Approach to a Patient with Productive Cough and Fever B4 – Dr. Remedios Coronel Garcia, Garcia, Garzon, Gaspar, Gatchalian, Gaw, Geraldoy, Geronimo, Geronimo Geronimo, Go, Go, Go, Go, Go, Go December 7, 2009

Objectives To present a case of a patient with productive cough and fever To account for the pathogenesis of the signs and symptoms To provide laboratory and ancillary procedures appropriate for a patient with productive cough and fever To formulate an effective management plan for a patient with productive cough and fever

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

History of Present Illness CC: Productive Cough 1 week PTA Cough with whitish sputum Easy fatigability Low grade fever – relieved by Paracetamol 500mg/tab (-) Accompanying symptoms 1 day PTA Persistent cough with yellowish sputum Dyspnea Fever recurred (-) Drug intake November 23, 2009 Admission

Past Medical History HPN (2005) - Highest BP 200/160; Usual BP – 120/80 Nifedipine, - unrecalled dosage; “Amcor” from a Chinese store Non-compliant LVH (2005) “ Food poisoning” (unrecalled cause) – UST Hospital (2005) External Hemorrhoids (2005) - resolved Claims to have complete childhood immunizations No history of surgery (-) DM (-) Bronchial asthma (-) PTB (-) Blood transfusion (-) Allergies (-) Trauma/ accident

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

Personal/Social History Drinks a lot of soft drinks (approximately 1L/ meal) (+) Smoking - 25 years (1969-1994); 2 pack/year)  Occasional alcohol drinker  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 - no ventilation and sunlight coming in Joined a marathon as his form of exercise

Review of Systems (-) anorexia, (+) weight loss (2 inches in waistline in the past 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 (-) dysuria, (+) paroxysmal nocturia every 2 hours, 4 times a night for the past 2-3 months, (+) polydipsia (1.5 L a night) (-) heat / cold intolerance (-) muscle pain (-) edema

Upon Admission (November 23, 2009) Upon Interview (November 27, 2009) Physical Examination Upon Admission (November 23, 2009) Upon Interview (November 27, 2009) 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 BP: 120/180 mmHg PR: 89bpm, RR: 20cpm, T: 36°C Ht=160 cm Wt=45 kg BMI=18

Upon Admission (November 23, 2009) Upon Interview (November 27, 2009) Physical Examination Upon Admission (November 23, 2009) Upon Interview (November 27, 2009) 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 6th LICS AAL, (-) parasternal heave, (-) thrills, S2>S1 at base, loud P2, S1>S2 and (+) S3 at apex, 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 Adynamic precordium, AB at 6th 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 Pulses full and equal, (-) cyanosis

Upon Admission (November 23, 2009) Upon Interview (November 27, 2009) Physical Examination Upon Admission (November 23, 2009) Upon Interview (November 27, 2009) 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

Upon Admission (November 23, 2009) Upon Interview (November 27, 2009) Physical Examination Upon Admission (November 23, 2009) Upon Interview (November 27, 2009) 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 Positives Pertinent Negatives 60 years old Male Productive cough with whitish  yellowish sputum (1 week) Easy fatigability Fever Dyspnea Known HPN (2005) LVH (2005) (+) Smoking 2 pack/year  Occasional alcohol drinker Currently sells candles Currently lives in a small apartment (+) weight loss (+) dizziness (-) colds (-) orthopnea and PND (-) Bronchial asthma (-) PTB (-) Allergies (-) edema

Salient Objective Features Pertinent Positives Pertinent 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 6th LICS AAL (+) S3 at apex 8 cm liver span MCL Septum midline (-) nasoaural discharge (-) palpable cervical lymphadenopathy S2>S1 at base,S1>S2 at apex 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

Acute Cough with Fever INFECTIOUS CAUSE NON-INFECTIOUS CAUSE Tracheobronchial Tree Pulmonary Parenchyma Bronchitis Pneumonia Malignancy Bronchiectasis Tuberculosis Asthma Broncholithiasis Lung Abscess Pulmonary Embolism CHF Emphysema SLE Aspiration Connective Tissue Disease

Differential Diagnosis Acute Cough with Fever URTI Tuberculosis Pneumonia Weight loss (+) Productive cough Fever Dyspnea Unremarkable lung findings AFB not performed Fever Cough Dyspnea (-) colds Septum midline (-) nasoaural discharge (-) palpable cervical lymphadenopathy

