inlfuenza fever patient history qcgh

8/10/2019 Inlfuenza Fever Patient History QCGH

1/24

Protacio, Najee Benvincent D. Protacio

Group 17 Thursday Group Dra Te History # 5

General Data

Pt Aiza Castro, 25 years old, single, house wife, catholic, was born on December 15,

1988 in acolod !egros "ccidental, currently residing at 151 #uirino $ighway aesa

#uezon City, 1sttime to see% consult in #uezon City &eneral $os'ital in "ut Patient

De'artment on (e't 11, 2)1*+

hie! o"plaint Cough

History o! Present illness

2 wee%s PC 't e-'erienced sudden 'roducti.e cough, 'legm is clear in color

describe as chest is tightness when coughing+ /t was Accom'anied with colds, which is

.iscous in consistency and clear in color+ he 'atient also e-'erienced headache and

dizziness with a 'ain scale of 8 out of 1), in the 'arietal area, the duration was whole day,

no medications ta%en but tries to relie.e by massage 'ain but it was not relie.e+ ac% 'ain

was also e-'erienced by the 'atient in the thoracic area, with a 'ain scale of 8 out of 1)

that radiates in the shoulder, e-'erienced whole day but aggra.ated during household

wor%+

1) days PC consulted the barangay clinic due to cough yellowish in color and her

sym'toms still 'ersists+ CC done, which resulted to a decrease in 0C count and was

diagnose as Anemia+ he doctor didnt 'rescribe any medications because currently the

'atient is breastfeeding+ /nstead the doctor 'rescribed errous (ulfate for her decrease

0C count+

3 days PC cough is still 'resent with same 4uality and it was accom'anied by body

malaise and .omited the food she ate during lunch, bitter and yellowish in color+ (he

e-'erienced difficulty in breathing accom'anied by midsternal 'ain+ he 'atient also

e-'erienced 2'illow ortho'nea at night+


2/24

1 day PC headache 'rogressed with a 'ain scale of 1) out of 1) that ga.e her

insomnia with low grade undocumented fe.er+ "ther conditions of cough, colds, and bac%

'ain were still 'resent that 'romted the 'atient to consult to #C&$+

Past $edical History

Pt has com'leted childhod .accines as .erbalized, $ad mum's, and 6easles+ "ther

adult disease was denied by the 't+ such as $y'ertension, Diabetes, and uberculosis+ !o

allergies to food, allergen+ !o history of blood transfusions+

%a"ily History

Pt is youngest in a breud of 2, ather and 6other and the rest the siblings area''arently healthy+ Presence of $eredofamilial Diseases were denied such as

$y'ertension, Cardio.ascular disorders, Diabetes, and Cancer

Personal and &ocial

7or%s before as a waitress for 1 year, $ouse 6aid for 5 years, urger (eller for 1

year, currently as a house wife+ $usband is a 6echanic that 'ro.ides the financial

concerns+ Pt non alcholic, nonsmo%er but was e-'osed to 2ndhand smo%er, Drin%s coffee

1 cu' times a wee%+ (lee's 8 hours a day, at A .ariety of food more on .egetables+

$as no form of e-ercise+ (ource of water is nawasa and they drin% in the faucet if the

su''ly is runned out, $ouse is made of concrete and wood with windows studio ty'e,

has a water 'ured comfort room, garbage is collected e.ery night+

'()Gyne History

$ad her menarche 11 y:o, flow is hea.y, last for 5 days, 5 na'%ins then regular flow,

!o other &yne Abnormality was noted+

"b (core &2'2 2))2

1. eb, 1*, 2)1 boy, nsd, ast A.enue, Doctor, fullterm

*. ;une2,2))8, female, nsd, ast A.enue, Doctor, fullterm


3/24

+evie o! &yste"s

&eneral

- Poor ppetite


4/24

$ematologic

E direct and consensual 'u'illary refle-es and normal accommodationB lens

are trans'arent

ar@ triangular in sha'e, symmetrical, no lesions, no deformities or tenderness

!ose@ nose are symmetrical, no flaring of alae nasi, 'atent .estibule, mucosa 'in%ish

in color, no swelling, no lesions, with clear .iscous secretios and no bleedingB no nasal

