Transcript June 2010
G.V., 26/M Presenting with Cough CASE PRESENTATION: GROUP 1 TAN J., TANCHULING, TE, TEO, TINDOC History SUBJECTIVE OBJECTIVE ASSESSMENT General Data G.V. 36 year old male from Laguna PLAN SUBJECTIVE OBJECTIVE ASSESSMENT Chief Complaint Cough of >3 weeks duration PLAN SUBJECTIVE OBJECTIVE ASSESSMENT PLAN History of Present Illness December 2009 GV 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 2010 There 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 2010 Patient’s cough worsened, became productive and he experienced DOB. Self medicated with Vick’s Formula 44 syrup Chest 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, 2010 Patient decided to have his CXR done. June 24, 2010 Patient 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 2010 Patient 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, 2010 Day 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 (+) frequent clearing of throat (-) PND (-) orthopnea (-)hemoptysis (-) dysphagia (-) diarrhea (-) nocturia SUBJECTIVE OBJECTIVE ASSESSMENT Past Medical History CV accident, Hypertension – Father PLAN SUBJECTIVE OBJECTIVE ASSESSMENT PLAN Family History Genogram of GV – July 27, 2010 52 Stroke 56 36 38 11 10 28 14 13 SUBJECTIVE OBJECTIVE ASSESSMENT PLAN Social History Smoked for 1-2 years, only a few sticks after each drinking session. Minimal alcohol intake Only 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 SUBJECTIVE OBJECTIVE 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 SUBJECTIVE OBJECTIVE 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. SUBJECTIVE OBJECTIVE ASSESSMENT PLAN Differential Diagnosis 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 Cough no paroxysmal, respiratory tract (-) posttussive vomiting infection SUBJECTIVE OBJECTIVE ASSESSMENT PLAN Differential Diagnosis Differentials Rule In Rule Out Post-nasal drip Chronic cough No runny nose, (-) exposure to allergic substances Pulmonary tuberculosis Stage V (suspected) Chronic cough Cannot be ruled out associated with anorexia, fever in the afternoon, history of exposure to TB, weight loss. 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 SUBJECTIVE OBJECTIVE ASSESSMENT Working Diagnosis Pulmonary Tuberculosis Stage V Concomitant GERD PLAN SUBJECTIVE OBJECTIVE ASSESSMENT PLAN Pathophysiology: GERD-related cough 1) Vagal Reflex acid stimulates esophageal receptors 2) Heightened Bronchial Reactivity exposure to esophageal acid may increase bronchial activity to other stimuli 3) Microaspiration gastric acid in the larynx and upper airway upper airway stimulation + increase airway resistance 4) Immune System Modification GERD may alter the immune system’s response to allergens, SUBJECTIVE OBJECTIVE ASSESSMENT PLAN Tuberculosis Etiologic organism: Mycobacterium tuberculosis Most common transmission: droplet nuclei aerosolized by coughing, sneezing, or speaking Factors 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 SUBJECTIVE OBJECTIVE ASSESSMENT PLAN 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). 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. SUBJECTIVE OBJECTIVE ASSESSMENT Diagnostic Plan For PTB: Sputum AFB Sputum TB culture Chest Radiograph For GERD None recommended PLAN SUBJECTIVE OBJECTIVE ASSESSMENT Therapeutic Plan: TB DOTS For Newly Diagnosed Smear Positive patients: 2HRZE daily (initial phase) 4HR daily or thrice-weekly (continuation phase) If MDR-TB, refer. PLAN SUBJECTIVE OBJECTIVE ASSESSMENT PLAN 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 OBJECTIVE ASSESSMENT PLAN 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 OBJECTIVE ASSESSMENT Therapeutic Plan: GERD Begin PPIs Omeprazole, 20 mg/tab, 1 tab/day, OD for 4 weeks PLAN SUBJECTIVE OBJECTIVE ASSESSMENT Adjunctive Therapy: GERD Vitamin B12 supplementation Calcium supplementation PLAN SUBJECTIVE OBJECTIVE ASSESSMENT PLAN Non-pharmacologic Therapy: GERD Head Elevation during sleep, 4-6 inches Limit vigorous exercise or other factors that increase intra-abdominal pressure Diet 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 OBJECTIVE ASSESSMENT PLAN Counseling Involve family members to entertain apprehensions, concerns, worries about TB Educate them on TB and its prevention Encourage them to help patient in adhering to TB treatment regimen Involve 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 OBJECTIVE ASSESSMENT PLAN 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 End.