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 ( ); 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. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. Differential Diagnosis
Pneumonia
Typical
Atypical
(-) 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

20. 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

21. 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

22. 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

23. ‘‘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)

24. 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)

25. 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)

26. 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.

27. 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.

28. 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.