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A case study of tammy, a 33-year-old patient presenting with a persistent cough. A differential diagnosis of five possible conditions, including bronchitis, pneumonia, acute sinusitis, asthma, and allergic rhinitis. It analyzes the symptoms and provides a treatment plan based on the most likely diagnosis. The document also discusses the impact of additional symptoms, such as fever and foul-smelling mucus, on the differential diagnosis and treatment approach.
Typology: Exams
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Discussion
Discussion Part Two (graded) Tammy is a 33-year-old who presents for evaluation of a cough. She reports that about 3 weeks ago she developed a “really bad cold” with rhinorrhea. The cold seemed to go away but then she developed a profound, deep, mucus- producing cough. Now, there is no rhinorrhea or rhinitis—the primary problem is the cough. She develops these coughing fits that are prolonged, very deep, and productive of a lot of green sputum. She hasn’t had any fever but does have a scratchy throat. Tammy has tried over-the-counter cough medicines but has not had much relief. The cough keeps her awake at night and sometimes gets so bad that she gags and dry heaves. Write a differential of at least five (5) possible diagnosis’s and explain how each may be a possible answer to the clinical presentation above. Remember, to list the differential in the order of most likely to less likely. Based upon what you have at the top of the differential how would you treat this patient? Suppose now, the patient has a fever of 100.4 and complains of foul smelling mucous and breath. Indeed, she complains of producing cups of mucous some days. She has some trouble breathing on moderate exertion but this is only a minor complaint to her. How does this change your differential and why? Topic responses
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Bronchitis
Bronchitis is an inflammation of the lower respiratory track of the bronchial tubes “Acute bronchitis is usually caused by a respiratory virus and occasionally by bacterial infection, although this occurs in less than 10 percent of cases” (Acute Bronchitis, 2016). The symptoms of
bronchitis include coughing up mucus that is yellow or green, a runny or congested nose that started a few days before the chest congestion, fatigue, wheezing, shortness of breath with activities, and “coughing fits.” The patient reports having a runny nose about three weeks ago when this started. A runny nose was her only complaint when the illness started. Once the runny nose went away, the cough and chest congestion started. She currently does not have a fever, but her throat is scratchy. Her throat could be scratchy from all of the coughing she has done. Her symptoms seem to fit all of the symptoms associated with bronchitis, especially since she is not running a fever and the fact bronchitis can last several weeks. The patient is not having any fever or chills, so this could indicate that it is viral, and there is no infection. Pneumonia Pneumonia is a lung infection that can have mild to severe symptoms. They symptoms range from a cough which can produce yellow, green, or bloody mucus, fever, shortness of breath, chills, headache, fatigue, loss of appetite, and sweating. Bronchitis and Pneumonia are very similar, that is why sometimes a person is diagnosed with one when they really have the other. An x-ray can rule out or confirm pneumonia. It can begin with a sore throat, dry cough, muscle aches, and then it will progress to having a productive cough with discolored sputum. It can be from bacteria, viral, or even fungal. The patient is at more of a risk for pneumonia because she did have a cold, it could have possibly turned into a pneumonia due to the congestion (Pneumonia, 2016). Acute Sinusitis “Sinuses are hollow spaces in the bones around the nose that connect to the nose through small, narrow channels” (Sinusitis, 2016). Acute sinusitis is an infection of the sinuses. It affects one in eight adults every year. What happens is the sinus cavities become inflamed and then are unable to empty mucus. The inflammation could have come from the cold, and now that the sinus cavities are blocked from inflammation, she has developed a sinus infection. Symptoms include congestion (chest or nose), pain, pressure, or fullness in the face, and yellow or green mucus. Bacterial sinusitis is suspected if it has been longer than 10 days, and the patient is not better. The patient has had symptoms for at least three weeks, and so acute bacterial sinusitis should be suspected (Sinusitis, 2016).
