g.v., 26/m presenting with cough
DESCRIPTION
G.V., 26/M Presenting with Cough. Case Presentation: GROUP 1 Tan J., Tanchuling , Te, Teo , Tindoc. History. SUBJECTIVE. OBJECTIVE. ASSESSMENT. PLAN. General Data. G.V. 36 year old male from Laguna. SUBJECTIVE. OBJECTIVE. ASSESSMENT. PLAN. Chief Complaint. - PowerPoint PPT PresentationTRANSCRIPT
CASE PRESENTATION: GROUP 1TAN J., TANCHULING, TE, TEO, TINDOC
G.V., 26/MPresenting with Cough
History
General Data
G.V. 36 year old malefrom Laguna
SUBJECTIVE OBJECTIVE ASSESSMENT PLAN
Chief Complaint
Cough of >3 weeks duration
SUBJECTIVE OBJECTIVE ASSESSMENT PLAN
History of Present Illness
December 2009GV had non productive cough less than a week; no
fever; no difficulty of breathing. He self- medicated with Solmux for 1 week with relief of symptoms.
From then on until March 2010, he was apparently well
March 2010There was recurrence of nonproductive cough; no
fever; no difficulty of breathing. No medications were taken but there was intermittent relief of symptoms until June 2010.
SUBJECTIVE OBJECTIVE ASSESSMENT PLAN
History of Present Illness
June 2010Patient’s cough worsened, became productive and
he experienced DOB. Self medicated with Vick’s Formula 44 syrupChest pain developed the next day. Pain is rated
8/10 and described as “makirot” located over the sternal area and lasting for 12-16 hours relieved by rest.
SUBJECTIVE OBJECTIVE ASSESSMENT PLAN
History of Present Illness
June 22, 2010Patient decided to have his CXR done.
June 24, 2010Patient consulted private doctor in Laguna and was
prescribed Co-amoxiclav 2x/day for 1 week, Salbutamol + Carbocisteine, and Mutlitvitamins. Patient reported to have good compliance.
SUBJECTIVE OBJECTIVE ASSESSMENT PLAN
History of Present Illness
End of June 2010Patient experienced frequent vomiting an hour
after meals. These episode occur around 5x/week. Vomitus was nonbilious and nonprojectile. There
was epigastric pain present before meals and before vomiting episodes.
July 27, 2010Day of consult
SUBJECTIVE OBJECTIVE ASSESSMENT PLAN
Review of Systems
(+) weight loss (+) intermittent fever
of 2 days duration (3pm) (-) rashes (-) headache (+) orthostatic
hypotension (-) ear discharge (+) itchy throat
SUBJECTIVE OBJECTIVE ASSESSMENT PLAN
(+) frequent clearing of throat
(-) PND (-) orthopnea (-)hemoptysis (-) dysphagia (-) diarrhea (-) nocturia
Past Medical History
CV accident, Hypertension – Father
SUBJECTIVE OBJECTIVE ASSESSMENT PLAN
Family History
Genogram of GV – July 27, 2010
SUBJECTIVE OBJECTIVE ASSESSMENT PLAN
52Stroke
56
36 38 28
11 10 14 13
Social History
Smoked for 1-2 years, only a few sticks after each drinking session.
