A 75-Year-Old Adult Case Study
In this case presented, a 75-year-old male patient presented to the office with a chronic hacking dry cough that had been present for three months and had not improved with over-the-counter antitussives and allergy drugs. Diabetes, hypertension, environmental allergies, and a colonoscopy with polypectomy six years ago are among the medical and surgical conditions that the patient has had in the past. The patient stated he had been prescribed lisinopril six months prior. In addition, the patient has reported he has been taking loratadine 10 mg daily, an over-the-counter allergy medication for several years, metformin XR 500 mg daily, and aspirin 81 mg once daily. His blood pressure is currently 145/70, and except for slight neuropathy caused by persistent diabetes mellitus, the physical examination is normal. After reviewing the patients’ history and current physical exam, it is evident that patient may be experiencing an angiotensin-converting enzyme inhibitor (ACEI)-induced cough. According to Yılmaz (2019), when taking an ACE inhibitor, a dry, tickly cough is the most prevalent side effect. Around 10% of people using ACE inhibitors are likely to develop a cough. Cough reflexes are heightened when ACE is inhibited. An accumulation of kinins, substance P, and prostaglandins may result from the impairment of kininase II activity, which may then lead to a cough. Providers should be aware that dry cough is the most prevalent side effect of ACE inhibitors, and that this symptom might occur months or even a year after starting treatment.
The medulla mediates coughing as a reflex response; however, coughing can be controlled voluntarily. The nasopharynx, larynx, ear, bronchi, and trachea all have mucosal neural receptors that can be stimulated to create a cough (Cash et al., 2021). Any patient who comes in with a cough as their primary complaint should have a thorough medical history taken and a focused physical examination performed.
Questions a Nurse Practitioner should ask a patient who presents to the clinic with a chief complaint of a cough include:
Can you tell me when the cough started? Did it occur gradually, or it appear suddenly? Has the cough gotten any worse, better or has it had no change since it began? Is the cough worse at night or during the day? Do you have any aggravating factors that could make the cough worse? (Cash et al., 2021).
Can you describe the severity and duration of the cough? Is the cough causing incontinence or fainting? When did it begin? (Cash et al., 2021).
Can you describe the cough, is it dry crackles? Is it a wet or a dry cough? Is it productive? Is it wheezy? Brassy? Whether or not the patient says it’s mucoid or bloody, the healthcare provider should inquire. It is important to include additional information, such as the odor, color and consistency of mucus or sputum (Cash et al., 2021). Bronchogenic carcinoma should be considered if a patient has a persistent or alternating cough that is also accompanied by weight loss. A dry, irritative cough is a strong indicator of a viral respiratory illness (Cash et al., 2021).
Ask the patient about what helps or worsens the cough. Exposure to cold, Tb exposure, irritants in the environment, or allergies might aggravate asthmatic coughs (Cash et al., 2021).
Ask the patient if they smoke or have been exposed to any secondhand smoking. If they have a history of smoking inquire about the duration, and amount. If exposed to second hand smoke ask about duration, amount, and quality of the person’s exposure to secondhand smoking (Cash et al., 2021).
The patient’s occupation and job history should be asked about during the interview (Cash et al., 2021).
Ask the patient if the cough has ever been aggravated after eating if the patient has had a feeling of choking or nasal blockage (Cash et al., 2021).
Question the patient about family history associated with respiratory disorders such as asthma and cystic fibrosis (Cash et al., 2021).
Discuss with the patient any health issue that could require further investigation, medical history such as asthma, chronic obstructive pulmonary disease, and high blood pressure (Cash et al., 2021).
Lastly ask the patient about current medications both prescribed and over the counter should be reviewed with the patient, because some medications such as ACE inhibitors, can cause a dry cough (Cash et al., 2021).
An adult with a chronic cough needs a proper physical examination that begins by doing vital signs, then examination of the ear, nose, throat, respiratory, and cardiovascular systems. Conducting a proper physical exam is necessary for a patient who complains of coughing and other respiratory issues. As a Nurse Practitioner, I would focus on examining the patient’s nasal passage, throat, sinuses, and neck veins, looking for specific signs of respiratory difficulties such as the use of accessory respiratory muscles, cyanosis and clubbing of the fingers I would also perform pulmonary and cardiac auscultation; chest precussion should be performed; assessing lung sounds and heart sounds checking for any gallops, rubs or murmurs (Cash et al.,2021).
Etiology of Patients Cough
According to Yılmaz 2019, cough is one of the most common side effects of taking angiotensin-converting enzyme inhibitors (ACEIs). Studies have shown numerous current evidence about how and why coughs happen when people take ACEIs. It also suggests a practical way to deal with coughs for the best cardiovascular (CV) risk reduction. Dry cough is more common in people who take ACEIs than in people who don’t. A cough is thought to come from several different things, but the use of ACEIs is the most common one. (Yılmaz, 2019).
