Case Study Essay- Family Medicine 13- 40-Year-Old Man with a Persistent Cough
Mr. Dennison, a 40-year-old man, seeks medical help due to a persistent cough that has lasted for two months, accompanied by clear sputum production and aggravating symptoms at night, as well as wheezing. Past medical history reveals a background of poorly managed allergic rhinitis. The primary diagnosis under consideration for Mr. Dennison is asthma exacerbation, supported by symptoms observed, notably the cough, nocturnal exacerbation, wheezing, and history of allergic rhinitis. Through a focused differential diagnosis and adherence to clinical guidelines, this essay aims to delineate the most probable diagnosis and devise a comprehensive diagnostic and treatment plan to address Mr. Dennison’s condition effectively.
Main Diagnosis
Asthma is the primary diagnosis for Mr. Dennison. The symptoms, such as persistent cough, nocturnal aggravation, wheezes, and a history of poorly controlled allergic rhinitis, are clinical features of asthma. Iordache et al. (2023) showed the relation between allergic rhinitis and asthma intensification, with allergic sensitization being a major contributor to the development and aggravation of asthma symptoms. These symptoms align with the ICD-10 guidelines for moderate persistent asthma (ICD-10 code: J45.30). Furthermore, unique to asthma exacerbation is the tendency for the symptoms to get worse at night, specifically the worsening of cough and wheezing, which can be explained by variations in the circadian rhythm of airway inflammation and bronchial.
ICD-10 Classification on Persistent Asthma
- Mild persistent asthma (ICD-10 code: J45.31): Symptoms occur more than twice a week but less than once per day. Nighttime awakenings due to asthma occur 3-4 times per month.
- Moderate persistent asthma (ICD-10 code: J45.32): Symptoms occur daily, and nighttime awakenings due to asthma occur more than once per week but not nightly.
- Severe persistent asthma (ICD-10 code: J45.33): Symptoms occur throughout the day, and nighttime awakenings due to asthma occur nightly.
Differential Diagnoses
Gastroesophageal Reflux Disease without Esophagitis | ICD-10 code: K21.9
UACS is attributable to Mr. Dennison’s clinical presentation of poorly controlled allergic rhinitis, a condition that usually results in postnasal drip and subsequent coughing. However, the lack of nasal discharge and the long-lasting symptom duration of over two months rule out UACS. Lucanska et al. (2020) provide clinical guidelines that a person suffering from UACS gets opaque and mucopurulent nasal discharge instead of a clear phlegm found in Mr. Dennison.
Gastroesophageal Reflux Disease | ICD-10 code: J31.2
GERD is one more of the differential diagnoses—the nighttime exacerbation of cough aligns with a common manifestation of GERD, where gastric acid reflux irritates the throat and airways, leading to coughing spells (Antunes et al., 2021). Mr. Dennison’s presentation does not manifest the typical GERD symptoms, such as heartburn or regurgitation, which is very prominent in GERD patients. The missing of these specific symptoms of GERD decreases the chances that the major diagnosis in Mr. Dennison’s case will be GERD (Antunes et al., 2021).
Diagnostics
Pulmonary Function Tests
Spirometry with bronchodilator reversibility testing is a useful method for measuring lung function and airway obstruction typical of asthma exacerbation. This test assesses lung function by evaluating parameters including forced expiratory volume in one second (FEV1) and forced vital capacity (FVC), which provides objective data on airway obstruction and responsiveness to bronchodilators.
Fractional Exhaled Nitric Oxide (FeNO) Measurement
Measurement of FeNO is a test that is non-invasive and has in its scope airway inflammation, particularly eosinophilic inflammation, which is popular in asthma. The fact that FeNO levels are high could support the diagnosis of asthma, and treatment decisions could be based on this level.
Peak Expiratory Flow (PEF) Monitoring
Periodic PEF readings collected with a peak flow meter help identify lung function impairment and assist in tracking asthma severity through time. PEF decreases may suggest airway obstruction worsening and the need for treatment measure changes.
