Response-Attending to Patients Who Present to the Facility with a Cough

Response-Attending to Patients Who Present to the Facility with a Cough

Responding to Evelyn

Thank you for your post. As a nurse working in the primary care setting, it is common to attend to patients who present to the facility with a cough. The presented cough can be categorized as either acute, subacute, or chronic. Cough in elderly patients may result from single or multiple causes that may lead to various types of chronic cough. The diagnosing nurse practitioner (NP) should focus on the presented symptoms, the underlying factors, and related bacteria to differentiate the type of chronic cough. A good differential diagnosis of cough in elderly patients is a prerequisite to the development of a patient-centered treatment and cough control therapies, as well as planning for future cough control (Morice et al., 2020). Failing to correctly diagnose and control chronic cough in elderly patients can lead to cough-related complications such as loss of speech and poor health-related quality of life (HRQoL) outcomes. Hire our assignment writing services in case your assignment is devastating you.

References

Morice, A. H., Millqvist, E., Bieksiene, K., Birring, S. S., Dicpinigaitis, P., Ribas, C. D., Boon, M. H., Kantar, A., Lai, K., McGarvey, L., Rigau, D., Satia, I., Smith, J., Song, W. J., Tonia, T., van den Berg, J. W. K., van Manen, M. J. G., & Zacharasiewicz, A. (2020). ERS guidelines on the diagnosis and treatment of chronic cough in adults and children. European Respiratory Journal, 55(1). https://doi.org/10.1183/13993003.01136-2019

Responding to Graciela

This is a good post, Graciela. Attending to a patient presenting with chronic cough with known risk factors such as smoking and a history of cough can help narrow down the diagnosis of the chronic cough. However, having a history of diagnosed HTN and manifesting other related complications such as frequent urination and suspected benign prostatic hyperplasia and diabetes can complicate the diagnosis. This will require a differential diagnosis focusing on chronic cough, diabetes, and urinary tract infections. Research focused on patients with COVID-19 has shown that comorbid chronic diseases increase the severity of chronic respiratory diseases (Liu et al., 2020). Additionally, despite properly managing chronic cough and treating other related chronic diseases and underlying factors, the disease can persist without any known cause. The chronic refractory cough can be symptomatically diagnosed using neuromodulators and managed with gabapentin or alternatively using macrolides (Visca et al., 2020).

References

Liu, H., Chen, S., Liu, M., Nie, H., & Lu, H. (2020). Comorbid Chronic Diseases are Strongly Correlated with Disease Severity among COVID-19 Patients: A Systematic Review and Meta-Analysis. Aging and Disease, 11(3), 668. https://doi.org/10.14336/AD.2020.0502

Visca, D., Beghè, B., Fabbri, L. M., Papi, A., & Spanevello, A. (2020). Management of chronic refractory cough in adults. European Journal of Internal Medicine, 81, 15–21. https://doi.org/10.1016/J.EJIM.2020.09.008

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Length: A minimum of 150 words per post, not including references
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1. Evelyn
For this week’s discussion, we are reviewing a 68-year-old male with two complaints, one of a cough for two months and frequent urination for four months. PHI consists of HTN, with no family history due to adoption, and he has smoked one-half pack of cigarettes for about 40 years. What are your differentials and diagnoses? What will be your plan of care for your patient?

So, suppose we first review his risk factors for his smoking; as the NP, we know he is at risk for cancer, heart disease, stroke, lung diseases, diabetes, and chronic obstructive pulmonary disease (COPD), including emphysema and chronic bronchitis. So, about the cough, we would need to ask a few questions to help us arrive at a diagnosis; these questions would focus on the cough at first, and then we can move on to his respiratory status. The characteristics of the cough would be helpful for the NP if the cough is dry, wet, productive non-productive, more when waking or at night, more when lying down or all the time, when exercising, or in cold air. For the respiratory status, does he have dyspnea with physical activity, wheezing, or does he notice that it is difficult to take a deep breath? Does he have any edema? Our physical findings would also help with the diagnosis, such as clubbing of the fingers, rhonchi vs. crackles, any sign of cyanosis, chronic bronchitis (cough DOE, mild cyanosis), verse emphysema (barrel chest, purse lip breather hunched over), (blue bloater/ pink puffer). (Mosenifar, MD, 2022)

