Case Study- Multimorbidity in Older Adults

Case Study- Multimorbidity in Older Adults

Multimorbidity among older adults is an issue of healthcare concern in primary care settings (Gontijo Guerra et al., 2019). A majority of morbid health conditions in older adults have related symptoms that create confusion over the source of the symptoms hence complicating diagnosis (Corbett & Bridges, 2019). Adequate and targeting questioning is required as a part of the medical history. The case study of focus involves a 75-year-old man who presented himself to the office with a major complaint of persistent dry hacking cough that does not improve with over-the-counter treatment with antitussives and allergy medications. The man has a history of hypertension, diabetes, environmental allergies, and colon polyps. Therefore, this article discusses the process of diagnosing the cough the 75-year-old man presents including possible questions to ask, physical aspects of the examination, causes of the cough, possible diagnosis, and other required diagnoses as well as treatment plan for the patient.

Questions that Would Have Been Asked as Part of the Medical History

The questions that would have been asked in the case as a part of the patient’s medical history include questions that focus on the period the older man has had the cough, how he feels when coughing, and if he has ever noticed changes in the coughing patterns based on the environment he was in or what he was doing. Other questions that would have been focused on as part of the medical history include whether he has been using new products he did not use in the past, whether he traveled or had a visitor from other parts of the nation or other countries, and whether he smokes or uses any tobacco products. It would have also been important if the questions focused on any symptoms the sounds experienced and heard during coughing and the status of the older man’s living conditions.

Physical Aspects of the Physical Exam

There are multiple physical aspects that would have been completed as a part of the physical exam history before the diagnosis of the condition of the 75-year-old man was made. The first physical examination to be completed would have been to assess the vital signs of the patient, including their heart rate, respiratory rate, blood pressure, and body temperature. The other essential physical examinations needed to comprehensively review the 75-year-old-man’s system functioning include throat and nasal passage examination for inflammation and auscultation of the patient’s lungs to determine the presence of abnormal sounds when breathing. Observing the patient’s overall appearance is also necessary to observe their orientation as well as identify any abnormalities on their extremities.

The Most Likely Cause of the 75-Year-Old Man’s Cough

A persistent dry cough is majorly drug-induced (Ding et al., 2020). The 75-year-old man is currently on a number of medications for both diabetes and hypertension. He uses metformin XR for diabetes and lisinopril for hypertension. He notes that he started using lisinopril six months ago, after which the coughing started three months ago. Lisinopril is an angiotensin-converting enzyme inhibitor (ACE inhibitor). ACE inhibitors are noted to be risk factors for dry cough when used (Ding et al., 2020). Therefore, based on the occurrence of the dry hacking cough three months after he started lisinopril and the lack of other environmental factors, it can be concluded that the medication, specifically lisinopril, is responsible for the cough.

Other Possible Diagnoses

Based on a review of the patient’s medical history, the most possible diagnosis is a drug-induced dry cough. Other possible diagnoses include a possible impairment of gas exchange in the lungs due to alveolar hypoventilation and airway obstruction, which can be evidenced by the level of oxygen saturation in the blood and the high respiratory rate observed after the physical examination. The other possible diagnosis is that the 75-year-old man is at an increased risk of swallowing impairment as a result of frequent episodes of acid reflux as evidenced by esophageal irritation. GERD is identified in the etiologies of nagging cough in some patients (Wu et al., 2022).

Other Required Tests

The review of medical history and physical examination do not conclusively diagnose the 75-year-old man’s cough as drug-induced as there are possibilities of chronic obstructive pulmonary disease (COPD) and GERD. A differential diagnosis is required, which will include lab tests such as spirometry to confirm or rule out COPD, an upper gastrointestinal endoscopy, and an esophageal impedance-pH study to confirm or rule out GERD.

Treatment Plan for the Patient

The treatment for the 75-year-old man will be based on the outcomes of the lab tests. If COPD and GERD are ruled out, the treatment will focus on managing the drug-induced cough. In this case, the patient will be put off lisinopril and on hydrochlorothiazide (HCTZ) 50 mg once daily to reduce the coughing as they manage their hypertension. The patient will also be educated on why their medications need to be switched. Patient education will also focus on the possible side effects the patient might experience due to the use of HCTZ and how to manage them.

Conclusion

In summary, as older adults are prone to multimorbid health conditions with conflicting and related symptoms, it is important to ask the proper questions as a part of the medical history and carry out the possible physical examination. Additionally, lab tests may be required in cases where multiple diagnoses are possible. Comprehensive patient assessment can properly diagnose the disease and ensure the 75-year-old male patient gets the right treatment to relieve the cough.

References

Corbett, T., & Bridges, J. (2019). Multimorbidity in older adults living with and beyond cancer. In Current opinion in supportive and palliative care (Vol. 13, Issue 3). https://doi.org/10.1097/SPC.0000000000000439

Ding, H., Shi, C., Xu, X., & Yu, L. (2020). Drug-induced chronic cough and the possible mechanism of action. Annals of Palliative Medicine, 9(5), 3562–3570. https://doi.org/10.21037/APM-20-819

Gontijo Guerra, S., Berbiche, D., & Vasiliadis, H. M. (2019). Measuring multimorbidity in older adults: Comparing different data sources. BMC Geriatrics, 19(1), 1–11. https://doi.org/10.1186/S12877-019-1173-4/TABLES/3

Wu, J., Ma, Y., & Chen, Y. (2022). GERD-related chronic cough: Possible mechanism, diagnosis, and treatment. In Frontiers in Physiology (Vol. 13). https://doi.org/10.3389/

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A 75-year-old man with a history of hypertension, diabetes, environmental allergies, and colon polyps presents to the office with a complaint of persistent dry hacking cough that does not improve with over-the-counter treatment with antitussives and allergy medications. The man reports that he has had the cough for 3 months and is tired of the coughing spells he experiences. His medical history reveals that he started taking lisinopril 6 months before this appointment, has taken an over-the-counter allergy medication for several years, had his last colon polyps removed 6 years ago, and his blood pressure today is 145/70. Other medications include metformin XR 500 mg daily, aspirin 81 mg once daily, and loratadine 10 mg daily. The physical exam is negative for any issues other than his mild neuropathy from long-term diabetes. The cough is noted to be dry and hacking as the patient has described. The man is not in acute distress.

Case Study- Multimorbidity in Older Adults

1. What questions would have been asked as part of the medical history?
2. What physical aspects would have been completed as part of the physical exam?
3. Based on the medical history and physical exam, what is the most likely cause of his cough?
4. What other possible diagnoses should be considered?
5. Are there any other tests that should be completed before producing a diagnosis?
Why or why not?
6. What is the treatment for this patient, including education?
*high-level scholarly references in APA from within the last 5 years.