se'tum in the midline, no 'erforations


5/24

6outh and hroat@ li's symmetrical, 'in%ish in color, moist, smooth, no lesionsB

buccal mucosa 'in% in color, no tongue de.iation on 'rotrusion, gingi.a is 'in%, tonsils

not swollen, u.ula midline+

!ec%@ s%in fair in color, no deformities, no masses, tra'ezius and sternocleidomastoid

muscles wellde.elo'ed, no tenderness, trachea in midline, no enlargement of cer.ical

lym'h nodes+

hest and 3un0s

(%in is fair in color, chest is symmetrical, no lagging and no widening of intercostals

s'aces /C(E, no retractions on the chest wall, no noted su'erficial blood .esselsB

res'iratory rate at 19 breath cycles 'er minuteB with tenderness noted in the midsternumB

no masses were notedB e4ual chest e-'ansion, no lagging notedB wih an increase tactile

fremitus on anterior lung filedB all lung fields resonant on 'ercussionB ilateral 0onchi is

heard on the a'ices of the lungs more 'ronounce on the right, broncho'hony and

whis'ered 'ectrilo4uy was noted+

ardiovascular

Precordium is adynamic, without bulging or .isible 'ulsationsB ugular .ein 'ulsation

noted ;FP was 3+5 cmB a'ical beat is at the 5 th/C(, no tenderness, no masses, no hea.es,

no thrills and no lifts notedB heart rate at 8 beats 'er minuteB heart rhythm is noted to be

regularB no murmurs, no gallo's or e-tra heart sounds notedB carotid 'ulse is strong,

regular and e4ual, without bruitsB radial, brachial 'ulses are strong, regular and e4ual+

(do"en

Abdominal circumference is 29, and it is flat, symmetrical, with in.erted umbilicus,

without bulging flan%s+ (%in is fair in color, no 'osto'erati.e scars or lesions were noted+

!o su'erficial blood .essels+ !o .isible mass or 'ulsations+ Patient has normoacti.e

bowel sounds of 3 'er minute+ !o friction rubs or bruits were heard o.er the abdominal

aorta+ Abdomen is soft all o.er, without muscle guarding or tenderness obser.ed+ Gi.er

and s'leen are not 'al'able+ Gi.er s'an is ? cm, All 4uadrants were tym'anitic u'on

'ercussion+ !o fluid wa.e 'ercei.ed, no shifting dullness u'on 'ercussion+


6/24

&pine and 24tre"ities

$ands, wrists and fingersnoted full range of motion 0"6E i+e+ fle-ion, e-tension and

adduction, of fingers and a''osition of thumbs for both handsB has no ulnar and radial

de.iation of wristsB no swelling, enlargement, nodes or tenderness of inter'halangeal and

metacar'o'halangeal oints u'on 'al'ation of both handsB nail beds 'in%, nails

rectangularB no clubbing of nails, brittle nails, floating nails, nail fold inflammation or

ingrown nails

H''er arms@ bilateral full 0"6 i+e+ fle-ion, e-tension, 'ronation and su'inationB no

swelling, inflammation, nodes or tenderness u'on 'al'ation of olecranon bursa elbow

ointEB no cre'itus or tenderness noted u'on 'al'ation of radius : ulna and muscles,

res'ecti.elyB muscles are symmetrical for both sides, with no atro'hy

(houlder oints@ bilateral full 0"6 as to abduction, adduction, e-ternal and internal

rotationB 'atient is able to do circumduction without restriction

('ine !o masses u'on 'al'ationB no asymmetry, ull 0"6 as to fle-ion, e-tension,

e-ternal and internal rotationB lower limbs are symmetrical, muscles showing no atro'hy

Inee oints@ bilateral full 0"6 as to e-tension and fle-ionB no tenderness, cre'itus,

masses, lesions or nodules noted

An%le oints and feet@ bilateral full 0"6 as to e.ersion, in.ersion, dorsifle-ion and

'lantar fle-ionB no swelling, enlargement, nodulations or tenderness u'on 'al'ation

oes and (oles@ bilateral full 0"6 as to fle-ion, e-tension, abduction and adductionB no

lateral de.iation of big toeB no inflammation of nail foldsB 'edal arc 'resentB blac% nail

