Case Study 5 -- Chronic Cough And Poorly Controlled Dm

***CASE STUDY 5 Chronic Cough and Poorly Controlled Diabetes Dated: 11 June 2007    (Final edition 22 January 2008) Patient’s Name: Koh S.K.           NIRC: S21*****I *** Submitted to SNB for APN certification process

TABLE OF CONTENTS                                                                               

 Page

1.

Patient Profile

2

2.

Health Assessment

2

3.

Physical Examination

3

4.

Diagnosis

6

5.

Management

6

6.

Evaluation

11

7.

APN Learning Points and Reflection

11

  A 60-year old gentleman, with diabetes mellitus for more than 30 years, presented with chief complaints of chronic cough for 4 months and HbA1C 9.9%. This case study focuses on 1) approach and management of chronic cough and 2) management of poorly controlled diabetes.

Elizabeth Ho Moon Liang

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PATIENT PROFILE Mr Stephen Koh (S21*****I), a 60-year-old gentleman, has Type 2 diabetes mellitus for more than 30 years. He has a strong family history of diabetes mellitus, as both his parents have diabetes mellitus. He was diagnosed with hypertension in year 2003 and dyslipidemia in year 2005. He also had a past medical history of pulmonary tuberculosis in year 2004. Mr Koh has been on follow up in Hougang polyclinic since year 2003. On 30th November 2006, he was noted to have a HbA1c% of 9.9% and a chronic cough for 4 months. This case study will thus focus on (1) management of poorly controlled Type 2 diabetes mellitus and (2) approach to the management of chronic cough. HEALTH HISTORY Chief Complaints: Mr Koh came for his regular diabetes follow up and medical review on 30 November 2006. He complained of a cough that had persisted for over 4 months. The cough was non-productive in nature and triggered mainly by the itchiness felt in the throat. There was neither wheeze nor shortness of breath. There was also no loss of weight, loss of appetite, night fever nor chills. There was no post-nasal drip or nasal congestion, nasal itch or sneezing bouts. There was neither sour taste in his mouth nor any reflux symptoms. His cough had no fixed diurnal or nocturnal pattern. It was also not related to postural change. Mr Koh has no personal history or family history of atopy such as asthma, allergic rhinitis or eczema. He has a 30-year smoking history. Mr Koh had pulmonary Tuberculosis in year 2004. There is no history of other lung diseases. He has no history of gastro-oesophageal reflux or vasomotor rhinitis. Mr Koh was started on Enalapril 2.5mg twice a day in February 2005. He tolerated Enalapril well and was not coughing subsequent to initiation of medication. Subsequently the dose of Enalapril was increased to 10mg twice a day in August 2006 for better blood pressure control.

Elizabeth Ho Moon Liang

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Social History – Mr Koh is married and is staying with his wife and children. He works as a lorry driver and eats out most of his time. He has a 30-year smoking history, during which he consumed 2 packs of cigarettes (40 sticks) a day. Recently this year, he reduced his smoking to 20 cigarettes a day. There are no family members at home with tuberculosis or persistent cough. CURRENT MEDICATIONS a) Glibenclamide 10mg twice a day b) Metformin 850mg three times a day c) Hydrochlorothizaide 25mg every morning d) Potassium Chloride 600mg every morning e) Enalapril 10mg twice a day f) Lovastatin 20mg every night DRUG ALLERGY: Nil reported. PHYSICAL EXAMINATION General appearance –. Comfortable. Has a BMI of 24.3. Afebrile. Nails – No pallor and clubbing seen. Eyes – Conjunctivae not pale. Nose – Nasal septum was not deviated. Inferior turbinates in both nasal spaces were not hypertrophied nor inflamed. Throat – Tonsils were not enlarged nor inflamed. Pharyngeal wall was pink and not inflamed. Tongue – Moist. Not cyanosed. Cervical lymph nodes – No cervical lymphadenopathy. a) CVS examination Pulse – 78 beats per minute. Regular. Blood Pressure – 140/ 90mmHg. Heart – Apex beat was palpable at the 5th intercostal space on the left mid clavicular line. There were no thrills and heave felt. S1 and S2 heart sounds were heard. No murmurs were detected. Jugular venous pressure was not raised. There was no pedal oedema.

