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 that
makes him look for medical attention. It was a non-productive cough and
associated with an on-and-off low grade fever. He denied chest pain. The
coughing had becoming worse at night and exacerbate by coldness. In
addition, he claimed there was transient shortness of breath together with
excessive coughing. The shortness of breath does not seem to be related to
any trigger factors in asthmatic patient. In addition, he did not experience the
similar episode of attack before this. He had mild headache, joint pain and
muscle aches. Normal hydration status and oral intake.

Past Medical History

No admission to hospital
No hypertension, diabetes mellitus, hypercholesterolemia
No history of childhood asthma

Drug History
Taken paracetamol OTC on the second day of coughing and the coughing get
relieved mildly
No known food or drug allergies

Family History
Father has been diagnosed with hypertension at 55 year old.
Mother has type 2 diabetes mellitus at 51 year old.
He has 3 siblings and all of them are healthy.
His younger son has asthma.

Social History
20 pack-year smoker
No alcohol consumption
Exercise occasionally
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Written Case

Candidate Number: M7769

No recent travel history

He stays with his wife and 2 sons
Their housing area is not a dengue hotspot and fogging usually be done once a
week.

Systemic enquiry
Constitutional symptoms: Absence of unintentional weight loss, loss of appetite
and night sweats, no bleeding tendency
Eyes: No visual changes
Cardiovascular: Absence of chest pain and palpitations
Gastrointestinal: No abdominal pain, normal defecation and no changes in
bowel habit
Genitourinary: Normal micturition
Neurological: No changes in sensation and motor functions

ICE
Idea: He thinks this might be an asthmatic attack because he has the similar
symptoms as his younger son who has asthma.
Concern: The coughing and shortness of breath affect his sleeping quality.
Expectation: He hopes that medication can be given to relieve his cough and
he needs medication certificate for 1 day-off from work.

Physical Examination
General examination

Alert and comfortable at rest

Normal skin colour
Mild pharyngeal erythema and no tonsillar enlargement/exudates

Vital signs

Body temperature 37.5C

Pulse rate 85 beats per minute
Respiratory rate 15 breaths per minute
Blood pressure 127/86 mmHg

Respiratory examination
Hand No nail changes, muscle wasting, tremor and CO2 retention flap
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Candidate Number: M7769

Neck Normal JVP and no lymphadenopathy (cervical lymph node)

Face No miosis and ptosis, no conjunctival pallor, no central cyanosis
Chest No surgical scars and chest deformity
Palpation Apex beat is in the 5th intercostal space at mid-clavicular line, no
tracheal tug and tracheal deviation, adequate symmetrical chest expansion
Percussion Normal resonant chest sounds
Auscultation Vesicular breath sounds are heard, normal vocal resonance

Differential Diagnosis
Acute pharyngitis
Acute exacerbation of COPD secondary to URTI

Investigation
Peak expiratory flow rate (PEFR)
-PEFR was 360 L/min (60% of the predicted PEFR for his height and weight)

Most Likely Diagnosis

Acute pharyngitis

Management
Medications
1) T. Paracetamol 1g qds
2) T. Ventolin 2mg tds
3) T. Bromohexine HCl 8mg tds
Advice
1)
2)
3)
4)

Maintain good water intake

Sufficient rest
Ask to seek medical help if symptoms get deteriorated
Smoking cessation

Learning points
1) Centor criteria in identifying the likehood of a bacterial infection in adult
patients complaining of a sore throat
a. Presence of Group A streptococcal
b. Diagnosis of streptococcal pharyngitis
Criteria (1 point for each)
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Written Case

Candidate Number: M7769

History of fever
Tonsillar exudates
Tender anterior cervical adenopathy
Absence of cough

Modified Centor Criteria

<15 year-old ( + 1 point)

>44 year-old ( - 1 point)
Throat culture

Antibiotic

-1, 0 or 1
2 or 3

4 or 5

Prescribe
antibiotic if
positive throat
culture
Prescribe
antibiotic without
doing throat
culture

Risk of
streptococcal
infection
<10 %
15% (2 points)
32% (3 points)
56%

By using Centor criteria in this case, there is only 1 point which

indicating the risk of streptococcal infection is less than 10%. Therefore,
it is most likely a viral infection in this case. Management will be focused
on symptomatic treatment as it is self-limiting.
2) Suspect COPD in smokers who are >35 year old instead of asthma.
A quick guide to the differences between COPD and asthma.
Factors
Age when it starts

Triggers/causes

Asthma
Typical in
childhood
Does not
generally worsen
with age
Allergens
Weather
Hereditary

Symptoms

Airflow

Patient is often
symptom-free
between attacks
Usually treatment
can be quickly

COPD
Occurs later in
adulthood
Worsens with age

Directly linked to
smoking
Less commonly
triggered by
inhaled fumes,
pollution, dusts,
and chemicals
Chronic
Some airflow can
be restored by
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Written Case

Candidate Number: M7769

and fully restore

airflow

quitting smoking
and taking
prescribed
medicines

3) Acute exacerbation of COPD are characterized by an increase of

symptoms and deterioration in lung function and health status.
Trigger factors
Bacterial / viral infections
Change in air quality
4) Recurrent URTI might be indicating immunocompromised state
a. HIV
b. Diabetes mellitus
c. Drug-related (steroids)