CASE DISCUSSION

Upper respiratory tract infection;

acute tonsillopharyngitis

ELOISA V. BAYLOSIS
CLINICAL HISTORY
 GENERAL DATA

Name: A.M.

Age: 59 y/0

Filipino

Catholic

Lives in
Dasmarinas,Cavite
 CHIEF
COMPLAINT
Cough and fever
 HISTORY OF PRESENT ILLNESS

4 days prior to consult,- (+) chills, relieved by resting

3 days prior to consult- (+) productive cough with whitish phlegm, (+)
rhinorrhea with clear watery secretions, (+) fever, (+) malaise, (+) joint
pains, (+) loss of appetite.

1 day prior to consult - (+) cough worsened, (+) purulent yellowish

sputum, (+) sore throat (-) weight loss (-) night sweats (-) hematemesis, (-)
nausea, (-) vomiting (-) dyspnea

This prompted the patient to take Ambroxol 10mg/tab, taken once. This
afforded no relief of signs and symptoms which prompted the patient to
consult at our institution.
 PAST MEDICAL HISTORY

(+) Rheumatoid Arthritis - Taking B

complex for relief/alleviate sign and
symptoms

No other diseases noted

(-) HTN (-) DM (-) Asthma (-) Goiter (-)

Heart disease (-) Kidney disease
 FAMILY HISTORY

(+) Asthma - Paternal

(+) Kidney disease - Maternal

PERSONAL-SOCIAL HISTORY

The patient was a housewife who eventually worked as a

stay-out house cook when her husband died.

The patient currently lives in a concrete bungalow house

located near a river. Water supply is supplied by the water
district and garbage is collected weekly.

She is a non-smoker, non-alcoholic beverage drinker and non-

drug user.
 REVIEW OF SYSTEMS

General: (+) weakness, (+) lightheadedness, (-) loss of appetite

SHEENT: (-) rashes, (-) pallor, (-) colds, (-) photophobia, (-) blurring of vision
Respiratory: (-) dyspnea, (-) cough, (-) tachypnea
Cardiovascular: (-) palpitations, (-) angina, (-) orthopnea
GIT: (-) constipation, (-) diarrhea, (-)pain
GUT: (-) dysuria, (-) polyuria, (-) nocturia
Musculoskeletal: (-) weakness (-) limitation in ROM
Neurologic: (-) paralysis (-) neurologic deficits
Hematologic: (-) bruising (-) bleeding
Autonomic: (-) incontinence
PHYSICAL EXAMINATION
 PHYSICAL EXAMINATION

Vital signs
BP: 110/70 mmHg, Left arm, sitting
Heart rate: 70 bpm
RR: 27
Temperature: 36.5

General
Patient is well developed, well nourished, awake, conscious,
coherent, ambulatory, and appears her chronological age of 59.
 SKIN
A. General Characteristics:
a. Gen. Color: (+) pallor (-) jaundice
b. Temperature.: afebrile
B. Skin Lesions:
a. Primary lesions:
(-) lesions
C. Skin appendages
a. Hair: (-) brittle hair, (+) black hair,
b. Nails: nail plate: transparent, (-) nail dystrophy nail bed: (-) nail bed lesions
(+) pale nailbeds
D. Turgor: Prompt return after finger pressure
d. Degree of moisture: (-) dryness, no excess moisture
e. Hardness /Sclerosis or Laxity: (-) sclerosis, (-) laxity
E. Mucosal Changes:
(-) oral/nasal/conjunctival lesions
 HEENT
A. A. Head & Neck
o Hair had normal texture and are equally distributed; Symmetrical facial features
o Midline Trachea
o (-) Tender cervical lymph nodes
o (-) Carotid bruits
B. Eyes
o Normal relationship of eyelids to the eyeballs
o (-) Ptosis
o Clear and slightly pale conjunctiva
o Pupils reactive to light
o Fundoscopy: not done
C. Nose
o Symmetrical external nose
o Equal size and shape of the external nares
o Midline Nasal Septum
o (-) Discharges, masses, lesions
D. Ears
o Mobile pinna devoid of masses
o Patent canal and auditory cavities
o Otoscopy not done
E. Oral Cavity
o (-) Lesions, Masses
o Tongue in midline, (-) lesions
o Smooth and pink mucosa
o (+) hyperemic, hypertrophic tonsils, non-exudative
 CHEST AND LUNGS

