Approach to a Patient with Productive Cough and Fever B4 – Dr. Remedios Coronel Garcia, Garcia, Garzon, Gaspar, Gatchalian, Gaw, Geraldoy, Geronimo, Geronimo

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

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


•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


•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


•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 Parenchyma

Bronchitis Pneumonia Malignancy

Bronchiectasis Tuberculosis Asthma

Broncholithiasis Lung Abscess Pulmonary Embolism

CHF

Emphysema

SLE

Aspiration

Connective Tissue Disease

Differential Diagnosis

• (-) 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

Differential Diagnosis

• (-) Immunocompromised• (-) Extrapulmonary manifestations

• (-) 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

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

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

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

• ‘‘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)

Uncommon Causes of CoughUdaya B.S. Prakash

Uncommon Causes of Cough*

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)


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)


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.


• 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.


• 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.

Documents

Approach to a Patient with Productive Cough and Fever B4 – Dr. Remedios Coronel Garcia, Garcia, Garzon, Gaspar, Gatchalian, Gaw, Geraldoy, Geronimo, Geronimo