Elizabeth Ho Moon Liang

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b) Lungs examination Lungs – Respiration rate was 12 breaths per minute. Trachea was not deviated. Chest expansion was equal bilaterally. The lung fields were bilaterally and symmetrically resonant to percussion. Cardiac and liver dullness were present. This implied that the lungs were not hyperinflated. Bilateral vesicular breath sounds were heard symmetrically. No crepitations or wheezes were heard. Vocal resonance was normal and symmetrical in both lung fields. Laboratory Tests 1) Diabetes Management History

HbA1C% LDL (mmol/L) TG (mmol/L) Creatinine (umol/L) Potassium (mmol/L) ACR (mg/g) BP (mmHg)

Medications

HbA1C% FBG (mmol/L) BP (mmHg)

Medications

Dec 04 9.8% -----140/80

Feb 05 9.3% 2.82 3.20 61 3.8 > 100 140/90

Metfomin 500mg tds Daonil 10mg bd HCTZ 25mg om Span K 1 tab om

Metformin 750mg tds Daonil 10mg bd HCTZ 25mg om Span K 1 tab om + Enalapril 2.5mg bd

Jun 05 8.7% -140/80 Metformin SR 850mg tds Daonil 10mg bd HCTZ 25mg om Span K 1 tab om Enalapril 5mg om & 2.5mg on

Elizabeth Ho Moon Liang

Apr 05 9.3% -----130/80 Same meds Not keen for insulin

Aug 05 9.7% -140/90

Dec 05 10.2% 9.7 140/90

Same meds Will consider insulin

Metformin SR 850mg tds Daonil 10mg bd HCTZ 25mg om Span K 1 tab om Enalapril 5mg bd ** Discuss insulin. Wants to control diet 1 more time. KIV insulin next visit**

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HbA1C% FBG (mmol/L) LDL (mmol/L) TG (mmol/L) Creatinine (umol/L) Potassium (mmol/L) ACR (mg/g)

Feb 06 10.0% 8.7 3.50 2.90 74 3.9 30-300

BP (mmHg)

130/70

Medications

Metformin SR 850mg tds Daonil 10mg bd HCTZ 25mg om Span K 1 tab om Enalapril 5mg bd + Acarbose 50mg bd

HbA1C% LDL (mmol/L) TG (mmol/L) BP (mmHg)

Medications

Aug 06 9.3% 3.8 2.8 160/80 Metformin SR 850mg tds Daonil 10mg bd HCTZ 25mg om Span K 1 tab om Enalapril 10mg bd Lovastatin 20mg on

Apr 06 10.2% ------134/80

Jun 06 10.2% ------150/90 (no meds for 4 days)

Metformin SR 850mg tds Daonil 10mg bd HCTZ 25mg om Span K 1 tab om Enalapril 5mg bd + Lovastatin 10mg on ** Refuse Acarbose too costly**

Same meds ** Refuse Acarbose too costly. Send to NP to advise on Insulin**

Nov 06 9.9% 2.4 1.4 140/90

Today’ s consult

2) Chest (PA) radiological report (done in August 2006) – There is evidence of scarring in the right upper lobe with elevation of right hilum. Calcific foci are noted in the right lower lung, which may represent calcified granulomas. The right dome of the diaphragm is mildly elevated. The aorta is ectatic. The heart size is within normal limits. There are no pleural effusions.

Elizabeth Ho Moon Liang

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DIAGNOSES 1. Chronic cough for investigation 2. Poorly controlled diabetes mellitus 3. Sub-optimal high blood pressure control 4. Dyslipidemia (on target since November 2006)

