1. Respiratory Infections
Case-3
Respiratory Infections

2. Wafa is a 25-year-old marketing executive
Wafa is a 25-year-old marketing executive. She is worried about her cough and hoarse voice, as she has to give a presentation to her company board next week. Wafa says that she developed symptoms of cough with thick mucus sputum, running nose, mild fever and tiredness 5 days ago. She used ‘cough lozenges’ for her symptoms and felt ‘a bit better.
She denies any sputum production or wheeze, or contact with anyone suffering from pertussis (whooping cough). Wafa is single and lives with her parents. She is a non-smoker and drinks alcohol only at social functions. She underwent a tonsillectomy at age 13.

3. She denies any history of asthma
She denies any history of asthma. She has no history of renal or hepatic disease and no known drug allergies. Her family history is unremarkable. Currently, she is not taking any medication.
On examination, she looks anxious. Her blood pressure is 126/84 mmHg, pulse 90 beats/min, respiratory rate 15/min and temperature 37.8 ºC. There is no cervical lymphadenopathy or cyanosis. Throat examination reveals no exudates. Respiratory examination reveals no chest wall tenderness and auscultation reveals normal breath sounds. There were no other significant findings.

4. Apply SOAP module to this scenario.

5. 2. Wafa is worried about her symptoms and requests an antibiotic prescription. She says she was prescribed an antibiotic for similar symptoms in the past and felt better after taking it.   Would you recommend an antibiotic for Wafa at this visit? Why/why not? If yes, please specify:
In 70% of patients who present with cough as the main symptom, acute respiratory tract infection is the main cause of the illness.
Most cases (more than 90%) of acute respiratory tract infections are due to non-bacterial causes.
Presence of purulent sputum is not predictive of bacterial infection.
Green or yellow sputum production is indicative of inflammatory reaction and does not imply bacterial infection.

6. 2. Wafa is worried about her symptoms and requests an antibiotic prescription. She says she was prescribed an antibiotic for similar symptoms in the past and felt better after taking it.   Would you recommend an antibiotic for Wafa at this visit? Why/why not? If yes, please specify:
Most acute respiratory tract infection symptoms usually resolve with in a week, but some (e.g., cough) may stay for 3–4 weeks.
Patients who perceive their symptoms as being severe or feel they are prolonged are more likely to consult a GP5 ; 20% of patients revisit their GP for the same symptoms in a month’s time.
Do not prescribe an antibiotic for acute cough.
Antibiotics only shorten illness by 1 day but are associated with adverse effects (e.g. diarrhoea, rash).

7. 2. Wafa is worried about her symptoms and requests an antibiotic prescription. She says she was prescribed an antibiotic for similar symptoms in the past and felt better after taking it.   Would you recommend an antibiotic for Wafa at this visit? Why/why not? If yes, please specify:
Consensus guidelines suggest antibiotics should be prescribed to patients who are systemically very unwell, are immunocompromised or have significant comorbidities.
Provide advice to reduce antibiotic use

8. 3. Would you recommend any over-the-counter medication(s) for Wafa’s symptoms? Why/why not? If yes, please specify:
There is no good evidence for the effectiveness of OTC cough and cold medicines.
Level I studies suggest that codeine does not have an effect in suppressing cough.
Studies also suggest that there is some evidence of benefit with antihistamines but there are associated side effects such as sedation.
Do not use beta2 agonists to alleviate cough in acute bronchitis.

9. 3. Would you recommend any over-the-counter medication(s) for Wafa’s symptoms? Why/why not? If yes, please specify:
A Cochrane review suggests no significant differences in daily cough scores or in the number of patients still coughing after seven days.
Studies suggest that zinc, vitamin C provide marginal efficacy in the treatment of common cold symptoms.
The Therapeutic Goods Administration advises that cough and cold medicines should not be given to infants aged under 2 years.

10. 4. What advice will you give Wafa about non-pharmacological strategies to manage her current condition?
Most patients who mention antibiotics during consultation do not mean to be prescribed one and their satisfaction is not related to antibiotic prescription.
Manage patient expectations by providing information on the expected course of illness, advising about appropriate symptomatic relief and providing a list of symptoms that may require a return visit.

11. 4. What advice will you give Wafa about non-pharmacological strategies to manage her current condition?
adequate rest
use of analgesics (paracetamol or ibuprofen) for headache, fever or muscle ache.
use of saline solution or steam inhalations to help clear mucus and ease chest tightness
use of honey and lemon, as they are simple to use and cheapest

12. Case-4
Empirical Antibiotic Use in Animal Bites

13. Mrs Lee presents with her 11-year-old grandson, Justin (45 kg) who is staying with her during his school holidays. Justin was bitten by her cat an hour ago because he pulled the cat’s tail while playing with it in the backyard.
Mrs Lee cleaned Justin’s wounds with tap water, used some tissues to stop the bleeding, and brought Justin to see you. On examination, Justin sustained scratches and obvious puncture wounds on his right hand, and scratches on his right lower arm.

14. You attempt to irrigate the wounds with normal saline and where necessary, debride the wounds. On your request, Mrs Lee rings Justin’s mother for further information.
Justin has asthma, but it is well controlled on fluticasone/salmeterol 50/25 micrograms (two puffs twice daily) and he rarely needs to use his ‘Ventolin’. Justin has received all his childhood vaccinations based on the recommended schedule.
The last ‘triple antigen’ was given at four years of age. Justin’s mother is unsure if Justin is allergic to any medications.

15. wounds with delayed presentation (≥8 hours)
2. Is an antibiotic required for Justin? Please state why OR why not. If ‘yes’, please provide details of the antibiotic(s) required.
Bite wounds presenting without evidence of clinical infection must be fully evaluated for risk factors for infection.
Presumptive antibiotic therapy is indicated for wounds with a high risk of infection including:
wounds with delayed presentation (≥8 hours)
puncture wounds unable to be debrided adequately
wounds on hands, feet or face
wounds with underlying structures involved (e.g. bones, joints, tendons)
wounds in the immunocompromised patient.

16. 2. Is an antibiotic required for Justin. Please state why OR why not
2. Is an antibiotic required for Justin? Please state why OR why not. If ‘yes’, please provide details of the antibiotic(s) required.
Amoxycillin+clavulanic acid is the drug of choice unless there is a history of immediate penicillin hypersensitivity.
The appropriate dose for Justin (45 kg) is mg of amoxycillin+clavulanic acid.
The recommended duration for presumptive antibiotic therapy for bite wounds is 5 days. 

17. 3. Is tetanus toxoid and/or immunoglobulin indicated for Justin
3. Is tetanus toxoid and/or immunoglobulin indicated for Justin? Please state why OR why not: 
In all bite wound injuries, the patient’s tetanus immunization status must be assessed.

18. Tetanus toxoid is now only available in combination with other vaccines.
Adult formulation diphtheria–tetanus vaccine (ADT Vaccine) is indicated for adults and children older than 8 years.
Paediatric formulation diphtheria–tetanus vaccine (CDT Vaccine) has been discontinued.
When tetanus prophylaxis is indicated for tetanus-prone wounds, a combination diphtheria and tetanus vaccine (i.e. ADT Vaccine) is recommended for adults and children aged 8 years or older.
In Justin’s case, if ADT Vaccine is given for tetanus prophylaxis, he should still receive an adult/adolescent formulation diphtheria–tetanus–acellular pertussis vaccine (Adacel or Boostrix) at 15–17 years of age as the latter vaccine can now be administered at any time following a previously administered dose of tetanus toxoid-containing vaccine.