Approach to a Patient with Cough B4 – Dr. Remedios Coronel Garcia, Garcia, Garzon, Gaspar, Gatchalian, Gaw, Geraldoy, Geronimo, Geronimo Geronimo, Go, Go, Go, Go, Go, Go December 4, 2009

Objectives 1.Case Presentation of a Patient with Cough 2.Management of patient with Community- Acquired Pneumonia

General Data Name: RM Age: 60 Sex: Male Status: Married Address: Quiapo, Manila Religion: Roman Catholic Race: Filipino

History of Present Illness CC: Productive Cough 1 week PTA Productive cough with whitish sputum Easy fatigability Afternoon fever (temperature not taken) Paracetamol 500mg/tab (-) Dyspnea, orthopnea, PND and night sweats 1 day PTA Cough with yellowish sputum Dyspnea Fever (-) Drug intake November 23, 2009 Admission

Past Medical History HTN (2005) - Highest BP 200/160; Usual BP – 120/80 – Nifedipine, Metoprolol, and Aspirin - unrecalled dosage – Non-complaint (?) LVH, possible MI (2005) “ Food poisoning” – UST Hospital (2005) External Hemorrhoids (2005) Claims to have complete immunizations No history of surgery (-) DM (-) Bronchial asthma (-) PTB (-) Blood transfusion (-) Allergies (-) Trauma/ accident

Family History (+) HTN – parents and siblings (+) Heart disease – parents and siblings (-) DM (-) Cancer (-) Allergy (-) Asthma (-) PTB (-) Thyroid diseases

Personal/Social History Drinks a lot of soft drinks (each meals) (+) Smoking pack/year Occasional alcohol drinker amt Mixed diet, preference to salty foods Used to work for customs as a “checker” for 2O years and retired in 2009 Currently sells candles in Quiapo church with his wife. Married with 8 kids Currently lives with his 20-year old son in a small apartment located in Abad Santos Joined a marathon as his form of exercise

Review of Systems (-) anorexia, (+) weight loss (8kg loss in a month) (-) itchiness (-) headache, (-) blurring of vision (+) dizziness (-) colds (-) chest pain, (-) palpitations (-) abdominal pain (-) vomiting, (-) diarrhea, (-) constipation (-) dysuria, (-) hematuria, (-)flank pain

Review of Systems (-) bleeding, (-) easy bruisability (-) polyuria, (-) polydipsia, (-) polyphagia (-) heat / cold intolerance (-) muscle pain (-) edema (+) asterixis

Physical Examination Upon AdmissionUpon Interview Conscious, coherent, ambulatory, not in CP distress BP: 160/100mmHg PR: 92bpm, regular RR: 21cpm, regular T: 37.5 °C Ht=160 cm Wt=45 kg BMI=18 Warm dry skin, no active dermatoses Pale palpebral conjunctivae, anicteric sclera, pupils 2-3mm ERTL Septum midline, no nasoaural discharge No tragal tenderness, non-hyperemic, no pain on mastoid area Conscious, coherent, ambulatory, not in CP distress BP: 120/180 mmHg PR: 89bpm, RR: 20cpm, T: 36°C Ht=160 cm Wt=45 kg BMI=18 Warm dry skin, no active dermatoses Pale palpebral conjunctivae, anicteric sclera, pupils 2-3mm ERTL Septum midline, no nasoaural discharge No tragal tenderness, non-hyperemic, no pain on mastoid area

Physical Examination Upon AdmissionUpon Interview Neck not rigid, no palpable cervical lymphadenopathy No chest wall deformity, symmetric chest expansion, no retractions, equal vocal and tactile fremiti, clear breath sounds Adynamic precordium, AB at 6 th LICS AAL, (-) parasternal heave, (-) thrills, S2>S1 at base, loud P2, S1>S2 and (+) S3 at apex, (+) hemic murmur, carotid artery: rapid upstroke, gradual downstroke, JVP 3cm at 30 angle Flat abdomen, NABS, soft, no mass, no tenderness, 8 cm liver MCL, traube’s space not obliterated, (-) hepatojugular reflux No palpable inguinal nodes, no CVA tenderness Pulse full and equal, (-) cyanosis Neck not rigid, no palpable cervical lymphadenopathy No chest wall deformity, symmetric chest expansion, no retractions, equal vocal and tactile fremiti, clear breath sounds Adynamic precordium, AB at 6 th LICS AAL, (-) heave, (-) thrills, base: S2>S1, apex: S1>S2 and (+) S3, carotid artery: rapid upstroke, gradual downstroke, JVP 3cm at 30 angle Flat abdomen, NABS, soft, no mass, no tenderness, 8 cm liver span MCL, traube’s space not obliterated, (-) hepatojugular reflux No palpable inguinal nodes, no CVA tenderness Pulses full and equal, (-) cyanosis

