Health Assessment
Evaluating Cough
Colleen Burgoyne, DNP, RN, FNP-BC
Case Study
You are practicing as a nurse practitioner at an urgent care clinic in upstate New York. This encounter occurs in January.
Chief Complaint
“I have a cough that is not getting better.”
Patient Profile
Name: Lodi Nazar
Age: 37
Gender: male
History of Present Illness
L.N. is a 37-year-old man who reports that he has been experiencing a persistent cough for about the past 4 weeks. He describes the cough as productive of small amounts of thick sputum, which is usually yellow, but occasionally contains small streaks of blood. The sputum production mostly occurs in the morning, with the cough generally being non-productive throughout the day. Mr. Nazar reports that he feels slightly more short of breath than usual but has been able to maintain most of his usual activities. He has also been experiencing fevers along with the cough. He reports that he usually feels well when he first gets up in the morning, despite this being the time when his cough is most productive. In the late afternoon and evening, he begins to experience chills, fatigue and malaise. When he has been able to check his temperature during these times, it has ranged from 100°F to 101.7°F. He has noticed that he often wakes up drenched in sweat during the night, requiring him to change his pajamas. He denies vomiting or diarrhea, but reports that his appetite is poor. He feels that he has likely lost weight, though notes that he does not carefully measure or track his weight.
He reports that he has had chronic lower back pain related to sciatica for the past year. The pain had flared up recently, which he attributes to the physical demands of his job. One of his roommates has a similar issue and suggested taking a steroid for a few days. This roommate had a supply of prednisone 20 mg tablets on hand from old prescriptions and provided this to Mr. Nazar, who took 3 tablets daily for a 7-day course, which he completed a few days before his cough started.
Mr. Nazar moved to the United States from his home country of Afghanistan in 2021 along with his wife and son. They live in a shared apartment with another Afghan family and several other single Afghan men. The apartment is in an old house in the city. Mr. Nazar states that he and his family are very anxious about the uncertainty of their immigration status and he does not want to miss any work time. Mr. Nazar denies any sick contacts from his family or his roommates.
Medications
Multivitamin, 1 tablet daily
Social History
- Mr. Nazar works as a cutter at a local countertop manufacturing company. He has also started doing some food delivery in the evenings and on weekends. He previously worked as a translator and journalist in Afghanistan.
- Smoking history: has never smoked
- Alcohol use: none
- Cannabis use: none
- Illicit substances: none
- Family/living situation: see HPI section
- Mr. Nazar and his family are practicing Sunni Muslims. They are active in their mosque community.
Family History
- Mother: Living in Afghanistan. Coronary artery disease.
- Father: Deceased by homicide 2 years ago.
- Brother: Deceased in military violence 1 year ago.
Review of Systems
- General: Reports unintentional weight loss, which he estimates to be about 10 pounds over the past month. Reports fatigue, malaise, recent fevers/chills, and night sweats.
- Skin: Denies any skin rashes, wounds or new lesions. Denies any changes in skin texture or color. Denies any changes in hair texture or distribution.
- HEENT:
- Head: Denies headache and recent trauma.
- Eyes: Denies pain, double vision, blurred vision, excessive tearing, drainage, and changes in visual acuity.
- Ears: Denies changes in hearing acuity, tinnitus, vertigo, pain, and drainage.
- Nose: Denies nasal drainage, epistaxis and sinus pain.
- Mouth and throat: Denies throat pain, difficulty swallowing, and hoarse voice. Denies any active tooth pain and lesions in the mouth.
- Neck: Denies pain, stiffness, and swollen lymph nodes.
- Respiratory: Reports cough and dyspnea. Denies wheezing. See HPI for more details.
- Cardiovascular: Denies chest pain, palpitations, and edema of extremities.
- Gastrointestinal: Denies nausea, vomiting, and diarrhea. Reports anorexia.
- Peripheral Vascular: Denies leg pain, varicose veins, swelling in the extremities, and changes in temperature or color of the extremities.
- Urinary: Denies dysuria, hematuria, suprapubic pressure, urinary frequency, urgency, and urinary incontinence.
- Genital: Denies discharge from the urethra, lesions on the penis, testicular swelling, or pain.
- Musculoskeletal: Denies any swollen or painful joints. Reports a history of chronic back pain which has become worse recently.