MANAGEMENT Approach to Chronic Cough Mr Koh has a chronic cough by definition of it lasting more than 8 weeks (Holmes & Fadden, 2004 and COFM, 2006). Defining the duration of cough in the initial history is important as it can help classify the cough into acute (< 3 weeks), sub-acute (3 to 8 weeks) or chronic categories to help narrow or broaden the differential diagnoses. Reaching the diagnosis and drawing the differentials for a chronic cough should be based on the combination of both history of cough, other related health history and physical examination. The characteristic of the cough is of little diagnostic value (Holmes & Fadden, 2004, Pratter et al 2006). The presence of sputum production, the colour of sputum might give certain diagnoses a higher index of suspicion. E.g. purulent (yellow or green) sputum indicates the possibility of an infection. Besides the duration of the cough, the pattern of the cough (day or night) and associated symptoms will give a clue to the cause of the chronic cough. The common causes of chronic cough in adults in the primary care setting are asthma, bronchitis, GERD, postnasal drip syndrome, smoking and ACE-induced cough (Lawler, 1998, Holmes & Fadden, 2004 and Pratter et al, 2006). Out of these 5 diagnoses, GERD, postnasal drip syndrome and ACE-induced cough are more likely to present as non-productive cough. Each of these causes of chronic cough has its own associated symptoms or signs as shown in Table 1. For asthma, bronchitis and cough related to smoking usually there is a moderate amount of sputum production. During history taking, it is important to note if there is presence of Angiotensin-converting Enzyme (ACE) inhibitors in the treatment plan and previous medical history.

Elizabeth Ho Moon Liang

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GERD

-- Cough pattern might be related to position or meals. -- Worsen on lying down or after a meal. -- Associated symptoms: sour taste in mouth, dyspepsia, abdominal bloatedness, water brash, dry throat/ mouth -- History of GERD. Postnasal drip -- Cough pattern might be related to position syndrome -- Worsen when lying down -- Associated symptoms: nasal congestion/ discharges, irritable throat -- History of allergic rhinitis, vasomotor rhinitis Ace-induced cough -- Not related to position or meals. -- Spasmodic in nature. -- Usually triggered by irritable throat Table 1: Non-productive chronic cough causes and their associated symptoms

Usefulness of Chest X-ray in this case As Mr Koh’s cough had been persisting for a significant period of more than 3 weeks, together with a past history of Tuberculosis about 2 years ago, a chest x-ray was done in the last visit. Mr Koh’s chest x-ray showed scarring and calcific granulomas that were manifestations of previous TB infections in year 2004. Abnormal findings from the chest x-ray can help direct management in alerting doctors to refer patient to respiratory specialist promptly for further investigations. Bronchiectasis, pneumonia, pulmonary abscess and tuberculosis may be picked up by the chest radiograph. For bronchogenic carcinoma, it is largely asymptomatic in its early stages and chest x-ray findings may be normal. For a smoker like Mr Koh, even with a normal chest radiograph, persistent symptoms and a negative response to the management for common causes of chronic cough may warrant a referral to a respiratory specialist for further investigations (e.g. CT scan or bronchoscopy). What is the approach to Mr Koh’s chronic non-productive cough? Mr Koh started on Enalapril 2.5mg twice a day in February 2005. According to Holmes and Fadden (2004), ACE inhibitors cause a non-productive cough in 5 to 20 percent of people on treatment. Anecdotally, this figure is possibly higher in the local population we serve. This side effect is not dose-related, and the cough may begin one week to several months after ACE inhibitor therapy is initiated. In Mr Koh’s case, it is relatively difficult to determine if the cough is due to ACE inhibitor therapy that was started in February 2005. Besides, he also has a history of being non compliant to medication. In any case, Enalapril was stopped in this consult to