Minimal alcohol intakeOnly sexual partner is his wife
SUBJECTIVE OBJECTIVE ASSESSMENT PLAN
Pertinent Findings
History of: - Low-grade fever in the afternoon-Retrosternal chest pain- Regurgitation of sour material into mouth- Chronic cough- habits that could exacerbate reflux disease: lying down right after eating, intake of coffee
SUBJECTIVE OBJECTIVE ASSESSMENT PLAN
Physical Exam
Patient is awake, alert, coherent and not in respiratory distress
Vital Signs Afebrile Pulse rate: 88bpm full and regular Respiratory rate: 20rpm BP: 110/80 Height= 161 cm Weight= 50.2 kg BMI=19.3
OBJECTIVESUBJECTIVE ASSESSMENT PLAN
Physical Exam
Head: no deformities, no masses, no lesion Eyes: anicteric sclera, brown iris, pink conjunctiva Ears: no tenderness, no discharge, no masses or deformities Nose: no discharge, nasal septum is in the midline Throat: no redness, no postnasal drip Neck: trachea is in the midline; no CLAD, no masses , no
tenderness, no lesions Chest: no deformities, no masses, no lesions, normal
anteroposterior diameter. Equal chest expansion, symmetrical tactile fremitus, normal breath sounds, no crackles or rhonchi heard
OBJECTIVESUBJECTIVE ASSESSMENT PLAN
Physical Exam
CVS: Normal heart sounds; distinct S1 and S2, no murmurs, no friction rubs
Abdomen: normoactive bowel sounds, no masses, (+) tenderness on deep palpation on the midline over the rectus abdominis exacerbated by coughing.
OBJECTIVESUBJECTIVE ASSESSMENT PLAN
Differential Diagnosis
SUBJECTIVE ASSESSMENT PLANOBJECTIVE
Differentials Rule In Rule Out
Asthma Chronic cough, chest discomfort
No dyspnea, episodic heezing, runny nose, (-) exposure to cold air, irritants, allergens
ACEI cough Chronic cough No intake of ACE inhibitors, no complaints of cough being worse at night and when supine
Post-infectious cough Chronic cough, history of respiratory tract infection
Cough no paroxysmal, (-) posttussive vomiting
Differential Diagnosis
SUBJECTIVE ASSESSMENT PLANOBJECTIVE
Differentials Rule In Rule Out
Post-nasal drip Chronic cough No runny nose, (-) exposure to allergic substances
Pulmonary tuberculosis Stage V (suspected)
Chronic cough associated with anorexia, fever in the afternoon, history of exposure to TB, weight loss.
Cannot be ruled out
Gastroesophageal Reflux
Chronic cough, eating habits (coffee only in the morning, lying down right after meals), history of heartburn and regurgitation of sour material.
(-) dysphagia (1/3 of patients)Cannot by ruled out
Working Diagnosis
Pulmonary Tuberculosis Stage VConcomitant GERD
SUBJECTIVE ASSESSMENT PLANOBJECTIVE
Pathophysiology: GERD-related cough
1) Vagal Reflexacid stimulates esophageal receptors2) Heightened Bronchial Reactivityexposure to esophageal acid may increase
bronchial activity to other stimuli3) Microaspirationgastric acid in the larynx and upper airway upper
airway stimulation + increase airway resistance4) Immune System ModificationGERD may alter the immune system’s response to
allergens,
SUBJECTIVE ASSESSMENT PLANOBJECTIVE
Tuberculosis
Etiologic organism: Mycobacterium tuberculosisMost common transmission: droplet nuclei
aerosolized by coughing, sneezing, or speakingFactors affecting infection:
probability of contact with person with infectious form of TB
Intimacy and duration of contact Degree of infectiousness Shared environment
Most important factors affecting development of TB: Person’s immunologic and nonimmunologic defenses Level of Cell-mediated Immunity
ASSESSMENTOBJECTIVE PLANSUBJECTIVE
Tuberculosis
Our patient has chronic cough, weight loss, and fever.
Patient is considered TB symptomatic because he exhibits cough, weight loss,, and fever. He is TB stage 5 because his diagnosis is pending (need labs).
ASSESSMENTOBJECTIVE PLANSUBJECTIVE
The tiny droplets dry rapidly; may remain suspended in the air for several hours and may reach the terminal air passages when inhaled.
Pathophysiology
Primary sites of TB: Lungs (Pulmonary TB) Kidney Brain Bone* Last three most
common sites of extrapulmonary TB
Pathophysiology
If patient is not immunocompromised, caseous necrosis will happen – latent TB,
Pathophysiology
If patients are immunocompromised, the granuloma may undergo liquefactive necrosis and leave a cavity.