- Psychiatric: Mr. Nazar reports that he has been stressed about his immigration status and the future of his family. He often misses family and friends that he left behind when he resettled in the United States. He denies any thoughts of self-harm, suicide, and harming others.
- Neurological: Denies confusion, headache, syncope, dizziness, numbness in any extremity, weakness in any extremity, tremors, and seizures.
- Hematologic: Denies easy bruising or bleeding.
- Endocrine: Denies heat or cold intolerance, excessive thirst, excessive hunger.
Physical Exam
Vitals
- Heart rate: 84 bpm
- Respiratory rate: 18 bpm
- Blood pressure: 116/64 mm Hg
- Oxygen saturation: 96% on room air
- Temperature: 101.2°F
- Height: 5 ft 10 in (177.8 cm)
- Weight: 129 lbs
- BMI: 18.5 (normal weight)
General Survey
Thin-appearing man. His clothes appear loose, but they are clean and appropriate for the weather. He appears comfortable and is not in distress.
- HEENT:
- Head: Head is normocephalic/atraumatic. Scalp is without lesions. Hair is of normal texture and distribution.
- Nose: Mucosa are pink, and the septum is midline. No sinus tenderness.
- Oral: Dentition appears to be in good repair with no obvious areas of decay or broken teeth. Gingival tissue is pink and without swelling. Tongue is midline. Pharynx is without exudate.
- Cardiovascular: S1/S2 with no murmur or rub. No edema in bilateral lower extremities.
- Respiratory: Breathing appears unlabored with no use of accessory muscles. Lung sounds are dull over the right upper and middle lobe with occasional crackles during inspiration. Lungs are clear to auscultation over the right lower lobe and the left lung lobes.
- Lymph: Enlarged, mobile, non-tender lymph nodes in bilateral axillae.
- Abdomen: Flat, soft, bowel sounds present in all quadrants. No tenderness with palpation. No masses detected on palpation.
- Neurological: Alert and cooperative. Oriented to person, place, time, and situation. Cranial nerves II-XII intact. 5/5 strength in bilateral upper and lower extremities.
Checkpoint
To help us build our differential diagnosis, characterize the acuity of Mr. Nazar’s cough from the choices below.
- Acute
- Subacute
- Chronic
- Intermittent
Evaluation of Cough
Acute cough is often due to infection of upper and/or lower respiratory tract. The differential for subacute and chronic cough is broader. The evaluation of a subacute or chronic cough starts with a careful history. The history should include a detailed characterization of the cough in terms of temporality, associated symptoms, alleviating and aggravating factors. Additionally, it is important to understand details of exposures including smoking habits, environmental and occupational exposures, medications, sick contacts with particular attention to exposure to pertussis or tuberculosis (Goroll & Mulley, 2021).
The physical exam is also an important part of assessment of subacute and chronic cough. This should include evaluation of the upper respiratory tract, respiratory and cardiovascular system at a minimum. The physical exam can help to elucidate if the patient has evidence of poor oxygenation, signs of upper respiratory tract pathology or heart failure, as well as identify signs of consolidation (Goroll & Mulley, 2021).
In some cases, it is necessary to obtain chest radiography after a detailed history and physical examination. Chest radiography is not needed for all patients with subacute or chronic cough. It is most useful when the differential diagnosis includes the possibility of carcinoma, pneumonitis, tuberculosis, heart failure, or bronchiectasis. Table 1 below summarizes key history and physical findings which indicate chest radiography (Goroll & Mulley, 2021).
| Signs and symptoms (from history and physical) |
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|---|---|
| Risk factors |
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Case Study Continued
Mr. Nazar has indications for chest radiography, including the presence of fevers, night sweats, and recent immigration from a country with endemic tuberculosis.
Diagnostic Testing
Chest radiography: The radiograph shows a heterogenous area of patchy consolidation in the right upper lobe with some small areas of cavitation in the right upper lobe and superior right middle lobe. There is evidence of lymphadenopathy in the hilar and mediastinal lymph nodes.
Checkpoint
Based on the chest radiography findings, the patient’s history and presenting signs and symptoms, which of the following diagnosis should be high in the differential diagnosis?
