Case Write-Up - Persistent Cough in a 60-Year-Old Male

CASE WRITE-UP PERSONAL DETAILS • Patients Initial : A.R.R. • Age : 60 • Occupation: businessman • Gender : Male CHIEF COMPLAINT(S): Cough for 1 month HISTORY OF PRESENT ILLNESS: The patient’s cough started during his trip to India 1 month ago and was initially accompanied with sore throat and runny nose in the first two weeks. While the symptoms of sore throat and runny nose resolved, his cough has persisted . Previously had occasional bouts of cough triggered by throat irritation. Currently cough persistent throughout the day and night. He notices his cough is worse at night or when lying flat, thus disturbing his sleep. It is relieved with cough medications and lozenges bought over the counter. There are no aggravating factors. There is appetite and weight loss (3 kg in 1 month), but no changes in diet He started noticing red, non-itchy rashes in the dorsal aspect of his hands since 4 days ago. No complaints of wheeze. No history of exertional dyspnoea, night sweats or fever. No history of fatigue or headache. No history of leg pain, redness or swelling No history of intake of new medication No contact history of respiratory infections or chronic cough Systems review Bowel and bladder habits normal No history of joint pains PAST MEDICAL / SURGICAL HISTORY: Diagnosed hypertension in 2019, not on medications. He is following up with the health clinic. Last BP measurement was 2 months ago – 130/80mmHg. His last medical check-up was 3 months ago. Not diagnosed with diabetes or heart conditions Not diagnosed with bronchial asthma, allergic rhinitis or eczema No prior hospital admissions No past surgeries done Not on any medications (prescribed or traditional). Only taking cough mixture and lozenges brought over the counter this month No known allergies to medications and food. FAMILY HISTORY: Parents are well, with no history of underlying respiratory conditions. He is the only child. SOCIAL HISTORY: Smokes 1pack/day for 30 years. No change in the number of cigarettes No alcohol consumption Does not exercise Travelled 1 month ago to India for a holiday. No other change in environment, no pets. No exposure to dust. Stays in a condominium. PSYCHOSOCIAL IMPACT Patient is concerned if cough is related to the haze or if it could be something more serious like tuberculosis PHYSICAL EXAMINATION GENERAL INSPECTION: He appears well and comfortable, is sitting propped up, not in pain or respiratory distress. No general cyanosis. He also appeared well-nourished. No abnormal sounds (cough or wheeze), no sputum cup, no odour. VITAL SIGNS: BP: 140/80mmHg P: 90 beats per minute, regular T: 36.8ºC RR: 16 breaths per minute HANDS / HEAD / MOUTH / NECK: Appearance of diffuse redness on the palms of his hands, non-blanching. No signs of excoriation. Sclera appears white and conjunctiva is pink. Fair oral hygiene with no tonsillar swelling and pharyngeal wall is not inflamed. No nicotine stain noted No peripheral cyanosis No sinus tenderness Nose – no deviated nasal septum, turbinates not enlarged RESPIRATORY Inspection: No chest deformities, no use of accessory muscles of respiration Palpation Trachea central Chest expansion symmetrical and good Apex beat was located in the 5th intercostal space, 1cm lateral to the right mid- clavicular line. Tactile Fremitus felt equal bilaterally Percussion Resonant note bilaterally Auscultation Normal vesicular breath sounds, equal and well heard No crepitations or rhonchi CARDIOVASCULAR: No chest wall deformities or presence of scars. Apex beat was located in the 5th intercostal space, 1cm lateral to the right mid-clavicular line. No thrills or parasternal heave. S1 and S2 heart sounds heard with no additional heart sounds or murmurs. ABDOMEN: Not done MUSCULOSKELETAL: Not done NEUROLOGICAL: Not done INVESTIGATION FINDINGS (IF ANY): None PROVISIONAL DIAGNOSIS: Most likely community acquired pneumonia DIFFERENTIAL DIAGNOSES: Tuberculosis