Asthma Even though asthma does not explain all of her symptoms, it is a possibility. The patient may have asthma and an irritant is exacerbating it, which is causing the sputum. These irritants could be pollen, smoke, or house hold chemicals. It also could explain the coughing fits she has
at night, and the shortness of breath with exertion. Symptoms of asthma include tightness in the chest, wheezing, coughing (sometimes with sputum). Sometimes the patient will experience coughing fits, and may occur especially in the morning and at night. She has coughing fits at night. She could have had a case of allergic rhinitis, and not the cold. The allergic rhinitis may have triggered an asthma flare up. The patient would need to find out what is triggering it, and avoid it. Allergic Rhinitis Allergic rhinitis is an inflammation of the nasal membranes such as the nose, eyes, eustachian tubes, middle ear, sinuses, and pharynx that is caused by allergies. The symptoms vary but are sneezing, congestion (chest or nose), headache, red eyes, fatigue, and itchy nose, ear or eyes. Histamine, tryptase, chymase, kinins, and heparin are released in the blood when exposed to an allergen. The release of these into the blood stream gives the patient symptoms that cause inflammation. Once you take the allergen away, the allergic rhinitis goes away. Allergic rhinitis affectes roughly 40 million people in the United States. (Sheikh, J., MD, & Kaliner, M., MD., 2015). She may be allergic to pollen, certain chemicals she has been using lately, or other things such as mold. Based upon what you have at the top of the differential how would you treat this patient? First, I would get a chest x-ray to ensure it is bronchitis and not pneumonia. Then I would prescribe a coughing medication such as Promethazine DM that helps the patient not cough as much, but helps to thin the mucus and get it up when they do cough. This would help with her coughing fits. We want her to cough and get the mucus up, but we do not want her to dry heave and gag due to coughing. I would also give a steroid injection such as Kenalog to help dry her secretions up. The patient can then take over the counter NSAIDS such as Ibuprofen and Tylenol, as well as rest and a lot of fluids. The fluids would also help to thin the mucus, which would make it easier to cough up. Suppose now, the patient has a fever of 100.4 and complains of foul smelling mucous and breath. Indeed, she complains of producing cups of mucous some days. She has some trouble breathing on moderate exertion but this is only a minor
complaint to her. How does this change your differential and why? “If it (the cold) hangs around for more than 10 days, or gets worse after it starts to get better, there’s a good chance you have sinusitis” (Sinusitis, 2016). I would then treat the patient for Sinusitis because her sinus cavities have had mucus built up for days and bacteria may be
starting to grow; especially since she has a fever now. One of the symptoms of acute sinusitis is foul smelling breath and mucus, along with fever. (Sinusitis, 2016). Acute Bronchitis, Symptoms, Causes, and Risk Factors. (2016). American lung association. http://www.lung.org/lung-health-and-diseases/lunheg- disease-lookup/acute- bronchitis/symptoms-causes-risk- factors.html. Asthma Symptoms, Causes, and Risk factors. (2016). American lung association. http://www.lung.org/lung-health-and-diseases/lung-disease- lookup/asthma/asthma- symptoms-causes-risk-factors/. Pneumonia. (2016). American lung association. http://www.lung.org/lung-health-and- diseases/lung-disease- lookup/pneumonia/?referrer=https://www.google.com/. Sheikh, J., MD, & Kaliner, M., MD. (2015). Allergic Rhinitis. http://emedicine.medscape.com/article/ 25-overview. Sinusitis. (2016). American academy of otolaryngology-head and neck surgery. http://www.entnet.org/content/sinusitis Show Less Janet Farrelly reply to Sarah Drum RE: Week 2 DB 2 Sarah,
Smoking and Tammy's condition:
This is a very well written answer as it is easy to follow and it contains a great deal of information! After I introduced myself to Tammy though, I would ask her if she smoked. I am one of six children and only one of my siblings smoke and even though she is not the oldest of us, she looks as though she is. Sometimes my other siblings will say, "Oh, I can't believe that she still smokes", but they don't understand the addictions of smoking and just by telling someone to
stop, this isn't going to work! A couple of years ago, I did a report on smoking for a previous class and I was absolutely dumbfounded on the amount of taxes on one pack of cigarettes alone. In the state of New Jersey, for example, the tax on one pack of cigarettes is $2.70 cents, while in the state of NY, the tax, for one pack is over $4.00 dollars! While the "politicians" decided to get together and raise prices on cigarettes, to dissuade individuals from smoking, this is not the solution. If a person wants to smoke, they are going to pay any amount for a pack of cigarettes. The solution is education and, as future nurse practitioners we are here to provide those services! I would teach Tammy, if she did smoke, that there is help out there to stop smoking and she doesn't have to do it alone! For example, if Tammy lived in New Jersey, I would refer her to the New Jersey Quit line at 1-866-NJSTOPS! Reference: Campaign for Tobacco Free Kids. (2016). Map of state cigarette tax rates. https://www.tobaccofreekids.org/research/factsheets/pdf/0222.pdf Show Less Jamie Miller reply to Sarah Drum RE: Week 2 DB 2 Hello, Sarah.
