Comprehensive Assessment and Management of a Patient with Persistent Cough: Navigating Insurance Coverage Challenges

QUESTION

As a certified FNP, you hold an Illinois and Wisconsin RN/APRN license. You are asked to float to an Illinois clinic during your next weekend to work. You have a 53-year-old African American female who hands you her new Illinois Medicaid insurance card and presents to the clinic today with complaints of a persistent non-productive cough, causing insomnia. She denies chest pain and has mild shortness of breath exacerbated with activity. She has a past medical history of asthma, unmanaged hypertension, and sickle cell trait. She is currently taking no medications and has a penicillin allergy.

1. What are 3 differential diagnosis?

2. What are the normal, abnormal, and atypical findings that can support the differential diagnoses?

3. What are the appropriate screening tools to develop a final diagnosis?

4. What is the final diagnosis?

5. What additional diagnostic and/or screening tests would you order to establish to confirm a primary (final) diagnosis.

6. What are the management options for this case ? (based on accessibility, coordination, safe and cost-effective equitable healthcare and prescription treatment options based on the Illinois Medicaid Preferred Drug List formulator restrictions for this patient’s insurance coverage)

7. What are the challenges in meeting this patient care needs with insurance coverage limitations and/or restrictions?

ANSWER

Comprehensive Assessment and Management of a Patient with Persistent Cough: Navigating Insurance Coverage Challenges

Introduction

In this scenario, a 53-year-old African American female presents to an Illinois clinic with a persistent non-productive cough, insomnia, and mild shortness of breath. As a certified Family Nurse Practitioner (FNP), tasked with providing care, the focus will be on conducting a thorough assessment, developing differential diagnoses, utilizing appropriate screening tools, establishing a final diagnosis, ordering diagnostic tests, and addressing management options. However, the challenges associated with insurance coverage limitations and restrictions will also be considered.

Differential Diagnoses

Asthma exacerbation: Given the patient’s past medical history of asthma, the presence of a persistent cough and shortness of breath may indicate worsening of her asthma symptoms.
Chronic obstructive pulmonary disease (COPD): Considering her age, smoking history, and respiratory symptoms, COPD should be considered in the differential diagnosis.
Gastroesophageal reflux disease (GERD): Chronic cough and symptoms worsening at night could be associated with GERD, especially since the patient denies chest pain.

Findings Supporting Differential Diagnoses

Asthma exacerbation: Abnormal findings may include wheezing on auscultation, increased respiratory rate, and decreased peak expiratory flow rate (PEFR).
COPD: Abnormal findings may include decreased breath sounds, prolonged expiratory phase, and evidence of chronic respiratory distress.
GERD: Atypical findings may include symptoms such as heartburn, regurgitation, and the absence of abnormal respiratory findings.

Appropriate Screening Tools

To develop a final diagnosis, several screening tools can be utilized, such as:
Spirometry: Spirometry can assess lung function and help differentiate between asthma and COPD.
Bronchoprovocation testing: This test can help confirm asthma by assessing airway hyperresponsiveness.
Gastrointestinal evaluation: If GERD is suspected, tools like upper endoscopy or pH monitoring can aid in diagnosis.

Final Diagnosis

Based on the presented case, the final diagnosis is likely an asthma exacerbation due to the patient’s past medical history, symptoms, and potential abnormal findings supporting this diagnosis.

Additional Diagnostic and Screening Tests

To confirm the primary diagnosis of asthma exacerbation, the following tests may be ordered:
Peak expiratory flow rate (PEFR) monitoring: This objective measurement can track changes in lung function over time.
Chest X-ray: Although not specific for asthma, a chest X-ray can help rule out other potential causes of the patient’s symptoms, such as pneumonia or lung masses.

Management Options

Considering the patient’s insurance coverage limitations, the management options should align with the Illinois Medicaid Preferred Drug List formulary restrictions. Possible management strategies include:
Short-acting bronchodilators (e.g., albuterol) for symptom relief.
Inhaled corticosteroids (e.g., fluticasone) for long-term control of asthma.
Patient education on asthma triggers, proper inhaler technique, and self-management strategies.

Challenges in Meeting Patient Care Needs with Insurance Coverage Limitations

Challenges arise when insurance coverage limitations and restrictions impact the patient’s access to certain medications or treatment options. This can compromise the patient’s ability to afford and adhere to prescribed treatments, potentially leading to suboptimal disease control. Addressing these challenges requires a collaborative approach involving healthcare providers, insurance companies, and policymakers to ensure equitable access to safe and cost-effective treatments for all patients.

Conclusion

In this case, the comprehensive assessment and management of a patient with a persistent cough involve considering differential diagnoses, utilizing appropriate screening tools, establishing a final diagnosis, ordering diagnostic tests, and addressing management options. However, the challenges associated with insurance coverage limitations and restrictions add an additional layer of complexity to delivering quality care. Addressing these challenges requires ongoing efforts to advocate for accessible and equitable healthcare, fostering collaboration between healthcare providers and insurance entities, and promoting policies that prioritize patient well-being and affordability.