Q1.
The other subjective data to obtain from the patient is about the onset of the cough and how it progressed either acutely or gradually. The cough should also be described further as either productive or unproductive, rattling or barking cough and whether associated with wheezing or SOB (shortness of breath). Any aggravating factors, such as exposure to cold and alleviating factors, should, are also critical subjective data to consider. Enquire if the patient uses medications or herbal formulas to alleviate the cough. Enquire about Hx of smoking and pack-years in case of positive smoking history.
Also, inquire about other occupational exposures that can contribute to this presentation to help rule out conditions such as allergic rhinitis, allergy, and asthma. Enquire about prior histories of COPD exacerbations and their causes, if present. Ask about other comorbidities, past medical and surgical conditions, and any relevant family Hx, such as Hx of atopy and social Hx, that could be relevant to this patient’s condition. Ask about Hx of TB exposure from close interactions, and on reviewing the respiratory system, ask about hemoptysis.
Q2.
The other relevant objective data to obtain is on physical examination, which involves inspection, palpation, percussion and auscultation of the thoracic cavity. Inspection will help identify the synchronicity of the breathing movements with chest movements, any form of kyphosis or lordosis, scars and symmetry of the chest. Palpation of the chest will help elicit any trachea deviation and palpable masses. Percussion will help elicit any chest dullness in case of lung congestion, and auscultation will elicit the character and intensity of crackles, pleural rubs and rhonchi. It will also help determine the presence of normal or abnormal breath sounds. Further assessment and diagnosis will be made using spirometry for lung functioning capacity (Lopes, 2019) and chest X-ray for an anatomical view of abnormalities such as lung collapse and sputum culture to rule out conditions such as tuberculosis. An ABG (arterial blood gas) can also help rule out respiratory acidosis or alkalosis, with a full hemogram to rule out infections such as pneumonia.
Q3.
The most appropriate diagnostic exams to perform on this patient include spirometry, which helps to determine lung functioning and capacity, measured in terms of FVC (forced vital capacity) and FEV1 (forced expiratory volume within a second. A chest X-ray will also be very helpful in ruling out conditions such as TB and types of pneumonia, as it shows structural abnormalities in anterior-posterior, lateral or posterior-anterior views. Full-hemogram will also help rule out infections such as pneumonia based on the differentials.
Q4
The possible differential diagnosis based on the presenting symptoms include;
- Acute COPD exacerbation (Mathioudakis et al., 2020)
- Sinusitis
- Pneumonia (community-acquired)
Q5
The reason for acute COPD exacerbation as a DDX is that the patient is reported to have a known Hx of COPD with acute onset of other symptoms. A DDX of sinusitis is given due to Hx of bilateral turbinate oedema and erythema, with significant amounts of yellow drainage and obstructed air passages (Psillas et al., 2021). DDX CAP is given due to Hx of fever, with cough and examination findings consistent with pneumonia. It is CAP because the symptoms occur before the patient visits the hospital (Lanks et al., 2019).
References
Lanks, C. W., Musani, A. I., & Hsia, D. W. (2019). Community-acquired pneumonia and hospital-acquired pneumonia. Medical Clinics, 103(3), 487–501.
Lopes, A. J. (2019). Advances in spirometry testing for lung function analysis. Expert Review of Respiratory Medicine, 13(6), 559–569.
Mathioudakis, A. G., Janssens, W., Sivapalan, P., Singanayagam, A., Dransfield, M. T., Jensen, J. U. S., & Vestbo, J. (2020). Acute exacerbations of chronic obstructive pulmonary disease: in search of diagnostic biomarkers and treatable traits. Thorax, 75(6), 520-527.
Psillas, G., Papaioannou, D., Petsali, S., Dimas, G. G., & Constantinidis, J. (2021). Odontogenic maxillary sinusitis: A comprehensive review. Journal of dental sciences, 16(1), 474-481.
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