Patient Analysis

Patient Name: Frank Dennison
• Age: 40
• Sex assigned at birth: male
• Gender identity: male
• Pronouns: he/him/his
• Language for medical communication: English

Mr. Frank Dennison, a 40-year-old cisgender male. Past visits for allergic rhinitis and refills of various antihistamines and nasal sprays.

Today’s encounter gives the following information:
• Chief Complaint/Reason for visit: Cough for two months.

Causes of Persistent Cough:
Top 3 causes are:

1. Upper Airway Cough Syndrome (UACS—previously called postnasal drip syndrome) refers to a cough resulting from nasal secretions. It is believed to be due to the secretions stimulating the cough reflex or that the patient has a more sensitive cough reflex. Patient often have nasal congestion, discharge and sensation in the throat or need to clear the throat. Physical findings include swollen turbinates, cobblestoning of the posterior pharynx. Treatment involves controlling the causes of congestion, such as nasal steroids to control allergic rhinitis.
2. Gastroesophageal reflux disease (GERD)
3. Asthma

Other less common causes include:
• Vocal cord dysfunction
• Medications such as angiotensin-converting enzyme inhibitors (ACE-inhibitors)
• Tobacco-related cough
• Post-infectious cough (often resolves within 8 weeks)
• Chronic Obstructive Pulmonary Disease (COPD—especially the chronic bronchitis type)
• Non-asthmatic eosinophilic bronchitis
• Other causes of persistent cough include:
• Obstructive Pulmonary conditions such as bronchogenic carcinoma of the lung, cystic fibrosis, bronchiectasis
• Restrictive Pulmonary conditions such as idiopathic pulmonary fibrosis, pneumoconiosis, sarcoid
• Other infectious causes such as aspergillosis, TB, pertussis
• Miscellaneous causes such as CHF, chronic aspiration, chronic inflammatory diseases, psychogenic, idiopathic (AKA “cough hypersensitivity syndrome”)

Mr. Dennison’s current & past medical history:

When asked “How may we help you today”, Mr. Dennison explains that he had been troubled by a persistent cough for the past two months. He clarifies that he did not have a fever and had tested negative for COVID-19 with a home test, suggesting he did not believe an infection was the cause. The patient describes that the cough worsens at night, often waking him with coughing spells that produce clear mucus, which provides temporary relief. He also mentions experiencing noisy breathing, particularly a musical, whistling sound when exhaling. Upon further inquiry, Mr. Dennison shares that this noisy breathing typically occurs one or two nights per week, accompanying his nocturnal coughing episodes, and was notably absent during the day except occasionally when he was out jogging. He did not experience any chest tightness or pain.

As you take the rest of Mr. Dennison’s history, you continue to consider the diagnosis of asthma. Bearing this in mind, you ask Mr. Dennison about his past medical history:

You note Mr. Dennison’s recent struggles, as he explains how his allergies, which were once manageable, have worsened over the past three to four months. He describes persistent congestion, frequent sneezing, and clear nasal drainage with an occasional yellow tinge. You inquire about his medication routine, and he says that he is taking cetirizine and fluticasone nasal spray only about two-thirds of the time, often neglecting them due to his busy schedule. He has missed several allergy shot appointments since starting a new job, which has made it difficult for him to attend regularly. You suggest discussing strategies to improve adherence to his medication regimen and ensure he receives his allergy shots consistently, to which Mr. D agrees, ready to explore solutions.

You see that Mr. Dennison’s allergic rhinitis is not under ideal control. You wonder if treating this more optimally would help with his cough and wheezing.

You also want to assess whether he has underlying sinusitis since that could also explain some of his symptoms.

Since Mr. Dennison has had symptoms (sneezing, nasal congestion, and drainage) for three to four months, so it is unlikely that this is due to acute sinusitis. Dr. Wilson asks you to consider a different hypothetical scenario.

“What if he presented with one week of upper respiratory symptoms including nasal congestion and drainage? On the day the symptoms began, he had a low-grade fever that has now resolved. His nasal congestion persisted and he has now had yellow nasal drainage for five days with associated mild headaches. On exam, he has a small amount of yellowish-clear drainage. There is tenderness when you lightly percuss his maxillary sinuses.”

