MDM - Acute Bronchitis

[##]-year-old [male/female] with history and exam consistent with acute bronchitis of likely [viral/bacterial] etiology.

Initial consideration in this patient included bronchitis, pneumonia, influenza, allergic rhinitis, upper respiratory infections (URI), pulmonary embolism (PE), and reactive airway diseases (asthma, chronic bronchitis) among others. 

Patient presented with cough [productive of sputum] and [reported/evidence of] wheezing consistent with bronchitis.  Patient’s lung sounds were [notable for expiratory wheezing/noted to be normal].  Patient noted to [have/have no] evidence of fever or other systemic infectious symptoms.  A chest x-ray [was/was not] obtained [and noted to have no evidence of consolidations suggestive of pneumonia or other acute abnormality/due to absence of abnormal lung sounds or other evidence suggestive of pneumonia or other acute intrathoracic pathology].  The patient [reported/denied] a history of obstructive lung disease (asthma or COPD).  Patient [reported/denied] a history of tobacco use [and we discussed smoking cessation prior to discharge with the patient noted to be pre-contemplative/contemplative/expressing desire to quit at this time].  Patient noted to have [mild/some/significant] improvement after treatment with [specify] in the ED prior to discharge.

We discussed return precautions, specifically for evidence of worsening difficulty breathing, treatment with [bronchodilators/steroids], and follow up with primary care doctor within [2-3 days/1 week] for further evaluation, and the patient demonstrated understanding and agreement with this plan.