Week 2 Assignment-Case Study-Adult

Patient History

During the first encounter with the patients, subjective and objective data are crucial in determining the health trends of the client. Comprehensive patient history is essential to guide the health care provider in determining the patient’s diagnosis by supplementing diagnostic tests. In history taking, each part represents its unique role, such as patient identification, medical history, and history of the current illness (Flugelman, 2021). To begin with the patient identity, biographic data is collected to identify the patient, such as the name, age, sex, religion, social and marital relations, and residence. In the medical history, the information captured under this décor is aimed at tracking the health trends of the patient. The information included here outlines the history of previous admissions, any chronic diseases diagnosed before the current issue, any allergies, and any possible genetic comorbidities in the family. Under the history of the current illness, the healthcare provider establishes what has been done in the management of the current situation, for instance, the onset of the current situation, duration of the trigger, aggravating factors, alleviating factors, the characteristics of the current issue, and how long the patient have been on the management of the illness. Patient history revolves around all the determinants of health that interact to give the health outcomes of the individuals (Flugelman, 2021).

Medical history

The patient’s medical history is aimed to include the past medical history, chief complaints, and the history of the current illness. Here, the health care provider depends wholly on the subjective data provided by the patient or the health surrogate following the professional probing through questions as well as a review of the previous medical records (Nichol et al., 2023). Some of the questions that the health care provider uses may include:

1. What has brought you to the hospital today? The onset, duration, alleviating factors, aggravating factors, characteristics of the chief complaint, and what remedies have been implemented.
2. What prescription and over-the-counter drugs have you been using?
3. What previous admissions have ever occurred, what was the diagnosis, how long did the admissions take, and when did the admissions occur?
4. Is there a history of any surgical procedures and blood transfusions? When?
5. What medications have you taken for the current problem?
6. What drugs and food allergies do you have apart from environmental allergies?
7. Have you been at risk or in contact with any allergens?
8. Do you use tobacco, drink alcohol, or abuse any other substance?

Patient case study

The patient presents with a chief complaint of a persistent, dry, debilitating cough that has been present for three months. His blood pressure during this encounter was 145/79 mmHg. His past medical history includes hypertension, diabetes, environmental allergies and a history of colon polyps. He has been on Lisinopril for six months and other allergy medications. For diabetes, the patient is using metformin 500mg, aspirin 81mg, and loratadine 10mg.

Physical Aspects to be Completed During a Physical Exam and Review of the System

The physical examination of a patient involves assessment techniques such as observation, palpation, auscultation, and percussion. These techniques gather the information and findings that comprise the physical aspects of the patient. For instance, the common physical aspects include the general appearance, which is done by observing signs of distress, respiratory effort, skin color, and any other observable aspects (Toney-Butler & Unison-Pace, 2023). Vital signs like heart rate, respiratory rate, and blood pressure are other physical aspects of physical assessment filled through physical techniques, mostly observation and auscultation. Another physical aspect to be filled is the respiratory examination to pick any abnormalities in the chest, like abnormal breath sounds on either percussion or auscultation. The other physical aspect is the cardiovascular examination, which is mainly done through auscultation to listen to the heart sounds. HEENT is another physical aspect to be filled to assess the nose, throat, sinuses, eyes, and ears. The other physical aspect is the extremities assessment for edema or signs of hypoxia such as cyanosis (Toney-Butler & Unison-Pace, 2023). From the case scenario in this assignment, the physical assessment reveals no significant abnormalities apart from mild neuropathy from diabetes.

Possible Cause of the Cough

The cough presented in the case can be termed a chronic cough whose etiology is undetermined. This is because the patient has been on cough management, but the symptoms do not subside. However, it has been scientifically proven that dry cough is one of the side effects of angiotensin-converting enzyme inhibitors (ACE inhibitors), a class of antihypertensive drugs. Lisinopril, being one of the drugs in this class, justifies the likelihood of the cough being a Lisinopril-induced cough (Pinto et al., 2020).