Treatment plan
Short-acting beta-agonists (SABA) Inhaler
For example, an Albuterol (or salbutamol) inhaler is administered as required for prompt relief of the main symptoms of asthma, such as coughing, wheezing, and shortness of breath. Mr. Dennison must be educated on appropriate inhaler techniques to ensure correct medication delivery. Marques and Vale (2022) state that to combat symptoms, the patient should puff a single or double puff about 15 minutes prior to starting the activity or coming into contact with any trigger.
Inhaled Corticosteroids (ICS)
Fluticasone propionate or other ICS aims to treat asthma long-term and reduce airway inflammation. ICS is suggested as the initial line of treatment for asthma attacks or exacerbations. The Global Initiative for Asthma guidelines defines daily maintenance doses of 100 to 250 μg, 250 to 500 μg, and 500 μg, respectively, of fluticasone propionate or equivalent for adults with asthma using the conventional terminology of low, medium, and high doses of inhaled corticosteroids (Beasley et al., 2019).
Systemic Corticosteroids
For example, oral prednisone or prednisolone would speed up airway inflammation reduction and improve lung function during acute episodes. In the regular regime, patients could take oral prednisone at a dose of 40-60 mg per day for 5-7 days, and then gradually reduce the dosage according to the clinical response.
Oxygen Therapy
Supplemental oxygen can be provided to keep SPO2 above 90%, especially if his oxygen saturation level drops below 90% during exacerbations. The dosage of oxygen for asthma attacks is typically determined based on the patient’s oxygen saturation levels and the severity of symptoms. It is usually administered via nasal prongs or a face mask at flow rates ranging from 2 to 15 liters per minute (L/min). It is important not to self-administer oxygen without medical guidance, as incorrect use can lead to complications.
Patient Education
Teaching about asthma is an endeavor to help this patient gain an understanding of asthma as a chronic inflammatory disorder of the airways, which is characterized by recurring episodes of wheezing, breathlessness, chest tightness, and coughing that are triggered by the exacerbation of the airway inflammation and the bronchoconstriction. In the discussion of medication management, the teaching is stricken through explaining each prescribed drug, its purpose, delivery technique, dosage, and frequency.
The nurse should stress the use of the Albuterol inhaler as a rescue medication with instant symptom relief as well as compliance with the prescribed dosage of corticosteroid aerosols. Practical scenarios are provided regarding the inhaler technique, which is used to assess whether inhalation is done well or not and to ensure correct hand positioning, inhalation technique, and coordination between actuation and inhalation. Proper identification and subsequent elimination of the main asthma triggers (allergens, irritants, respiratory infections, running, and weather changes) are as important as the prevention of their exposure.
Further, the course would focus on the quick recognition of the early signs of the worsening process and the apprehension about the moment to use the first aid medicine or call for emergency help. Besides, an individualized asthma action plan is then crafted, spelling out absolute measures that one will take depending on any changes in the symptoms or peak flow readings, including the doses of medication that one needs to take and when one should run to emergency for care, or contact one’s healthcare service provider.
Family Education
Involving Mr. Dennison’s family in his asthma management obligations is of fundamental importance for achieving holistic care and assistance. Teaching them about asthma, its triggers, signs, and treatment can provide them with the necessary knowledge needed to better understand Mr. Dennison’s situation as well as help manage his care (Martin et al., 2022). Mr. Dennison’s family members should be well informed about his asthma action plan, such as when and how to administer the medications, recognize the attack symptoms, and, if needed, seek the doctor’s advice. Furthermore, the family should be taught to sanitize the environment to eradicate the aggravators of Mr. Dennison’s illness and healthy living in general.
Appropriate Follow-up Plan
An organized place for continuing the treatment and the monitoring of Mr. Dennison’s asthma is created by the plan of follow-up. The follow-up schedule will be specifically developed for him based on his condition and reaction to the treatment. It will typically include regular visits to his primary care physician or asthma specialist. The pulmonary clinic’s follow-up appointments should assess Mr. Dennison’s asthma control, medication adherence, inhaler technique, and any changes in symptoms or exacerbation triggers. Having been evaluated, modifications to his treatment plan can be done as needed for effective asthma control and avoidance of future episodes.
