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Case Study: What’s Causing This Cough?

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SafetyNurse1968 has 20 years experience as a ADN, BSN, MSN, PhD and specializes in Oncology, Home Health, Patient Safety.

12 Followers; 54 Articles; 17,872 Profile Views; 340 Posts

How well do you know your way around a cough?

A new case study in which the patient, H.T. an 82-year-old Hispanic man presents to his primary care clinic with cough, malaise and confusion. How well do you know your way around a cough? Is it a cold, a virus, a bacterial infection? Maybe it’s TB? Pneumonia? Figure it out before it’s too late.

Case Study: What’s Causing This Cough?
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Chief Complaint: 

Provided by caregiver: “My grandfather is confused and pretty sick. He was up most of the night coughing.”

History of Present Illness: 

H.T. is an 82-year-old Hispanic male who is widowed and a retired grocery store owner. His 28-year-old granddaughter lives with him. He uses a walker and takes daily walks in the neighborhood with her. He can perform most ADLs, but his granddaughter prepares his meals. He presents to the clinic with his caregiver who reports that about a week ago, Mr. T. came down with a cold and had a runny, stuffy nose. He visited the curandero and has been drinking gordolobo tea with honey, lemon and a generous dollop of tequila. He appeared to be getting better, but then several days ago he developed a cough. Over the last two days, the cough has become worse and he can’t seem to catch his breath. He was confused last night and nearly fell getting out of bed. 

General Appearance:  

The patient’s age is consistent with that reported. He is well-groomed and neat, uses a walker for ambulation and walks with a pronounced limp. He is lethargic, frail and thin oriented to self only. Patient is coughing and using accessory muscles to breathe. Appears uncomfortable and in moderate respiratory distress.

Past Medical History: 

  • Tobacco dependence x 60 years
  • Chronic bronchitis for 10 years
  • Urinary overflow incontinence for 10 years
  • HTN x 5 years, BP averages 140/80 with medication
  • Mild right hemiparesis caused by CVA 3 years ago
  • Bipolar x 50 years
  • Constipation x 6 months
  • Influenza vaccination 3 months ago

Family History: 

(+) for HTN and cancer, (-) for CAD, asthma, DM

Social History: 

  • Lives with granddaughter in his home
  • Smokes ½ ppd
  • Some friends recently ill with “colds”
  • Occasional alcohol use

Medications:

  • Atenolol 100 mg po QD
  • HCTZ 25 mg po QD
  • Aspirin 325 mg po QD
  • Aripiprazole 15 mg po QD
  • Combivent MDI 2 puffs QID (caregiver states patient rarely uses)
  • Albuterol MDI 2 puffs QID PRN
  • Docusate calcium 100 mg po HS

Allergies: 

Penicillin (rash)

Okay, super sleuths, what are all the possible reasons for a cough? What’s causing his confusion? I think the most fun way to play is to imagine you only get 5 questions. With that limit in mind, what information could you ask for that would give you the most information for a diagnosis? What labs do you want? What other diagnostic tests should we run? Ask me some questions!

REMEMBER: DON’T post the ANSWER HERE! Ask questions and I’ll give you more information.

Dr. Kristi Miller, aka Safety Nurse is an Assistant Professor of nursing at USC-Upstate and a Certified Professional in Patient Safety. She is also a mother of four who loves to write so much that she would probably starve if her phone didn’t remind her to take a break. Her work experiences as a hospital nurse make it easy to skip using the bathroom to get in just a few more minutes on the computer. She is obsessed with patient safety. Please read her blog, Safety Rules! on allnurses.com. You can also get free Continuing Education at www.safetyfirstnursing.com. In the guise of Safety Nurse, she is sending a young Haitian woman to nursing school and you can learn more about that adventure: https://www.gofundme.com/rose-goes-to-nursing-school

12 Followers; 54 Articles; 17,872 Profile Views; 340 Posts

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DextersDisciple has 7 years experience as a BSN, RN.

294 Posts; 3,886 Profile Views

Can we get an ABG and a full set of signs? 