- Primary viral pneumonia
- Chronic obstructive pulmonary disease
- Tuberculosis
- Asthma
Epidemiology
Epidemiological risk is a major factor in positioning tuberculosis as the most likely diagnosis. Tuberculosis is rare in the United States, but it remains a major public health issue globally, with an estimated 10.8 million people infected in 2023 (Kasaeva et al., 2024). For this reason, it should be considered in patients with consistent presentations who have lived in or traveled to areas of the world where tuberculosis is prevalent. Afghanistan is considered a country with a high-burden of tuberculosis with an incidence rate of 180 per 100,000 population (World Health Organization, 2025).
Refugee and migrant populations are at particularly high risk for acquiring tuberculosis on account of living conditions, which are often overcrowded and with limited access to nutritious food, clean water, or hygiene resources. Additionally, migrant and refugee populations often have limited access to healthcare due to their mobile status, economic circumstances, and the social disruption and infrastructure breakdown of their communities. Migrant and refugee populations may also face working conditions, which increase their risk of tuberculosis infection through exposure to chemicals or other substances which can irritate or injure the respiratory tract (Kasaeva et al., 2024).
Tuberculosis is a disease caused by the bacteria Mycobacterium tuberculosis. The bacteria can spread from human to human via airborne transmission. Many people do not develop symptoms after infection with M. Tuberculosis, the bacteria is harbored in the person’s body but they have no signs or symptoms of disease. There is a risk that the infection could progress to active disease at some point in the future. The risk of developing tuberculosis disease is highest during the first 2 years after inoculation. The pulmonary system is the most common site of disease, but many other areas of the body can be affected as well (Pozniak, 2025).
| No TB infection |
|
|---|---|
| TB Infection (previously called latent TB infection) |
|
| Reactivation TB disease (previously called active TB |
|
| Primary TB disease |
|
In the United States, a majority of tuberculosis cases occur in people who were born in other countries that have a high burden of disease. Most of these cases occurring after immigration to the United States are reactivation tuberculosis disease, rather than primary disease. Risk for tuberculosis disease is related to host factors that center around impaired immunity and environmental factors, which include increased exposure to infected people (Horsburgh, 2025).
| HIV infection |
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|---|---|---|---|
| Glucocorticoids |
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| Tumor necrosis factor inhibitors |
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| Substance use | Drug use |
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| Smoking |
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| Alcohol |
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| Nutritional Status | Underweight |
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| Vitamin D |
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| Iron status |
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| Systemic disease |
Silicosis |
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| Malignancy |
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| Diabetes |
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| Renal disease |
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| Gastric surgery |
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| Celiac disease |
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| Cirrhosis |
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| COPD |
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| Age | Resource-limited setting |
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| Resource-abundant settings (e.g. United States) |
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| Sex |
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| Household contacts |
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|---|---|
| Birth in a TB-endemic area |
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| Community setting |
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Review Questions
Click the arrow to expand the section and view the correct answers.
- Which of the following is the appropriate diagnostic testing to evaluate Mr. Nazar for pulmonary tuberculosis?
- Start with a tuberculin skin test (TST). If this is negative then tuberculosis has been ruled out. If positive then tuberculosis is the confirmed diagnosis
- Start with a tuberculin skin test (TST). If this is positive then tuberculosis is the confirmed diagnosis. If the TST is negative, then proceed to the interferon-gamma release assay (IGRA) blood test. If the IGRA is negative then tuberculosis has been ruled out. If the IGRA is positive then tuberculosis is the confirmed diagnosis
- Obtain 3 sputum samples at least 8 hours apart for acid-fast bacteria smear and culture. If any of these are positive, then tuberculosis is confirmed as the diagnosis.
- Send a blood sample for fungal culture.