Differential Diagnosis Pneumonia Typical Atypical (-) Immunocompromised (-) Extrapulmonary manifestations

Clinical Impression Community-Acquired Pneumonia CRB-65 Group 2, PSI (?) Tuberculosis suspect Hypertensive Cardiovascular Disease Left Ventricular Hypertrophy, NYHA Functional Class I Stage B DM suspect

implementation of CAP guidelines resulted in: Guidelines for the diagnoses and treatment of adult lower respiratory tract infections: a true ‘‘European cooperative effort’’ M.I. Restrepo, and A. Anzueto European Respiratory Journal: WOODHEAD et al. present the guidelines of the European Respiratory Society (ERS) and European Society of ClinicalMicrobiology and Infectious Diseases (ESCMID), for the diagnosis and treatment of the three most common LRTIs help clinicians to stratify patients by risk factors, provide a range of diagnostic and treatment options implementation of CAP guidelines resulted in: a significant reduction in morbidity and mortality; safely identified patients that can be treated as outpatients, decreased hospitalizations rates; decreased the hospital stay; significant improvement in the processes of care of this disease outlined the lack of clinical evidence in certain areas

Guidelines for the diagnoses and treatment of adult lower respiratory tract infections: a true ‘‘European cooperative effort’’ M.I. Restrepo, and A. Anzueto The ERS/ESCMID CAP guidelines are centered on the following main questions: how do I diagnose or identify CAP?; How should I treat my patient with CAP?; how should I prevent CAP? To differentiate pneumonia from other LRTIs, the patient should have the following clinical findings: acute onset of cough, dyspnea, new focal chest signs, tachypnea, and fever 4 days, presence of an infiltrate on a chest radiograph

Guidelines for the diagnoses and treatment of adult lower respiratory tract infections: a true ‘‘European cooperative effort’’ M.I. Restrepo, and A. Anzueto Emphasis: there is a strong probability of a viral etiology, antibiotics should be withheld to reduce cost and simultaneouslyminimize the emergence of antibiotic-resistant bacterial strains in the community

‘‘Antibiotic therapy if indiscriminately used, may turn out to be a medicinal food that temporarily cleans and heals, but ultimately destroys life itself.’’ F. Marti-Ibanez, a Spanish physician and historian (1955)

Uncommon Causes of Cough Udaya B.S. Prakash Pulmonary disorders Tracheobronchomalacia Airway stenosis/strictures Tracheobronchopathia osteoplastica Mounier-Kuhn syndrome (tracheobronchomegaly) Tracheobronchial amyloidosis Airway foreign bodies Broncholithiasis Lymphangioleiomyomatosis Pulmonary Langerhans cell histiocytosis Pulmonary alveolar proteinosis Pulmonary alveolar microlithiasis Tonsillar hypertrophy Mediastinal masses Pulmonary edema Pulmonary embolism Drug-induced cough Miscellaneous (eg, vocal cord dysfunction, surgical sutures in airways)

Uncommon Causes of Cough Udaya B.S. Prakash Nonpulmonary disorders Connective tissue disorders‡ Vasculitides (eg, WG, GCA, and RPC) Esophageal disorders (tracheoesophageal and bronchoesophageal fistula) Inflammatory bowel diseases (eg, Crohn disease and ulcerative colitis) Thyroid disorders (goiter, thyroiditis)

Uncommon Causes of Cough Udaya B.S. Prakash Recommendations 1. In patients with chronic cough, uncommon causes should be considered when cough persists after evaluation for common causes and when the diagnostic evaluation suggests that an uncommon cause, pulmonary as well as extrapulmonary may be contributing. 2. In patients with chronic cough, until uncommon causes that potentially may be contributing to the patient’s cough have been ruled out, the diagnosis of unexplained cough should not be made.

Uncommon Causes of Cough Udaya B.S. Prakash 3. If cough persists after consideration of the most common causes, perform a CT scan and, if necessary, a bronchoscopic evaluation. Level of 4. In patients who present with abrupt onset of cough, consider the possibility of an airway foreign body.

Uncommon Causes of Cough Udaya B.S. Prakash 5. In patients with unexplained cough, evaluate the possibility of drug-induced cough. 6. In patients with unexplained cough, consider a therapeutic trial of withdrawing the drug that is suspected to cause the cough.