CARIAGA, DEEVON M.

MEDICINE 2
SECTION 3A
CLINICAL SCENARIO: COUGH
General Data:
Name: C.E.M
Age: 74 years old
Sex: Male
Religion: Roman Catholic
Address: Marulas, Valenzuela City

History of Present Illness: 

A 74-year-old male presents after admission to the general medical/surgical hospital ward with a chief complaint of cough. he reports that he was
seen for similar symptoms previously at his primary care physician’s office six months ago. At that time, he was diagnosed with acute bronchitis
and treated with bronchodilators, empiric antibiotics, and a short course oral steroid taper. This management did not improve his symptoms, and
he has gradually worsened over six months. he reports a 20-pound intentional weight loss over the past year. he denies any sick contacts.
5 days prior to admission, patient had positive signs and symptoms of cough, yellowish phlegm, persistent fever and back pain. Knowing that
these signs and symptoms were just forms of little discomforts, she self-medicated with paracetamol. However, she noticed no changes and
experienced difficulty of breathing so she sought medical consultation.
3 days prior to admission, patient presents with fever and cough with onset of nasal stuffiness, mild sore throat, and a cough productive of small
amounts of clear sputum.
Today, he decided to seek physician assistance because of an increase in temperature to 38.3°C and spasms of coughing that produce purulent
secretions. On one occasion, he noted a few flecks of bright-red blood in his sputum.

Past Medical History: The patient has no history of familial illness, hospitalizations, or trauma. There are no drug allergies or intolerance. The
only medication he takes is acetaminophen occasionally, for headaches. He drinks beer or wine in moderation.
Personal and Social History: His tobacco use is 33 pack-years; however, he quit smoking shortly prior to the onset of symptoms, six months ago.
he denies alcohol and illicit drug use. he is married, in a monogamous relationship, and has three children aged 15 months to 5 years. His former
job is a car mechanic for 40 years.
ROS:
A brief review of systems is negative for night sweats, palpitations, chest pain, nausea, vomiting, diarrhea, constipation, abdominal pain, neural
sensation changes, muscular changes, and increased bruising or bleeding. he admits a cough, shortness of breath, and shortness of breath on
exertion.

Physical Exam:
His body temperature is, his pulse is 110 beats/min and regular, and his respiratory rate is 20 breaths/min. His oxygen saturation is 93% while
breathing room air. There is mild erythema of the mucosa of the nose and posterior oropharynx. Inspiratory “rales” are heard at the right lung base.
Vitals: Temperature: 38.9°C; heart rate 88; respiratory rate, 22; blood pressure 130/86; body mass index, 30
General: he is well appearing but anxious, a pleasant male lying on a hospital stretcher. he is conversing freely, with respiratory distress causing
her to stop mid-sentence.
Respiratory: he has diffuse rales and mild wheezing; tachypneic.
Cardiovascular: he has a regular rate and rhythm with no murmurs, rubs, or gallops.
Gastrointestinal: Bowel sounds X4. No bruits or pulsatile mass.
Primary diagnosis and basis:
Community Acquired Pneumonia: cough, dyspnea, and low-grade fever are clinical features of pneumonia. The most common symptom of
pneumonia is a cough that produces sputum, but chest pain, chills, fever, and shortness of breath are also common.
Differential diagnosis and basis
Asthma: Intermittent coughing spells and dyspnea brought on by specific triggers (e.g., exercise, allergen exposure) are the hallmark of asthma.
No personal and family history of atopic dermatitis and allergy, which are often associated with asthma.
Acute bronchitis: Symptoms of productive, painful cough and low-grade fever following an upper respiratory infection support the diagnosis of
acute bronchitis in this patient. Acute bronchitis is viral in > 90% of cases and as such does not usually require antibiotic treatment. However, this
patient's symptoms pre-date his URI. The worsening of symptoms over the past few days is probably due to bronchial hyperresponsiveness to
increased mucus production.
Pathophysiology:
Virulent Microorganism
 Streptococcus Pneumoniae

Microorganism enters the nose (nasal passages)

Passes through the larynx, pharynx, trachea

Microorganism enters and affects both airway and lung parenchyma

Airway damage Lung invasion

Infiltration of bronchi flattening of epithelial cells

Infectious organism lodges macrophages and leukocytes

Stimulation in bronchioles necrosis of bronchial tissues mucus and phlegm production

Alveolar collapse narrowing of air passage COUGHING

Productive/non-productive
Increase pyrogen in the body DIFFICULTY OF BREATHING

FEVER
 Necrosis of pulmonary tissue

Overwhelming sepsis

DEATH
Diagnostic Exam
Laboratory and radiographic findings. His hemoglobin level is 12.5 g/dL, with a hematocrit of 36%. His WBC count is 13,500 cells/µL, with
82% polymorphonuclear cells, 11% band forms, and 7% lymphocytes. His platelet count is 180,000 cells/µL. The results of a multichemistry
screen are unremarkable. Chest radiography documents bilateral lower lobe infiltrates that are more pronounced on the right side. There are no
pleural effusions.
Arterial blood gas analysis, pulse oximetry: to assess the severity of the condition and test whether the patient's blood is sufficiently oxygenated
CBC with differential: A WBC count can help determine if an infection is present and if it is bacterial or viral. Eosinophilia may be seen
on CBC in asthma patients.
Peak flow monitoring: for monitoring response to a trial of bronchodilator therapy
Pulmonary function testing (PFTs): PFTs are the first-line diagnostic test for asthma and will show a decreased FEV1 and other signs
of obstructive lung disease. The obstruction is reversible when bronchodilators are administered. 
Methacholine challenge test: used to provoke symptoms in patients with intermittent asthma who have normal PFTs
CXR: to rule out pneumonia
Treatment:
First-line antibiotics that might be selected include the macrolide antibiotics azithromycin (Zithromax) or clarithromycin (Biaxin XL); or the
tetracycline known as doxycycline.
Other appropriate antibiotics may include the fluoroquinolone antibiotics such as levofloxacin (Levaquin); or combined therapy of a beta-lactam
such as amoxicillin or amoxicillin/clavulanate (Augmentin) with a macrolide antibiotic.
Prognosis:
Most pneumonia is treated successfully, especially if antibiotics are started early. Pneumonia can be fatal. The very old and frail, especially those
with many other medical conditions, are most vulnerable.

Pneumonia usually does not cause permanent damage to the lungs. Rarely, pneumonia causes infected fluid to collect around the outside of the
lung, called an empyema. The empyema may need to be drained with a special tube or surgery. With aspiration pneumonia, the affected lung may
develop a lung abscess that needs many weeks of antibiotic therapy.

SOURCE:
Harrison’s Internal Medicine 20th edition