Mr. Dennison’s nasal symptoms have lasted more than 12 weeks are not due to acute sinusitis. You consider whether Mr. Dennison may have chronic sinusitis. There may be additional diagnostic tests that will be needed later to confirm this.

Symptoms of Chronic Sinusitis:
• Patients with chronic sinusitis have similar symptoms to patients with acute sinusitis, but they last at least 12 weeks.

They must have two of the following symptoms:
• Nasal obstruction or congestion
• Mucopurulent drainage (anterior, posterior, or both)
• Facial pain, pressure, or fullness
• Decreased sense of smell
• They must also have signs of inflammation on physical examination or radiological studies.

It is important to note that some patients with chronic sinusitis may have more subtle symptoms, such as only a mild increase in nasal congestion, so some patients with otherwise unexplained symptoms may still need further evaluation for chronic sinusitis.

He has no other chronic conditions, has never been hospitalized, and has not undergone any surgeries. He does not take any other medications. He has no medication allergies and can tolerate aspirin without issues. He has never smoked cigarettes or cigars, nor has he chewed tobacco. You say that is a good thing since it would make his current allergy symptoms worse.

Mr. Dennison reports no alcohol or drug use. He lives with his wife and two children, who are all healthy. His father is deceased but had allergic rhinitis and asthma.

You next review the other conditions that commonly coexist with asthma. You note that Mr. Dennison’s current BMI classifies him as overweight.

You ask Mr. Dennison the following questions, and he replies “No” to all three of them:

1. Have you ever had any symptoms of heartburn?
2. Has your wife ever commented on the way you sleep—snoring a lot or breathing unusually?
3. Are you feeling stressed or down/depressed?

You ask Mr. Dennison to change into a gown for the physical exam while you go speak with Dr. Wilson.

Physical Exam – Persistent Cough

• Vital Signs:
o Temperature is 36.8 C (98.2 F)
o Pulse is 80 beats/minute
o Respiratory rate is 16 breaths/minute
o Oxygen saturation is 97% on room air
o Blood pressure is 118/68 mmHg
o Height is 172.7 cm (68 in)
o Weight is 86.2 kg (190 lbs)
o Body mass index (BMI) is 28.9 kg/m2
• Eyes: Normal sclerae and conjunctivae. No discharge, “allergic shiners”, or infraorbital folds.
• Ears: Tympanic membranes are normal.
• Nose: Swelling of the inferior turbinates, pallor of the nasal mucosa with some clear drainage present.
• Sinuses: No frontal or maxillary sinus tenderness.
• Throat: Normal appearing; no signs of postnasal drainage.
• Neck: No jugular venous distension with the head of the exam table elevated to 45 degrees; normal carotid pulses; normal thyroid; no enlarged lymph nodes.
• Chest: No respiratory distress; normal, symmetrical expansion of the lungs; all areas resonant to percussion; mild scattered wheezes heard throughout.
• Cardiovascular: Normal S1 and S2 without murmurs. No S3 or S4 heard.
• Skin: No skin lesions. No areas of eczema were noted.
• Extremities: No clubbing, cyanosis, or edema.

After the exam you sit down across from Mr. Dennison and tell him, “At this point, it sounds like the coughing and whistling noises that you are making at night may be due to asthma. Asthma is a very common breathing problem caused by swelling of the airways in the lungs. It can’t be cured, but it can be controlled. We would like to perform a test to confirm whether or not you have asthma.” Mr. Dennison nods and asks you to tell him about the test; he agrees that he will do it.in the next few days. He asks what medications he should take for his symptoms in the meantime. You ask Mr. Dennison if there are ways, he could remember to take his cetirizine and nasal spray every day. He decides that he will put the medications near his toothbrush so he will remember to take them when he brushes his teeth in the morning. You also recommend the fluticasone inhaler two puffs twice daily and albuterol inhaler, two puffs four times per day as needed, while you are waiting for the results of the sputum and spirometry test. You explain that fluticasone and albuterol are more effective and easiest to use with a spacer device. You give Mr. Dennison a handout on how to use an inhaler and spacer.

