A 65-year-old woman with acute cough illness and an important engagement.

DR REYNOLDS: Mrs W is a 65-year-old woman who recently switched to a commercial Medicare insurance plan and who presents for an urgent visit with symptoms of an upper respiratory tract infection [URI]. She works in the family business and lives with her husband; they have 3 grown children. Because her new insurance plan did not cover her former physician, Mrs W made an appointment with a new physician in a large, university-affiliated group practice. Before her initial appointment, however, she became ill and requested an urgent visit. Seen the same day, she complained of 24 hours of sore throat, cough occasionally productive of small amounts of green sputum, and subjective fevers and chills. She also had mild shortness of breath, but no pleuritic chest pain. She had not taken her temperature at home. She denied ear pain, sinus pressure, headache, orthopnea, or paroxysmal nocturnal dyspnea. She had been treating herself with fluids and acetaminophen. Her husband had similar symptoms the previous week and had been empirically treated with levofloxacin. Mrs W requested antibiotics because she hoped to feel well for a planned family party for her birthday, and because she wanted to avoid infecting her family, especially her pregnant daughter. Mrs W’s medical history is significant for hypertension, hypothyroidism, iritis (6 episodes, positive for HLA-B27 antigen), and arthritis. Her medications at the time of her visit were atenolol (25 mg/d), levothyroxine (0.125 mg/d), triamterene (37.5 mg/d), aspirin (81 mg/d), and acetaminophen as needed. Mrs W does not smoke, drinks alcohol in moderation, and exercises with a personal trainer several times weekly. Her family history is significant for a father with a distant history of tuberculosis, a sister with uterine cancer, and a son who had an angioplasty at age 32. One brother has ankylosing spondylitis. Another brother died in an airplane crash on September 11, 2001. On physical examination, Mrs W had a temperature of 99.9°F. Her ears, mouth, neck, lungs, and heart were all normal. No laboratory studies or radiographs were obtained. The treating physician, Dr C, explained that Mrs W’s illness was very likely viral and would be best treated with fluids, rest, and a cough suppressant. Mrs W repeatedly requested antibiotics, and Dr C prescribed azithromycin, with the caveat that the antibiotic was unlikely to prevent transmission of the illness to family members. Five days after her visit with Dr C, Mrs W was seen in an initial visit by her new primary physician. She complained of a persistent cough. Her physician began albuterol and steroid inhalers and checked her white blood cell count, which was normal. Later that evening, after starting the inhalers, Mrs W called the on-call physician to report an increase in her cough and a fever of 101°F. The on-call physician sent her to a local emergency department, where she had normal chest radiographs. As she had just finished her 5-day course of azithromycin, the emergency physician prescribed a 1-week course of levofloxacin, and Mrs W was released with a diagnosis of bronchitis.