7 Edition
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Week 2: Discussion Question – Respiratory
A 52-year-old male presents to the clinic with a productive cough for 5 days.
Describe at least 5 more questions the FNP should ask this patient in the health history.
Please generate at least 5 differential diagnoses for a cough. Describe how the FNP would
clinically manage and follow up this patient based on each differential diagnosis.
When performing an initial intake of this patient and his symptom of productive cough. I
would go through the acronym OLD CARTS to assess his cough further. Onset: When did the
cough start? What factors may have prompted the cough? Location; I could ask if he notices if
the cough seems to be coming from the upper or lower respiratory tracts. Duration: How
persistent is the cough? Do you cough constantly or intermittently? Character: I could ask about
the quality, consistency, amount, and color of the sputum and if there is ever any blood present.
Aggravating factors: Is there anything that makes the cough worse? Relieving factors: Is there
anything that makes the cough better? Have you used any cough drops or other over-the-counter
medications that have helped? Timing: Might be questions about if the cough seems worse at
night or during the day. And Severity: How bad is the cough, how is the cough affecting your
normal daily life, quality of life (Dunphy et al., 2019).
Differential diagnoses and recommendations for follow up for cough could include;
(1) Bronchiectasis: Supportive interventions such as; assessing adequate oxygenation,
rest, increasing fluid intake, and using a cool-mist humidifier. Acetaminophen (Tylenol), 500 to
1000 mg Q6H for fever or malaise (adults). Expectorants such as guaifenesin with
dextromethorphan for minor cough, throat irritation, 10mL by mouth every 4 hours. Antibiotics
are not recommended if an acute episode is viral, however they should be considered if
symptoms persist for longer than two weeks. Erythromycin, 250 to 500 mg by mouth four times
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per day. Albuterol for patients with wheezes or rhonchi, 2 puffs every 4 to 6 hours. Instruct
patient to follow up if symptoms do not improve or worsen within 48 hours, high fever, chills,
chest tightness or pain, and shortness of breath. Recommend annual flu and pertussis
vaccinations. Refer the patient to a physician if symptoms persist, if in respiratory distress or if
you suspect pneumonia. (Cash et al., 2020).
(2) Common Cold/Upper Respiratory Infection: Consider a rapid strep test if the
patient has had a recent exposure or a throat culture if strep is negative and the patient is
symptomatic. Treatment recommendations for the common cold are supportive, such as rest and
fluids. Saline nose drops for moisture. For rhinorrhea and nasal congestion decongestant, nasal
spray such as pseudoephedrine (Afrin) 0.05% 2-3sprays per nostril twice daily. Warn the patient
that using nasal sprays longer than 2-3 days can cause rebound congestion and drug abuse. Oral
decongestants such as; pseudoephedrine (Sudafed) 60 mg every 4-6 hours or 120 mg every 12
hours for adults. For headache relief Acetaminophen (Tylenol), 500 to 1000 mg every 6 hours or
ibuprofen (Advil) 200-400 mg every 4-6 hours. Cough suppressants if needed; dextromethorphan
10 to 20 mg every 6-8 hours. No, follow up recommended unless symptoms persist longer than 7
days or if the patient is experiencing pain that is worsening in the ears, sinuses, nose, throat,
neck, or chest, has green or yellow nasal drainage, or has a temperature higher than 100.4. Talk
to the patient about reducing transmission by covering mouth and nose when coughing and
sneezing and good hand hygiene. Consult MD if the patient has been reevaluated and given a
new treatment plan and symptoms are not improving. (Cash et al., 2020).
(3) Gastroesophageal Reflux Disease: Management depends on the cause and severity
of the symptoms. Prevention includes; avoiding smoking, avoiding wearing tight clothing and
belts that may increase abdominal pressure, do not lying down for 3 hours after a meal, avoid
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large, heavy meals and alcohol. Lose weight if indicated, stop smoking, elevate the head of the
bed on 6” blocks. Some medications can promote relaxation of the lower esophageal sphincter
(LES) and may need to be eliminated for symptom improvement, such as; NSAIDs, benzos,
calcium-channel blockers, and nitrates, to name a few. Medications to reduce GERD symptoms
may include a proton pump inhibitor (PPI) such as Omeprazole (Prilosec) 20 mg tablet daily.
PPIs can increase the risk of community-acquired pneumonia and GI infections. Histamine 2-
receptors agonists (H2 blockers) such as famotidine (Pepcid) can help treat mild and less
frequent symptoms on an as-needed basis. Schule follows up for 1-2 weeks to reevaluate for
relief of symptoms. Refer if patients do not improve after trying two different medications (Cash
et al., 2020).
(4) Medication-induced cough from ACE-inhibitors: A repeat trial should be
attempted if the patient’s cough ceases after ACE inhibitors are stopped or if it is decided that the
patient needs to continue treatment with these drugs. ACE inhibitors should be considered
entirely or partially causative in a patient with a persistent cough, regardless of the time interval
between commencement of ACE inhibitor therapy and the onset of cough. Discontinuation of
therapy is the only consistently successful treatment for ACE inhibitor-induced cough (Cash et
al., 2020)
(5) Coronavirus Disease (COVID-19): General therapies for mild symptoms (without a
positive test result) are generally supportive in nature and might include increasing fluid intake,
rest, and follow-up with a primary care physician to evaluate outcome. Patients should cancel or
reschedule travel, adhere to any local limitations, avoid big gatherings, and stay at home if they
feel unwell, even if the symptoms are mild. If a patient’s screen is positive, they should be
followed up according to the severity. Patients with minor symptoms should be called every two
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days for up to 14 days, or until symptoms improve. Patients experiencing more severe symptoms
should be seen every 24 hours. The WHO does not recommend self-medication with any drug,
including antibiotics, as a means of preventing or treating COVID-19. Anypyretics such as
Acetaminophen (Tylenol), 500 to 1000 mg every 4-6 hours. Avoid the use of NSAIDs as they
may have a negative outcome for the patient. Expectorants such as guaifenesin with
dextromethorphan can be used to treat minor cough from bronchial/throat irritation. Consult with
a physician if the pateint has acute respiratory decompensation. Consider sending pateint to the
hospital if they are exhibiting RED FLAG symptoms such as; severe shortness of breath,
hemoptosis, chest pain, cool clammy skin, or cyanosis (Cash et al., 2020).
References
Cash, J. C., Glass, C. A., & Mullen, J. (2020). Family practice guidelines. Springer Publishing
Company. https://doi.org/10.1891/9780826153425.0018b
Dunphy, L. M., E, J., Porter, B. O., & Thomas, D. J. (2019). Primary care: Art and science of
advanced practice nursing – an interprofessional approach (5th ed.). F.A. Davis
Company.
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