G.V., 26/M Presenting with Cough

1. G.V., 26/MPresenting with Cough Case Presentation: GROUP 1 Tan J., Tanchuling, Te, Teo, Tindoc

2. History

3. SUBJECTIVE OBJECTIVE ASSESSMENT PLAN General Data • G.V. • 36 year old male • from Laguna

4. SUBJECTIVE OBJECTIVE ASSESSMENT PLAN Chief Complaint • Cough of >3 weeks duration

5. 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.

6. 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.

7. 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.

8. 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

9. Review of Systems SUBJECTIVE OBJECTIVE ASSESSMENT PLAN • (+) 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

10. Past Medical History SUBJECTIVE OBJECTIVE ASSESSMENT PLAN • CV accident, Hypertension – Father

11. Family History Genogram of GV – July 27, 2010 SUBJECTIVE OBJECTIVE ASSESSMENT PLAN 52 Stroke 56 36 28 38 11 14 10 13

12. Social History SUBJECTIVE OBJECTIVE ASSESSMENT PLAN • Smoked for 1-2 years, only a few sticks after each drinking session. • Minimal alcohol intake • Only sexual partner is his wife

13. 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

14. Physical Exam SUBJECTIVE OBJECTIVE ASSESSMENT PLAN • 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

15. Physical Exam SUBJECTIVE OBJECTIVE ASSESSMENT PLAN • 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

16. Physical Exam SUBJECTIVE OBJECTIVE ASSESSMENT PLAN • 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.

17. Differential Diagnosis SUBJECTIVE OBJECTIVE ASSESSMENT PLAN

18. Differential Diagnosis SUBJECTIVE OBJECTIVE ASSESSMENT PLAN

19. Working Diagnosis SUBJECTIVE OBJECTIVE ASSESSMENT PLAN • Pulmonary Tuberculosis Stage V • Concomitant GERD

20. Pathophysiology: GERD-related cough SUBJECTIVE OBJECTIVE ASSESSMENT PLAN 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,

21. Tuberculosis SUBJECTIVE OBJECTIVE ASSESSMENT PLAN • 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

22. Tuberculosis SUBJECTIVE OBJECTIVE ASSESSMENT PLAN • 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).

23. The tiny droplets dry rapidly; may remain suspended in the air for several hours and may reach the terminal air passages when inhaled.

24. Pathophysiology • Primary sites of TB: • Lungs (Pulmonary TB) • Kidney • Brain • Bone * Last three most common sites of extrapulmonary TB

25. Pathophysiology • If patient is not immunocompromised, caseous necrosis will happen – latent TB,

26. Pathophysiology • If patients are immunocompromised, the granuloma may undergo liquefactive necrosis and leave a cavity.

27. 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

28. 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.

29. Extrapulmonary Disease • One will observe symptoms relating to other parts of the bory (ex. kidney). Our patient likely has Primary Progressive Disease.

30. Diagnostic Plan SUBJECTIVE OBJECTIVE ASSESSMENT PLAN Sputum AFB Sputum TB culture • For PTB: • For GERD Chest Radiograph None recommended

31. Therapeutic Plan: TB SUBJECTIVE OBJECTIVE ASSESSMENT PLAN • DOTS • For Newly Diagnosed Smear Positive patients: • 2HRZE daily (initial phase) • 4HR daily or thrice-weekly (continuation phase) • If MDR-TB, refer.

32. Adjunctive Therapy: TB SUBJECTIVE OBJECTIVE ASSESSMENT PLAN • 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

33. Prevention: TB SUBJECTIVE OBJECTIVE ASSESSMENT PLAN • 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

34. Therapeutic Plan: GERD SUBJECTIVE OBJECTIVE ASSESSMENT PLAN • Begin PPIs • Omeprazole, 20 mg/tab, 1 tab/day, OD for 4 weeks

35. Adjunctive Therapy: GERD SUBJECTIVE OBJECTIVE ASSESSMENT PLAN • Vitamin B12 supplementation • Calcium supplementation

36. Non-pharmacologic Therapy: GERD SUBJECTIVE OBJECTIVE ASSESSMENT PLAN • 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

37. Counseling SUBJECTIVE OBJECTIVE ASSESSMENT PLAN • 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

38. 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 SUBJECTIVE OBJECTIVE ASSESSMENT PLAN

39. End.