Case Study For Patient Complaining Of Productive Cough Discussion

Case Study For Patient Complaining Of Productive Cough Discussion

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“Patient JB, 39 yo Caucasian female, is seen by her care provider for a complaint of productive cough, weakness, and “I just haven’t felt good for the past 2 weeks.” The care provider completes an assessment of listening to her lungs by having her take 2 deep breaths and informs her that her lungs are clear and to take OTC cough medication and hydrate well. The next day, JB feels worse and visits a different care provider who at this time, assesses her head, eyes, ears, nose, throat, auscultates her heart sounds and hears a murmur (which she did not know she had), auscultates her lungs by having her to take 4 deep breaths, performs percussion techniques, and tells her there is fluid on her lungs, examines her lower extremities and notices that there is bilateral 2+ pitting edema, and lastly, reviews her vital signs and tells her that her heart rate is 120, respirations are 22, and she has a temp of 101. Case Study For Patient Complaining Of Productive Cough Discussion

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Questions:

1.) Is the health history about the patient’s complaint thorough?

2.) Which provider’s examination would provide the patient with an accurate diagnosis and treatment plan?

3.) What diagnoses (we call them differential diagnoses) would be considered, and how would you rule them out to come up with an actual diagnosis?

The health history about the patient’s complaint is not thorough enough. In view of the Subjective, Objective, Assessment and Plan (SOAP) note method, there appears to lack specific information on the medical history, family history and surgical history of the 39-year old, Caucasian female patient. Equally, there is on provided information on current medications and allergies, occupational history, environmental history and comprehensive review of systems. Performing a physical examination may help the involved healthcare provider to collect relevant objective information through a review of systems on the vital signs and symptoms, cardiovascular, gastrointestinal, respiratory, musculoskeletal, psychiatric, endocrine and neurological aspects (King et al., 2021). Some of the diagnostic tests utilized to secure an accurate diagnosis include performing a chest X-ray or CT scan, sputum (mucus) test, blood tests, pulmonary function test, and metacholine challenge test. Regarding the differential diagnosis, the chronic and productive cough experienced by the patient can be linked to a number of health conditions namely: chronic bronchitis, pneumonia, and tuberculosis (Sharma et al., 2023)Case Study For Patient Complaining Of Productive Cough Discussion. Whilst chronic bronchitis is characterized by frequent coughing, wheezing and production of mucus, the patient did not report having experienced shortness of breath or tightness in her chest. Although the patient presents some of the signs and symptoms of tuberculosis including feelings of weakness or sickness, productive cough, fatigue, wheezing and fever, the examination does not indicate any signs of weight loss, night sweats, breathing problems, chest pains, coughing of blood, appetite loss and chills (Orlova, 2020). A more likely diagnosis for this particular patient is pneumonia since the patient is experiencing weakness, prolonged and productive cough, fever, and fatigue. The treatment plan should combine the use of antibiotics for bacterial pneumonia and antiviral medicines for viral pneumonia. Over-the-counter medications may be recommended for treatment of fever, breathing issues, fatigue, and muscle pain (King et al., 2021)Case Study For Patient Complaining Of Productive Cough Discussion.

References

King, J., Wingfield Digby, J., Hennessey, S., Marsden, P., & Smith, J. (2021). Productive cough, a forgotten phenotype of refractory chronic cough. Monitoring airway disease. https://doi.org/10.1183/13993003.congress-2021.pa1941

Orlova, N. V. (2020). Chronic cough: Differential diagnosis and treatment. Meditsinskiy sovet = Medical Council, (17), 124-131. https://doi.org/10.21518/2079-701x-2020-17-124-131

Sharma, S., Hashmi M.F., Alhajjaj M.S., et al. (2023).Cough (Nursing).Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK568776/ Case Study For Patient Complaining Of Productive Cough Discussion