And a CXR please 😊

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1 Follower; 6,985 Posts; 32,791 Profile Views

Alcohol  is contraindicated with the first four meds

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3 Followers; 4,617 Posts; 36,024 Profile Views

What is gordo lobo tea?

Cough productive?  If so, of what?  Culture it if we can get some sputum.

Likely had TB vaccination in the past, if not native to America, so likely not TB

I would like CBC with differential.

Edited by Kooky Korky

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SafetyNurse1968 has 20 years experience as a ADN, BSN, MSN, PhD and specializes in Oncology, Home Health, Patient Safety.

12 Followers; 54 Articles; 340 Posts; 17,872 Profile Views

Great questions so far. I will be sending out ABGs and vital signs in a few days as well as sputum description and culture and a CBC.

Gordolobo - Mullein flowers, grows in central and northern Mexico. Gordolobo tea is made from boiling the flowers and stalks in water. It is taken to expel phlegm (mucus), to treat bronchial asthma and coughs, sore throat, sneezing, dysentery, diarrhea and diphtheria. Works well in sores and wounds on the skin as well as healing burns. Gordolobo tea is also used for gastrointestinal complaints, because of its anti-inflammatory activity. The tea can be applied externally as a poultice to reduce hemorrhoids. It is very important to strain the tea before drinking it, as the plant material may irritate the throat...and of course you should consult your physician before using this product! 

It's a commonly prescribed remedy in hispanic cultures. Has anyone looked to see if it might be interacting with any of his meds?

Great catch on the alcohol interaction by the way! What impact does alcohol have on his medications? 

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NutmeggeRN has 25 years experience as a BSN and specializes in kids.

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Any changes in the doses of his meds?

What is the interaction of the herbal with the cardiac meds?

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Montucky Murse is a ADN, CNA, LPN, RN and specializes in Ambulatory - Urgent Care.

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Lung sounds

what is baseline orientation

Peripheral edema¿

Hx of PE or DVT

what percent appeteite is he at compared to baseline

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Montucky Murse is a ADN, CNA, LPN, RN and specializes in Ambulatory - Urgent Care.

4 Posts; 40 Profile Views

a CBC and sputum cx are great ideas, but wouldnt be regularly ordered unless pt was exhibiting signs such as fever, focal findings, toxic and ill appearing etc. If someone had a cough/malaise going on for a long period even without focal findings, that would provide clinical justification for testing to further narrow differential. if the cough just started, and pt is rapidly deteriorating and has fever that would point to something a little more specific, i mean deteriorating over 24 to 36 hours, but wont mention any dx here, to make sure i dont break the rules

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Montucky Murse is a ADN, CNA, LPN, RN and specializes in Ambulatory - Urgent Care.

4 Posts; 40 Profile Views

Another important factor is the severity of his COPD, it may not take much of a bug to put him into respiratory distress. the accessory muscle use, are we talking just abdominal, or is this sternal/costal retractions.

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SafetyNurse1968 has 20 years experience as a ADN, BSN, MSN, PhD and specializes in Oncology, Home Health, Patient Safety.

12 Followers; 54 Articles; 340 Posts; 17,872 Profile Views

On 1/29/2020 at 12:05 PM, NutmeggeRN said:

Any changes in the doses of his meds?

What is the interaction of the herbal with the cardiac meds?

No changes to the meds. I couldn't find any information about the interaction of Mullein/Gordolobo with any of the medications. Not a lot of info out there. Great questions.

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2 Posts; 124 Profile Views

Is he oxygen dependent at home? Does he believe the cough improve when smoking?

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SafetyNurse1968 has 20 years experience as a ADN, BSN, MSN, PhD and specializes in Oncology, Home Health, Patient Safety.

12 Followers; 54 Articles; 340 Posts; 17,872 Profile Views

22 minutes ago, Crazynursern said:

Is he oxygen dependent at home? Does he believe the cough improve when smoking?

No oxygen at home, no change in cough with smoking. Thanks for asking!

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