Good post. For this scenario, I had a difficult time trying to decide if Tammy's primary diagnosis was bronchitis or pneumonia. I ultimately choose pneumonia, and it seems I am in the minority. However, I choose pneumonia for certain reasons. First, acute bronchitis caused by a virus does not usually produce a productive cough and bronchitis caused by bacteria is rare in healthy adults (Brashers & Huether, 2013). Viral pneumonia is often caused by a secondary infection, which I believe Tammy started with as the common cold
virus (Brashers & Huether, 2013). Community-acquired pneumonia is
common in otherwise healthy people who do not have contact with the health care environment (Musher & Thorner, 2014). However, the final determination of the primary diagnosis does require an x- ray to confirm. References Brashers, V. L. & Huether, S. E. (2013). Alterations of pulmonary function. In K. L. McCance, S. E. Huether, V. L. Brashers, & N. S. Rote (Ed.), Pathophysiology: The biologic basis for disease in adults and children (7th ed., pp. 1248-1289). St. Louis, MO: Mosby. Musher, D. M. & Thorner, A. R. (2014). Community-acquired pneumonia. The New England Journal of Medicine, 371 , 1619-
Bronchitis seems to fit the picture the best. As you mentioned, bronchitis is an inflammation in the lower respiratory track. The inflammation causes irritation and coughing. I thought your article was interesting that bronchitis is usually causes by viral infections because if that is the case then as you mentioned the 10 percent of causes being bacterial, that means that 90 percent are being mistreated or that antibiotics are being way over prescribed for these infections. "There is the potential for extensive antimicrobial use, some of which might be inappropriate" (Vergidis,
Hamer, Meydalni, Dallal & Barlam, 2011). I have seen multiple cases on the recent news about the overprescribing of antibiotics. This overprescribing epidemic does have serious consequences sometimes such as other illnesses like Clostridium difficile associated disease. Its always best to make sure the treatments we offer have benefits that outweigh the risk. Vergidis, P., Hamer, D. H., Meydani, S. N., Dallal, G. E., & Barlam, T. F. (2011). Patterns of antimicrobial use for respiratory tract infections in older residents of long-term care facilities. Journal Of The American Geriatrics Society , 59 (6), 1093-1098. doi:10.1111/j.1532- 5415.2011.03406.x Show Less Melissa Gushard Discussion Part Two
Show Less Sarah Drum reply to Melissa Gushard RE: Discussion Part Two
You do have a good plan, but it would be nice to see more specifics of how you would treat the patient. I too agree that the patient has bronchitis, but I would treat it differently. According to the National Heart, Lung, and Blood Institute, I would first get a chest x-ray to cross out pneumonia (How is Pneumonia, 2016). You state if she does not get any better you would then get an x-ray to rule out pneumonia. Instead of her possibly having to make two trips to the office, we could get an x-ray and limit to this one visit. Also, you state antivirals can be prescribed if it is thought she has the flu. The flu could be ruled out by doing a rapid flu test. Then she would not have to have more medication. I worked at a physician’s office when I was an LPN and I saw cases like this all of the time. Most of the time an antibiotic is not needed for bronchitis. “Acute bronchitis is usually caused by a respiratory virus and
occasionally by bacterial infection, although this occurs in less than 10 percent of cases” (Acute Bronchitis, 2016). Since most cases are caused by a virus, I would treat with medication, rest, fluids, and NSAIDS like you said. The medication I would
give is Promethazine DM because it helps to thin the mucus and calm coughing fits, but it does not stop the coughing. We do not want to give anything with codeine in it because that would make her stop coughing, and we want her to continue to cough. We want the patient to cough up the mucus in the lungs. I would then give her a steroid injection if she does not have diabetes because steroids would help to dry the mucus out. If she has diabetes I do not think I would give that because that would make her sugar levels go up more. I would then recommend lots of rest and fluids along with Ibuprofen or Tylenol if needed. Acute Bronchitis, Symptoms, Causes, and Risk Factors. (2016). American lung association. http://www.lung.org/lung-health-and-diseases/lunheg- disease-lookup/acute- bronchitis/symptoms-causes-risk- factors.html. How is Pneumonia Diagnosed? (2016). National heart, lung, and blood institute. http://www.nhlbi.nih.gov/health/health- topics/topics/pnu/diagnosis. Show Less Instructor Brown reply to Melissa Gushard RE: Discussion Part Two Melissa,
