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Case and Discussion

Kathryn

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• What additional questions would you ask to learn more about his cough?

What factors may have prompted the cough? (any respiratory infections or exposure to noxious agents)

Is there a seasonal pattern?

Is it related to any hobbies or work?

Does the cough occur on arising? At night? During exercise? Throughout the night?

What factors stimulate the cough?

Does anything aggravate the cough?

Does cold air, exercise, certain chemicals or exercise cause an increase in coughing?

Do you have any reactive airway disease?

Does anything relive the cough?

What have you tried to alleviate the cough?

Can you describe the quality of the cough? Is it dry, wet, raspy, deep, throaty or hacking?

Is the cough productive?

If it is productive, can you describe the sputum that is produced with the cough?

How much sputum do you cough up a day?

What color and consistency is the sputum?

When is the cough the most productive?

Do you have any symptoms associated with the cough? Such as dizziness, fever, wheezing, edema, chills, dyspnea.

Do you smoke?

Do you have any shortness of breath?

Do you take any over the counter drugs?

What prescriptions do you currently take?

• How would you classify his cough based on the duration to help with the diagnosis?

Coughs can be classified based on the duration. Acute coughs are coughs that are present less than three weeks and subacute are coughs that are present 3-8 weeks (Sharma, Hashmi & Alhajjaj, 2019). Chronic coughs are coughs that a present greater than 8 weeks (Sharma, Hashmi & Alhajjaj, 2019). Based on this classification and the patient having his cough for three months, his cough would be considered chronic. It is important to classify the cough based on duration because it helps with making a diagnosis. Acute coughs are usually self-limiting and typically resolve within three weeks. It often occurs due to upper respiratory tract infections (Mahashur, 2015). Chronic coughs should be diagnosed accurately because it can lead to disturbance of sleep, cough syncope, urinary stress incontinence, exhaustion and work absenteeism (Mahashur, 2015).

• What diagnostic tests do you want to include to help you with your diagnosis?

Diagnostic tests that should be ordered to help decide on a diagnosis for this patient include, a chest x-ray, chest CT, spirometry, complete blood count (CBC) with differential, arterial blood gas, oximetry, EKG, complete pulmonary function testing and peak expiratory flow rate. A chest x-ray and complete pulmonary function testing are diagnostic measures that should help with making a diagnosis. But if both of these are normal and there is no other information from the history and physical examination are leading to a certain diagnosis then the patient may require a referral to a pulmonologist for further evaluation (Sharma, Hashmi & Alhajjaj, 2019).

Create a differential diagnosis flow sheet for this patient for this patient and include the diagnostics as well as the pharmacological management and rationale related to the differentials. Support your discussion with evidence-based research.

1. Asthma:

Diagnostics: spirometry, oximetry, peak expiratory flow rate, chest x-ray, arterial blood gas, CBC with differential.

Pharmacological management: Once daily controller medication: inhaled corticosteroid: fluticasone metered dose inhaler (44mcg/puff), once daily.

Inhaled beta-2 agonist as needed: albuterol metered dose inhaler (90mcg/puff), 2 puffs every 4-6 hours PRN.

Rationale: Patient states he has frequent nasal congestion especially when he is exposed to dust and cold weather. Allergens and environmental factors can cause triggers for asthma. Based on his symptoms and his cough lasting more than 3 months with the cough being dry and more frequent at night, its characteristics point to asthma. One characteristic that helps with the diagnosis of asthma is that his cough is worse at night (Dunphy, Winland-Brown, Porter & Thomas, 2015).

2. COPD:

Diagnostics: spirometry, arterial blood gases, CBC with differential, blood chemistry panel, chest x-ray, oximetry and EKG

Pharmacological management: Inhaled beta-2 agonist as needed: albuterol metered dose inhaler (90mcg/puff), 2 puffs every 4-6 hours PRN.

Inhaled beta-2 agonists are the first line of treatment for COPD stage 1 (Dunphy et al., 2015). If this patient is diagnosed with COPD it will need to be staged so that they proper treatment can be ordered. The medication therapy would be different if the patient was diagnosed with a higher stage. The patient might also need a diuretic if the patient has any evidence of right sided heart failure. Inhaled beta-2 agonists such as albuterol would be prescribed as the treatment if the patient was diagnosed with COPD stage 1.

Rationale: Patients that present with COPD usually have a chronic productive cough and increased shortness of breath (Dunphy et al., 2015). This patient states his cough is dry, but over the course of the past 3 months it could have been productive at some point. He also states it is worse at night, and he could also have paroxysmal nocturnal dyspnea which would make his cough more severe. Further diagnostic workup and physical exam will help determining if this patient has COPD.

3. GERD:

Diagnostics: Esophageal pH monitoring

Pharmacological management: antacids and histamine2 receptor antagonists (H2RAs)

Prescribe Maalox 5-30ml every 30-60 minutes for acute management and 5-30ml 1h and 3h after meals and at bedtime for maintenance and famotidine 20mg bid (Woo & Robinson, 2016).

Trial this management and if no improvement in 4 weeks use the step-up treatment guidelines

Rationale: This patient is presenting with cough and no other symptoms were mentioned. Since he has not had any wheezing, weight loss or change in appetite this could be a diagnosis not related to a respiratory condition. GERD can present with atypical symptoms such as chronic cough, adult-onset asthma and a sore throat (Dunphy et al., 2015). GERD is reported to be the cause of chronic cough in 40% of patients (Mahashur, 2015). It causes cough by intraesophageal reflux, laryngopharyngeal reflux and microaspiration. Each of these mechanisms can act directly by triggering a cough or indirectly by sensitization of the cough reflex. In 75% of cases of patients with GERD-related coughs, they present with no other gastrointestinal symptoms (Mahashur, 2015). Until further diagnostic workup is completed, GERD should be considered a possible diagnosis.

4. Medication-induced cough:

Diagnostics: no diagnostic workup is required, just complete history of medications and over the counter drugs

Pharmacological management: If patient is currently on an angiotensin-converting enzyme (ACE) inhibitors switch to a different medication such as angiotensin II receptor blockers (ARB) and prescribe losartan, dosing dependent on dose of ACE inhibitor.

Rationale:

After completing a history and physical and assessing patients’ medications and if he is currently on an ACE inhibitor will help determine if his cough is medication induced. If he is on an ACE inhibitor, then his cough could be a side effect of his medication. 10% of patients that take ACE inhibitors have a cough (Dunphy et al., 2015). Once a complete history of the patient’s current medications is done then it can be determined if his cough is medication-induced.

References

Dunphy, L. M. H., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2015). Primary Care: The Art and Science of Advanced Practice Nursing (4th ed.). Philadelphia, PA: F.A. Davis Company.

Mahashur A. (2015). Chronic dry cough: Diagnostic and management approaches. Lung India 32(1), 44–49.

Sharma, S., Hashmi, M. F., Alhajjaj, M. S. (2019). Cough. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK493221/

Woo, T. M., & Robinson, M. V. (2016). Pharmacotherapeutics for Advanced Practice Nurse Prescribers (4th ed.). Philadelphia, PA: F.A. Davis Company.