Stages of Tuberculosis
Latent Tuberculosis After infection, the bacilli are controlled in the
calcified nodules. Patient will not feel sick and is not infectious.
Primary Disease Often asymptomatic (labs are often only evidence of
disease); may have fever, pleuritic chest pain, or dyspnea; pleural effusion may occur
Primary Progressive Disease Active TB develops in only 5-10% of infected Early signs and symptoms often non-specific; progressive
fatigue, malaise, weight loss, and low grade fever accompanied by chills and night sweats; Wasting may occur due to lack of appetite and altered metabolism associated with inflammatory and immune response.
Cough eventually develops in most patients (initially nonproductive but advances to productive cough of purulent sputum). Hemoptysis may occur if lesion breaks near a blood vessel.
Pleuritic chest pain may be caused by inflamed parenchyma. Dyspnea/Orthopnea may be caused by increased interstitial
volume leading to a decrease in lung diffusion capacity. Anemia, leukocytosis may occur.
Extrapulmonary Disease One will observe symptoms relating to other parts of
the bory (ex. kidney).
Our patient likely has Primary Progressive Disease.
Diagnostic Plan
For PTB:
For GERD
SUBJECTIVE ASSESSMENT PLANOBJECTIVE
Sputum AFBSputum TB
culture
Chest Radiograph
None recommended
Therapeutic Plan: TB
DOTSFor Newly Diagnosed Smear Positive
patients: 2HRZE daily (initial phase) 4HR daily or thrice-weekly (continuation phase)
If MDR-TB, refer.
SUBJECTIVE ASSESSMENT PLANOBJECTIVE
Adjunctive Therapy: TB
Zinc (Grade A) Accelerates upregulation of Th1 response, bacterial
clearance and clinical improvement
Vitamin A if deficient (Grade C)Arginine (Grade C)
Production of nitric oxide and nitrogen intermediaries
SUBJECTIVE ASSESSMENT PLANOBJECTIVE
Prevention: TB
DOTS may utilize the following for monitoring and improving adherence to treatment repeated home visits, reminder letters, cash
incentives, health education by nurses, and the use of community health advisers.
Contact tracing
SUBJECTIVE ASSESSMENT PLANOBJECTIVE
Therapeutic Plan: GERD
Begin PPIs Omeprazole, 20 mg/tab, 1 tab/day, OD for 4 weeks
SUBJECTIVE ASSESSMENT PLANOBJECTIVE
Adjunctive Therapy: GERD
Vitamin B12 supplementationCalcium supplementation
SUBJECTIVE ASSESSMENT PLANOBJECTIVE
Non-pharmacologic Therapy: GERD
Head Elevation during sleep, 4-6 inchesLimit vigorous exercise or other factors that
increase intra-abdominal pressureDiet change
<45 g of fat in 24 h No coffee, tea, soda, mint, citrus, alcohol, smoking. Avoid ingesting large quantities of fluids with meals
Stop smoking
SUBJECTIVE ASSESSMENT PLANOBJECTIVE
Counseling
Involve family members to entertain apprehensions, concerns, worries about TB
Educate them on TB and its preventionEncourage them to help patient in adhering to TB
treatment regimenInvolve family members to help with diet plan,
prevent him from straining himself excessively.Educate the patient about GERD and its
complications. Advise if his symptoms return after cessation of therapy, lifelong meds may be needed
SUBJECTIVE ASSESSMENT PLANOBJECTIVE
SUMMARY
Diagnostic: Sputum AFB and/or Sputum Culture and CXR
Therapeutic: 2HRZE then 4HR (under DOTS); PPI
Adjunctive: Arginine, Zinc, Vitamin A, Vitamin B12, Calcium
Non-pharmacologic: Head elevation, limit vigorous activities, diet, stop smoking
Counseling
SUBJECTIVE ASSESSMENT PLANOBJECTIVE
End.