A 72-year-old male presents to the clinic with 4 weeks of productive cough. He has a 10-year history of diagnosed COPD. He has a 45-year history of two packs a day cigarette smoking. He states he quit smoking due to financial needs about 6 years ago. He complains of pain in his chest from coughing, saying it is sore. He has noticed some dark-colored blood on his tissue.
Vital Signs: BP 137/90; HR 82; RR 22; BMI 23.
Chief Complaint: Persistent cough won’t go away with my normal cough medicine. Noticed blood on tissue from coughing.
Discuss the following:
1) What additional subjective information will you be asking of the patient?
2) What additional objective findings would you be examining the patient for?
3) What are the differential diagnoses that you are considering?
4) What radiological examinations or additional diagnostic studies would you order?
5) What treatment and specific information about the prescription will you give this patient?
6) What are the potential complications from the treatment ordered?
7) What additional laboratory tests might you consider ordering?
8) Will you be looking for a consult?
Full Answer Section
Objective Findings
In addition to the vital signs that were already recorded, I would examine the patient for the following:
- Lung sounds
- Heart sounds
- Neck veins
- Chest pain
- Sputum production
Differential Diagnoses
The differential diagnoses for this patient include:
- Acute bronchitis
- Chronic bronchitis
- Pneumonia
- Tuberculosis
- Lung cancer
- Heart failure
Radiological Examinations or Additional Diagnostic Studies
I would order a chest X-ray to assess the patient's lungs. I might also order a sputum culture to look for bacteria or other organisms. If the patient has a fever, I might also order a blood test to check for infection.
Treatment and Prescription Information
The treatment for this patient will depend on the underlying diagnosis. However, some general treatment options include:
- Cough suppressants
- Antibiotics
- Bronchodilators
- Oxygen therapy
I would give the patient specific information about the prescription, including the dosage, how often to take it, and any potential side effects.
Potential Complications from the Treatment Ordered
The potential complications from the treatment ordered include:
- Allergic reaction to the medication
- Drug interactions
- Worsening of the underlying condition
Additional Laboratory Tests
I might consider ordering additional laboratory tests, such as a
white blood cell count or a chest CT scan, if the patient's condition is not responding to treatment or if there are any other concerns.
Consult
I would not necessarily look for a consult, but I would keep the patient's primary care doctor informed of their progress.
Conclusion
This patient is presenting with a productive cough that has been going on for 4 weeks. He has a history of COPD and smoking, so these are both important factors to consider. The differential diagnoses for this patient are broad, so it is important to order the appropriate tests to narrow down the diagnosis. The treatment for this patient will depend on the underlying diagnosis.