Case Study: What's Causing This Cough?

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!