A. Inspection
o AP:Transverse diameter=1:2
o (-) Masses or lesions
o (-) Abdominal breathing (-) Intercostal retractions
B. Palpation
o (-) Cervical Lymphadenopathies
o (-) Tenderness
o (-) Masses or lesions on the chest
o Symmetrical chest expansion
C. Percussion
o Not done
D. Auscultation - Bronchovesicular breath sounds
o (-) Wheezing
o (-) Crackles
 CARDIOVASCULAR
A.Inspection
o (-) Precordial bulging
JVP- 10cmH20
B. Palpation
o Apex beat on 5th ICS LMCL
o (-) Ventricular heaves and thrills
C. Percussion
Not done
D. Auscultation
o Heart Rate = 70 bpm
o Regular rhythm, S3 inaudible
o S1>S2 on the apex
o S2>S1on the base
o (-) Murmurs
 ABDOMEN
A. Inspection
o (+) globular and symmetrical abdomen
o (-) Discoloration
o (-) Visible mass (-) Scars or lesions
o (-) Visible peristalsis
o (-) Visible pulsations
B. Auscultation
o Normoactive bowel sounds = 10sounds per minute at the LUQ
o (-) Bruits
C. Palpation
o (-) Direct tenderness
o (-) Masses
o Spleen and liver not palpable
D. Percussion
o Liver span not enlarged
 EXTREMITIES
A. Inspection
o (-) dryness
o (-) mass
o (-) edema
o (-) deformity
o (-) atrophy
o True and apparent leg lengths equal
B. Palpation
o (+) Full and equal pulses
C. Range of Movement
o (-) crepitus
o (-) limitation of motion
vii. Genitourinary
o (-) dysuria
o (-) polyuria
o (-) hematuria
o (-) no gross deformity
 NEUROLOGIC
A. Mental Status Exam
The patient was mobile, awake, coherent and oriented to time, place, and person; with normal
stream of talk. The patient’s general behavior was good. She had no other content of thoughts,
average intellectual capacity.

B. Cranial Nerves
CNI - (-) anosmia
CNII - (+) Direct and Consensual light reflex
CNIII - (+) Corneal Reflex
CNVII - (-) Facial Asymmetry
CNIII -intact EOM
CNIX,X -(+) good shrug
CNXII - Tongue in midline, (-) atrophy, (-) fasciculations

C. Reflex Examination - DTR ++ on all extremities, (-) Babinski reflex

D. Meningeal- (+) Heel to sheen
CASE DISCUSSION
 DIAGNOSIS
upper respiratory tract
infection:

acute tonsillopharyngits,
non-exudative
 DIFFERENTIAL DIAGNOSES

Acute Bronchitis
Chronic Bronchitis usually manifest with
dyspnea/breathlessness, coughing, fatigue,
weakness, fever, and mucopurulent sputum.
This is initially considered due to the signs
and symptoms presented however the patient
does not have adventitous breath sounds
upon auscultation. The patient also does not
have differentiating physical examination
results which include increased fremiti which
reveals a lung lobe pathology.
 DIFFERENTIAL DIAGNOSES

Pulmonary Tuberculosis
Tuberculosis is epidemic in the Philippines
due to its prevalence and the susceptibility of
smokers just like our patient who was previously
exposed to smokers. Also due to the signs and
symptoms presented such as cough, easy
fatiguability, fever, chills as well as loss of appetite,
this was highly considered. However, there was no
night sweats, and/or hemoptysis, and weight loss.
Although these are not pathognomonic of TB, we
rule out this diagnosis due to the non-severity of
coughing and high suspicion for URTI. Sputum
exam /culture should be done to completely rule
out this diagnosis.
 DIFFERENTIAL DIAGNOSES

Bronchial Asthma
Bronchial asthma also presents with cough
that is associated with rhinorrhea and/or allergic
type of cough which may include throat
irritation. The patient also had increased
secretions which is included in the triad of
asthma. However, dyspnea was not so much
evident and the patient had fever which was not
usually present in asthma. Upon physical
examination, this was ruled out due to clear
breath sounds and absence of wheezing and/or
rhonchi.
 DISCUSSION

This is a case of a 59 year old female with a chief complaint of cough and fever.
The patient initially manifested with chills, malaise, and joint pains which were the
initial manifestations of infection which was further supported by the development of
fever. On the 2nd day of the disease, the patient eventually developed productive
cough and rhinorrhea which is indicative of a respiratory tract infection. The patient
also complained of sore throat which lead the suspicion of an upper respiratory tract
infection. Further, patient also had fever, chills, and the cough worsened with
yellowish sputum that persisted for more than 3 days. These manifestations lead us
to the assumption of having a bacterial infection.

Upon physical examination, the patient was pale and had dry skin. The patient had
hyperemic, hypertrophic, non-exudative tonsils. On the other hand, chest expansion
was symmetrical, breath sounds were clear, no wheezing, no crackles, no rhonchi
noted. Other systems were normal which lead us to the diagnosis of an upper
respiratory tract infection.
 DISCUSSION
This is a case of upper respiratory tract infection, probably bacterial which is diagnosed
to specifically be Acute Tonsillopharyngitis. Acute bacterial tonsillopharyngitis is the
bacterial infection of the tonsils and pharynx which produces tonsil swelling and
hyperemia due to the inflammation caused by the bacterial invasion. It may be
exudative or non-exudative in manifestation but the latter is mostly caused by bacterial
pathogens. ATP can be a stand-alone disease of may co-exist/ have other co-
morbidities especially other respiratory tract diseases due to ascending/descending
infection and/or opportunistic pathogens. It usually occurs during the cold season due
to the inability of the secretions to be humidified which causes accumulation in the
respiratory tract that serves as the bacterial or viral culture site. The most common
manifestation of ATP are sore throat, cough, malaise, fever, and loss of appetite which
are all present in the patient. The URTI of the patient may also mean that the patient
has bronchitis due to the increase in sputum production and worsening of cough.
Nonetheless, antibiotic therapy is the plan of management in this case which may
cover the pathogens that are usually infecting the URT such as Streptococcus
pneumonia and Haemophilus Influenzae.
 PLAN/MANAGEMENT