Elizabeth Ho Moon Liang

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evaluate the response in the next visit (Pratter et al, 2006). Nifedipine LA 30mg was added for the hypertension control. If Mr Koh’s cough persists during the follow up visit despite discontinuation of the ACE inhibitor therapy, a trial of empirical treatment for postnasal drip may be tried for 2 weeks. Postnasal drip has been identified as the commonest cause of chronic cough (34 percent of the cases). This is followed by asthma at 28 percent and GERD at 18 percent (Lawler, 1998). If the response is poor, than starting the empirical treatment for GERD may be considered next. Due to Mr Koh’s long smoking history, I will also arrange a spirometry appointment concurrently during his next follow up visit for a lung function assessment. The spirometry will be able to screen for potential chronic obstructive lung diseases and asthma (Pratter et al 2006). Approach to Uncontrolled Diabetes Mellitus Mr Koh has diabetes for 30 years. He is a man of few words. His glycemic control has been in the unacceptable range since 2004. Although he has been advised and counselled on many visits to start on insulin, he is quite adamant over not starting insulin. The cause of Mr Koh’s poorly controlled diabetes can also be the progressive nature of diabetes. Ideas, Concerns and Expectations Mr Koh is a lorry driver and the main breadwinner of the family. He is always on the road and his meals are usually settled in the hawker centres or coffee shops. Mr Koh finds it difficult and frustrating to eat “healthily” with outside meals. I get the impression that he feels the recommended HbA1C% target of less than 7% is not achievable. Mr Koh insists that fear of pain or injections are not the reasons for refusing insulin. He believes that his glycemic control or diabetes status is not as “bad” as the healthcare professionals think. He feels perfectly well and that he can still work to support his family. Thus, there is a difference between Mr Koh’s and healthcare professionals’ ideas, concerns and expectations of diabetes control and management. How far should we push or insist? This is a question that has always puzzled me when I deal with patients who are resistant to starting insulin. On one hand, it is really easy for any physician to order insulin, the nurse to teach the technique and send Mr Koh home to continue treatment. However, there is always that high probability that Mr Koh will be non-compliant and ends up

Elizabeth Ho Moon Liang

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not taking insulin. This is especially so when the issue of differential expectations is not well addressed.

Mr Koh’s Expectations and Beliefs

Healthcare Professionals’ Expectations

Perception of Glycemic Control

Perception of OHGA efficacy

Successful Insulin Initiation Figure 2: Hypothesized Components in Insulin Initiation The components to insulin acceptance from this case study can be hypothesized: 1) Mr Koh’s expectations and beliefs 2) Healthcare professionals’ expectations 3) Perception of glycemic control and 4) Perception of OHGA efficacy. Both parties may have to reach the same perception of glycemic control and the impact of current treatment before successful insulin initiation. Various issues from motivating factors, potential barriers and misconceptions around the topics of diabetes, glycemic targets, treatment plans, complications to psychosocial environment, and finance should be explored with the intention to bring Mr Koh to a common understanding to control and manage his diabetes well. A more structured coordination of care within a multidisciplinary team comprising of physicians, Care managers, medical social workers and dieticians was introduced in 2003 to manage chronic disease patients with complex psychosocial issues in Hougang Polyclinic. The Advanced Practice Nurse and psychologist are 2 new personnel introduced into the multi-disciplinary chronic disease management team recently.

Elizabeth Ho Moon Liang

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Each of the team members contributes to different needs of the patients such as medical management, self-management/ education, healthy eating, coping and psychosocial support. The aim of the chronic disease management team is to cater to the individual needs of the patients with poor control. I realised during our conversation that Mr Koh has issues with his diabetes treatment regime, low self-motivation and low self-efficacy level demonstrated by his perception that eating healthily is an impossible task for him to achieve. Mr Koh is a patient who will benefit from the team-based disease management approach. During the consult with Mr Koh on 30 November 2006, I came to understand that Mr Koh is not ready to start on insulin treatment. He is not convinced that this is the therapy to bring his glucose to optimal control. Thus during the consult, a particular health behaviour was detailed out and agreed to be worked on. The emphasis is for Mr Koh to try his best within his means to do that particular health behaviour for three months. If no improvement is seen during the next visit, he has to come to an understanding that something more has to be done. We reach an agreement for him to add more vegetable portions in his lunch and dinner. When eating out, the following food will be considered in priority: Mixed vegetable rice (2 green vegetable dishes and 1 meat dish with small serving of rice), Chinese Bean-curd Noodles “Niang Dou Fu” (preferably bee hoon with lots of green vegetables) and Fish soup rice. The other hawker centre/ coffee shop dishes for example: fishball noodles and chicken rice are lower in the priority because of the lack of fibre and the high carbohydrate content. The decision to work on one health behaviour is to allow Mr Koh to actualise that behaviour and thus enhance his self-efficacy. It will be pointless to teach Mr Koh everything about diet control, whose complexity will overwhelm him and he may deem these tasks as impossible to achieve. Has the glycemic oral agents being optimised? This is also a question worth asking for clinicians treating diabetes. For Mr Koh, his Metformin (Biguanides) and Glibenclamide (Sulphonyluera) are already at maximum doses. Some practitioners will add a third OHGA such as alphaglucosidase inhibitor (Acarbose) or Thiazolidinediones (Avandia) to manage the diabetes. However factors like cost issues may prevent the addition of these agents. Mr Koh has refused Acarbose for a period of time due to the cost of medicine and thus adding Rosiglitazone to the management may not be feasible.

