Discussion Part One (Assessment and Differential Diagnoses)
In essence, this discussion aims at establishing the additional assessment questions that Katie needs to answerfor the determination of the most likely diagnosis for presenting chief complaint (persistent coughing). Additionally, it focuses on establishing a differential diagnosis list for Katie’s condition, the focused physical assessment techniques and diagnostic tests.
Additional Assessment Questions
Of utmost importance to the comprehensive history taking of this patient are various questions envisaged in the mnemonic “OLDCARTS”. According to Lewis, Dirksen, Heitkemper, Bucher, and Harding, (2014),OLDCARTS stands for the onset, location, duration, characteristic, aggravating factors, relieving factors, treatment used and severity of the chief complaints. Based on this mnemonic the questions that one can ask Katie are as follows:
Onset- When did you start coughing? “One week ago”. The time that Katie started coughing is important since it helps specify the duration. Persistent coughing for more than 2weeks duration is indicative of tuberculosis while coughing for less than 2weeks can be due to other causes (Buttaro, Trybulski, Polgar-Bailey, & Sandberg-Cook, 2013).
Location- Where is the location of the pain associated with the pain? “Chest” Chest pains are common in individuals suffering from tuberculosis, bronchitis and heart conditions such as heart attack (Winkelman, Workman, &Ignatavicius, 2013).
Duration- How long has the coughing lasted? “One week”. Persistent coughing for more than 2weeks duration is indicative of tuberculosis while coughing for less than 2weeks can be due to other causes such as pneumonia and influenza(Buttaro, Trybulski, Polgar-Bailey, & Sandberg-Cook, 2013).
Characteristic-What are the associated symptoms of the coughing?“Fatigue, weight loss and reduced energy levels”. Fever and productive coughing if present would be suggestive of respiratory conditions such as bacterial pneumonia and acute bronchitis (Winkelman, Workman, &Ignatavicius, 2013).
Aggravating factors- What factors worsen or aggravate the coughing? “Cough is worse at night”. In acute bronchitis, the coughing is worse in the morning hours (Buttaro, Trybulski, Polgar-Bailey, & Sandberg-Cook, 2013). Also, exposure to allergens such as pollen grains can be a trigger for the coughing.
Relieving factors- What relief strategies have you employed to stop the cough? “Unspecified by the patient”. In the case of asthma, a relief strategy would be to move away from the trigger.
Treatment- What medications have you taken to relieve the coughing?
Severity- On a scale of the 1-10, what is the rating of the pain associated with the coughing?
Differential Diagnosis List
Acute bronchitis (J20.9):Of significance to the diagnosis of this condition is a history of smoking (active and passive) (Buttaro, Trybulski, Bailey, & Sandberg-Cook, 2013). In Katie’s case, she does not smoke but presents with coughing, and chest pain, which are among the clinical manifestations associated with acute bronchitis (Copstead-Kirkhorn, &Banasik, 2014).
Tuberculosis (A15.3):Persistent coughing for more than two weeks,chest pain, fatigue, prolonged sweating at night, dyspnea, and weight loss are among the clinical manifestations of tuberculosis (Buttaro, Trybulski, Bailey, & Sandberg-Cook, 2013). Katie presents with some of these clinical features (coughing, chest pain, fatigueand weight loss) and thus the likelihood of this diagnosis.
Community-acquired pneumonia (CAP) (J18.9): In patients with this diagnosis, the most likely causative agent is bacteria, which infiltrates the lungs and results in manifestations such as fever, productive cough, dyspnea, crackles breath sounds and pleuritic chest pain (Buttaro, Trybulski, Polgar-Bailey, & Sandberg-Cook, 2013). Katie presents with coughing and chest pain that point to the likelihood of this diagnosis.
Focused Physical Examination, Diagnostic and Lab Tests
Of significance to the diagnosis of Katie’s condition are focused physical assessment and various diagnostic as well as laboratory tests.A focused chest examination will target to identify respiratory symptoms associated with these respiratory disorders. For instance, crackles breath sounds on auscultation and increased tactile fremitus may be suggestive of pneumonia and acute bronchitis (Buttaro, Trybulski, Polgar-Bailey, & Sandberg-Cook, 2013).
The diagnostic and laboratory tests include pulse oximetry test, rapid influenza diagnostic test for ruling out of influenza as a cause of Katie’s ill health, complete blood count for establishment of the presence of an infection, and chest-X rayfor the confirmation of the pulmonary infiltrate seen in this condition (Copstead-Kirkhorn, &Banasik, 2014).
Buttaro, T., Trybulski, J., Bailey, P., Sandberg-Cook, J. (2013). Primary care a collaborative practice (4th ed.). [VitalSource Bookshelf Online]. Retrieved from https://digitalbookshelf.southuniversity.edu/#/books/978-0-323-07501-5/
Copstead-Kirkhorn, L., &Banasik, J. L., (2014). Pathophysiology (5th ed.).
Lewis, S. M., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Harding, M. (2014). Medical-surgical nursing: Assessment and management of clinical problems. St. Louis, Missouri: Elsevier/Mosby
Winkelman, C., Workman, M., &Ignatavicius, D. (2013). Clinical companion, Ignatavicius Workman, Medical-surgical nursing (1st ed.). St. Louis, MO: Elsevier Saunders.