*Re-upload of slides originally posted 16th April 2019.*
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Case presentation of a patient (anonymised) seen in outpatient clinic during course of medical school studies.
NOTE: Slide 7 references the patient never having had a flu vaccination due to their egg allergy. Although trivalent influenza vaccinations are grown in embryonated hens' eggs, other preparations (such as the Influenza A-specific flu vaccine) are grown in mammalian cells and are therefore safe for patients with egg allergy.
Sources for all imagery and sources listed in references section where possible. I do not claim ownership of any images or graphics. Slides for educational purposes only, and should not replace clinical judgement. No monetary gain was made for this work.
2. Presenting complaint
28 y/o female with
Productive cough
Fever
Sinusitis
Post-nasal drip
Persisting for roughly one month.
3. History of presenting complaint
M. first developed a cough and runny nose roughly four
weeks prior to this visit
She has had two visits to the doctor since symptoms
began, but her complaints progressed to include
symptoms of sinusitis (congestion, headache) and she
developed a fever
She had CBC results from a prior visit, which she brought
with her
4. Medical history
First visit to clinic in February XXXX: upper respiratory
infection, which resolved itself
October XXXX: hip pain radiating to right leg, suspected
muscle strain, referred to physiotherapy. Symptoms
resolved with massage therapy.
January XXXX: nonspecific gastric pain. No clear cause
on USG. Pain suspected to be caused by reflux. Patient
prescribed PPI and symptoms resolved.
No history of chronic conditions or past surgical
procedures
5. Medications
No longterm medications
Over the past month she was prescribed
Tafen (budesonide) nasal spray - corticosteroid
ACC (acetylcysteine) – mucolytic
Irigasin – sodium chloride nasal irrigation
Sinupret 1,2
– supplement advertised to relieve symptoms
of sinusitis/URI
She reported these to be ineffective
6. Family history
Grandmother died of pancreatic cancer
Grandfather died of MI
Otherwise no reported history of any chronic
conditions in relatives
7. Other
Social: Nonsmoker, drinks ETOH infrequently
Vaccination status: immunised as a child, no
vaccinations since
Allergies: NKDA, but allergic to egg whites (she has
therefore never received a flu shot)
8. Physical exam
Heart rate within normal limits, regular, no abnormal/extra
sounds
Breathing rate normal, no crackles, ronchi, wheezes
appreciable
Temperature was 37.2 °C
No abdominal pain, signs absent
BP not taken. Last reading (roughly two weeks ago) was
126/79. M. has no history of hypertension, and reports no
symptoms.
9. CBC
Patient showed largely normal CBC from previous
visit
Only three abnormal results, all very minor:
↑ PLTs – elevation during infection is common, particularly
with UR infections
2
due to increased reactivity
3,4
↓ basophils – common in infection, level deplete due to
inflammation
↑ monocytes – indicates high WBC turnover, even in
absence of increase in other lymphocyte forms or total
white cell count
10. Differentials
Bronchitis: given lack of severity on physical
exam combined with patient history showing
almost no predisposition, this is certainly not the
most likely diagnosis
Flu: no myalgia, symptoms far too mild
Pneumonia: extremely unlikely patient, and no
specific signs even for walking pneumo
11. Diagnosis
Persistent URI – J06.9
She was prescribed:
Glimbax (diclofenac)
Erdomed (erdosteine)
Echinacea (herbaceous plant)
Rutinacea (supplement)
Vitrum D3 (VitD supplement)
Drink plenty of water!
12. References
Popovich V., Koshel I. (2017), Sinupret ® as add-on therapy to saline irrigation for
children with acute Post-Viral Rhinosinusitis, Clinical Phytoscience 3(10)
Neubauer N., März R. (1994), Placebo-controlled, randomized double-blind clinical
trial with Sinupret® sugar coated tablets on the basis of a therapy with antibiotics and
decongestant nasal drops in acute sinusitis, Phytomedicine 1(3): 177-181
Zheng S., Xiao Q., et al., (2016), Association between secondary thrombocytosis and
viral respiratory tract infections in children, Scientific Reports 6
Assinger A. (2014), Platelets and Infection – An Emerging Role of Platelets in Viral
Infection, Frontiers in Immunology 5: 649
Kreutz R., Tantry U., Bliden K., Gurbel P, (2007), Inflammatory changes during the
'common cold' are associated with platelet activation and increased reactivity of
platelets to agonists, Blood Coagulation & Fibrinolysis 18(8): 713-718
Thank you!
Questions?