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.
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. 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.
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:
Pneumonia is a severe form of an acute lower respiratory infection that specifically affects
the lungs and is typically caused by bacteria, viruses or fungi. The lungs reaction to these
foreign microbes is to cause an inflammatory response causing the bronchioles and alveoli
to fill with fluid and become solid
The body has several defense mechanisms against the agents that can cause Pneumonia:

• Coughing
• Mucociliary escalator - lines the airway that assists the movement of bacteria out of the
airways and away from the lungs
• Macrophages
 If these mechanisms fail and a microbe is successful in colonizing the alveoli they then
multiple and quickly move over into the lung tissue(coughing) activating an inflammatory
response(fever); the result is Pneumonia.

Pneumonia has four stages, namely consolidation, red hepatization, grey hepatization and
resolution.

• Consolidation
• Occurs in the first 24 hours
• Cellular exudates containing neutrophils, lymphocytes and fibrin replaces the alveolar air
• Capillaries in the surrounding alveolar walls become congested
• The infection spreads to the hilum and pleura fairly rapidly
• Pleurisy occurs
• Marked by coughing and deep breathing
• Red Hepatization
• Occurs in the 2-3 days after consolidation
• At this point, the consistency of the lungs resembles that of the liver
• The lungs become hyperaemic
• Alveolar capillaries are engorged with blood
• Fibrinous exudates fill the alveoli
• This stage is "characterized by the presence of many erythrocytes, neutrophils, desquamated
epithelial cells, and fibrin within the alveoli"

• Grey Hepatization
• Occurs in the 2-3 days after Red Hepatization
• This is an avascular stage
• The lung appears "grey-brown to yellow because of fibrinopurulent exudates, disintegration
of red cells, and hemosiderin"
• The pressure of the exudates in the alveoli causes compression of the capillaries
• "Leukocytes migrate into the congested alveoli"

• Resolution
• This stage is characterized by the "resorption and restoration of the pulmonary architecture"
• A large number of macrophages enter the alveolar spaces
• Phagocytosis of the bacteria-laden leucocytes occurs
• "Consolidation tissue re-aerates and the fluid infiltrate causes sputum"
• "Fibrinous inflammation may extend to and across the pleural space, causing a rub heard by
auscultation, and it may lead to resolution or to organization and pleural adhesions"

• The elderly, infants, young children and those with a weakened immune system are at a
higher risk of acquiring Pneumonia. Other causes such as frequent exposure to asbestos and
cigarette smoke have an increased risk of contracting community-acquired pneumonia than
young and middle-aged adults.
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 multi-chemistry
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:
Drugs used in the management of pneumonia includes: penicillin, cephalosporin, macrolides,
carbapenems, fluoroquinolones.
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.