Differentials and diagnoses for the Cough:

Chronic obstructive pulmonary disease (COPD) (J44. 9) symptoms will include chronic cough, sputum production, and dyspnea (the largest risk factor, smoking). We would confirm the diagnosis with spirometry by looking at the FEV1 and the FEV1/FVC; this would allow us to determine the airflow limitations as a whole, so we know that any score of 0.70 or 70% would confirm that he does have COPD (Mosenifar, MD, 2022). (We would always do a CXR to make sure that there are no underlying conditions such as masses, pneumonia, or TB) For the treatment based on the group (A, B, C) and the CAT score that the patient falls in, we would start with providing a SABA PRN and the LABA (Mosenifar, MD, 2022). Depending on the severity of the acute exacerbation, we may need to use systemic steroids, which will assist in the inflammation; according to Medscape, medical treatments such as steroids have been known to increase the rate of improvement in lung function and dyspnea over the first 72 hours (Mosenifar, MD, 2022). The NP would need to strongly encourage smoking cessation, which would be an effective treatment and management of COPD.

Bronchitis (J40) A history would need to be obtained, asking if there has been any exposure to toxic substances. The patient’s smoking history would be an important factor in his diagnosis. The most common symptom of bronchitis is a cough with the addition of sputum production, which can be clear, yellow, green, or possibly blood-tinged (Fayyaz, DO, 2021). The underlying disease factor is chronic obstructive pulmonary disease [COPD] (Fayyaz, DO, 2021). Diagnosis would consist of CBC with differential, Procalcitonin levels; this will help the NP to be able to distinguish bacterial from nonbacterial infections, sputum cytology if productive cough, chest radiography to rule out possible pneumonia, spirometry (looking at the overall function of the lung) (Fayyaz, DO, 2021). Treatment would consist of Bronchodilators; we can use ipratropium bromide and theophylline; we can also use a LABA and an inhaled corticosteroid to help control the cough (Fayyaz, DO, 2021). Nonsteroidal anti-inflammatory drugs (NSAIDs) can be used for pain. Guaifenesin for cough, dyspnea, and wheezing (Fayyaz, DO, 2021). As stated by Medscape, using antibiotics in otherwise healthy people is unnecessary. Still, it is recommended for the elderly over 65 years of age with comorbid conditions that put the patient at risk for serious complications (Fayyaz, DO, 2021). We would also encourage the Influenza vaccination, which will help with upper respiratory tract infections. And or the development of acute bacterial bronchitis. (Fayyaz, DO, 2021)

Emphysema (J43. 9) Emphysema and chronic bronchitis are airflow-limited states and directly relate to chronic obstructive pulmonary disease (COPD) (Boka, MD, 2019). Most patients will present with dyspnea, chronic cough or sputum production, and a history of exposure to risk factors, smoking is the number one risk factor. Most patients will adapt to the dyspnea, and then they will ignore the cough, have a barrel chest, have a hunched-over body, and breathe with purse lip breathing (Boka, MD, 2019). If doing spirometry, the forced expiratory volume in 1 second (FEV1) will usually be only 50%; these patients will be breathless upon minimal exertion (Boka, MD, 2019). In diagnostic studies, spirometry is required to confirm a diagnosis. LABS consists of arterial blood gas analysis assessing mild-to-moderate hypoxemia without hypercapnia (Boka, MD, 2019). Hematocrit due to hypoxemia which may lead to polycythemia. Serum bicarbonate is to check for respiratory acidosis, which will lead to compensatory metabolic alkalosis and a sputum evaluation. With a diagnosis of emphysema, the sputum will be mucoid, and there will be macrophage (Boka, MD, 2019). Treatment The goal of any of the therapies is to help with any symptoms, prevent disease progression, and improve activity tolerance and health status; the goal of the NP is to help prevent and treat complications and exacerbations and reduce mortality (Boka, MD, 2019). As stated by Medscape, smoking cessation is the single most effective therapy for any condition with restricted airflow (Boka, MD, 2019). Bronchodilators are the gold treatment of any COPD treatment regimen, but the best therapy is when the bronchodilators are used in combination with anti-inflammatory drugs, such as corticosteroids (Boka, MD, 2019). Medscape stated that for any acute exacerbations of COPD, it is ok to use empiric antibiotic coverage with a macrolide, a beta-lactam, or doxycycline, and the use of oxygen therapy if needed (Boka, MD, 2019).