ACEIs are frequently associated with adverse symptoms such as low blood pressure, hyperkalemia, dizziness, and headache, as well as a chronic dry cough. After stopping ACEIs, a tickling feeling in the throat disappears. Patients on ACEIs experienced a dry cough at a rate of 1.5–11%, according to one study (Yılmaz, 2019). Many ACEI studies have been hampered by small sample sizes and lack of long-term follow-up, which has resulted in considerable disparities in reported incidences of cough, which in turn has contributed to the discrepancies (Sanchis-Gomar et al., 2020). Cough incidence varies among ACEIs, and only a few ACEIs have real time clinical practice data to back up findings from randomized trials, further complicating matters. The basic causes of the ACEI-induced cough are a lot of different things. People who take ACEIs have a cough because of angioedema and bradykinin buildup. (Sanchis-Gomar et al., 2020).
Diagnosis to consider for patient with a chronic cough
Various respiratory and non-respiratory conditions can lead to a persistent cough. some diagnosis for cough includes infections of the upper respiratory tract with viruses, postnasal drip syndrome, gastro-esophageal reflux disease, cough variant asthma, bronchitis with eosinophilia, tumors of the mediastinum and the lung, interstitial fibrosis early in the course of the disease and the use of an ACEI are all common causes of chronic cough (Mahasur, 2017). Psychogenic and idiopathic cough are also common causes of chronic cough. Almost 50% percent of patients who come to a specialized clinic with a cough, the cause of the cough is unknown (Mahasur, 2017).
Diagnostic testing to consider for patient with a persistent cough
Determining the root cause of a chronic cough might be difficult because individuals generally have more than one cause for their cough. As a result, a wide variety of tests are employed to pinpoint the root of the problem. Diagnostic testing should be based not only on the chronic cough, but also on the other presenting symptoms. To identify if an infection is present and causing the cough, lab testing might be used to diagnose patient’s condition. These lab test includes a CBC with differential, and a lung function test. The pulmonary lung function tests will tell your provider how well your lungs are functioning (Mahasur, 2017). A spirometry or a methacholine challenge test can also be done, these monitor your inhalation and exhalation patterns. Aside from spirometry, other lung function tests include lung volume testing, gas diffusion investigations, and the six-minute walk test (Mahasur, 2017).
Lastly, X-rays, CT and MRI scans, ultrasound, and nuclear testing are all examples of imaging diagnostic testing which are used to diagnose a chronic cough. X-rays reveal lung disease and cancer as the causes of chronic cough, such as a build-up of fluids in the areas that aid breathing. You can get further information about breathing-related areas by using various imaging examinations (Mahasur, 2017).
According to Mahasur 2017, patients’ insurance companies should be considered before placing an order diagnostic testing. It is essential to make sure that patients’ insurance can cover these diagnostic procedures due to the expense of the testing. Therefore, it is beneficial to perform a careful analysis of the information gathered during a patient’s medical history and physical examination to ensure proper testing is ordered.
Treatment and Education of Patient with a Chronic Cough
According to the 75-year-old man’s detailed description of his cough, it is fair to say the use of ACE inhibitors should be deemed entirely or largely responsible for the patient’s persistent cough, regardless of how long it has been since the ACE inhibitor therapy was started or when the cough first appeared. Some medications have been proven to reduce the effects of ACE inhibitor-induced cough, even though withdrawal of therapy is the only uniformly effective treatment (Silver & Weinberger, 2021).
According to Silver &Weinberger, 2021 a recommended approach is to stop the medication for a short period of time and then restart it once the coughing discontinues. Studies have also show that when medication was administered at night, coughing was a minor complication. Additionally, it is vital to design strategies to keep the ACE inhibitor treatment going, if possible, using these techniques. In the event of recurrent, distressing symptoms, and after all other plausible reasons of cough have been ruled out, switching to angiotensin receptor blockers should be advised.
Kaplan A. G. (2019). Chronic Cough in Adults: Make the Diagnosis and Make a Difference. Pulmonary therapy, 5(1), 11–21. https://doi.org/10.1007/s41030-019-0089-7
Mahashur A. (2017). Chronic dry cough: Diagnostic and management approaches. Lung India : official organ of Indian Chest Society, 32(1), 44–49. https://doi.org/10.4103/0970-2113.148450
Silvestri, R. C., & Weinberger, S. E. (2021). Patient education: Chronic cough in adults (Beyond
the Basics). UpToDate. https://www.uptodate.com/contents/chronic-cough-in-adults-
Yılmaz İ. (2019). Angiotensin-Converting Enzyme Inhibitors Induce Cough. Turkish thoracic journal, 20(1), 36–42. https://doi.org/10.5152/TurkThoracJ.2018.18014
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