What questions need to be asked and what body part needs to be examined?
If a patient comes in with a cough there are several questions that need to be asked. Such as: When did the cough start? Has it lasted less than 3 weeks or lasted longer? Are there any factors that may have prompted the cough? Is the cough productive or non-productive? If productive can you please describe the amount of sputum, its color, odor and consistency? When does the cough occur? It is 24/7? Do you have any reactive airway disease? Are there any relieving factors? Have you taken any medication for the cough? Do you cough more when you are laying down? Do you have any other symptoms with the cough such as shortness of breath, fever, wheezing? What prescriptions do you take and any OTC drug use? Do you smoke? Also using OLDCARTS to gain subjective data from the patient.
Body parts that need to be examined include the mouth/ throat, ears, neck, nose, thorax and chest. The ears should be assessed for cerumen or hairs that could be impinging on the tympanic membrane (Dunphy, Winland-Brown, Porter & Thomas, 2015). The nose should be assessed for any discharge, edema or sinus tenderness. Looking at the throat for any signs of postnasal drip. The neck should be palpated and assessed for any enlarged lymph nodes or masses (Dunphy et al., 2015). The thorax and chest should be assessed to see if the patient has any cardiac or pulmonary problems. The heart and lungs should be auscultated. Listening for any abnormalities such as fluid or rhonchi in the lungs and heart murmurs.
What diagnostic tests need to be obtained and why?
A chest x-ray should be taken if the patient has signs and symptoms of pneumonia to confirm the diagnosis (Dunphy et al., 2015). It could also pick up other things such as a hidden tumor. A complete blood cell count needs to be obtained to diagnose or rule of a bacterial infection. If the patient is able to produce a sputum sample that should be sent out to culture. A computed tomography (CT) scan of the chest can be used to detect small peripheral lung nodules and distinguish the chest wall from other areas of pleural or parenchymal disease (Dunphy et al., 2015). This scan can also be used when pulmonary thromboembolism is questioned. Sinus films can be used to rule out sinusitis if the patient presents with a history of having chronic postnasal drip or chronic sinus infections. Spirometry should be used to determine if the patient has COPD or restrictive lung disease. This test can detect COPD even before symptoms start to develop.
How would you handle abnormal finding?
I would handle abnormal findings by exploring the findings and coming up with a diagnosis. I would also try to figure out the cause of the abnormal findings and order further testing if required to make a diagnosis such as a bronchoscopy. I then would explain the abnormal findings to the patient. Depending on what the abnormal findings were, I will make a treatment plan with the patient. If needed, I will consult a pulmonologist.
What will be your list of differentials?
Acute coughs are commonly due to a viral upper respiratory infection. It can also be due to an acute exacerbation of chronic pulmonary disease (COPD), pneumonia and pulmonary embolism (Silvestri & Weinberger, 2019). Other differentials would include acute bronchitis, postnasal drip, asthma, medication use such as an ACE inhibitor, post infection, GERD and occupational/ environmental factors (Dunphy et al., 2015). More serious causes of a cough can include tumors, aortic aneurysm, tuberculosis, and lung abscess. Cough can also be cardiovascular in origin and a sign of left-sided heart failure (Bickley, 2017).
References
Bickley, L. S. (2017). Bateâs Guide to Physical Examination and History Taking (12 ed.). Philadelphia, PA: Wolters Kluwer.
Dunphy, L. M. H., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2015). Primary Care: The Art and Science of Advanced Practice Nursing (4th ed.). Philadelphia, PA: F.A. Davis Company.
Silvestri, R., & Weinberger, S. E. (2019). Evaluation of subacute and chronic cough in adults. Retrieved from https://www.uptodate.com/contents/evaluation-of-su
