1. 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

2. 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

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

4. 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

5. 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

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

7. 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

8. 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

9. 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

10. 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 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

11. 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 6 th 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 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

12. 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 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

13. 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 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

14. Salient Subjective Features Pertinent PositivesPertinent 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

15. 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 (+) 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

16. Acute Cough with Fever INFECTIOUS CAUSENON-INFECTIOUS CAUSE Tracheobronchial TreePulmonary Parenchyma BronchitisPneumoniaMalignancy BronchiectasisTuberculosisAsthma BroncholithiasisLung AbscessPulmonary Embolism CHF Emphysema SLE Aspiration Connective Tissue Disease

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

18. Differential Diagnosis PneumoniaTypicalAtypical (-) Immunocompromised (-) Extrapulmonary manifestations (-) Immunocompromised (-) Extrapulmonary manifestations

19. 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