Other Possible Diagnoses

Apart from the confirmed diagnoses of hypertension, diabetes, and environmental allergies, the symptoms of the patient suggest other diagnoses. For instance, the history of the dry chronic cough might be in line with other diagnoses such as GERD, gastroesophageal reflux, Asthma, especially cough-variant asthma, chronic bronchitis or chronic obstructive pulmonary disease, post-nasal drip syndrome that causes post-nasal drip (Morice et al., 2020). In this scenario, another possible diagnosis might be pertussis or viral infection, which is justified by the drug resistance of the cough. Chronic hypertension and diabetes are known to bring various heart diseases as their complications. For this reason, heart failure is one of the possible diagnoses to consider, irrespective of the absence of other symptoms.

Additional Tests

            Additional tests can be considered in this scenario to establish the cause of the persistent cough and rule out other underlying conditions that may be present. Some of the tests that may be done include a chest X-ray that may be done to rule out chest abnormalities, infections, malignancies, or interstitial lung disease that could be causing the cough. This is a standard initial investigation for the persistent cough. The other test is spirometry which should done to evaluate asthma or COPD due to the cough. A complete blood count (CBC) should be done to check for signs of infection, anemia, or conditions that might contribute to the chronic cough. A basic metabolic panel (BMP) to assess kidney function, especially considering the patient’s history of hypertension and diabetes, will help rule out electrolyte imbalances. The other test is the echocardiogram or B-type Natriuretic peptide (BNP) levels that elucidate the heart failure after having done the physical assessment. The upper GI series or Esophagogastroduodenoscopy should be done due to the suspected GERD attributed to the chronic cough. Lastly, the ACE inhibitor cessation trial should be considered in attempts to establish the cause of the cough and if it is confirmed it is Lisinopril, another class of anti-hypertensive should be considered.

Treatment and Education

The treatment plan for this patient should aim to first reduce the chronic cough. This will be done through discontinuation of Lisinopril or replacement with other alternative anti-hypertensive drugs that do not typically cause a cough. A follow-up appointment of 2-4 weeks is needed to reassess the patient after discontinuing Lisinopril, and this will be targeted to evaluate the blood pressure management with the new management. The other treatment management should involve symptomatic relief, such as cough suppressants for short-term relief and hydration to help soothe the throat. Lastly, managing other comorbidities such as diabetes and blood pressure control. Patient education should involve medication education, such as information on replacing Lisinopril with other antihypertensives due to cough.  Teach the patient when to seek medical attention, including the warning signs, and teach about health maintenance, such as blood pressure monitoring and diabetes management.

References

Flugelman, M. Y. (2021). History-taking revisited: Simple techniques to foster patient collaboration, improve data attainment, and establish trust with the patient. GMS Journal for Medical Education, 38(6), Doc109. https://doi.org/10.3205/zma001505

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., Berg, J. W. K. van den, Manen, M. J. G. van, & 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

Nichol, J. R., Nelson, G., & Sundjaja, J. H. (2023, April 30). Medical History. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK534249/

Pinto, B., Jadhav, U., Singhai, P., Sadhanandham, S., & Shah, N. (2020). ACEI-induced cough: A Review of Current Evidence and Its Practical Implications for Optimal CV Risk Reduction. Indian Heart Journal, 72(5). https://doi.org/10.1016/j.ihj.2020.08.007

Toney-Butler, T., & Unison-Pace, W. (2023). Nursing Admission Assessment and Examination. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK493211/

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Week 2 Assignment-Case Study-Adult

Assignment Prompt

A 75-year-old man with a history of hypertension, diabetes, and environmental allergies, 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, and his blood pressure today is 150/92. 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.
1. What questions would have been asked as part of the medical history?

Week 2 Assignment-Case Study-Adult

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?
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Expectations
• Research: (APA Assignment), Title Page, Introduction, Headings. Citation and reference page is required.
• Length: A minimum of 1100 words, not including references
• Citations: At least two high-level scholarly references in APA from within the last 5 years.