Most likely diagnosis is Community-Acquired Pneumonia (CAP) because acute onset of cough with

thick and yellowish sputum, fever associated with chills and pleuritic chest pain. Moreover, his job as
a lorry drive and smoker increase the risk of getting CAP. Since no history of recent admission to any
Heath facility /Hospital, therefore Hospital Acquired Pneumonia can be rule out. Clinical examination
and chest X-ray are suggestive.

As a rule of thumb, I will with history taking which includes: 1. Detail history about cough and the
sputum (onset, duration, any aggravating and relieve factor, the amount of sputum, any other
associated symptoms beside fever like SOB, wheezing, any regurgitation (sour or bitter tasting acid
backing up into throat or mouth) and any stomach bloating. 2. History about pleuritic chest pain
(descript the pain whether is it sharp pain, stabbing or burning, any relieve factors, and any
associated symptoms like palpation, SOB, sweating and nausea/vomiting) 3. Past medical history
(Any admission before to hospital due heart problems) 4. Past Surgical history.5. Family history
(Anyone in the family has HPT, DM, heart diseases, BA, and any other medical illness) 6. Social
history (In this case MR RJ is smoker past 20year with 1pack per day I would like to know whether
ever he tries to quit smoking, how is his daily diet and like to know his income per month. ).7. Drug
history (any other medication that he has been taking beside cough mixture, any history of drug
allergic).

*other relevant symptoms and information already stated in the case.

followed by physical examination (other relevant physical examination that I would like to perform)
like CVS examination, any sign of heart disease (pedal oedema and raised IJVP) and wound at any
part of body especially at foot. I also would like to check his SpO2 and his BMI (23.3- normal
according to WHO).

Other Investigations that I like to do such as FBC- to look for raised TWC, ECG-look for coronary heart
diseases, BUSE/CR- look for urea as need in CURB

In my clinic setting (KK Sandakan, Sabah) we do screen for PTB for chronic smoker, therefore I will
advice patient for sputum AFB.

Future investigation that I would like to do is NCD screening (FLP, FBS) in view he is 43-year old and
chronic smoker.

For the foremost, I will assess the severity or in other word determine whether Mr RJ need for
hospital admission or can be treated as an outpatient. There are few prediction tools to assess the
severity such as Pneumonia Severity Index, CURB or CURB65. All these tools divide to low risk,
moderate/intermediate risk and high risk. However, all the severity tools need to combine with
clinically assessment by doctor.
I will manage Mr RJ as an outpatient. His CRB65 score (NICE guideline) is 0 which is low risk.
Whereby he is alert and conscious, BP 130/80mmHg, pulse 90/min and RR is 20/min (not
tachypnoea) and there are no comorbiditiesin this patient (as stated in case no know past medical
illness) such as congestive heart failure, renal disease, CVD, liver disease and neoplastic disease. I will
discharge this patient with: 1. Table Erythromycin400mg BD for 1 week (if patient not allergic to
macrolides) 2. Table Paracetamol 1G QID/PRN for 5 days. 3. Table bromhexine 8mg TDS 5 days.

Besides that, will counsel the patient to stop smoking by explaining the risk and complication of
smoking like coronary heart disease (MI), peripheral vascular disease, CVD (stroke), Lung and
oropharyngealCancer, COPD and infertily. I will discuss the benefit of smoking cessation includes:

1. The level of carbon monoxide in the blood drop and level of oxygen returns to normal by few
hours.

2.Blood circulation and lung function improved by 3 months.

3. By one year able to decrease risk of coronary heart disease about 50%.

4. By 5-10 years risk of lung cancer reduces to about half that of non-smoker.

I Will do Fagerstrom test and will refer to ‘KBM (KlinikBerhentiMerokok)’ if patient agree and keen to
smoking cessation. In my clinic (

Finally, I will give TCA in 1-week time to reassess his condition and to review his other blood ix like
FLP, FBS and sputum. Also, will advise on warning symptoms like SOB, dizziness, nausea/vomitingand
not able to tolerate orally to TCA stat. Advise on wearing protection mask to reduced spread of the
diseases to others (most important his children- close contact).
Assignment 2

a) According to GINA guideline and Malaysia CPG, her level of asthma symptoms is
uncontrolled. She has all the 4 asthma symptoms control which includes: 1. daytime
symptoms (shortness of breath and wheezing induced by exertion 3-4 times/week).2. Night
walking due to asthma (nocturnal cough twice/week). 3. Reliever needed for symptoms (her
daytime symptoms relived after using MDI salbutamol for each time 3-4 times a week) 4.
Activity limitation due to asthma (her daytime symptoms sometimes disturbed her daily
work).

b) The worsening of her asthma can be due to: 1. Occupational exposures because she just
started working in a factory for the past 3 months and her asthma symptoms getting worsen
for past 2 months. 2. Inadequate ICS, can be due to insufficient of ICS dose (she on MDI
beclomethasone 200mcg BD only) or compliance issues. 3. Incorrect/poor inhaler technique.
4. Pregnancy (She is 24-year-old, in reproductive age). 5. Frequent use of SABA, she need
MDI salbutamol more often to reliever her symptoms until she is running out of her MDI
supply.