Addressing the frequent urination for four months, as we realize follow-up questions are always needed, again is to help with getting to the differential diagnosis.

UTI (N39.0), asking about pain or burning or blood with urination, pain in the back or bladder; if all of that does not reveal that the patient does have a UTI, we can obtain a UA C&S and final answer for the differential of UTI. If the UA did come back that there was a UTI, then we can start him on antibiotics after the C&S is final.

BPH (N40. 1), we can first complete the American Urology Association System score (AUASS); we would review the onset, duration, and course of their symptoms, such as hesitancy, urinary retention, the feeling that their bladder is always full, urgency, frequency, nocturia, the answers will help the NP better understand what is going on, this will lead the NP decided what diagnostic studies they are going to do about the differential diagnosis (Deters, MD, 2021). The first thing we would do is a bladder scan which would tell us if there is retention, and then we would obtain a urinalysis to look for a possible infection (Deters, MD, 2021). Depending on the age of the patient and family history, we would obtain a PSA, but because we did not have the family history on this patient, a PSA could be warranted; we would also get a urodynamic study depending on the results of the test we would refer to urology for a possible cystourethroscopy (Deters, MD, 2021). For drug therapy for BPH, there the long-acting alpha-1 antagonists such as Hytrin, Flomax, and Cardura, or the 5-alpha-reductase inhibitors, which include Proscar and Avodart (Deters, MD, 2021). There is also the use of an herbal supplement, saw-palmetto, but the FDA has not approved this (Deters, MD, 2021). The key for the NP would be to follow the American Urological Association (AUA) guidelines on the management of benign prostatic hyperplasia (BPH) (Deters, MD, 2021). The guideline includes an algorithm for diagnosing and treating lower urinary tract symptoms, which will help the NP with treatment (Deters, MD, 2021).
2. Graciela
Chronic cough in adults is defined as a cough for greater than four weeks. Chronic cough can severely interfere with an individual’s ability to function normally in their everyday lives (Morice et al., 2019). This patient has a smoking history of 20 pack years. Smoking is known to cause chronic health conditions such as cancer, cardiovascular disease, emphysema, asthma, and/or congestive obstructive pulmonary disease (Centers for Disease Control, 2022). This patient reports a cough for 2 months, classifying it as a chronic cough. A thorough physical assessment would help narrow down differential diagnoses which include ACE inhibitor cough, upper/lower respiratory infection, pulmonary hypertension, and/or cardiovascular disease. This patient was diagnosed with HTN 5 years ago; an inquiry regarding the prescribed medication for his HTN should be made. If the patient was recently started on an ACE inhibitor, it should be stopped and replaced by an ARB. Due to this patient’s history of smoking, I would be highly concerned about chronic respiratory diseases such as COPD. The main test for COPD includes spirometry which can detect COPD by measuring the force of exhaled breaths (National Institute of Health, 2022). If ACE inhibitor cough has been excluded, further testing such as spirometry for COPD is necessary. Imaging such as CXR and/or CT can help identify pulmonary edema, PNA, and/or the presence of structural changes in the airway.

This patient is also reporting frequent urination which could be a symptom of benign prostatic hyperplasia (Persons et al., 2021). Differential diagnoses include diabetes and/or urinary tract infections. I would order a PSA level, UA, and HgA1C, along with a thorough history and physical assessment to gather more information regarding his symptoms. The treatment would be dependent on the test results and clinical findings. BPH can be treated with the use of medications such as alpha-blockers (tamsulosin, doxazosin, or terazosin) (Persons et al., 2021). If the cough is related to ACE inhibitors, I would stop them and replace them. If the cough was accompanied by symptoms such as abnormal breath sounds, secretions, and/or fever the treatment could include expectorants, cough suppressants if dry cough, and antipyretics. If COPD reigns as the main diagnosis, the patient should be encouraged and educated regarding smoking cessation. This patient might need supplemental oxygen, long-acting bronchodilators, and/or inhaled corticosteroids (Dunphy et al., 2019).