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Approach to a patient with cough

Approach to a patient with cough. B4 – Dr. Remedios Coronel Garcia, Garcia, Garzon , Gaspar, Gatchalian , Gaw , Geraldoy , Geronimo, Geronimo Geronimo , Go, Go, Go, Go, Go, Go December 4, 2009. General Data. Name: RM Age: 60 Sex: Male Status: Married Address: Quiapo , Manila

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Approach to a patient with cough

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  1. Approach to a patient with cough B4 – Dr. Remedios Coronel Garcia, Garcia, Garzon, Gaspar, Gatchalian, Gaw, Geraldoy, Geronimo, Geronimo Geronimo, Go, Go, Go, Go, Go, Go December 4, 2009

  2. General Data • Name: RM • Age: 60 • Sex: Male • Status: Married • Address: Quiapo, Manila • Religion: Roman Catholic • Race: Filipino

  3. History of Present Illness • CC: Productive Cough

  4. Past Medical History • HTN (2005) - Highest BP 200/160; Usual BP – 120/80 • Nifedipine, Metoprolol, and Aspirin - unrecalled dosage • Non-complaint (?) • LVH, possible MI (2005) • “ Food poisoning” – UST Hospital (2005) • External Hemorrhoids (2005) • Claims to have complete immunizations • No history of surgery • (-) DM • (-) Bronchial asthma • (-) PTB • (-) Blood transfusion • (-) Allergies • (-) Trauma/ accident

  5. Family History • (+) HTN – parents and siblings • (+) Heart disease – parents and siblings • (-) DM • (-) Cancer • (-) Allergy • (-) Asthma • (-) PTB • (-) Thyroid diseases

  6. Personal/Social History • Drinks a lot of soft drinks (each meals) • (+) Smoking pack/year • Occasional alcohol drinker amt • Mixed diet, preference to salty foods • Used to work for customs as a “checker” for 2O years and retired in 2009 • Currently sells candles in Quiapo church with his wife. • Married with 8 kids • Currently lives with his 20-year old son in a small apartment located in Abad Santos • Joined a marathon as his form of exercise

  7. Review of Systems • (-) anorexia, (+) weight loss (8kg loss in a month) • (-) itchiness • (-) headache, (-) blurring of vision • (+) dizziness • (-) colds • (-) chest pain, (-) palpitations • (-) abdominal pain • (-) vomiting, (-) diarrhea, (-) constipation • (-) dysuria, (-) hematuria, (-)flank pain

  8. Review of Systems • (-) bleeding, (-) easy bruisability • (-) polyuria, (-) polydipsia, (-) polyphagia • (-) heat / cold intolerance • (-) muscle pain • (-) edema • (+) asterixis

  9. Physical Examination on Interview • Conscious, coherent, ambulatory, not in CP distress • BP: 160/100mmHg PR: 92bpm, regular RR: 21cpm, regular T: 37.5 °C Ht=160 cm Wt=45 kg BMI=18 • Warm dry skin, no active dermatoses • Pale palpebral conjunctivae, anicteric sclera, pupils 2-3mm ERTL • Septum midline, no nasoaural discharge • No tragal tenderness, non-hyperemic, no pain on mastoid area

  10. Physical Examination on Interview • Neck not rigid, no palpable cervical lymphadenopathy • No chest wall deformity, symmetric chest expansion, no retractions, equal vocal and tactile fremiti, clear breath sounds • Adynamicprecordium, AB at 6th LICS AAL, (-) parasternal heave, (-) thrills, S2>S1 at base, loud P2, S1>S2 and (+) S3 at apex, (+) hemic murmur, carotid artery: rapid uptsroke, gradual downstroke, JVP 3cm at 30 angle • Flat abdomen, NABS, soft, no mass, no tenderness, 8 cm liver span midclavicular line, traube’s space not obliterated, (-) hepatojugular reflux • No palpable inguinal nodes, no CVA tenderness • Pulses full and equal, (-) cyanosis

  11. Physical Examination on Interview • Conscious, coherent, oriented to 3 spheres GCS 15 • Sense of smell intact • Isocoric pupils: , 2-3mm ERTL, no visual field cuts • Fundoscopy: (+) ROR, no papilledema, no hemorrhages, clear disc margins • EOMs full and equal, (+) conjugate eye movements • Intact V1-V3 • Can clench teeth, raise eyebrows, frown, no gross facial asymmetry • Gross hearing intact, (-) lateralization on Weber • Uvula midline on phonation

  12. Physical Examination on Interview • Can shrug shoulders, turn head side to side against resistance • Tongue midline on protrusion • MMT: 5/5 on all extremities • No sensory deficits • No atrophy, no fasciculations, no spasticity • Cerebellar functions intact • DTRs: (++) on all limbs • No Babinski, no chaddocks, no oppenheims • No nuchal rigidity, no Brudzinski, no Kernigs

  13. Salient Subjective Features

  14. Salient Objective Features

  15. Etiology of Cough

  16. Differential Diagnosis • (-) orthopnea, PND • JVP 3cm at 30 angle • AB at 6th LICS AAL • S3 at apex • (-) hepatojugularreflux • (-) edema • Dyspnea • 8 cm liver span MCL • Weight loss • Dyspnea, • (-) chest pain • (-) syncope • (-) tachycardia • (-) cyanosis • (-) hypotension • Fever • Cough • Dyspnea • (-) colds • Septum midline • (-) nasoaural discharge • (-) palpable cervical lymphadenopathy

  17. Clinical Impression • Community-Acquired Pneumonia

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