approach to a patient with cough
DESCRIPTION
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. General Data. Name: RM Age: 60 Sex: Male Status: Married Address: Quiapo, Manila - PowerPoint PPT PresentationTRANSCRIPT
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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
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General Data
• Name: RM• Age: 60• Sex: Male• Status: Married• Address: Quiapo, Manila• Religion: Roman Catholic• Race: Filipino
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History of Present Illness • CC: Productive Cough
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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
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Family History
• (+) HTN – parents and siblings• (+) Heart disease – parents and siblings• (-) DM• (-) Cancer• (-) Allergy• (-) Asthma • (-) PTB• (-) Thyroid diseases
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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
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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
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Review of Systems
• (-) bleeding, (-) easy bruisability• (-) polyuria, (-) polydipsia, (-) polyphagia • (-) heat / cold intolerance• (-) muscle pain • (-) edema• (+) asterixis
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Physical Examination on 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
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Physical Examination on 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 6th LICS AAL, (-) parasternal heave, (-) thrills, S2>S1 at base, loud P2, S1>S2 and (+) S3 at apex, (+) hemic murmur, carotid artery: rapid uptsroke, gradual downstroke, JVP 3cm at 30 angle
• Flat abdomen, NABS, soft, no mass, no tenderness, 8 cm liver span midclavicular line, traube’s space not obliterated, (-) hepatojugular reflux
• No palpable inguinal nodes, no CVA tenderness• Pulses full and equal, (-) cyanosis
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Physical Examination on 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
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Physical Examination on 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
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Salient Subjective FeaturesPertinent Positives Pertinent 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
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Salient Objective FeaturesPertinent 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• 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
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Etiology of Cough
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Differential Diagnosis
• (-) colds•Septum midline •(-) nasoaural discharge • (-) palpable cervical lymphadenopathy
• (-) orthopnea, PND• JVP 3cm at 30 angle • AB at 6th 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
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Clinical Impression
• Community-Acquired Pneumonia