40-year-old male with a persistent cough
Complete only the History, Physical Exam, and Assessment sections of the Aquifer virtual case: Family Medicine 13: 40-year-old male with a persistent cough.
Family Medicine 13: 40-year-old male with a persistent cough
Assignment
Complete only the History, Physical Exam, and Assessment sections of the Aquifer virtual case: Family Medicine 13: 40-year-old male with a persistent cough.
Scenario:
You are working in Dr. Wilson’s office. The first patient of the morning is Mr. Frank Dennison, a 40-year-old cisgender male.
As you and Dr. Wilson open the electronic medical record, you note past visits by Mr. Dennison for allergic rhinitis and refills of various antihistamines and nasal sprays. Then you look at today’s encounter which gives the following information:
Reason for visit: Cough for two months.
Vital signs:
Temperature is 36.8 C (98.2 F)
Pulse is 80 beats/minute
Respiratory rate is 16 breaths/minute
Oxygen saturation is 97%
Blood pressure is 118/68 mmHg
Height is 172.7 cm (68 in)
Weight is 86.2 kg (190 lbs)
Body mass index (BMI) is 28.9 kg/m2
Dr. Wilson asks you to “do a focused history, then let me know what you find.”
Before you go into the exam room, you review common conditions that can lead to a persistent cough.
HISTORY 1
Dr. Wilson has already obtained permission from the patient for you to see him.
You introduce yourself, and begin by asking:
“How may we help you today?”
Mr. Dennison responds, “I’ve had this nagging cough for two months.”
“Tell me more about your cough.”
“I don’t have a fever so I don’t think I have an infection. The cough is worse at night. In fact, I wake up some nights with coughing spells. Eventually, I cough up some clear mucous, and then I feel better. Sometimes I notice that my breathing gets noisy.”
“What kind of noise do you make when you are breathing?”
“It’s kind of a musical, whistling sound, especially when I breathe out.”
“How often do you notice this noisy breathing?”
“On one or two nights of the week, I will wake up coughing and get that noisy breathing at the same time. When I cough up some clear mucous, I feel better. I have never had the noisy breathing during the day. In fact, when I jog or bicycle, my breathing is fine.”
“Do you get any chest tightness or chest pain?”
“No.”
HISTORY 2
As you proceed to take the rest of Mr. Dennison’s history, you continue to consider the diagnosis of asthma. Bearing this in mind, you ask Mr. Dennison about his past medical history:
“I see that you have a history of allergic rhinitis. How is that going?”
“What medications do you take for this?”
“Why haven’t you been receiving your allergy shots regularly?”
“Let’s discuss some options to help you take your medications and receive your shots.”
Through these questions, you realize Mr. Dennison’s allergic rhinitis is not under ideal control. You wonder if treating his allergic rhinitis would help control his cough and wheezing.
Next, you wish to see if he has an underlying sinusitis since that also is a co-morbid condition of asthma that could explain some of his symptoms.
DISCUSSING DIFFERENT CLINICAL SCENARIOS
CLINICAL REASONING
You know that Mr. Dennison has had chronic nasal symptoms (sneezing, nasal congestion, and drainage) for three to four months, so it is unlikely that he has acute sinusitis. Dr. Wilson asks you to consider a different hypothetical scenario.
“What if Mr. Dennison presented with one week of upper respiratory symptoms including nasal congestion and drainage? On the day the symptoms began, he had a low-grade fever that has now resolved.
His nasal congestion persisted and he has now had yellow nasal drainage for five days with associated mild headaches. On exam, he is afebrile and in no distress. Examination of his tympanic membranes and throat are normal. Examination of his nose is unremarkable although a slight amount of yellowish-clear drainage is noted. There is tenderness when you lightly percuss his maxillary sinuses.”
ACUTE VERSUS CHRONIC TEACHING
You and Dr. Wilson turn your attention back to Mr. Dennison.
By definition, nasal symptoms lasting more than 12 weeks are not acute sinusitis. So you consider chronic sinusitis and recall what you know about the symptoms of chronic sinusitis and you realize with the patient’s chronic nasal congestion and mucopurulent drainage, he may have chronic sinusitis. There may be additional physical signs and diagnostic tests that will be needed later to confirm this.
HISTORY 3
“Do you have any other chronic conditions; have you had hospitalizations or surgeries?”
“Do you take any medications other than the ones we have discussed?”
“Do you have any allergies to any medications, particularly aspirin?”
“Have you ever smoked cigarettes or cigars or chewed tobacco?”
Mr. Dennison reports no alcohol or drug use. He lives with his wife and two children, who are all healthy. His father is deceased, but had allergic rhinitis and asthma.
You remember that there are still some potential asthma comorbid conditions to ask about such as overweight and obesity, gastroesophageal reflux disease, obstructive sleep apnea, stress and depression. Also, you review his current weight and BMI and note that his current BMI classifies him as overweight, but not obese.
You ask Mr. Dennison this series of questions and discover the review of systems is negative:
“Have you ever had any symptoms of heartburn?”
“Has your wife ever commented on the way you sleep—snoring a lot or breathing unusually?”
“How are you doing emotionally; are you stressed or depressed?”
You explain that you would like Mr. Dennison to change into a gown while you go discuss your findings thus far with Dr. Wilson. And, when you return in a moment, you will perform a physical exam.
You find Dr. Wilson in the hallway and give him a synopsis of the history you’ve obtained from Mr. Dennison.
Discussion Question 1
Based on your performance and the expert feedback in your HISTORY collection, describe two missed questions and your understanding of why they were important to collect for this case history. Use specific references from your text to explain.
Discussion Question 2
Based on your performance and the expert feedback in your PHYSICAL EXAM collection, describe two errors in your exam performance or documentation. Use specific references from your text to explain the importance of these findings in correct assessment of this client.
Discussion Question 3
Based on your performance on the PHYSICAL EXAM collection, describe one key finding that you included in your list and describe a specific physical exam that you can perform at the point-of-care to further evaluate the finding. Use specific references from your text.
Discussion Question 4
Based on your performance and the expert feedback in your ASSESSMENT identification of problem categories, choose one missed/incorrect category and use specific references from your text to explain the importance of this category in arriving at correct differential diagnoses for this client.
Discussion Question 5
Based on your performance and the expert feedback in your ASSESSMENT of differential diagnoses, describe one incorrect/missed differential diagnosis and use specific references from your text to support the inclusion of the diagnosis for this client.
