The use of templates is ok with regards to Turn it in, but the Patient History, CC, HPI, Assessment, and Plan should be of your own work and individualized to your made-up patient.

Title: Acute Bronchitis: Assessment and Treatment

Introduction:
Acute bronchitis is a common respiratory condition characterized by the inflammation of the bronchial tubes leading to coughing, chest discomfort, and sputum production. It typically occurs as a result of viral infection, although bacterial and environmental factors can also contribute to its development. This paper presents an assessment and treatment plan for a patient with acute bronchitis, considering their medical history and presenting symptoms.

Patient History:
The patient is a 35-year-old male who presents with a chief complaint of persistent cough and mild chest pain for the past three days. He reports a recent upper respiratory tract infection, characterized by nasal congestion, sore throat, and malaise. The patient denies any history of chronic respiratory conditions such as asthma or chronic obstructive pulmonary disease (COPD). He has no known allergies and is a non-smoker. The patient’s medical history reveals no significant underlying health conditions.

Chief Complaint (CC):
The patient’s chief complaint is a persistent cough and mild chest pain.

History of Present Illness (HPI):
The patient’s cough began approximately three days ago and is characterized as non-productive. He reports chest discomfort that worsens with coughing. The cough has been accompanied by nasal congestion and a sore throat, suggesting an upper respiratory tract infection. The patient reports mild fatigue but no fever or shortness of breath. He has tried over-the-counter cough syrup, but it has provided only minimal relief.

Assessment:
Based on the patient’s symptoms and history, the most likely diagnosis is acute bronchitis. Acute bronchitis is often viral in nature and commonly follows an upper respiratory tract infection. The absence of fever and shortness of breath suggests a mild presentation, while the presence of chest discomfort supports the diagnosis.

Differential Diagnosis:
To ensure that the diagnosis is accurate, it is important to consider other potential causes of the patient’s symptoms. Differential diagnoses for a persistent cough and chest pain may include pneumonia, asthma exacerbation, chronic bronchitis, and gastroesophageal reflux disease (GERD). However, given the absence of fever, sputum production, and known risk factors for these conditions, acute bronchitis remains the most likely diagnosis.

Physical Examination:
Upon physical examination, the patient’s vital signs are within normal limits, with no fever or respiratory distress observed. Chest auscultation reveals scattered wheezes and rhonchi, consistent with bronchial inflammation and bronchospasm.

Diagnostic Tests:
Although no specific diagnostic tests are required to confirm the diagnosis of acute bronchitis, a chest X-ray may be considered if the patient’s symptoms persist or worsen beyond the expected time frame. Additionally, a sputum culture may be obtained if there is concern for a bacterial etiology or if the patient fails to respond to initial treatment.

Treatment Plan:
The primary goals of treating acute bronchitis include symptom relief and prevention of complications. As the condition is primarily viral in nature, antibiotic therapy is usually not indicated unless a secondary bacterial infection is suspected. Non-pharmacological measures, such as rest, hydration, and humidification, are recommended.

Pharmacological interventions may include short-acting bronchodilators, such as albuterol, to relieve bronchospasm and improve airflow. This can be administered via inhalation using a metered-dose inhaler with a spacer or a nebulizer. Antitussive agents, such as dextromethorphan, may be used to suppress coughing, especially at night to improve sleep quality. However, it is important to note that cough suppression should be weighed against the potential risk of retained secretions.

Lastly, analgesics, such as non-steroidal anti-inflammatory drugs (NSAIDs), may provide relief from chest pain and discomfort. These should be used judiciously, considering the patient’s contraindications and any potential drug interactions.

Follow-up Plan:
The patient should be advised to follow up in two weeks for reassessment if his symptoms do not resolve within 7-10 days. Follow-up appointments allow for monitoring of symptom progression and the need for further diagnostic tests or potential changes in treatment.

Conclusion:
Acute bronchitis is a common respiratory condition characterized by inflammation of the bronchial tubes. Symptom management, rest, hydration, and supportive care are the cornerstone of treatment. Pharmacological interventions, such as bronchodilators and antitussive agents, may be used as adjuncts to relieve symptoms. Regular follow-up is essential to assess response to treatment and ensure resolution of symptoms.+