- Arrange for an urgent bronchoscopy for collection of bronchoalveolar lavage (BAL) samples and tissue samples. The BAL samples should be sent for acid-fast bacilli culture and the tissue samples for acid-fast bacilli cultures and pathology. If evidence of tuberculosis is found on any of these, then the diagnosis of tuberculosis is confirmed
Answer:
C. Obtain 3 sputum samples at least 8 hours apart for acid-fast bacteria smear and culture. Feedback: Diagnosing tuberculosis requires the isolation of M. tuberculosis from a sample of body fluid or tissue. In this case, Mr. Nazar’s symptoms indicate pulmonary infection, which is also the common form of the disease. Therefore, he will need to submit 3 sputum samples for acid-fast bacilli smear and culture. The sputum samples should be collected at least 8 hours apart and one should be an early morning sample (Bernardo, 2025). Many laboratories in the United States also can perform nucleic acid amplification testing (NAAT) to detect M. tuberculosis in clinical specimens. NAAT testing is useful because by producing results much more quickly, generally less than 2 hours, it allows treatment and public health interventions to be initiated sooner. However, NAAT testing should complement but not replace acid-fast smear and culture, which is the gold standard for diagnosis and importantly allows for characterization of the antibiotic-susceptibility of the M. tuberculosis.
- It appears likely that Mr. Nazar had a latent tuberculosis infection, which recently progressed to active pulmonary disease. Which of the following was the most likely factor to cause Mr. Nazar’s disease to progress to active pulmonary tuberculosis?
- Being born in Afghanistan
- Weight loss
- Muslim religious practices
- Recent use of corticosteroids
Answer:
D. Recent use of corticosteroids. Feedback: Although his country of origin, Afghanistan, was the major risk factor for Mr. Nazar becoming infected with tuberculosis, it did not impact the reactivation of the infection and development of tuberculosis disease. Unintended weight loss is a symptom, not a cause of the development of tuberculosis disease. Muslim religious practices are not related to tuberculosis disease. Corticosteroid use has been associated with the reactivation of tuberculosis infection because of the impairment of the immune system.
- Mr. Nazar works in a countertop fabrication plant. This is an occupational risk factor for which of the following respiratory conditions?
- Silicosis
- Asthma
- Chronic obstructive pulmonary disease
- Bronchiectasis
Answer:
A. Silicosis. Feedback: Silicosis is a pulmonary disease caused by inhalation of free crystalline silica, a compound found in soil, rocks, and minerals. Silicosis can cause acute and chronic pulmonary disease with a wide range of severity. In general, silicosis results in collagenous nodules in the lungs which can coalesce into widespread fibrosis. There are no specific treatments for silicosis. Any occupation that involves processing silica-containing rocks or ores is a risk factor for silicosis. Some examples include mining, quarrying, sandblasting, masonry, stone cutting, foundry work, and ceramics.
Silicosis increases the risk of other serious conditions, including mycobacterial infections, particularly tuberculosis, lung cancer, and chronic necrotizing aspergillus, a fungal infection (Rose, 2025).
- The nurse practitioner needs to ensure that this case of suspected tuberculosis is reported to the local health department.
- True
- False
Answer:
A. True. Feedback: Tuberculosis is a communicable disease, which clinicians are required to report to local health departments.
Communicable Disease Reporting
In order to fulfill their obligation to protect the health and safety of the public, health authorities must collect protected health information, particularly related to communicable diseases. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) includes federal privacy protections for identifiable health information under the HIPAA Privacy Rule. However, the HIPAA Privacy Rule contains explicit exceptions which allow protected health information to be shared when it is essential to meet public health needs. Included in these exceptions is allowance for protected health information to be shared with public health authorities for surveillance, investigations, and interventions or when required by other laws, whether federal, tribal, state, or local (CDC, 2003).
The responsibility for reporting confirmed or suspected cases of communicable diseases is shared amongst physicians, nurse practitioners, registered nurses, other clinicians, healthcare facilities, and laboratories. In New York State, these reporting requirements are legislated under New York Sanitary Code (10NYCRR 2.10).
Clinical Pearls
Tuberculosis has been and remains a major cause of morbidity and mortality worldwide.
- ~ 90% of people infected with TB develop latent infection
- ~ 5% of people infected with TB develop active TB disease within the first 2 years after infection
- ~ 5% of people infected with TB develop active TB disease more than 2 years after infection
| Immunocompromised state | Causes of immunocompromised state |
| Older age | |
| Genetic diseases causing immunodeficiency | |
| Human Immunodeficiency virus (HIV) | |
| Transplantation | |
| Prolonged corticosteroid use | |
| Chemotherapy | |
| Tumor necrosis factor (TNF) antagonists | |
| Malnutrition | |
| Diabetes | |
| Tobacco use | |
| Excessive alcohol use | |
History
- Patients with latent TB are asymptomatic.
