EXAMINATION CARD No. 23 — Clinical Case: Complete Solution

The Case Summary

• Paroxysmal dry cough, severe abdominal pain on coughing, chills, fever 38°C, retrosternal soreness, headaches, general weakness
• History: Illness started 5 days ago with runny nose + eye irritation (resolved after 4 days), then respiratory complaints began; over last 24 hours, cough worsened with severe burning behind sternum, no expectoration
• Objectively: Agitated, pained expression; skin moist, hot, light pink; conjunctivae congested bilaterally; increased muscle tone in shoulder girdle and abdomen (painful on palpation); nasal breathing difficult; voice hoarse; RR 17/min; vocal fremitus symmetric; boxy (box-like) percussion sound; harsh breathing with bilateral wheezing; bronchophony not increased; BP 110/70 mmHg; HR 100 bpm; abdomen slightly tense, Shchetkin-Blumberg and Mendel signs NEGATIVE

Task 1: Identify Syndromes and Formulate a Preliminary Diagnosis

Syndromes Present

• Justification: Boxy percussion note (indicates air trapping/hyperinflation from narrowed airways), bilateral diffuse wheezing, harsh breathing, paroxysmal dry cough, hoarse voice, RR 17/min (mildly elevated). The bronchial lumen is narrowed by mucosal edema and hypersecretion following viral infection - Fishman's Pulmonary Diseases, p. 2218.

• Justification: Fever 38°C, chills, headaches, general weakness, moist/hot skin, HR 100 bpm (reflex tachycardia), conjunctival congestion, myalgias (painful shoulder girdle on palpation) - Tintinalli's Emergency Medicine, p. 478.

• Justification: Initial runny nose + eye irritation (resolved), now difficult nasal breathing and hoarse voice - indicating laryngeal/tracheal involvement - Fishman's Pulmonary Diseases, p. 2218.

• Justification: Substernal burning pain on coughing, paroxysmal nonproductive cough, retrosternal soreness - classic features of tracheal mucosal inflammation - Fishman's Pulmonary Diseases, p. 2218: "Substernal discomfort on inhalation and nonproductive paroxysmal cough are noted."

• Justification: Severe abdominal pain on coughing + tender abdominal muscles with negative Shchetkin-Blumberg and Mendel signs - this is muscular fatigue/strain from repeated violent coughing, NOT an acute abdomen - Fishman's Pulmonary Diseases, p. 2218: "After several days of coughing, chest wall or abdominal discomfort that is muscular in nature may be noted."

Preliminary Diagnosis

Acute viral tracheobronchitis with bronchospasm (bronchial obstruction syndrome). ARVI (Acute Respiratory Viral Infection), influenza or parainfluenza etiology.

• Typical prodrome: 5 days ago with URI symptoms (rhinitis, conjunctivitis) that subsided and gave way to lower respiratory tract involvement - classic "descending" viral respiratory infection pattern
• Predominant tracheobronchial symptoms: substernal burning, paroxysmal dry cough, hoarseness
• Bilateral diffuse wheezing + boxy percussion = bronchospasm + mucosal edema (diffuse, not focal)
• Absence of focal consolidation signs (no dullness, bronchial breathing, or increased bronchophony) - rules out pneumonia
• Influenza A is the most common cause; parainfluenza and adenovirus also likely - Fishman's Pulmonary Diseases, p. 2219

Task 2: Mechanism of Development of Intoxication Syndrome

1. Viral invasion of respiratory epithelium - The virus (most likely influenza) invades the mucosa of the upper respiratory tract, then descends to the trachea and bronchi via direct spread.
2. Direct cytopathic effect - Viral replication destroys ciliated epithelial cells, causing mucosal inflammation, edema, and hypersecretion. This stimulates airway irritant receptors, triggering cough.
3. Release of inflammatory mediators - Infected and damaged cells release cytokines (IL-1, IL-6, TNF-α, interferons). These act on the hypothalamus:
   • Fever (38°C): IL-1 and prostaglandin E2 reset the hypothalamic thermostat, causing fever and chills
   • Headache: Vasodilation and increased intracranial pressure from cytokine-mediated vascular changes
   • Myalgias/arthralgia: Systemic cytokine effects on muscles and joints (painful shoulder girdle palpation)
   • General weakness/malaise: Cytokine-induced metabolic inhibition and reduced cellular energy production
4. Systemic viremia (early phase) - During initial viremia, circulating viral particles and their components (e.g., hemagglutinin, neuraminidase) directly activate innate immune responses, amplifying cytokine release.
5. Reflex tachycardia (HR 100) - Fever increases metabolic demands; every 1°C rise in temperature increases HR by ~10 beats/min.
6. Conjunctival congestion - Systemic vasodilation from cytokine-mediated inflammation affects conjunctival vessels.
7. Moist skin - Compensatory sweating due to pyrexia.

• Tintinalli's Emergency Medicine, p. 478; Fishman's Pulmonary Diseases, p. 2218-2219

Task 3: What Can Topographic Percussion of the Lungs Reveal?

• Due to air trapping from bronchial narrowing (mucosal edema + bronchospasm), air accumulates in the alveoli (acute emphysematous distension / hyperinflation)
• The lower border of both lungs descends 1-2 intercostal spaces below normal

• Normal lower border excursion is 6-8 cm; in bronchial obstruction it is reduced (2-4 cm or less) because the over-inflated lungs cannot fully expand or retract
• This is detected by measuring the shift of lower border on maximal inspiration vs. maximal expiration

• Due to bilateral pulmonary hyperinflation, the narrow band of resonance over the apex widens

• The boxy percussion note heard on general percussion confirms this: it reflects increased air content and loss of normal elasticity - consistent with acute airway obstruction causing air trapping

Task 4: Prescribe and Justify Additional Examinations

Task 5: Treatment Principles

Non-pharmacological

• Bed rest during febrile period; adequate hydration (warm fluids)
• Humidification of inhaled air to soothe inflamed tracheal mucosa
• Avoidance of irritants (smoke, cold air, pollutants)

Pharmacological

• Oseltamivir (Tamiflu) 75 mg twice daily x 5 days - if influenza confirmed/suspected within 48-72h of symptom onset; reduces duration and severity
• NOT recommended: antibiotics are NOT indicated in uncomplicated viral acute bronchitis - Symptom to Diagnosis, 4th Ed.: "Antibiotics do not provide major clinical benefit and are not recommended for most patients with acute bronchitis"

• Bronchodilators (salbutamol/albuterol inhaler) - relieves bronchospasm; addresses the bronchial obstruction syndrome; short-acting beta-2 agonist 2.5 mg via nebulizer or 100-200 µg MDI q4-6h as needed
• Mucolytics (ambroxol or acetylcysteine) - reduces mucus viscosity, facilitates mucociliary clearance
• NSAIDs (ibuprofen 400 mg TID) or paracetamol 500-1000 mg - fever, headache, myalgias; avoid aspirin in viral illness (Reye's syndrome risk)

• Antitussives (butamirate/codeine-containing) - with caution - only if cough is severely disabling and non-productive; avoid suppressing productive cough
• Nasal decongestants (oxymetazoline) - for nasal obstruction, short course only (≤3-5 days)
• Warm inhalations / steam inhalation - soothes tracheal mucosa, reduces retrosternal burning

• Reassess in 3-5 days; if fever persists >7 days or productive purulent sputum develops - reconsider secondary bacterial infection and initiate antibiotics (amoxicillin or azithromycin)
• If SpO2 drops below 94% or RR increases significantly - consider hospitalization

Summary Diagnosis Box