Discussion Question: When posting this week, think about a patient that you felt a bit stuck as to what may be causing their cough? What decision did you ultimately make, and why?A cough is often a presenting chief complaint and has several differential diagnoses. Choose one differential diagnosis for cough and discuss the presenting symptoms, diagnostic testing, and treatment.

Use APA 6th edition format. Use in text citation. Use at least 2 scholarly journals.

Respond to each classmate response at least 1 paragraph

(approx100words) .Be respectful. Use APA 6th edition.Use in text citation also.

Timothy’s Response

According to Silvestri and Weinberger (2017), the symptom of a cough, which is responsible for approximately 30 million clinician visits annually in the United States, is one of the most common symptoms for which outpatient care is sought. In an outpatient pulmonary practice, evaluation and management of persistent cough can account for up to 40 percent of the practice volume. Cough can be classified based upon the duration of the cough; within each category are likely diagnostic possibilities. Acute cough exists for less than three weeks and is most commonly due to an acute respiratory tract infection. According to File (2018), acute bronchitis is a common clinical condition characterized by cough, with or without sputum production, which lasts for at least five days. It is typically self-limited, resolving within one to three weeks. Acute bronchitis is a lower respiratory tract infection involving the large airways (bronchi) without evidence of pneumonia that occurs in the absence of chronic obstructive pulmonary disease. According to File (2018), acute bronchitis is one of the most common conditions encountered in clinical practice. It accounts for approximately 10 percent of ambulatory care visits in the United States, or 100 million visits per year. The incidence of acute bronchitis is highest in late fall and winter when transmission of respiratory viruses peaks. Symptoms result from inflammation of the lower respiratory tract and are most frequently due viral infection. Treatment is focused on patient education and supportive care. Antibiotics are not needed for the great majority of patients with acute bronchitis but are greatly overused for this condition. Reducing antibiotic use for acute bronchitis is a national and international healthcare priority. According to File (2018), Acute bronchitis should be suspected in patients with cough for at least five days (often one to three weeks) who do not have clinical findings suggestive of pneumonia (eg, fever, tachypnea, rales, signs of parenchymal consolidation) and do not have chronic obstructive pulmonary disease. For most patients, the diagnosis can be made based upon the history and physical examination. Testing is generally reserved for cases in which pneumonia is suspected, clinical diagnosis is uncertain, or when results would change management (eg, a positive influenza test result in a patient who meets criteria for antiviral therapy). The primary reason for obtaining a chest radiograph is to exclude pneumonia; reasonable indications for suspecting pneumonia and obtaining imaging include abnormal vital signs (pulse >100/minute, respiratory rate >24 breaths/minute, temperature >38°C [100.4°F], or oxygen saturation <95 percent) and signs of consolidation on chest examination (rales, egophony, or tactile fremitus). The last reason for obtaining a chest radiograph would be because of a mental status or behavioral changes in patients >75 years old, who may not mount a fever. According to File (2018), the treatment for most patients with acute bronchitis, symptoms are self-limited, resolving in about one to three weeks. Reassurance and symptom control are the cornerstones of care. Antibiotics are not recommended for routine use. For patients who request antibiotics, we encourage having an explicit discussion on the risks and benefits of their use. For the great majority of patients, use of antibiotics does not hasten recovery or prevent complications but puts patients at increased risk of adverse effects including potentially severe complications such as Clostridium difficile infection and anaphylaxis. For patients with acute bronchitis who are bothered by cough, offering nonpharmacologic options for cough relief such as throat lozenges, hot tea, honey, and/or smoking cessation or avoidance of secondhand smoke is a reasonable first step. For patients with acute bronchitis who desire medication for cough relief, we suggest offering over-the-counter (OTC) medications, such as dextromethorphan or guaifenesin. Most patients with acute bronchitis recover without complications within 1 to 3 weeks and do not require follow-up but should be educated on features that warrant concern such as new-onset fever, difficulty breathing, symptoms lasting >3 to 4 weeks, or bloody sputum.

References

File, T. M. (2018). Acute bronchitis in adults. UpToDate. Retrieved from https://www.uptodate.com/contents/acute-bronchitis…

Silvestri, R. C., & Weinberger, S. E. (2017). Evaluation of subacute and chronic cough in adults. UpToDate. Retrieved from https://www.uptodate.com/contents/evaluation-of-su…

April’s Response

Community-Acquired Pneumonia

A cough is produced when irritant receptors in the central airways or stretch receptors in the distal airways are stimulated. While normally a protective mechanism, a cough is considered abnormal when it is painful, persistent, or productive (Ainslie, 2009). Community-acquired pneumonia (CAP), a leading cause of global morbidity and mortality, is just one of the many differential diagnoses for cough. While CAP can be caused by both bacterial and viral causes, the most common pathogens are categorized as either typical bacteria, atypical bacteria, or viral (Ramirez, 2018).

Signs and Symptoms of CAP

CAP can vary from mild to severe cases, with severity depending on the intensity of local and systemic immune responses. In addition to cough, which may be with or without sputum production, additional symptoms of CAP include dyspnea, pleuritic chest pain, fever, chills, fatigue, and malaise. The sputum produced in CAP may be yellow, green, or rust colored. Upon examining the individual with CAP, the provider may note tachypnea, increased work of breathing, tactile fremitus, egophony, dullness to percussion, and adventitious ling sounds including rales, crackles, and rhonchi. Tachycardia, hypotension, and altered mentation may be signs of sepsis associated with more severe cases of CAP (Ramirez, 2018).

Diagnostic Testing

According to Ramirez, the above signs and symptoms are nonspecific and therefore inadequate for the diagnosis of CAP without chest imaging. When considered alongside the presenting symptoms, the demonstration of an infiltrate on a chest radiograph can lead to a definitive diagnosis of CAP. While a chest x-ray is adequate in the majority of patients, a CT of the chest may be indicated in those who are immunocompromised or have been exposed to certain pathogens. Labwork, including a CBC, CMP, lactic acid, blood cultures, and sputum cultures, may be indicated with moderate to severe cases of suspected CAP (Ramirez, 2018).

Treatment of CAP

The Pneumonia Severity Index (PSI), which ranks patients according to their mortality risk, can be useful in determining whether outpatient or inpatient treatment in indicated. Antibiotics are the mainstay of outpatient treatment, the selection of which is determined by the prediction of the most likely pathogen, local susceptibility, and the presence or absence of comorbidities (Uphold & Graham, 2013). An empiric antibiotic regimen that targets both typical and atypical pathogens is often selected. For individuals who warrant hospital admission, intravenous antibiotics are often necessary, and the empiric antibiotic regimen should be expanded to cover additional pathogens (Ramirez, 2018). A number of tables and algorithms exist to aid clinicians in making an appropriate choice. Once the pathogen has been identified via culture, target therapy should be implemented (Uphold & Graham, 2013).

References

Ainslie, G. (2009). Assessment of cough. African Journals Online CME, 27, 68-71.

Ramirez, J. A. (2018, September 17). Overview of community-acquired pneumonia in adults. Retrieved from https://www.uptodate.com/contents/overview-of-community-acquired-pneumonia-in-adults?search=pneumonia&source=search_result&selectedTitle=3~150&usage_type=default&display_rank=3#H3728463829

Uphold, C. R. & Graham, M. V. (2013). Clinical guidelines in family practice (5th ed.). Gainesville, FL: Barmarrae Books, Inc.