Chronic Cough case study

Chronic Cough case study
A cough is a forceful expulsion of air from the lungs. The patient described in the above case study is a thirty-year-old woman who has presented with coughing that has persisted for three months. The coughing begins in the evenings and during cold periods. She does not report any form of hemoptysis, weight loss, fever, wheezing, or changes in appetite. This article will include more questions that I would have asked as her nurse practitioner to establish her diagnosis. It will also include a history of presenting illness. The cough classification will be included based on the duration of the cough, and, eventually, there will be a differential diagnosis. The symptoms presenting are similar to those of other diseases hence a differential diagnosis to arrive at a true diagnosis.

What other questions?

We have been able to establish the history of the cough but partly. There are other details that a practitioner tries to find out with this presentation. One would try to determine whether the cough is constant or intermittent, whether it comes and goes, or is always bothering the patient. Another point that one would try to find out is whether the condition worsens each time it occurs or its not progressing in morbidity (Poulose, Tiew, & How.,2016). One would also need to find out the frequency. Is it always in the evenings and dusty places, or it sometimes fails to occur? Again try to find out how many times in a day that these symptoms occur. I would also try to find out whether the presentation comes with night sweats.

Classification of the cough

Coughs are usually the body’s natural way of clearing irritants from the throat and the airways. They are not considered a medical problem until they become a bother to the patient. Coughs may also be a symptom of a medical problem or an adverse effect of some medications. Prolonged coughs may lead to chest pain, fractured ribs, loss of bladder control, exhaustion, dizziness, and even sleep interference.

Depending on the duration, a cough could be described as either acute, subacute, or chronic. Acute coughs last less than three weeks and are usually due to a cough or an upper respiratory tract infection such as pneumonia, whooping cough, and flu. Subacute coughs typically last between three and eight weeks and are usually the residual cough after an illness or infection is resolved (Morice et al., 2020). Chronic coughs last longer than eight weeks and are caused by medical conditions or medications such as Angiotensin-Converting Enzyme Inhibitors (ACEs). For this woman’s case, the cough can be classified as chronic since it has lasted three months.

A cough can further be classified as productive or unproductive. The productive cough produces mucus from the lungs or nasal sinuses. These are caused by viral illnesses, bacterial infection, tobacco use, postnasal drip, or stomach acid reflux. On the other hand, the nonproductive cough does not produce any mucus. These come as a residual effect of viral illnesses or bacterial infection, bronchospasm, allergies, medications, exposure to irritants, asthma, or airway blockage.

Diagnostic tests to include

There is no clear consensus for the best test to diagnose coughs. Several may have to be done, or the condition treated empirically. In the case of these woman, we will look at the diagnostic tests to be done for a chronic and dry cough since, according to the woman, the cough had lasted more than eight weeks. Current diagnostic protocols for chronic cough were coined twenty years ago by Irwin and colleagues. According to Morice et al. (2020), their approach appreciates anatomic sites of receptors comprising the human cough reflex’s afferent limb. It uses a combination of history, physical exam, and laboratory investigations directed at these anatomical sites. Combination therapy may be required as persistent cough may have more than one cause.

One of the tests that can be used is chest radiography. If the findings are abnormal, treatment will depend on the specific results of the radiography. If a mass is found, further steps are taken, such as bronchoscopy, computed tomography, or fine-needle aspiration to rule out cancer. Another test that can be done is the sputum culture. This is done to determine the specific causative organism of the cough to inform the choice of treatment. Evidence of infection will call for more tests to find out the causative microbial organism. Most chronic cough patients are usually healthy. However, they are expected to have the following conditions as the cause of the cough: upper airway cough syndrome, asthma, gastroesophageal reflux disease (GERD), or nonasthmatic eosinophilic bronchitis.

Another test that can be done is spirometric and peak expiratory flow measurements. According to Irwin, French & Madison. (2020), these measurements are focused on the diagnosis of airflow obstruction. However, this method appears to have limitations compared to conventional measures of forced expiratory volume in one second (FEV1). However, this method is not frequently used in clinics. Furthermore, another test for chronic cough is upper airway provocation studies. This is done by measuring the maximal inspiratory flow-volume curve during a conventional bronchial challenge testing. Variable extra thoracic upper airway obstruction has been observed in patients who were previously on postnasal drips but recovered.

Gastrointestinal investigations are also done to rule out Gastroesophageal Reflux Disease. A twenty-four-hour esophageal pH monitoring is done to determine the correlation between chronic cough and gastroesophageal reflux disease (Kahrilas et al., 2016). It should be noted that even non-acidic pH may still cause a chronic cough. Therefore, patients should be treated while considering both pHs.

The differential diagnosis for chronic cough (over eight weeks)

FLOWSHEET

condition	Symptoms	Diagnostics	Treatment
Asthma	Bronchial hyperresponsiveness, wheezing, dyspnea, difficulty in breathing	Spirometry, bronchodilator reversibility, bronchial provocation challenge	Empirical Use bronchodilators Leukotriene receptor antagonists
Gastroesophageal Reflux Disease	Heartburn, dysphagia, a feeling of pressure	Swallow evaluation, 24-hour pH monitoring,	Proton pump inhibitors, diet and lifestyle changes
Nonasthmatic eosinophilic bronchitis	Persistent cough of at least three months per year for more than two years	Evaluate for sputum eosinophils	Inhaled corticosteroids
Upper airway cough syndrome	Abnormally-increased nasal mucus secretion	Sinus imaging	Use antihistamine and decongestants

References

Irwin, R. S., French, C. L., & Madison, J. M. (2020). Managing unexplained chronic cough in adults: what are the unmet needs?. The Lancet Respiratory Medicine, 8(8), 745-747.

Kahrilas, P. J., Altman, K. W., Chang, A. B., Field, S. K., Harding, S. M., Lane, A. P., … & Adams, T. M. (2016). Chronic cough due to gastroesophageal reflux in adults: CHEST guideline and expert panel report. Chest, 150(6), 1341-1360.

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

Poulose, V., Tiew, P. Y., & How, C. H. (2016). Approaching chronic cough. Singapore medical journal, 57(2), 60.

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