'olish noted on toenails


7/24

Neurolo0ic 24a"

Cerebrum : 6ental (tatus

Patient is conscious, coherent, alert, oriented to time, 'lace and 'erson, coo'erati.e,

and is able to follow sim'le commands+ /mmediate, recent and remote memory intact,

and can do sim'le math calculations, e-hibit abstract thin%ing and a''ro'riate moral

udgment+

Cerebellum

Patient has no intention tremors, and able to 'erform fingertonose test, ra'id

alternating mo.ements+

Cranial !er.es

C! /@ cant be detected due to colds

C! //@ able to read small characters from a distance of 1ft, no gross .isual defects

C! // ///@ 'u'ils e4ually round and res'onds to direct and indirect light stimuli,

'u'il constricts to about 2mm

C! ///, /F F/@ normal e-traocular muscle mo.ement

C! F@ can feel 'in'ric% : brushing sensation on her faceB no atro'hy or

fasciculations of mastication muscles and normotonicB muscle tension u'on teeth

clenching symmetrical and e4ual

C! F F//@ 'ositi.e corneal refle-

C! F//@ muscles of u''er and lower face show no atro'hy or fasciculations,

symmetrical and normotonicB muscle tension u'on closing of eyes is symmetrical

and e4ual

C! F///@ can fairly localize source of sound by rubbing fingersB can hear and

relay whis'ered words from both ears

C! /J J@ u.ula midlineB 'haryngeal walls rise symmetrically u'on 'honation

and stimulation of the gag refle-B no hoarseness noted or .ocal anomalies

C! J/@ able to shrug shoulders e4uallyB able to rotate head against resistanceB no

atro'hy or fasciculations of muscles, muscles normotonic, muscle tension


8/24

symmetrical

C! J//@ tongue is midlineB no a''arent de.iation u'on 'rotrusionB no

fasciculation or atro'hy noted

6otor -am

6uscles are symmetrical in both u''er and lower e-tremities, without atro'hy or

fasciculations+ 6uscles normotonic ha.e a muscle strength inde- of 5:5+

(ensory -am

Patient has intact 'ain, crude touch, and 'osition sense on both u''er and lower

e-tremities+ Patient e-hibits stereognosia and gra'hestesia+

0efle-es

;oint refle-es intact, symmetrical, normorefle-i.e, with negati.e abins%i sign

6eningeal (igns

!egati.e Iernigs and rudzins%y signs were elicited+ Absent nuchal rigidity or 'ain

elicited u'on straightleg test

Di!!erential Dia0nosis

n!luena /iral %lu

asis@ (igns and sym'toms that were seen in the 't such as e.er, $eadache, with

'rogression to a 'roducti.e cough+ And also .iral fe.er are common now a days because

of rainy season in the country+ / rulled out this disease because it was already two wee%sand usually .iral influenza are self limiting and also she has a''arent signs of bacterial

etiology such yellowish or greenish secretions+

/ ncubation 'eriod@ 1 to * days+

ransmission@ Aerosol 1 day before the onset of sym'toms or .ia asym'tomatic 'ersons


9/24

Firal shedding@ occurs at the onset of sym'toms or ust before the onset of illness )2*

hoursE and continues for 51) days

Gaboratory wor% u'+

asis of clinical criteria,

Com'lete blood count Geu%o'enia and relati.e lym'ho'eniaE

lectrolyte le.els+

hroat (wab+ enzyme in throat swabs, nasal swabs, or nasal washes+ 0esults within

) minutesE

0PC0 testing .iral culture of naso'haryngeal or throat secretionsE standard for

confirming influenza .irus infection+ Culture or 3 days+

PC0 9)K sensiti.e within 2* hoursE

Pre.ention

Faccines

1+E /nfluenza .irus .accine tri.alent Afluria, luGa.al, luari-, lu.irin, luzone,

luzone $ighDose, luzone /ntradermalE

2E /nfluenza .irus .accine 4uadri.alent luari- #uadri.alent, luzone #uadri.alent,