Hospitalizations and Consults When Appropriate
Hospitalization and consultations with specialists, whenever needed, should be guided by professional, evidence-based guidelines. Severe asthma attacks are incredulously immune to outpatient administration, especially patients with severe respiratory distress or no response to the initial therapies, and may require emergency admission to the hospital for an increased level of surveillance, intensive treatment, and supplemental diagnostic testing. Referral to pulmonologists or allergists might be necessary in complex cases, such as uncontrolled asthma or developed cases when alternative therapeutic modalities are considered. Collaboration with respiratory therapists, as well as asthma educators, could also be useful in maximizing Mr. Dennison’s asthma care outcomes.
References
Antunes, C., Aleem, A., & Curtis, S. A. (2021). Gastroesophageal reflux disease. PubMed; StatPearls Publishing. https://pubmed.ncbi.nlm.nih.gov/28722967/
Beasley, R., Harper, J., Bird, G., Maijers, I., Weatherall, M., & Pavord, I. D. (2019). Inhaled corticosteroid therapy in adult asthma. Time for a new therapeutic dose terminology. American Journal of Respiratory and Critical Care Medicine, 199(12), 1471–1477. https://doi.org/10.1164/rccm.201810-1868ci
Iordache, M., Balica, N. C., Horhat, D. I., Morar, R., Tischer, A. A., Milcu, A. I., Salavat, M. C., & Borugă, V. M. (2023). A review regarding the connections between allergic rhinitis and asthma – Epidemiology, diagnosis and treatment. PubMed, 49(1), 5–18. https://doi.org/10.12865/chsj.49.01.5
Lucanska, M., Hajtman, A., Calkovsky, V., Kunc, P., & Pecova, R. (2020). Upper airway cough syndrome in the pathogenesis of chronic cough. Physiological Research, 69(Suppl 1), S35–S42. https://doi.org/10.33549/physiolres.934400
Marques, L., & Vale, N. (2022). Salbutamol in the management of asthma: A review. International Journal of Molecular Sciences, 23(22), 14207. https://doi.org/10.3390/ijms232214207
Martin, J., Townshend, J., & Brodlie, M. (2022). Diagnosis and management of asthma in children. BMJ Paediatrics Open, 6(1), e001277. https://doi.org/10.1136/bmjpo-2021-001277
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Question 
- PLEASE review the requirements and outline of the sample essay to follow. This is NOT a report on the disease process or a complete summary of the case. The expectation is that you can identify 3 differential diagnoses and develop a final diagnosis utilizing the evidence from the case study. In addition to including pertinent diagnostics, patient education, and developing the treatment plan UTILIZING a CLINICAL PRACTICE guideline (see rubric).
Case Study Essay- Family Medicine 13- 40-Year-Old Man with a Persistent Cough
Assignment Prompt
- Complete the required Aquifer case studies as assigned each week and take a screenshot of your student summary report after each case. (Done this already, I attached the summary)
- write an essay on the case, per the guidelines below. Please note: Your instructor reserves the right to assign the cases to students. If you are not sure if your instructor will assign the case for the essay, or if you are able to choose, email to ask them. They will usually make a course announcement if they will assign the cases. Other instructors may allow you to choose.
- The case studies with both case summaries and the single essay must be completed by the end of the day on Monday by 11:59 pm PST.
Essay Elements:
- One to three pages of scholarly writing in paragraph format, not counting the title page or reference page
- Brief introduction of the case
- Identification of the main diagnosis with supporting rationale
- Identification of at least two additional differential diagnoses with a brief rationale for why these were ruled out
- Diagnostic plan with supporting rationale or references
- A specific treatment plan supported by recent clinical guidelines
- Please refer to the rubric for point value and requirements. In general, these elements must be covered as per the rubric.