Case and Discussion
A 60-year-old man comes to your office because of a persistent cough that has been bothering him for the past 3 months. His cough is dry and is more frequent during the evenings. He also notes frequent nasal congestion, especially when he is exposed to dust and cold weather. He reports no hemoptysis, weight loss, wheezing, fever, or changes in his appetite. He reports he is taking medication for his cholesterol as well as his blood pressure but he cannot remember the name of the medications.
- What additional questions would you ask to learn more about his cough?
- How would you classify his cough based on the duration to help with the diagnosis?
- What diagnostic tests do you want to include to help you with your diagnosis?
Create a differential diagnosis flow sheet for this patient for this patient and include the diagnostics as well as the pharmacological management and rationale related to the differentials.
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Expert Solution Preview
Introduction:
When a patient presents with a persistent cough, it is essential to gather a detailed history to help with the diagnosis and management. In this case, a 60-year-old man presents with a persistent dry cough and frequent nasal congestion. The objective is to gather more information about his cough, classify his cough based on duration, and determine which diagnostic tests are necessary to make a diagnosis. Additionally, we will create a differential diagnosis flow sheet for this patient, including diagnostics and pharmacological management.
1. What additional questions would you ask to learn more about his cough?
To gather more information about the patient’s cough, some additional questions include if the cough is present throughout the year or seasonal. Also, ask if the patient has a history of allergies or exposure to irritants such as chemicals or fumes. Additionally, it is crucial to enquire if he smokes tobacco or any other substances and if he has been exposed to someone with a similar cough or respiratory illness.
2. How would you classify his cough based on the duration to help with the diagnosis?
Coughs can be classified as acute, subacute, or chronic based on duration. Acute coughs last less than three weeks, subacute coughs last between three and eight weeks, and chronic coughs persist for more than eight weeks. In this scenario, the patient’s cough has lasted for three months, which qualifies it as a chronic cough.
3. What diagnostic tests do you want to include to help you with your diagnosis?
For this patient, some diagnostic tests to consider include a chest X-ray to check for any lung abnormalities. Additionally, spirometry can evaluate lung function and check for any obstructive lung diseases such as COPD or asthma. Other tests may include a complete blood count, sputum culture and sensitivity, and a CT scan of the chest if necessary.
Differential Diagnosis Flow Sheet:
Possible diagnosis | Diagnostic testing | Pharmacological management
Allergic rhinitis | History, physical exam, allergy testing | Antihistamines, decongestants, intranasal corticosteroids
Asthma | Spirometry, bronchial provocation test | Inhaled corticosteroids, bronchodilators
GERD | Upper endoscopy, 24-hour pH monitoring | Proton pump inhibitors, H2 receptor blockers
Non-specific chronic cough | History, physical exam, chest X-ray, spirometry | Antitussives, inhaled corticosteroids
Conclusion:
The patient’s symptoms indicate a chronic cough. More detailed history should be conducted to determine the cause of his cough. Some possible causes include allergic rhinitis, asthma, GERD, or a non-specific chronic cough. Diagnostic tests will then guide appropriate pharmacological management.