[24F] With severe cough, ear pain, and overheating

Patient Description

A 24-year-old female presents with a progressively worsening wet and painful cough over the past week and a half, sometimes leading to vomiting. The cough is more aggressive when lying down and produces yellow mucus. The patient also reports extreme fatigue, dizziness, ear pain with a static noise in the right ear, sore throat, and bilateral side pain (left side more severe). She experiences episodes of overheating and sweating lasting up to an hour, rated 8 to 9 out of 10 in severity. She has a dry mouth, possibly due to medication, and an itchy head. The patient recently had a black eye after getting drunk but does not remember the incident. She uses an inhaler for shortness of breath and takes daily allergy medication. No recent exposure to sick individuals or known allergens. Medical history includes ADHD, depression, anxiety, panic attacks, and possible autism. Current medications are Clonidine 0.2 mg, Bupropion 150 mg, Adderall 15 mg (slow release), Loratadine 10 mg, and Meloxicam 7.5 mg. Occasional use of Tussin DM Max for cough. Allergic to Tylenol.

Arora's Assessment

What might be happening

Based on the symptoms you've described, several potential diagnoses come to mind:

1. Respiratory Infection

Acute Bronchitis or Pneumonia: Your wet, painful cough producing yellow mucus, along with fatigue, dizziness, and shortness of breath, could indicate a respiratory infection like bronchitis or pneumonia. These conditions often cause a persistent cough, mucus production, and sometimes fever and chills.
Typical Treatments: These may include antibiotics if a bacterial infection is suspected, rest, fluids, and over-the-counter medications to manage symptoms. A chest X-ray might be needed to confirm pneumonia.

2. Asthma Exacerbation

Asthma: Given your history of possible asthma, your symptoms could be an exacerbation of asthma, especially since you mentioned using an inhaler. Asthma can cause wheezing, coughing, and shortness of breath.
Typical Treatments: Inhalers (bronchodilators), corticosteroids, and avoiding known triggers. A peak flow meter might be used to assess lung function.

3. Sinusitis or Ear Infection

Sinusitis or Otitis Media: Ear pain, a static noise in your ear, and a sensation of blocked hearing could indicate a sinus or ear infection. These infections can also cause dizziness and a sore throat.
Typical Treatments: Antibiotics if bacterial, nasal decongestants, and pain relievers. An ear examination might be necessary.

4. Dehydration and Medication Side Effects

Dehydration: Your dry mouth and dizziness could be signs of dehydration, especially if you've been sweating excessively.
Medication Side Effects: Some of your medications, like Clonidine and Bupropion, can cause dry mouth and dizziness as side effects.
Typical Treatments: Increasing fluid intake, adjusting medications under a doctor's guidance.

What you can do

For Your Cough and Respiratory Symptoms:

See a Doctor: Given the severity and persistence of your cough, it's important to see a healthcare provider. They may perform a chest X-ray and prescribe antibiotics if a bacterial infection is suspected.
Stay Hydrated: Drink plenty of fluids to help thin mucus and stay hydrated.
Use a Humidifier: Adding moisture to the air can help soothe your throat and ease coughing.
Rest: Ensure you get plenty of rest to help your body fight off the infection.

For Ear Pain and Hearing Issues:

Consult a Doctor: An ear examination is necessary to determine if you have an ear infection or sinusitis. They may prescribe antibiotics or recommend other treatments.
Warm Compress: Applying a warm compress to the affected ear can help alleviate pain.

For Overheating and Sweating:

Stay Cool: Use fans, air conditioning, or cool showers to help manage overheating. Wear light, breathable clothing.
Monitor for Fever: Check your temperature regularly. If you have a fever, seek medical attention.

For Dizziness and Fatigue:

Stay Hydrated: Drink plenty of water to prevent dehydration.
Avoid Sudden Movements: Move slowly and avoid sudden changes in position to reduce dizziness.
Review Medications: Discuss with your doctor if any of your medications might be contributing to these symptoms.

For General Well-being:

Symptom Journal: Use MDandMe to journal your symptoms, track progress, and share insights with your healthcare provider.
Seek Support: Given your history of mental health conditions, ensure you have support in place, whether through therapy, support groups, or trusted friends and family.

What you should look out for

Given the severity of your symptoms, you should seek medical care as soon as possible. Reasons to seek care even more urgently include:

High Fever: If you develop a high fever, it could indicate a serious infection.
Difficulty Breathing: If your shortness of breath worsens or you have difficulty breathing, seek immediate medical attention.
Persistent Vomiting: If you continue to vomit or can't keep fluids down, you may need medical intervention.
Severe Chest Pain: If you experience severe or persistent chest pain, seek emergency care.

Remember, while I can provide information and suggestions, it's crucial to consult with a healthcare professional for a formal diagnosis and appropriate treatment.