luGa.al #uadri.alentE

+

reatment

he .iral fe.er of the 't is self limiting in days for most cases+ /ncrease luid

/nta%e and Fitamin C su''lementsE

Anti.iral Pharmacologic hera'y chemo'ro'hyla-is and treatmentE

"seltami.ir, Lanami.ir, Amantadine and 0imantadine


10/24

6pper +espiratory Tract n!ection

Basis (igns and sym'toms that were seen in the 't such as e.er, $eadache, with

'rogression to a 'roducti.e cough+ his may be due to a .iral and bacterial infection 't

has colds that ma%es me consider it is an H0/+ but / rulled out this disease because it

was more 'rominent in the large airways that was seen in the 'hysical e-am li%e ronchi

which is not commonly seen in H0/+

6anifestations

Firal naso'haryngitis @

Patients with the common cold may ha.e a 'aucity of clinical findings des'ite notable

subecti.e discomfort+, !asal mucosal erythema and edema are common

!asal discharge@ Profuse discharge is characteristic of .iral infections than bacterial

infectionsB initially clear secretions ty'ically become cloudy white, yellow, or green o.er

se.eral days+

&rou' A stre'tococcal 'haryngitis @

rythema, swelling, or e-udates of the tonsils or 'haryn-

em'erature of 8+MC 1))+9ME or higher

ender anterior cer.ical nodes N1 cmE

Absence of conuncti.itis, cough, and rhinorrhea, which are sym'toms that may suggest

.iral illness

Acute bacterial rhinosinusitis @


11/24

Persistent nasal discharge any ty'eE or cough lasting 1) days or more without

im'ro.ement

7orsening course new or worse nasal discharge, cough, fe.erE after initial im'ro.ement

/n older children and adults, sym'toms eg, 'ain, 'ressureE tend to localize to the affected

sinus+

Gaboratory

lood count and cultures 'atients with H0/s may ha.e an increased white blood cell

7CE count with a left shift+ Aty'ical lym'hocytes, lym'hocytosis, or lym'ho'enia

may be seen in some .iral infectionsB lym'hocytosis may also be seen in 'ertussis+

Culturing of throat swabs, nasal swabs or washes, or nasal as'irates remains the standard

for confirming bacterial H0/ 'athogens+

or confirming .iral naso'haryngeal infection, .iral cultures remain the standard+

0a'id tests for .iruses include .arious antigen, immunofluorescence, and PC0 assays+

reatment

Antibiotics used in grou' A stre'tococcal infection are as follows@

Penicillin FI Penicillin FE

Amo-icillin Amo-il, 6o-atag, rimo-E

Penicillin & benzathine icillin GA, Perma'enE

Antibiotics used in e'iglottitisare as follows

Cefuro-ime CeftinE

Ceftria-one 0oce'hinE

Cefota-ime ClaforanE


12/24

Antibiotics used in 'ertussisare as follows@

Clarithromycin ia-inE

rythromycin 6ycin, rythrocin, ryc, ryab, ++(+E

Azithromycin Lithroma-E

Antibiotics used in acute bacterial rhinosinusitis are as follows@

Amo-icillin:cla.ulanate

Do-ycycline

linical $ain Dia0nosis 3oer +espiratory Tract n!ection Bacterial Pneu"onia8

Basis

$P/@ (udden 'roducti.e cough, 'legm is clear in color then yellowish, Accom'anied

with colds, which is .iscous and clear also e-'erienced headache and dizziness+ ac%

'ain in the thoracic area, radiates in the shoulder, also with malaise and .omiting (he

e-'erienced difficulty in breathing accom'anied by midsternal 'ain+ /n a 2 wee%s ime+

Personal (ocial@ -'osure to 2ndhand (mo%ing

Fital (igns@ ebrile 3+?

