Devary posted Jun 21, 2018 4:40 PM

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What questions need to be asked and what body part needs to be examined?

When a patient presents to a clinic with a cough it is important to identify the type of cough the patient is presenting with. Michaudet and Malaty (2017) discuss how an acute cough presents less than three weeks, a sub-acute cough is anything from three weeks to eight weeks, and a chronic cough is considered when the cough lasts more than eight weeks. The most common presenting symptom of patients of all ages is a cough with undifferentiated duration (Michaudet & Malaty, 2017). According to Dunphy, Winland-Brown, Porter, and Thomas (2015) some of the question to be asked should include:

• When did the cough first start?
• Is there anything that prompts the cough?
• When does the cough start (in the morning, at night, working out)?
• Does anything make your cough worse?
• Does anything make your cough better?
• Is your cough dry, wet, raspy, deep or hacking?
• Is your cough productive or unproductive?
• Do you cough more lying down?

A complete medical history should be obtained including history and symptoms of the ear, nose, throat, respiratory tract and digestive tract (Guiyuan, Xinying, Tianlin, & Dongping, 2016). A complete physical assessment should be done that focuses on the ears, nose, throat, respiratory tract and digestive tract as well. Some specific body parts to exam and target is throat congestion, follicular hyperplasia, and retropharyngeal postnasal drip (Guiyuan, Xinying, Tianlin, & Dongping, 2016). Dunphy, Winland-Brown, Porter, and Thomas (2015) discuss the need to focus on the ears for cerumen or hairs, look at the nose for discharge, edema, polyps, and sinus tenderness, looking into the throat for cobblestoning, and palpate the neck for enlarged lymph nodes. Lastly, the thorax and chest should be examined to rule out any cardiac or pulmonary issues (Dunphy, Winland-Brown, Porter, and Thomas, 2015).

What diagnostic tests need to be obtained and why?

Most commonly a chest x-ray will be obtained to rule out any infectious, inflammatory, and malignant thoracic conditions (Michaudet & Malaty, 2017). The chest x-ray is useful when there is a suspect of pneumonia, TB, tumor, aspiration, and a foreign body as well (Dunphy, Winland-Brown, Porter, and Thomas, 2015). Using spirometry as a diagnostic test can distinguish if there is a prescense of obstructive or restrictive lung disease (Dunphy, Winland-Brown, Porter, and Thomas, 2015). To rule out a bacterial infection a complete blood count with differential should be obtained (Dunphy, Winland-Brown, Porter, and Thomas, 2015). A CT scan might be ordered of the chest to identify lung nodules, lesions, and differentiate between the chest wall and from areas of pleural or parenchymal disease (Dunphy, Winland-Brown, Porter, and Thomas, 2015). If the patient was immunosuppressed, positive for AIDS, or exposed to environmental factors a fungal serology is useful in the diagnosis of coccidiomycosis, histoplasmosis, and aspergillosis (Dunphy, Winland-Brown, Porter, and Thomas, 2015). In chronic coughs it may be useful to not only complete a chest x-ray but to do a bronchodilator test, methacholine-challenge test, a CT imaging of the sinuses or endoscopy to obtain a diagnosis (Guiyuan, Xinying, Tianlin, & Dongping, 2016).

How would you handle abnormal finding?

Abnormal findings should be communicated with the provider and the patient. Then I would come up with a treatment plan and implement the treatment plan with the patient. Lastly, I would re-check the patient and monitor the patient for improvements. If the abnormal findings are above my scope of practice guidelines I would complete a referral process for the patient to be seen by a pulmonologist or otolaryngologist depending on the findings (Michaudet & Malaty, 2017). However, evaluation should focus on the etiologies with a targeted treatment and then monitory of the patient for resolution of the cough (Michaudet & Malaty, 2017).

What will be your list of differentials?

The list of differentials is dependent on a chronic cough versus an acute cough. Michaudet and Malaty (2017) discussed differentials for a chronic cough includes: upper airway cough syndrome, GERD, asthma, non-asthmatic eosinophilic bronchitis, ACE inhibitor use, environmental triggers, tobacco use, COPD, and obstructive sleep apnea. Other differential diagnosis for a cough include and are not limited to: postnasal drip, postinfection, PE, tumors, aortic aneurysm, heart failure, aspiration, bronchiectasis, TB, sarcoidosis, foreign body obstruction, diaphragmatic irritation, and lung abscess (Dunphy, Winland-Brown, Porter, and Thomas, 2015). All of the differential diagnoses are interchangeable because a differential diagnosis for a chronic cough such as GERD may have been caught sooner than the eight week mark that considers it chronic.

References

Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2015). Primary care the art and science of advanced practice nursing (4th ed.). Philadelphia, PA: F.A. Davis Company.

Guiyuan, J., Xinying, H., Tianlin, L., & Dongping, X. (2016). Chronic cough: clinical characteristics and etiologies of 510 cases. Turkish Journal of Medical Sciences, 46(6), 1734-1739. doi: 10.3906/sag-1508-133

Michaudet, C. & Malaty, J. (2017). Chronic cough: evaluation and management. American Family Physician, 96(9), 575-580.