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• Religion: Roman Catholic• Race: Filipino

History of Present Illness • CC: Productive Cough

1 week PTA

• Productive cough with whitish sputum• Easy fatigability• Afternoon fever (temperature not

taken)• Paracetamol 500mg/tab• (-) Dyspnea, orthopnea, PND and night

sweats

1 day PTA•Cough with yellowish sputum•Dyspnea•Fever•(-) Drug intake

November 23, 2009

•Admission

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

Family History

• (+) HTN – parents and siblings• (+) Heart disease – parents and siblings• (-) DM• (-) Cancer• (-) Allergy• (-) Asthma • (-) PTB• (-) Thyroid diseases

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

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

Review of Systems

• (-) bleeding, (-) easy bruisability• (-) polyuria, (-) polydipsia, (-) polyphagia • (-) heat / cold intolerance• (-) muscle pain • (-) edema• (+) asterixis

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

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

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

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

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

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

Etiology of Cough

Cough

Irritants/ Allergic reaction

Neoplasm

MassACEI

intake

Congestive Heart Failure

Parenchymal Lung Disease

Infection

Cough

Acute (<3 weeks)

URTI

Congestive Heart Failure

Pulmonary Embolism

Pneumonia

Chronic(>3 weeks)

Smoker

COPD

Bronchogenic CA

Non-smoker, normal CXR, No ACEI

Postnasal drip

Asthma

Gatroesophageal reflux

Differential DiagnosisAcute Cough (<3 weeks)

URTI Congestive Heart Failure

Pulmonary Embolism

Pneumonia

• (-) 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

Clinical Impression

• Community-Acquired Pneumonia