Chest and Gungs@ an increase tactile fremitus on anterior lung filedB all lung fields

resonant on 'ercussionB ilateral 0onchi is heard on the a'ices of the lungs more

'ronounce on the right, broncho'hony and whis'ered 'ectrilo4uy was noted+

nalysis

he 't may ha.e de.elo'ing 'neumonia that initially 'resents as a 'roducti.e cough

which is bacterial in origin+ he color changes of the s'utum of the 'atient from clear to

yellowish indicates a bacterial ty'e and not the .iral 'neumonia, which is in two wee%s

time time, if other res'iratory .irus are considered the disease itself must be in to 5 days


13/24

self limiting com'ared to the 't case which is already in two wee%s time+ /t was followed

by non s'ecific sym'toms such headache, dizziness, bac% 'ain+ H'on Physical

e-amination ronchi were heard on both lung fields that indicates infiltrates in the large

airways and with broncho'ony and whis'ered 'ectorilo4uy+

-'ected indings in Penuemonia

Patho'hysiology

he causes for the de.elo'ment of 'neumonia are e-trinsic or intrinsic, and .arious

bacterial causes are noted+ -trinsic factors include e-'osure to a causati.e agent,

e-'osure to 'ulmonary irritants, or direct 'ulmonary inury+ /ntrinsic factors are related tothe host+ Goss of 'rotecti.e u''er airway refle-es allows as'iration of contents from the

u''er airways into the lung+

acteria from the u''er airways or, less commonly, from hematogenous s'read, find

their way to the lung 'arenchyma+ "nce there, a combination of factors including

.irulence of the infecting organism, status of the local defenses, and o.erall health of the

'atientE may lead to bacterial 'neumonia+ he 'atient may be made more susce'tible to

infection because of an o.erall im'airment of the immune res'onse and:or dysfunction of

defense mechanisms eg, smo%ing, chronic obstructi.e 'ulmonary disease, tumors,

inhaled to-ins, as'irationE+ Poor dentition or chronic 'eriodontitis is another 'redis'osing

factor+

hus, during 'ulmonary infection, acute inflammation results in the migration of

neutro'hils out of ca'illaries and into the air s'aces, forming a marginated 'ool of

neutro'hils that is ready to res'ond when needed+ hese neutro'hils 'hagocytize

microbes and %ill them with reacti.e o-ygen s'ecies, antimicrobial 'roteins, and

degradati.e enzymesB they also e-trude a chromatin meshwor% containing antimicrobial

'roteins that tra' and %ill e-tracellular bacteria, %nown as neutro'hil e-tracellular tra's

!sE+ Farious membrane rece'tors and ligands are in.ol.ed in the com'le- interaction

between microbes, cells of the lung 'arenchyma, and immune defense cells
http://emedicine.medscape.com/article/807143-overviewhttp://emedicine.medscape.com/article/807143-overview


14/24

(igns and sym'toms

Cough, 'articularly cough 'roducti.e of s'utum, is the most consistent 'resenting

sym'tom of bacterial 'neumonia and may suggest a 'articular 'athogen, as follows@

(igns of bacterial 'neumonia may include the following@

$y'erthermia fe.er, ty'ically O8MC, achy'nea, Hse of accessory res'iratory muscles,

achycardia O1)) b'mE, Central cyanosis

Physical findings may include the following@

Ad.entitious breath sounds, such as rales:crac%les, rhonchi, or wheezes, Decreased

intensity of breath sounds, go'hony, 7his'ering 'ectorilo4uy, Dullness to 'ercussion

!ons'ecific sym'toms such as fe.er, rigors or sha%ing chills, and malaise

CH0?5 is a scoring system de.elo'ed from a multi.ariate analysis of .arious factors

that a''eared to 'lay a role in 'atient mortality+

C onfusion Altered mental status

H remia lood urea nitrogen H!E le.el greater than 2) mg:dG

0 es'iratory rate ) breaths or more 'er minute

lood 'ressure (ystolic 'ressure less than 9) mm $g or diastolic 'ressure less than ?)

mm $g

Age older than ?5 years

Pneumonia se.erity inde- he P(/ , is a 'rediction rule for mortality and se.erity based

on characteristics deri.ed from cohorts of 'atients+

Gaboratory


15/24

Arterial blood gas A&Edetermination $y'o-ia and res'iratory acidosis may be

'resent+

Fenous blood gas determination central .enous o-ygen saturationE

Com'lete blood cell CCE Geu%ocytosis

(erum free cortisol .alue

(erum lactate le.el

Creacti.e 'rotein C0PE le.el may be 'redicti.e of more serious disease+

inlfuenza fever patient history qcgh

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