Physical Examination Upon AdmissionUpon Interview Conscious, coherent, oriented to 3 spheres GCS 15 Sense of smell intact Isocoric pupils:, 2-3mm ERTL, no visual field cuts Fundoscopy: (+) ROR, no papilledema, no hemorrhages, clear disc margins EOMs full and equal, (+) conjugate eye movements Intact V1-V3 Can clench teeth, raise eyebrows, frown, no gross facial asymmetry Gross hearing intact, (-) lateralization on Weber Uvula midline on phonation Conscious, coherent, oriented to 3 spheres GCS 15 Sense of smell intact Isocoric pupils:, 2-3mm ERTL, no visual field cuts Fundoscopy: (+) ROR, no papilledema, no hemorrhages, clear disc margins EOMs full and equal, (+) conjugate eye movements Intact V1-V3 Can clench teeth, raise eyebrows, frown, no gross facial asymmetry Gross hearing intact, (-) lateralization on Weber Uvula midline on phonation

Physical Examination Upon AdmissionUpon Interview Can shrug shoulders, turn head side to side against resistance Tongue midline on protrusion MMT: 5/5 on all extremities No sensory deficits No atrophy, no fasciculations, no spasticity Cerebellar functions intact DTRs: (++) on all limbs No Babinski, no chaddocks, no oppenheims No nuchal rigidity, no Brudzinski, no Kernigs Can shrug shoulders, turn head side to side against resistance Tongue midline on protrusion MMT: 5/5 on all extremities No sensory deficits No atrophy, no fasciculations, no spasticity Cerebellar functions intact DTRs: (++) on all limbs No Babinski, no chaddocks, no oppenheims No nuchal rigidity, no Brudzinski, no Kernigs

Salient Subjective Features Pertinent PositivesPertinent Negatives 60 years old Male Productive cough with whitish  yellowish sputum (1 week) Easy fatigability Fever Dyspnea Known HTN (2005) LVH, possible MI (2005) (+) Smoking pack/year Occasional alcohol drinker amt Currently sells candles Currently lives in a small apartment (+) weight loss (8kg loss in a month) (+) dizziness (?) (+) asterixis (?) (-) colds (-) orthopnea, PND and night sweats (-) Bronchial asthma (-) PTB (-) Allergies (-) edema

Salient Objective Features Pertinent PositivesPertinent Negatives Conscious, coherent, ambulatory, not in CP distress BP: 160/100mmHg, PR: 92bpm, regular RR: 21cpm, regular T: 37.5 °C BMI 18 Pale palpebral conjunctivae Adynamic precordium AB at 6 th LICS AAL S2>S1 at base, loud P2, S1>S2 and (+) S3 at apex, (+) hemic murmur (?) 8 cm liver span midclavicular line Septum midline (-) nasoaural discharge (-) palpable cervical lymphadenopathy No chest wall deformity Symmetric chest expansion No retractions Equal vocal and tactile fremiti Clear breath sounds (-) parasternal heave, (-) thrills JVP 3cm at 30 angle (-) hepatojugular reflux Traube’s space not obliterated

Etiology of Cough Cough Irritants/ Allergic reaction NeoplasmMassACEI intake Congestive Heart Failure Parenchymal Lung Disease Infection

Cough Acute (<3 weeks) URTI Congestive Heart Failure Pulmonary Embolism Pneumonia Chronic (>3 weeks) SmokerCOPDBronchogenic CA Non-smoker, normal CXR, No ACEI Postnasal dripAsthma Gatroesophageal reflux

Differential Diagnosis Acute Cough (<3 weeks) URTI Congestive Heart Failure Pulmonary Embolism Pneumonia (-) colds Septum midline (-) nasoaural discharge (-) palpable cervical lymphadenopathy (-) orthopnea, PND JVP 3cm at 30 angle AB at 6 th LICS AAL S3 at apex (-) hepatojugular reflux (-) edema Dyspnea 8 cm liver span MCL Weight loss Dyspnea, (-) chest pain (-) syncope (-) tachycardia (-) cyanosis (-) hypotension Fever Cough Dyspnea

Clinical Impression Community-Acquired Pneumonia