Friday, December 30, 2011

A Patient with a Productive Cough



I was working in an urgent care setting when a 40ish African-American normal weight patient came into be seen.  After she was checked in by the medical assistant I went into see her.  I noticed that her vital signs showed she had a normal pulse, her respirations were 20 (within normal range), and a normal blood pressure. 
“Hi, my name is Sharon.  I’m a physician assistant.  How can I help you?”
“Hi.  I’m Carla and I can’t quit coughing, it’s keeping me up at night.”  She was barely able to get that out of her mouth without being interrupted by several hacking coughs.  She used a kleenex to catch her productive green sputum.  Afterwhich she proceeded to catch her breath.
“I see.  How long have you been sick?  And, do you have any fevers?”
“I’ve been sick for the past 4-5 days.  I’ve had chills and sweats, is that what you mean??”
“That will do.  What about sore throat, or sinus drainage?”
“My throat just feels raw from all of the coughing I think.  But my nose won’t stop running, green crude  just drains from it, every time I blow my nose.  I just feel crappy, I’m so tired I just want to sleep.”
“Okay, any other symptoms?”
“No, I think that’s it.”
“No, wait,” said Carla.  “It hurts here when I cough.”  As she spoke these words she pointed to her right front chest wall.
“Any alcohol or smoking use?”
“No, I don’t smoke and I only have an occassional drink of wine around the holidays.”
“Okay, well how about any medications you take on a regular basis?”
“I’m just on a blood pressure medication for my hypertension, that’s it.”
“Anything else in your past medical history, such as asthma, or problems with acid reflux?”
“No, nothing else.”  As she spoke she had another round of hacking coughs. 
“Alright, well let me take a look at you , listen to your chest and all, then I’ll decide if you need a chest x-ray or not.”

Patients typically present with various signs and symptoms that are characteristic of pneumonia.  These can include:
1)      sinus drainage
2)      productive or non-productive cough
3)      fevers or chills/sweats
4)      fatigue
5)      a rapid heart rate
6)      rapid breathing

There are various different host factors which can contribute to a patient coming down with pneumonia.  They include:
1)      smoking
2)      alterations in the level of consciousness
3)      alcohol
4)      low oxygen levels
5)      breathing in toxic chemicals
6)      malnutrition
7)      being immunosuppressed, i.e. on cancer chemotherapy, or taking steroids
8)      elderly > 65 yrears of age
9)      cystic fibrosis patient
10)   having COPD, chronic obstructive pulmonary disease
11)   lung cancer

After looking into Carla’s ears, nose, throat, feeling her neck glands and then listening to her chest and heart sounds, she had some very definitive positive findings.  Her sinus’ were swollen and red, her throat was red, she had some slightly enlarged lymph nodes in her neck, but most striking were the fine crackles I heard at the base of her right lung, on her front and backside.  When I listened over the one place that she said it hurt when she coughed I also heard a characteristic ‘squek’ sound (typical sound of a pleural rub, or pleurisy).
“Okay, well Carla it looks as though you have what is called community acquired pneumonia.  You also have a pleural rub, or what we call pleurisy.  So I’m going to send you next door to have an chest x-ray done and once that’s done, then come back over here to me.  Here’s your radiology request, I’ll see you back in a little while.”
As Carla slid off of the exam table she proceeded to let out several more hacking coughs.  She picked up her purse and slowly walked next door.

It is not unusual for patients with pneumonia to have co-existing pleurisy.  Pleurisy just means that the lining of the lung is inflammed from the local infection.  The best way to address this pain/discomfort is for the patient to take non-steroidal anti-inflammatory medications for two weeks, at which point the pleurisy will be totally resolved.  The use of the non-steroidal will also address their fevers/chills/sweats.

We look at patients with five questions in mind to determine whether they need to be hospitalized for their pneumonia.  These five questions we ask ourselves consists of:
1)      is the patient confused
2)      what is the patient’s urea (a part of the patient’s kidney function).  Given the patient had a normal blood pressure coming into the clinic and was on appropriate blood pressure medication, I would expect her kidney function to be normal.
3)      what is the patient’s respirations, are they higher than normal?
4)      what is the patient’s blood pressure, is it below normal?
5)      are they over the age of 65?
Each question is given 1 point and if the patient has 2 points they need to be admitted to the hospital, and if their total points are 3 or highter they could need to be admitted to an intensive care unit of the hospital.

About thirty minutes later, Carla showed back up with her chest x-ray in her hand.
“Come back on into the exam room, Carla, I’ll take your chest x-ray, and I’ll be right back.”  I walked down the hall and slide the x-ray into the lighted reader.  As I expected Carla had a clouded look to her right lower lung (white opacity) which was characteristic of pneumonia.   I walked back down the hall and walked into the exam room where Carla was sitting. 
“Okay, Carla, you chest x-ray showed what I expected, you have pneumonia of your right lower lung.  So I’m going to start you on Biaxin, which is an antibiotic that I need you to take twice a day.  But before I do this, I need to make sure that you are not allergic to any drugs, are you?”
“No, I’m not allergic to anything.”
“Okay, well then here’s your prescription for the Biaxin.  I want you to take the Biaxin for the next 10 days.  I also want you to take some over the counter Aleve, which also goes by the name of Naprosyn, two tablets twice a day for the next two weeks.  This will help take care of the pleurisy you have, which is caused by the inflammation from your pneumonia.  Does that make sense?”
“Yes.”
“Okay, well then for your cough and sinus drainage I want you to take some over the counter Mucinex D for your sinus’ and then some plain robitussin pearls, which is just cough medicine without anything else in it.  You can also take Delsym if you can’t find the robitussin pearls.  Don’t take anything else for your fevers/sweats/chills, the Naprosyn will address these symptoms.  So no Tylenol or Motrin.  Drink plenty of fluids and you should start feeling better in a few days.  I need you to come back in and be seen by us here in the urgent care clinic in 10 days.  We need to make sure that your symptoms are almost gone and your physical exam shows that your pneumonia has resolved.  Any questions?”
“No, I think I have it.”
“Okay, well then I’ll see you back in 10 days.  I wish you well.”
“Thanks.”

The typical bacteria/virus’ that can cause pneumonia are varied.  They include:
1)      Strep pneumoniae
2)      H. flu
3)      Staph. aureaus
4)      gram negative bacilli
5)      Legionella
6)      Mycoplasma
7)      Chlamydia pneumoniae
8)      various virus, usually flu virus
9)      misc. agents: tularemia, anthrax

With the above pathogens in mind, we treat patients with pneumonia by giving them a broad spectrum antibiotic.  Typically this is a macrolide (of which Biaxin is one, the other one is Zithromax), or we use doxycycline.  If we suspect that they patient may have a resistant Strep pneumoniae then we can combine the macrolide with a beta lactam antibiotic such as Augmentin. 

About 10-11 days later, Carla showed back up at the urgent care clinic.  She was checked in and I went into see her.  She was still a little fatigued, but her cough, sinus drainage and lung findings were all back to normal, which made me happy.  I was glad that her pneumonia had resolved on the antibiotics I had prescribed her.  I dismissed Carla from the clinic with a ‘high five’ hand slap.  

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