Week 3 NSG6320: Cough

Week 3 NSG6320: Cough

 

Cough

In the United States, cough is among the most common complaint for which patients seek medical care accounting for approximately 26 million office visits every year. Most of the time, the cough is normally caused by a self-limited acute viral upper respiratory tract infection. Nevertheless, there are other several causes of cough beyond this, comprising of both non-respiratory tract and respiratory tract etiologies. According to the American College of Chest Physicians (ACCP), cough which lasts for more than 4 weeks among young children less than 14 years, and more than 8 weeks among adults is considered chronic. Such chronic cough accounts for up to 38% of pulmonary outpatient visits (Spanevello et al., 2020). The purpose of this paper is to review the case of a patient who came in with a chief complaint of cough for three months.

Assessment of the Patient

            A cough that lasts for less than 4 weeks is considered acute. The assessment for patients with acute cough normally entails taking a complete medical history in addition to symptom-oriented physical examination. Technical diagnostic investigations are not necessary in such a case. However, for the case of a patient with chronic cough (lasting for over 2 months) like the one in the assigned scenario, both a focused history and physical examination in addition to chest radiography are normally necessary (Lai et al., 2021). Standard anteroposterior and lateral chest roentgenograms are normally obtained. Additionally, the physician will need to perform spirometry with the use of a bronchodilator to confirm whether the patient has asthma in case reversible obstructive airway disease is present. If the patient’s baseline spirometry value is normal, a methacholine inhalation challenge test may be performed.

Red Flags

Patients with acute cough will present with several signs and symptoms including running nose, shortness of breath, heartburn, sore throat, postnasal drip, and wheezing. However, when the cough persists for more than 2 months, some potential red flags that will be noticed include hemoptysis, respiratory distress, severe systemic illness, and altered level of consciousness associated with the cough (Morice et al., 2020). In such a case, the patient should be referred for further evaluation and management.            

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Review of Systems

During the assessment of chronic cough, the review of systems must focus on both the pulmonary and extrapulmonary symptoms. However, the 2018 CHEST guidelines emphasize the importance of specifically evaluating the patient for hemoptysis which is considered a potential red flag symptom that requires a more thorough evaluation for infectious causes of the chronic cough like tuberculosis or malignancy (Irwin et al., 2018).

Differential Diagnosis

             The most common differential diagnosis for chronic cough in adults includes upper airway cough syndrome (UACS), asthma, and Gastroesophageal Reflux Disease (GERD). UACS is caused by various upper respiratory conditions. Patients with UACS will display normal chest radiography (Lai et al., 2021). However, the diagnosis of this condition also depends on additional symptoms such as nasal discharge, throat clearing, and posterior pharynx drainage among others. Asthma is the other commonly misdiagnosed condition for chronic cough. Spirometry is however required to confirm or rule out this diagnosis. GERD on the other hand can also be mistaken for chronic cough. However additional symptoms such as daily heartburn and regurgitation are required to confirm this diagnosis.

Causes of Cough

In most cases, chronic cough normally results from asthma, gastrointestinal disease, or postnasal drainage either alone or combined. Studies show that most asthmatic patients will present with cough as the main manifestation, in response to the irritant which forces constriction or spasm of the bronchial tubes (Koo et al., 2018). In gastrointestinal reflux disease, the acid reflux normally stimulates the cough reflex afferent limb by irritating the upper respiratory tract with no aspiration or irritating the lower respiratory tract with aspiration. Postnasal drip on the other hand can lead to chronic cough as a result of the excess mucus flowing from the sinuses and nose to the throat. Other possible causes of chronic cough include bronchiolitis, bronchiectasis, chronic aspiration, chronic heart failure, and COPD among others.

Sample HPI

A 25-year-old male patient came to the clinic complaining of persistent cough for the past 3 months. He claims that the cough started mild and worsened over time. His description of the cough states that it is watery and clear. His cough becomes worse at night, which affects his sleep. As such, he does not focus at work and suffers from fatigue. He also reports frequent runny nose, as well as a cold and sore throat. He reports taking cough syrup which was effective at first but currently does no good. He also has a history of asthma but stopped using the inhaler at the age of 16 years, when it was well controlled. He denies any drug, food, or environmental allergies. He also denies smoking tobacco.

Conclusion

Persistent cough for 3 months is considered chronic and thus requires thorough evaluation to determine the causative condition. Unlike in the assessment of acute cough, CHEST guidelines recommend the incorporation of more technological diagnostic tools such as chest radiography for further evaluation of the patient’s condition. Physicians are also advised to check for red flags such as hemoptysis for evaluation of chronic infectious conditions which might have caused the cough such as tuberculosis.

References

Irwin, R. S., French, C. L., Chang, A. B., Altman, K. W., Adams, T. M., Azoulay, E., … & Weinberger, M. (2018). Classification of cough as a symptom in adults and management algorithms: CHEST guideline and expert panel report. Chest, 153(1), 196-209. https://doi.org/10.1016/j.chest.2017.10.016

Koo, H. K., Park, S. W., Park, J. W., Choi, H. S., Kim, T. H., Yoon, H. K., … & Kim, D. K. (2018). Chronic cough as a novel phenotype of chronic obstructive pulmonary disease. International journal of chronic obstructive pulmonary disease, 13, 1793. DOI: 10.2147/COPD.S153821

Lai, K., Zhan, W., & Zhan, C. (2021). Lower Airways: Assessment and Treatment for Cough. In Diagnosis and Treatment of Chronic Cough (pp. 37-45). Springer, Singapore. https://doi.org/10.1007/978-981-33-4029-9

Morice, A. H., Millqvist, E., Bieksiene, K., Birring, S. S., Dicpinigaitis, P., Ribas, C. D., … & Zacharasiewicz, A. (2020). ERS guidelines on the diagnosis and treatment of chronic cough in adults and children. European Respiratory Journal, 55(1). DOI: 10.1183/13993003.01136-2019

Spanevello, A., Beghé, B., Visca, D., Fabbri, L. M., & Papi, A. (2020). Chronic cough in adults. European Journal of Internal Medicine, 78, 8-16. https://doi.org/10.1016/j.ejim.2020.03.018

For this assignment, you will review the latest evidence based guidelines as they pertain to the case below. Discussion of the case emphasize the core learning objectives for an evidence-based primary care curriculum. Throughout your nurse practitioner program, case study discussions are used to promote the development of clinical reasoning through the use of ongoing assessments and diagnostic skills, and to develop patient care plans that are grounded in the latest clinical guidelines and evidence-based practice.
A patient comes in to see you complaining of a cough for three months. How does your assessment of this cough differ from a patient who has had a cough for five days?
Tasks:
• What are the potential red flags?
• What is important not to miss in your review of systems?
• What are the differential diagnosis for a cough lasting three months?
• What are the top three causes of a cough lasting three months?
• Write a sample HPI for the above patient.
As in all assignments, cite your sources in your work and provide references for the citations in APA format.