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

Physical ExaminationUpon 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

Physical ExaminationUpon 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

•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, (-) 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 ExaminationUpon 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

Physical ExaminationUpon 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

Salient Subjective FeaturesPertinent 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 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•(+) 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 FeverINFECTIOUS CAUSE NON-INFECTIOUS CAUSE

Tracheobronchial Tree Pulmonary ParenchymaBronchitis Pneumonia Malignancy

Bronchiectasis Tuberculosis Asthma

Broncholithiasis Lung Abscess Pulmonary Embolism

CHF

Emphysema

SLE

Aspiration

Connective Tissue Disease

Differential DiagnosisAcute Cough with Fever

URTI Tuberculosis Pneumonia

• (-) colds• Septum midline • (-) nasoaural

discharge • (-) palpable cervical

lymphadenopathy

• Fever• Cough• Dyspnea

• Weight loss (+) • Productive cough• Fever• Dyspnea• Unremarkable lung

findings • AFB not performed

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