Reference no: EM133210850
Chief Complaint
"Persistent bad cough."
History of Present Illness
A 50-year-old woman presents to her PCP with a complaint of ongoing dry, non-productive cough for 4 weeks with intermittent harsh coughing episodes, burning chest, and SOB. She states she had an upper respiratory infection 4 weeks ago that resolved after 2 weeks. She states the cough lingered and worsened. There is an increase in mucous, and SOB has developed. The cough is worse at night or when talking. She is having difficulty doing her job, where she is expected to talk for long periods. For the last week, she has been taking frequent puffs of an albuterol rescue inhaler she has for asthma. She states she is fatigued and thinks she is getting worse. Her family complains of the frequent loud and harsh cough. She thinks the recent forest fires and bad air quality in her area have contributed to her cough. She states most of the family who lives with her also developed a "cold" around the same time, but they are all doing well now, except her.
Review of Systems
The patient's ROS is positive for a harsh, frequent, non-productive cough with intermittent SOB. She denies a history of smoking cigarettes or other inhalants but states she grew up with parents who smoked in the home. She had a flu shot 6 weeks ago. Her ROS is negative for fever, hemoptysis, wheezing, chest pain, night sweats, poor appetite, body aches, pain, ear pain, nasal congestion, sore throat, history of pneumonia or lung disease, nausea, vomiting, diarrhea, recent travel, exposure to tuberculosis, or rash. She states her asthma and acid reflux are controlled with routine medication.
Relevant History
The patient's history is relevant for seasonal allergies, asthma, and acid reflux disease. Surgical history includes tonsillectomy and adenoidectomy (age 14). She is up to date on immunizations. She is a full-time high school teacher. She denies smoking and recreational drug use but does enjoy one drink, usually wine, several days per week. Her exercise level is usually light to moderate but since getting sick she has been sedentary. Her family history is significant for asthma and seasonal allergies.
Allergies
No known drug allergies; no known food allergies.
Medications
- Fluticasone propionate/salmeterol inhaled 250/50, 1 puff BID.
- Albuterol rescue inhaler, q4-6h PRN.
- Esomeprazole, 40 mg PO QD.
- Fluticasone propionate nasal spray, 1 spray in each nostril PRN.
Physical Examination
-Vitals: T 36.9°C (98.4°F), P 100, R 20, BP 126/82, SpO2 96%, HT 162.56 cm (64 in.), WT 74.4 kg (164 lbs), BMI 28.
-General: Well dressed with good hygiene. Appears tired.
-Psychiatric: Cooperative with exam and appropriate to situation.
-Skin, Hair, and Nails: No rash. No abnormal findings with hair or nails.
-Eyes: PERRL, sclera clear.
-ENT/Mouth: TMs present bilaterally with good light reflex. No tenderness to palpation. Nares patent and pale and body with small amount clear drainage. Oral mucosa moist and normal. Normal dentation. Pharynx normal.
-Neck: No cervical or pre- or post-auricular lymphadenopathy. No tenderness. FROM.
-Chest: Symmetrical.
-Lungs: Positive for frequent, dry, and loud cough, non-productive. Coughing increases with talking and deep breaths. Lungs were mostly clear with a scattered wheeze bilaterally. No rhonchi or crackles.
-Heart: RRR. No murmur.
-Abdomen: BS present. Abdomen soft with no tenderness to palpation.
-Neurologic: A&O×3.
Discussion Question 1: What is the most likely diagnosis? Why?
Discussion Question 2: Should tests/imaging studies be ordered? Which ones? Why? Think about tests/imaging beyond the primary care setting as well.
Discussion Question 3: Think about interprofessional collaboration for this case. Provide a list of specialties or other disciplines and indicate what contribution these professionals might make to managing the patient.