Explain the importance of hydration? How much fluid I lost with fever? Excessive respiration. Show Less Melissa Gushard reply to Instructor Brown RE: Discussion Part Two Dr. Brown,
Although hydration is important for general health, hydration is critical for the body's
temperature control and to replenish fluid lost from sweating (Popkin, D'Anci, & Rosenberg, 2010). Hydration from excessive sweating results in a loss of electrolytes, reduction in plasma volume, and may lead to increased plasma osmolarity (Popkin, D'Anci, & Rosenberg, 2010). Fluid loss via skin can range from 0.3 L/h in sedentary conditions to 2.0 L/h with increased temperature and high activity (Popkin, D'Anci, & Rosenberg, 2010). According to Jequier and Constant (2010) normal water loss by evaporation through the respiratory tract is 250-350 ml/day. Excessive respirations would increase this amount, and would also need to be replenished through hydration. Melissa References Jequier, E., & Constant, F. (2010). Water as an essential nutrient: the physiological basis of hydration. European Journal of Clinical Nutrition. 64. 115-123. doi: 10.1038/ejcn.2009.111 Popkin, B., D'Anci, K., & Rosenberg, I. (2010). Water, hydration and health. Nutrition Reviews. 68 (8). 439-458. doi: 10.1111/j.1753-4887.2010.00304.x
Show Less Loretta Karpinski reply to Melissa Gushard RE: Discussion Part Two
Melissa, Thank you for sharing the information on the chronic cough. My father is a liver transplant patient and for the last few years he has had this terrible dry cough. I finally brought it up toShow More Mijanou Marretta- Lewis Discussion Two Week Two heaves. Dr. Brown and Classmates,
Respiratory diseases can be difficult to diagnose. Many of the general symptoms from respiratory diagnoses can overlap symptoms and mirror more serious conditions (McCance , Heuther, Brashers,& Rote,2013). Symptoms such as cough, with or with productivity of sputum, fever, chills, lethargy and general malaise are common complaints (Goroll &Mulley, 2014). In this scenario Tammy had been suffering from a cold like symptoms for the past three weeks. The need to obtain a complete health history would also include whether she is a smoker, what over the counter medications were working and what was not, history of seasonal allergies, environmental allergies and is she on an angiotensin-converting-enzyme (ACE) inhibitor, which has been associated with dry nocturnal coughing, with a higher incident among women than men (Goroll &Mulley, 2014). She has a productive purulent cough so the ACE inhibitor if she is on one may not be the cause to her issue.
Differential Diagnoses:
to the cilia and epithelial cells of the respiratory tract. It can be cause by viral or bacterial infection processes. Symptoms include: cough with or without sputum, sore throat,low grade fever, post nasal drip and fatigue with body aches. In many incidents if the cough is longer than several days, bronchitis would be a likely diagnosis. The possibility of a viral upper respiratory infection can also mirror the symptoms and signs of bronchitis. Although Tammy states her symptoms of her cold had dissipated, a cough can continue for several weeks. In this case the patient has complained of upper respiratory issues at the onset of the cough with purulent drainage which leads to a strong possibility of acute bronchitis (File, 2016). Treatment for this primary differential diagnosis. The need for a chest x=ray, with a follow up to four to six weeks is needed to see if patient has gone back to base line (Gorollo & Mulley, 2014). If the chest x-ray is abnormal the need for a computerized tomography (CAT) scan may reveal a more definitive diagnosis. A sputum culture should be obtained to isolate the infection and to rule out any organism. If there is a bacterial infection then the use an antibiotic would be necessary with a narcotic cough suppressant, expectorant, possible steroid use with a sliding scale, decongestant; possible antihistamine could help to alleviate these symptoms (Gonzales, Anderer, McCulloch, Maselli, Bloom et al., 2013). Gargling with hot salt water can help with the sore throat and clean the throat of any residual mucous.