Elizabeth Ho Moon Liang

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Approach to sub-optimal Hypertension and Microalbuminuria. Enalapril has been replaced by Nifedipine LA 30mg every morning to assess if the cough resolves during the next consult. The presence of microalbuminuria highlights the onset of potential renal complications. According to the MOH Clinical Practice Guidelines for Diabetes Mellitus (2006), both ACE inhibitors and Angiotensin II Receptor Blockers (ARB) can be used to retard progression of renal complication. Thus, it will be appropriate to start Mr Koh on an ARB in the next visit, once the cough symptoms resolve. EVALUATION Mr Koh was discharged with the following medications: 1) Glibenclamide 10mg BD 2) Metformin 850mg TDS 3) Nifedipine LA 30mg OM 4) Hydrochlorothiazide 25mg OM 5) Potassium Chloride 600mg OM 6) Lovastatin 20mg ON 7) DMP tablet 15mg TDS At the next visit, we will need to evaluate the resolution of the chronic cough. The blood pressure control and tolerance of Nifedipine will also be evaluated. For diabetes, HbA1C% and fasting blood glucose will be the monitoring guide for future management. I will also be assessing Mr Koh’s new behaviour in choosing a more healthy food option. From this assessment, I hope to enhance Mr Koh’s self-efficacy and explore barriers to promote further behaviour changes. APN RFLECTION AND LEARNING POINTS Acute cough from common cold is a very common problem in the polyclinic. This case study has given insights to an APN-intern on approaching patients with cough. My role as an APN in future will require me to treat common URTI symptoms. As such, I must be keenly aware of various different causes of cough in relation to its duration. Chronic cough can be a result of drug adverse effects. Others would originate from other systemic conditions (e.g. Cardiovascular: Heart Failure). From this case study, I’ve learnt that cough is a symptom which

Elizabeth Ho Moon Liang

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may have a multi-systemuc origin for example, a) Respiratory system: bronchiectasis, asthma, COPD, b) ENT system: postnasal drip syndrome, c) Gastroenterology system: GERD. In each case, I must be highly suspicious of a cough that could potentially result from a sinister cause e.g . malignancy. Attached in Annex 1 is NHGP APN Protocol for managing URTI. There is a role for APN in the management of poorly controlled diabetes patients and patients about to start on insulin treatment. As diabetes progresses and more intensive treatment is needed, the partnership between the healthcare professionals and the patients is the key to successful management. Patients need to be engaged to explore their own expectations, assured to verbalize to the healthcare team and motivated to do something for themselves. The training of an APN in managing both the biomedical and psychosocial perspectives of patients allows the APN to deal with the situation in a more holistic manner. REFERENCES Department of Community, Occupational and Family Medicine (COFM), (2006). Common Symptoms in Ambulatory Care. Singapore: National University of Singapore. Holmes, R. and Fadden, C.T. (2004). Evaluation of the patient with chronic cough. Retrieved from http://www.aafp.org/afp/20040501/2159.html on 10 April 2007. Lawler, W.R. (1998) An office approach to the diagnosis of chronic cough. Retrieved from http://www.aafp.org/afp/981200ap/lawler.html on 10 April 2007. Ministry of Health, Singapore (2006). Clinical Practice Guidelines for Diabetes Mellitus Management. Pratter, M.R., Brightling, C.e., Boulet, L.P. and Irwin, R.S. (2006). An empiric integrative approach to the management of cough – ACCP evidence-based clinical practice guidelines. Retrieved from http://www.chestjournal.org/cgi/content/full/129/1_suppl/222S on 5 April 2007

Elizabeth Ho Moon Liang

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