Are there any tests that should be completed before producing a diagnosis? Why or why not?

Discussion Peer/Participation Prompt [due Sunday at 11:59 pm]
Instructions:
Please respond to at least 2 of your peer’s posts. To ensure that your responses are substantive, use at least three of these prompts:
Do you agree with your peers’ treatment plan approach?
Take an opposing view to a peer and present a logical argument supporting an alternate approach.
Share your thoughts on how you support their treatment plan and explain why.
Present new references that support your opinions.
Responses need to address all components of the question, demonstrate critical thinking and analysis, and include peer reviewed journal evidence to support the student’s position.
Please be sure to validate your opinions and ideas with in-text citations and corresponding references in APA format.
Please review the rubric to ensure that your response meets the criteria.
I will provide each peer post please use updated references for each response.
peer#1
Dawn Stevens
TuesdayJan 25 at 8:39pm
What questions would have been asked as part of the medical history?
I would obtain a detailed history including time and clinical setting of onset. I would ask of any associated symptoms and exacerbating factors. It is also important to ask of any recent history of illness, smoking, drug or vape history as well as any recent occupational or pollution exposure. It would be important to obtain any precipitating factors during onset and since then such as cold air or exercise. It would be important to ascertain if the cough typically happens during a time of day or when the patient is supine. Is the cough productive? I would ask about cough severity including frequency and intensity of expulsive effort, impact of the cough on the patient’s quality of life, and the importance of the cough as perceived by the patient (Leconte et al., 2010). It is also important to question of any additional treatments tried and results.
What would you assess for/what body systems would you assess as part of the physical exam?
I would assess HEENT to assess for dizziness, enlarged lymph nodes or masses, nasal and eye drainage, hoarseness, nasal edema, polyps and sinus tenderness. I would check the ears for cerumen or hairs impinging on the tympanic membrane (Dunphy et al., 2019). I would also check the throat for any cobblestoning. A complete assessment of the lungs and chest to assess the pulmonary and cardiovascular systems is essential to determine any adventitious lung sounds, murmurs, bruits or gallops. I would assess the GI system to assess for possible GERD and dysphagia. A peripheral assessment to assess for any pedal edema.
Are there any tests that should be completed before producing a diagnosis? Why or why not? Identify the recommendations made in the IOM Future of Nursing report.Based on the medical history and physical exam, what is the likely diagnosis? Include your differentials.
If ROS and physical exam are unremarkable, I do not believe any testing needs to be completed prior to producing a diagnosis. If assessments didn’t yield any new pertinent information, a diagnosis of cough as an adverse event of the patient’s ACE inhibitor medication for his hypertension would be determined. This cough occurs in 10% of all patients taking ACE inhibitors (Dunphy et al., 2019). If exam revealed any pertinent positives, a chest x-ray and blood work that includes CBC, WBC, total IgE blood test for allergic bronchopulmonary aspergillosis, a QuantiFERON-TB Gold test to rule out TB as well as spirometry to determine any presence of restrictive disease would be ordered. I would not jump to order a costly test such as a CT scan without determining other causes first.
Differentials would include upper airway cough syndrome, asthma, lung cancer, sarcoidosis, interstitial pulmonary fibrosis, GERD, zenker diverticulum, pneumonia, TB, post infectious cough, foreign body, and somatic cough syndrome.
What is the treatment for this patient, including education? Any medications should include full prescribing information.
Based on the diagnosis of chronic cough due to ACE inhibitor therapy, the use of the ACE inhibitor should be stopped. Diagnosis is confirmed by the resolution of the cough, usually within 1-4 weeks (Gibson et al., 2016). Patient should be started on a different antihypertensive medication such as Losartan 50mg by mouth daily due to history of diabetes.
References
Dunphy, L. E., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2019). Primary care: the art and science of advanced practice nursing-an interprofessional approach (5th ed.). F.A. Davis.
