A 26-year-old previously well lady presented to you with x5/7 ho cough and runny nose associated with fever.
Question 1: How would you approach and manage this lady?
Question 2: What are your differential diagnoses?
Question 3: How would you differentiate between bacterial and viral URTI?
Drug Discussion: What types of cough mixtures are available in the Klinik Kesihatan? What are their mode of actions and common side effects? What other medications would you like to prescribe for her?
Take history, doing physical examination and outline the management for this patient
ReplyDeletehistory
-introduce ourself, ask patient name, age and occupation
-ask the presenting complaint that bring her to clinic.
history for cough:
-when it started?
-how would you describe the cough?
-do you cough out sputum?
-describe the sputum- colour,amount, smell, any blood
-is there any burning sensation in your throat or chest when you cough?
-did you noticed any changing in your voice(hoarseness)
-have you noticed any other symptm?
-any chest pain, shiver or sweats?
-do you have wheeze?
-any LOW?
-any contact with TB patient?
- anyone surrounding you got the same symptom?
family, friend
for fever
-when it started?
-is the fever continous of intermittent?
it is same all the day or worsen at particular time eg at night
-it is associated with chill and rigor?
do you take your own at home temperature? if yes what wa the value?
-any muscle or joint pain, abdominal pain or vomiting,any skin rash any bleeding episode?
- do you take any medication for the fever. Does it resolve your fever
Systemic review
General- malaise and tiredness,nasal congestion
CNS- headeache, LOC, weakness
RESPI-sneezing, hemoptysis, chest pain
CVS- chest pain, palpitation, edema
Genitourinary- dysuria, suprapubic pain, hematuria
GIT- diarrhea
MSK- as above( joint n muscle pain)
Menses history
PMH/ PSH- any medical problem eg: asthma,chronic sinusitis, HPT,DM
Drug history- any medication that might cause cough
Family history- anyone have asthma or any other chronic diseases and malignancy
Social history
- status, lives with whom and where, it is a dengue prone area?
- smoking, alcohol consumption and drug uses
Physical examination
Vital sign- BP,PR, RR,Temp
General-hydrational status, any skin rash, pallor, lymp node enlargement
Throat examination- check for injected throat/ tonsillitis
Don’t forget to check ear and nose as well because ear, nose and throat are connected to each other so the problem might come from one if this
Respiratory examination- check if there dullness on percussion, reduce air entry and vocal resonance and any rhonci or crepitation(to exclude lung infection)
Management (for viral fever)
-patient education
From what you tell me and examination, you might have a viral fever. It is a self-limiting infection so no need to take any antibiotic just make sure that’s you get enough sleep and rest, drink a a lot of plain water and avoid close contact with other because it is infectious.
-Lifestyle modification
Take a good diet and do regular exercise to improve your immune system
-investigation
FBC- check WBC, Hb, platelet(to exclude bacterial infection)
-medication
Analgesic- paracetamol / aspirin
Cough mixture- diphenhydramine
Refer to drug discussion for detailed.
Safety netting
• To came back again if fever not settled (most of viral fever settled completely within a week), any severe abdominal pain, vomiting, marked changes in body temperature, from fever to low temperature change in mental status such as irritability or lethargy(warning sign for dengue fever)
Thank you for your answer
ReplyDeleteMedications:
symptom relief -
1)antipyretic: PCM 1g Qid/ PRN
we don't normally give aspirin
2) syp benadryl 15mls TDS/ PRN (cough)
3) antihistamine - actifed/ piriton
4) no need for antibiotics as it is viral in origin
You check FBC TRO viral thrombocytopenia and also to exclude bacterial infection as you mentioned
Viral fever is self limiting - normally last for 4-5 days and resolve by one week as you mentioned
warning signs for DF MUST also include any bleeding tendnecies such nose bleed, PR bleed, haemoptysis, hemetemesis, gum bleed and heavy menses
the other important warning signs of DF is abdominal pain( eigastric pain) with inability to tolerate orally (nausea/ poor appetite with vomitting +/- diarrhea)
Bed rest and increase fluid intakes (any fluids) is the best advise for viral fever. Advise taking soups/ porridge if they have poor appetite. Exercising may be a bit too much for them.
DO you know what is the name of the criterias to differentiate between viral and bacterial infections in a patient presenting with fever, cough and RN?
sorry dr..i'm trying to find it but could'nt find the proper answer in the book and also from internet..i'm just know that in viral the fever is mild compared to bacteria..i will try to find it again and let you know
ReplyDeleteRecommendation is that antibiotics (either penn v, amoxycillin or erythromicin) should be started in urti pts if they have at least 3 out of 4 criteria (tonsillar exudate, fever T> 38, cervical LN, absent of cough). This criteria indicates that the urti is bacteria rather than viral.
ReplyDeleteThe name of the criteria is McIsaac criteria. Please refer to Cpg sore throat.
ReplyDelete