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

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Chief Complaint

Cough of >3 weeks duration

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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.

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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.

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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.

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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

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Review of Systems

(+) weight loss (+) intermittent fever

of 2 days duration (3pm) (-) rashes (-) headache (+) orthostatic

hypotension (-) ear discharge (+) itchy throat

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(+) frequent clearing of throat

(-) PND (-) orthopnea (-)hemoptysis (-) dysphagia (-) diarrhea (-) nocturia

Past Medical History

CV accident, Hypertension – Father

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Family History

Genogram of GV – July 27, 2010

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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

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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

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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

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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

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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.

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Differential Diagnosis

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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

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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

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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,

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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

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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.

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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

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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

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Therapeutic Plan: GERD

Begin PPIs Omeprazole, 20 mg/tab, 1 tab/day, OD for 4 weeks

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Adjunctive Therapy: GERD

Vitamin B12 supplementationCalcium supplementation

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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

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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

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End.