Gibson, P., Wang, G., McGarvey, L., Vertigan, A. E., Altman, K. W., Birring, S. S., Adams, T. M., Altman, K. W., Barker, A. F., Birring, S. S., Blackhall, F., Bolser, D. C., Boulet, L.-P., Braman, S. S., Brightling, C., Callahan-Lyon, P., Canning, B. J., Chang, A. B., Coeytaux, R.,…Wiener, R. (2016). Treatment of unexplained chronic cough. Chest, 149(1), 27–44. https://doi.org/10.1378/chest.15-1496 (Links to an external site.)
Leconte, S., Ferrant, D., Dory, V., & Degryse, J. (2010). Validated methods of cough assessment: A systematic review of the literature. Respiration, 81(2), 161–174. https://doi.org/10.1159/000321231
peer#2
Amarilis Sotolongo
WednesdayJan 26 at 12:22pm
1.What questions would have been asked as part of the medical history?
– Using the OLDCARTS method, we are able to further ask question on the patient symptoms. Such as, when did the cough begin? How long has the cough been going on? Are there any alleviating or aggravating factors? Aside from question related to the patient symptoms, we want to ask question to rule out other possible causes. Such as:
Do you smoke? how many cigarettes/packs a day?
Do you experience any digestive problems such as acid reflux?
Do you experience heartburn?
Do you have difficulty swallowing?
Do you experience of regurgitation of food or sour liquid?
Do you feel a sensation of a lump in your throat?
Do you have problems sleeping at night due to your persistent coughing?
Due to his BP being elevated at the office visit, I would also ask about his management of hypertension. I would ask if he has been taking his medication as prescribed. I would also like to know if he has been tracking his BP at home to know how he usually runs. Lastly, I want to know more information about his colon polyps. A patient with polyps has an increased risk for colon cancer, which may have metastases to his lungs. So, I want to know when his last colonoscopy was or if he has any bowel issues.
2.What would you assess for/what body systems would you assess as part of the physical exam?
– I would definitely do a thorough respiratory examination, including auscultation, inspection, cyanosis, and pursed lips breathing. Additionally, I would do a cardiovascular and GI assessment; to rule out any cardiac or reflux problems.
3.Are there any tests that should be completed before producing a diagnosis? Why or why not?
If on assessment there is nothing abnormal or alarming, I would probably just order simple cbc or cmp to check for infection or other possible diagnosis. If something cardiac or GI comes back abnormal, then an endoscopy or ECHO would be ordered to determine diagnosis.
4.Based on the medical history and physical exam, what is the likely diagnosis? Include your differentials.
– Based on the patient’s medical history and physical examination, I would most likely diagnose the patient with an ACE inhibitor-induced cough as this can occur from hours to months after initiating an ACE inhibitor (Yilmaz, 2019). The incidence of cough associated with ACE-I is reported to be 3.9% to 35% conducted in different populations (Yilmaz, 2019).
5.What is the treatment for this patient, including education? Any medications should include full prescribing information.
– To ensure this is the correct diagnosis, the patient would have to take off the lisinopril medication for a month and assess whether the symptoms improve or worsen. The patient needs to be educated to keep a BP log to monitor his blood pressure. If his symptoms do not start to improve in a few weeks, he needs to be educated to please return to get reassessed.
While we wait to see if his symptoms improve, the patient still needs something to control his BP. Metoprolol is a good alternative that is not an ace inhibitor. Metoprolol is a beta-blocker that works by reducing the heart rate, the heart’s workload, and the heart’s output of blood, which lowers blood pressure (Morris, 2021).
Reference
Morris, J. (2021, July 13). Metoprolol. StatPearls [Internet]. Retrieved January 26, 2022, from https://www.ncbi.nlm.nih.gov/books/NBK532923/
Yılmaz İ. (2019). Angiotensin-Converting Enzyme Inhibitors Induce Cough. Turkish Thoracic Journal, 20(1), 36–42. https://doi.org/10.5152/TurkThoracJ.2018.18014 (Links to an external site.)
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