Case Study: Respiratory
A 30-year-old woman comes to your office because of a persistent cough that has been bothering her for the past 3 months. Her cough is dry and is more frequent during the evenings. She also notes frequent nasal congestion, especially when she is exposed to dust and cold weather. She reports no hemoptysis, weight loss, wheezing, fever, or changes in his appetite.
What additional questions would you ask to learn more about her cough?
What would be included in your HPI and your subjective questioning?
How would you classify her 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 and include the diagnostics as well as the pharmacological management and rationale related to the differentials.
- Social History:
- Smoking history (current or past), including pack-years.
- Occupational exposures (e.g., dust, fumes, chemicals).
- Alcohol and drug use.
- Exercise habits.
- Family History:
- Any family history of lung diseases (e.g., asthma, COPD, lung cancer, tuberculosis).
HPI and Subjective Questioning:
- HPI: A 30-year-old female presents with a 3-month history of a persistent, dry cough, more prominent in the evenings. She also reports frequent nasal congestion, particularly when exposed to dust and cold weather. She denies hemoptysis, weight loss, wheezing, fever, or changes in appetite.
- Subjective:
- Past Medical History: No significant past medical history.
- Social History: Non-smoker, no alcohol or drug use, no recent travel.
- Family History: No significant family history of lung disease.
Classification of Cough:
- Chronic Cough: A cough lasting longer than 8 weeks.
Diagnostic Tests:
- Chest X-ray: To rule out pneumonia, lung nodules, or other lung abnormalities.
- Pulmonary Function Tests (PFTs): To assess lung function and rule out conditions like asthma or COPD.
- Complete Blood Count (CBC): To rule out infection or other underlying conditions.
- Sputum Culture and Sensitivity: If the cough becomes productive, to identify any bacterial infections.
- Allergy Testing: To assess for allergies to environmental allergens.
- Endoscopy: In some cases, an endoscopy may be necessary to evaluate the upper airways for potential causes of cough, such as GERD or vocal cord dysfunction.
Differential Diagnosis Flow Sheet
| Diagnosis | Possible Causes | Diagnostic Tests | Pharmacological Management | Rationale |
|---|---|---|---|---|
| Upper Respiratory Tract Infection (URI) | Viral or bacterial infection | CBC, nasal swab for culture (if indicated) | Supportive care (rest, fluids, antipyretics as needed), consider decongestants or antihistamines if symptoms are severe | Most common cause of acute cough |
| Post-Nasal Drip | Allergic rhinitis, sinusitis | Nasal endoscopy, sinus imaging (if indicated), allergy testing | Nasal corticosteroids, antihistamines, decongestants | Relieving nasal congestion may improve cough |
| Asthma | Airway inflammation | PFTs, methacholine challenge test | Inhaled corticosteroids, bronchodilators | To control airway inflammation and improve airflow |
| GERD | Acid reflux | Upper endoscopy (if indicated), esophageal manometry | Proton pump inhibitors (PPIs), lifestyle modifications (elevating the head of the bed, avoiding late-night meals) | To reduce acid reflux and its effects on the airway |
| Chronic Bronchitis | Chronic inflammation of the airways | PFTs, chest X-ray | Bronchodilators, mucolytics | To improve airway clearance and reduce inflammation |
| Lung Cancer | Malignant growth in the lungs | Chest X-ray, CT scan, bronchoscopy | Varies depending on stage and type of cancer | To identify and treat lung cancer |
| Tuberculosis | Bacterial infection | Sputum culture for acid-fast bacilli, chest X-ray | Anti-tuberculosis medications | To eradicate the infection and prevent spread |
Additional Questions:
- Character of Cough:
- Is the cough productive (with sputum) or non-productive (dry)?
- If productive, what is the color and amount of sputum?
- Is the cough worse at night or in the morning?
- Does anything seem to worsen or improve the cough? (e.g., lying down, exercise, specific allergens)
- Nasal Congestion:
- Is the nasal congestion accompanied by any other symptoms, such as runny nose, sneezing, or postnasal drip?
- Are there any nasal polyps or sinus pain?
- Past Medical History:
- Any history of asthma, allergies, smoking, GERD, or other respiratory conditions?
- Any recent upper respiratory infections?
- Any recent travel history?
- Any history of chronic medical conditions (e.g., diabetes, autoimmune diseases)?