• Increase oral fluid intake

• Co-Amoxiclav 625mg/tab thrice a day for 7days
• Nafarin-A tablet thrice a day for 5 days
• Paracetamol 500mg/tab PRN for fever
• Fluimucil 600mg/tab, dissolve in 1/2 glass of water ODHS for 5
days
• Ascorbic acid with zinc once a day
• Follow-up after 1 week or if with problems
Diagnostics: CBC, Chest-xray - if with no relief with antibiotic
therapy/treatment
 PLAN/MANAGEMENT

Supportive management include chest physiotherapy, suctioning

of secretion, and positioning to drain the secretions. Nebulization
may also be done due to humidify the secretions, dilate the airways,
and relieve the dyspnea. O2 supplementation should be continued
in order to prevent dyspneic episodes. Increase in both oral and
intravenous fluid is also necessary. Proper diet, good hygiene is also
encouraged in order to strengthen the immune system. Vitamins
and minerals should also be given since the patient is an elderly.
 FAMILY REPORT
BERNAL-MARTINEZ FAMILY
Interview date: December 14, 2017
FAMILY CLASSIFICATION
FAMILY LIFELINE
FAMILY LIFELINE
FAMILY PROFILE
FAMILY GENOGRAM
 ECONOMIC PROFILE
Angelita earns an average of 8000-10,000 per month (400/day)
depending on how many days she cooks for the household she was
working for.

She sustains for her daily needs and food costing her around 5,200 since
her grandchildren comes to her to get food most of the time.

Her electricity costs and average of about 300, water costs 180, while her
daily transportation consumes 1,200 of her income.

Other expenses include toiletries, groceries which amounts to 1,500. She

allocates around 1,600 per month for her grandchildren who often comes
to her for allowance.

There are no emergency funds and/or alloted expenses for medical

health.
ECONOMIC PROFILE
ENVIRONMENTAL
PROFILE
The patient lives alone in a concrete
bungalow house in Dasmarinas, Cavite
which was well ventilated, and well lit.
Their water source is from water
district. Their area is near a river. They
have a wood burning stove and a pour
latrine toilet system. Their garbage is
collected weekly by the LGU. There are
no nearby factories, pig pens or
hazardous wastes in the area.
 PSYCHODYNAMICS
The family has a democratic type set up where they respect each
other’s decisions. Although her children are old and have their own
families, they let them decide for themselves, and teach them
different values in life.

Angelita lives alone but her grandchildren and children visits her
frequently especially her 2nd son who lives nearby. His second son
is the one who sometimes sleeps at her house so that she is not
alone.

She feels that she is closer to her son than it is to her daughter but
still manages to treat them equally without any favoritism. Her usual
problems include her grandson who got involved with vices such as
smoking and drinking alcohol. She usually disciplines her other
grandchildren so that they may not go astray.
FAMILY MAPPING
FAMILY FUNCTION
APGAR 1
 APGAR 1
Adaptation- Angelita verbalized that her children helps her but more often it is her whom
they depend on in times of need especially financially.

Partnership- The family is very open to discussion regarding their problems. They help
each other especially when her grandchildren are into vices. She is very keen in helping
the children towards a better future.

Growth- The family approves of her work but she thinks that she needs to retire/stop
working soon due to her old age. She thinks that she needs to do more church work but in
order to do that, the other family members should not depend on her financially.

Affection- Angelita is contented of how expressive her family is towards her. However,
she wants her daughter to visit more often even if they live far from her home. She
mentioned that she barely knows her grandchildren from her youngest child.

Resolve- Despite being away from them most of the time, they still have that bond as a
family and would hang out together and watch the television or she will cook for her
grandchildren when they come to her house.
 APGAR II

Quality of
Name Age Sex
Relationship
Lando 37 M good
Martinez
SCREEM
SCREEM
 INDIVIDUAL REACTION TO ILLNESS

Before the check up was made, the patient tried to self-

medicate with ambroxol thinking that it will resolve easily.
However, the persistence of signs and symptoms prompted
her to consult since she knows that she needs medication to
get better.
 ASSESSMENT OF IMPACT OF ILLNESS

Since the illness is not a major one for the patient, there are no
changes in the roles, responsibilities and function of the family.
However, the patient will be absent for work for almost a week which
means that she has no income. This might force her to ask for advance
salary from her employer.
IDENTIFIED PROBLEMS AND RECOMMENDATIONS

Angelita, being a widow and alone in the house needs to be visited by

her children and grandchildren more often or more so, have someone
to be with her from time to time since she is getting old and all the
responsibilities are already taking a toll on her. Angelita should also be
keen in saving up for medical emergencies and have a means of open
communication with her children. Also, the children should be advised
to take care of her and remind her to take medications in times of
illness.