9 575 Reply To This Discussion

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9 575 Reply To This Discussion

Case and Discussion

Yves

A 60-year-old man comes to your office because of a persistent cough that has been bothering him for the past 3 months. His cough is dry and is more frequent during the evenings. He also notes frequent nasal congestion, especially when he is exposed to dust and cold weather. He reports no hemoptysis, weight loss, wheezing, fever, or changes in his appetite. What additional questions would you ask to learn more about his cough?

Additional questions to ask regarding the cough are…When did the cough start? How long does it last? Does it worsen throughout the day? Does it change with any specific activity? What makes it worse? What makes it better? Is it constant or does it come and go? Any associated symptoms such as chest pain? Any known allergies? Are you on any medication (especially blood pressure medications)? Any medical problems that you know of? Do you smoke? What is your travel history? According to Michaudet and Malaty (2017), the first evaluation should be geared towards finding potential triggers, such as the use of an ACE inhibitor, environmental exposures, smoking status, and COPD.

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

A cough can be acute, subacute or chronic depending on the duration. According to Kenny (2015), an acute cough lasting less than 3 weeks is oftentimes related to a cold or other upper respiratory tract infection such as flu, pneumonia, or whooping cough. A subacute cough normally lasts between 3-8 weeks and is frequently considered to be a residual cough after an illness or infection. A chronic cough lasts longer than 8 weeks and can be caused by medical conditions and/or medications. A cough can also be classified as productive or nonproductive. A productive cough is when an individual produces sputum, mucus or phlegm. A nonproductive cough is also known as a dry cough. Based on the clinical scenario above, his cough would be classified as a chronic nonproductive cough.

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

Research completed by Randel (2016) showed adults with unexplained chronic cough should undergo objective testing for bronchial hyperresponsiveness, eosinophilic bronchitis, or a therapeutic corticosteroid trial. After a detailed and focused H&P, I would order the following diagnostic test and labs chest x-ray, CBC, CMP, ESR, and spirometry. I would also order a CT sinus if symptoms did not improve after medication. If the cough were to worsen or the labs and test came back as inconclusive I would order a CT chest and refer to ENT and/or pulmonary.

  • Create a differential diagnosis flow sheet 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.

Upper airway cough syndrome-according to Michaudet and Malaty (2017), this is the most common cause of chronic cough. Initial treatment includes a decongestant combined with a first-generation antihistamine. Other forms of therapy include intranasal corticosteroids, saline nasal rinses, nasal anticholinergics, and antihistamines.

Asthma-Chest x-ray, CBC and spirometry According to Michaudet and Malaty (2017), treatment includes an inhaled bronchodilator, high-dose inhaled corticosteroid or a leukotriene receptor antagonist after counseling the patient and figuring out their triggers.

GERD-According to Michaudet and Malaty (2017), studies completed have demonstrated an association between GERD and chronic cough, but the pathophysiology is complex and treatment is controversial. Adding a histamine H2 receptor antagonist and/or baclofen to the treatment plan may make a difference.

Nonasthmatic Eosinophilic Bronchitis (NAEB)-According to Michaudet and Malaty (2017), oral corticosteroids are rarely needed but can be considered if high-dose inhaled corticosteroids are ineffective.

References

Kenny, K. (2015). Cough: Navigating the classifications. Pharmacy Times. Retrieved from https://www.pharmacytimes.com/publications/issue/2015/November2015/Cough-Navigating-the-Classifications

Michaudet, C., & Malaty, J. (2017). Chronic cough: Evaluation and management. American Family Physician, 96(9), 575–580. Retrieved from https://search-ebscohost-com.libauth.purdueglobal.edu/login.aspx?direct=true&db=rzh&AN=125623325&site=ehost-live

Randel, A. (2016). ACCP releases guideline for the treatment of unexplained chronic cough. American Family Physician, 93(11), 950. Retrieved from https://search-ebscohost-com.libauth.purdueglobal.edu/login.aspx?direct=true&db=rzh&AN=115489967&site=ehost-live