Dr. Wilson tells you, “We can now officially give Mr. Dennison the diagnosis of asthma, and there are several things to consider before deciding on appropriate treatment options.”
You tell Dr. Wilson, “I don’t think he has gastroesophageal reflux disease, obstructive sleep apnea, stress, or depression that are contributing to his symptoms. He does have rhinitis or sinusitis which may aggravate his asthma, so we will need to address this. He also is overweight and we should address that at some point too.”

Dr. Wilson replies, “You are right that we will need to address those things along with his knowledge and skills for self-management—we’ll talk more about all of that. Right now I’d like to classify the severity of his asthma since that will help us determine the appropriate treatment.”
Dr. Wilson says, “let’s choose the appropriate medications based on his severity of asthma. But before we do that, let’s consider the pathophysiology you are trying to affect with treatment.”
Answer: Combination of low dose inhaled corticosteroid and a long acting beta2 agonist inhaler, and a medium dose inhaled corticosteroid.
“All right,” says Dr. Wilson, “now that we’ve determined the severity of Mr. Dennison’s asthma and come up with an initial treatment plan to present to him, let’s talk about the other things we’ve touched on that we should discuss. He has had allergy tests in the past and has known allergies to dust mites and certain pollens. It will also be important to check in with him about his housing, utilities, and other factors that could make it harder for him to control his asthma or avoid the things he needs to avoid.”
Specific actions that clinicians can take, when appropriate, to address the social and structural determinants of health that impact an individual patient’s diagnosis.
• Advocate for individual patient needs through direct action
• Advocate for policies that impact the conditions that may contribute to the patient’s diagnosis
• Connect the patient with community resources
• Administer a universal and standardized screening tool
• Consider the impact of social/structural factors that may be outside of the patient’s control
• Work with or hire community health workers, patient navigators, or other professionals
After Mr. Dennison fills out the AAFP Social Needs Screening tool provided to him by your medical assistant, you review his answers and determine that his home does not have conditions (such as mold) that could be worsening his asthma, and that he has the financial stability to purchase some of the tools that may help him to prevent exposure to dust mites.
Dr. Wilson says, “What else can Mr. Dennison do to improve his allergic rhinitis?”
“He is now taking his nasal spray and oral antihistamines regularly. Maybe we can help him get his allergy shots regularly, too.”
“Yes,” says Dr. Wilson, “let’s talk with him to see how we can work together on this.”
“He has chronic nasal congestion and mucopurulent drainage; should we treat Mr. Dennison for chronic sinusitis?” you ask.
Dr. Wilson responds, “It is a possibility that he has chronic sinusitis in addition to allergic rhinitis—and both of these are exacerbating his asthma. But, more testing will be needed to establish whether he has chronic sinusitis.”
According to current immunization guidelines, below are the immunizations you should offer to Mr. Dennison?
• Influenza vaccine
• Pneumococcal conjugate (valent-15) vaccine +Pneumococcal polysaccharide (valent-23) vaccine (PPSV) one year later
• Pneumococcal conjugate (valent-20) vaccine (PCV20)
• Tetanus, diphtheria, acellular pertussis vaccine (Tdap)
• COVID vaccination per CDC guidelines
As you walk back to the patient’s room, Dr. Wilson shows you the handout he has just printed, “My Asthma Plan.” He says, “One good way by which to help Mr. Dennison manage his asthma is to complete this asthma action plan with him.”
• First page of “My Asthma Plan”
o The top contains a summary of the patient’s maintenance and relief medications, dosages, and instructions on use.
o The bottom contains sections defining three levels of asthma control: Green Zone (doing well), Yellow Zone (getting worse), and Red Zone (medical alert). For each zone, there is a description of symptoms to be aware of and levels of peak flow readings that correspond to the different zones. At the bottom of the Red Zone section is a description of what symptoms should prompt the patient to seek emergency care.
• Second page of “My Asthma Plan”
o The second page summarizes environmental factors that may make asthma worse and how to address them.
After completing the peak flow cutoffs for the different zones, you go to the top of the form and begin explaining the medications to Mr. Dennison. You explain his long-term maintenance medication ICS-formoterol and a rescue medication. You talk about using his spacer device with inhalers.

You also discuss the environmental measures that may be helpful in preventing exacerbations. You recommend that he talk to his allergist about flexible scheduling so that he can restart his allergy shots, and you let him know that you or his allergist should be able to help him navigate work absences for this if needed.