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Written Case Candidate Number: M7769

A man with sore throat and cough

Presenting Complaint

A 36 year-old Malay gentleman was complaining about coughing and sore

throat.

History of Presenting Complaint

The onset of coughing was 3 days ago and becoming progressively worsen thatmakes him look for medical attention. It was a non-productive cough andassociated with an on-and-o low grade fever. !e denied chest pain. Thecoughing had becoming worse at night and e"acerbate by coldness. Inaddition# he claimed there was transient shortness of breath together withe"cessive coughing. The shortness of breath does not seem to be related toany trigger factors in asthmatic patient. In addition# he did not e"perience thesimilar episode of attack before this. !e had mild headache# $oint pain and

muscle aches. %ormal hydration status and oral intake.

Past Medical History

%o admission to hospital

%o hypertension# diabetes mellitus# hypercholesterolemia

%o history of childhood asthma

Drug History

Taken paracetamol &T' on the second day of coughing and the coughing get

relieved mildly

%o known food or drug allergies

Family History

(ather has been diagnosed with hypertension at )) year old.

Mother has type * diabetes mellitus at )+ year old.

!e has 3 siblings and all of them are healthy.

!is younger son has asthma.

Social History

*, pack-year smoker

%o alcohol consumption

"ercise occasionally

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Written Case Candidate Number: M7769

%o recent travel history

!e stays with his wife and * sons

Their housing area is not a dengue hotspot and fogging usually be done once aweek.

Systemic enquiry

'onstitutional symptoms Absence of unintentional weight loss# loss of appetiteand night sweats# no bleeding tendency

yes %o visual changes

'ardiovascular Absence of chest pain and palpitations

/astrointestinal %o abdominal pain# normal defecation and no changes inbowel habit

/enitourinary %ormal micturition

%eurological %o changes in sensation and motor functions

ICE

Idea !e thinks this might be an asthmatic attack because he has the similarsymptoms as his younger son who has asthma.

'oncern The coughing and shortness of breath aect his sleeping 0uality.

"pectation !e hopes that medication can be given to relieve his cough andhe needs medication certi1cate for + day-o from work.

Physical Eamination

/eneral e"amination

Alert and comfortable at rest %ormal skin colour Mild pharyngeal erythema and no tonsillar enlargement2e"udates

ital signs

4ody temperature 35.)' 7ulse rate 8) beats per minute 9espiratory rate +) breaths per minute 4lood pressure +*5286 mm!g

9espiratory e"amination

!and : %o nail changes# muscle wasting# tremor and '&* retention ;ap

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7/26/2019 Primary Care Written Case

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Written Case Candidate Number: M7769

%eck : %ormal

(ace : %o miosis and ptosis# no con$unctival pallor# no central cyanosis

'hest : %o surgical scars and chest deformity

7alpation : Ape" beat is in the )th

intercostal space at mid-clavicular line# notracheal tug and tracheal deviation# ade0uate symmetrical chest e"pansion

7ercussion : %ormal resonant chest sounds

Auscultation : esicular breath sounds are heard# normal vocal resonance

Di!erential Diagnosis

Acute pharyngitis

Acute e"acerbation of '&7? secondary to @9TI

In"estigation

7eak e"piratory ;ow rate =7(9>

-7(9 was 36, 2min =6,B of the predicted 7(9 for his height and weight>

Most #i$ely Diagnosis

Acute pharyngitis

Management

Medications

+> T. 7aracetamol +g 0ds*> T. entolin *mg tds3> T. 4romohe"ine !'l 8mg tds

Advice

+> Maintain good water intake*> CuDcient rest3> Ask to seek medical help if symptoms get deterioratedE> Cmoking cessation

#earning points+> 'entor criteria in identifying the likehood of a bacterial infection in adult

patients complaining of a sore throata. 7resence of /roup A streptococcalb. ?iagnosis of streptococcal pharyngitis

'riteria =+ point for each>

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Written Case Candidate Number: M7769

!istory of fever Tonsillar e"udates Tender anterior cervical adenopathy Absence of cough

Modi1ed 'entor 'riteria

F+) year-old = G + point> HEE year-old = - + point>

Throat culture Antibiotic 9isk ofstreptococcalinfection

-+# , or + - - F+, B* or 3 G 7rescribe

antibiotic ifpositive throatculture

+)B =* points>3*B =3 points>

E or ) - 7rescribeantibiotic withoutdoing throatculture

)6B

4y using 'entor criteria in this case# there is only + point whichindicating the risk of streptococcal infection is less than +,B. Therefore#it is most likely a viral infection in this case. Management will be focusedon symptomatic treatment as it is self-limiting.

*> Cuspect '&7? in smokers who are H3) year old instead of asthma.A 0uick guide to the dierences between '&7? and asthma.

(actors Asthma '&7?Age when it starts Typical in

childhood ?oes not

generally worsenwith age

&ccurs later inadulthood

orsens with age

Triggers2causes Allergens eather !ereditary

?irectly linked tosmoking

ess commonly

triggered byinhaled fumes#pollution# dusts#and chemicals

Cymptoms 7atient is oftensymptom-freebetween attacks

'hronic

Air;ow @sually treatmentcan be 0uickly

Come air;ow canbe restored by

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Written Case Candidate Number: M7769

and fully restoreair;ow

0uitting smokingand takingprescribedmedicines

3> Acute e"acerbation of '&7? are characteriJed by an increase ofsymptoms and deterioration in lung function and health status.

Trigger factors 4acterial 2 viral infections 'hange in air 0uality

E> 9ecurrent @9TI might be indicating immunocompromised statea. !Ib. ?iabetes mellitusc. ?rug-related =steroids>

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