c) Spirometry , to measure lung function specifically the amount

d) As a first thing I will start with history taking which includes: 1. Detail history about nocturnal
cough (the severity of cough, whether need any relieved, any aggravating and relieving
factor, any other associated symptoms like SOB, PND, orthopnoea, discomfort in upper
abdomen, and any regurgitation symptoms) 2. Detail history about the day time symptoms
which she has SOB and wheezing by exertion (onset of the symptoms, what type of exertion
that aggravating her symptom (like heavy lifting, or by light working) and any other
associated symptoms like cough, chest pain, and epigastric pain). 3. Other symptoms like
chronic runny nose and nasal congestion, sneezing, post nasal drip, regurgitation symptoms
(heart burn after eating, regurgitation food or sour liquid), loud snoring during sleeping, any
abrupt awakening accompanied by gasping or choking, any sleeping disburdens or anxiety
symptoms. 4. Past medical/surgical history (any admission before to hospital due to severe
asthma and required intubation) 5. Family history (Ay family history of allergic, family history
of severe asthma or any death in the family due to asthma) 6. Social history (most
importantly I would like to know how is the working environment, what type of work she is
doing, is her day time symptoms improve or no symptoms when she away from work place
(during holiday), anyone is smoking at home, is she married or not, when is her LMP, and like
to explore any socioeconomic issues (depression or anxiety symptoms). 7. Allergic history
(any food or drug allergic) 8. Drug history (like to assess the inhaler technique and like to
know whether she taking any over counter medication for asthma)

As a rule of thumb after full history taking will be followed by physical examination which
includes: 1. General appearances (look for any respiratory distress sign, any rashes on the
body (eczema rashes) and oedema, however in this case she is comfortable and respiratory
distress sign) 2. Vital sign (BP, HR, RR, Sp02, Temperature) 3. Lung and CVS examination
(auscultated for any rhonchi and crepitation but for this case the lung examination clear,
hear for any murmurs or any addition sounds. 3. Nose examination (look for any allergic
rhinitis sign or nasal polyposis)

Investigations that I like to do are: 1. spirometry as mentioned in question no 3. For this case
she is 24-year-old and her height is 152 therefore her predicted normal values for FEV1 is
2.81L, FVC is 3.21 and FEV1/FVC is 85.5%. If the FEV1 and FEV1/FVC ration are lower than
predicted normal value, then it indicated airways obstruction. 2. UPT if necessary depends
on LMP and her mensuration cycle (keep in mind that she is in reproductive age).

 PEER already stated in the case scenario

For this case her symptoms are uncontrolled and her PEFR (340L/min) low then expected
peak expiratory flow (430L/min for her age and height) whereby the variability is > 20%.
Therefore, l would to step up her MDI beclomethasone to 400mcg BD and continue MDI
salbutamol 200mcg prn. Beside that I would advise her on avoiding the triggers factors, in
her case most like her work environment cause her symptoms worsen therefore I would
suggest her to change her working place (if she agrees because we need keep in the mind
her socioeconomic status) or write a memo to employer consider to change her working
environment (like less dusty). I would advise her to use protection (face mask) during work. I
also would like to emphasis on MDI technique (for patient to demo in front of me and will
demo correct method if patient wrong) and compliances to medication. Finally, I would like
to give TCA in 2week time to reassess her symptoms and PEFR. Not to forget to advice on
acute exacerbation symptoms and the action plan.
According to Mclsaac criteria the change of the boy getting streptococcal pharyngitis is 10%. His
score point is 1 whereby he has history of fever for 2 days. Other symptoms and sign like cough, sore
throat, non- tender anterior cervical lymph node, tonsils on examination are normal and his age (15-
year-old) does give any point to increase the likelihood ratio for streptococcal pharyngitis.

As usual I like to start with history taking which contains : 1. Detail history about cough and sore
throat (onset, duration, aggravative and relieved factors, is there any sputum (if there is production
of sputum then describe about the sputum) and any other associated symptoms like SOB, wheezing,
pleuritic chest pain, any hoarseness of voice, any dysphagia, and rhinnorrhea) 2. History about fever
(onset, duration, any relieving factor and any associated symptoms like chilis, rigor, malaise or
fatigue, headache, rashes, nausea/vomiting, abdominal pain, and diarrhea). 3. Any other symptoms
like watery eye and itchiness, any regurgitation symptoms, any UTI symptoms. 4. Past medical/
surgical history (History BA, allergic rhinitis, any ENT problems/ surgeries done before) 5. Family
history (anyone sick at home or having same symptoms like patient or anyone just recovered from
URTI, any family history of BA and allergic rhinitis) 6.Social history (smoking or second-hand smoke,
any alcohol consummation or taking any recreational drug and any high-risk behaviours)

Following by physical examination which included: 1. General appearances/examination (is the

patient comfortable and alert, hydration state, any respiratory distress, look for any conjunctivitis
sign, look for any other lymph nodes enlargement. 2. Vital sign (BP, HR, RR, SpO2, Temperature).
3. Nose examination (look for any allergic rhinitis sign or nasal polyposis) 4. Lung and CVS
examination (listen for any rhonchi or crepitation and listen for any heart murmur)5. Abdomen
examination (examine for heptosplenomegaly).

Future investigation that should be performed are rapid antigen detection tests / throat culture
however I not able to proceed with neither one of the test due to the limitation at my clinic setting.

I will explain to the patient’s mother that for his current condition does need antibiotic because
most common cause of acute pharyngitis is viruses which not required for antibiotic. Antibiotic only
required if its bacteria cause (which generally do not have cough). I would like to explain to the
patient’s mother that in our general practice we use criteria called Mclssac criteria to rule out
bacteria (streptococcal) infection whereby if the score is high its more suggestive for bacterial
infection and need treatment with antibiotic. If the score is low or moderate its need future test and
follow up. Will inform the patient’s mother that her son’s score is 1 out of 5 and its fall on moderate
risk which need supportive treatment and future follow up. Therefore, I will discharge the patient
with antihistamine and antipyretic. Will not forget to inform, to TCA stat if develop any warning sign
(high grade if fever, worsening of sore throat, not able to tolerate orally, any painfully lymph nodes
or develop any other new symptoms.) Will give TCA in 3 days time for reassessment.