- Key history of present illness features of active TB infection
- Insidious onset
- Cough
- Fever
- Weight loss
- Night sweats
- Malaise
- Can also include site-specific symptoms for patients with extra-pulmonary disease
- The history and physical features of TB can be quite non-specific, therefore ascertaining the patient’s risk of having been exposed to TB is particularly important.
- History of prior TB infection
- Contact with a person with TB infection
- Country of origin
- Foreign travel
- Family history
- Occupational and residential exposures
| Does the patient have any symptoms of TB? | General symptoms of TB disease | Symptoms of pulmonary TB | Symptoms of extrapulmonary TB |
|---|---|---|---|
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| Does the patient have known exposure to a person with TB? |
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| Does the patient have risk factors for exposure to TB? |
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| Does the patient have underlying immunocompromising conditions that increase their risk for progression from latent TB infection to TB disease? |
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Screening for Latent TB Infection
- Populations that should undergo screening for latent TB infection include:
- People living with HIV
- Household and other close contacts of individuals with active TB
- Patients initiating anti-tumor necrosis factor therapy
- Dialysis patients with end-stage renal disease
- Patients anticipating organ or bone marrow transplants
- Patients with silicosis or a history of occupational silica exposure
- General populations in areas with an estimated TB prevalence of 0.5% or higher
- Patients in subpopulations experiencing structural risk factors for TB (people who are experiencing homelessness, migrants, internally displaced, incarcerated, Indigenous)
- Testing options for screening for latent TB:
- Tuberculin skin tests
- Acceptable alternative in situations where a TB blood test is not available, too costly, or too burdensome
- TB skin test is the method of testing for children younger than 5 years of age
- TB blood test (Interferon Gamma Release Assay [IGRA])
- Preferred screening method in the United States
- Tuberculin skin tests
Radiography
- Chest radiographs help differentiate between latent TB infection and pulmonary TB disease in people with positive results from a TB blood test or TB skin test.
- A posterior-anterior chest radiograph is recommended. Lesions may appear anywhere in the lungs and may differ in size, shape, density, and cavities. These abnormalities may suggest TB disease but cannot be used to definitely diagnose TB disease.
- Normal findings on chest radiography generally can be used to rule out pulmonary TB in a person who has had a positive result on a TB blood test or TB skin test and has no other symptoms of disease.
- Rare exceptions have been noted in patients with HIV whose immune status has not been restored by anti-viral treatment.
Microbiological Tests
- Examination of clinical specimens from the site of presumed TB disease are important for diagnosis and treatment.
- Patients presumed to have pulmonary TB disease may cough up sputum into a sterile container for processing and examination.
- Patients should have at least three consecutive sputum culture specimens examined, each collected in 8-24 hour intervals (at least one collected early in the morning).
- Specimens should be collected in an airborne infection isolation room.
References
Centers for Disease Control and Prevention (2023). HIPAA privacy rule and public health: Guidance from CDC and the U.S. Department of Health and Human Services. Morbidity and Mortality Weekly Report, 52, 1-12. Retrieved from: https://www.cdc.gov/mmwr/preview/mmwrhtml/m2e411a1.htm
Gandhi, R. T. (2025). COVID-19: Clinical features. UpToDate. Retrieved May 29, 2025 from https://www.uptodate.com/contents/covid-19-clinical-features
Goroll, A. H. & Mulley, A. G. (2021). Primary care medicine: Office evaluation and management of the adult patient (8th ed.). Wolters Kluwer.
Kasaeva, T., Mavhunga, F., Viney, K., Días, H. M., van den Boom, M., Severoni, S., Pellet, J. N., Ismail, D. A., & Al-Harahsheh, S. (2024). Innovative solutions for the elimation of tuberculosis among refugees and migrants: Report of the 7th edition of the world innovation summit for health. World Health Organization. https://wish.org.qa/wp-content/uploads/2024/09/Innovative-Solutions-for-the-Elimination-of-Tuberculosis-Among-Refugees-and-Migrants.pdf
Lewinsohn, D., Kain, D., & Parrish, N. (2025). Microbiology, pathogenesis and immunology. UpToDate. Retrieved June 6, 2025 from https://www.uptodate.com/contents/tuberculosis-microbiology-pathogenesis-and-immunology
Pozniak, A. (2025). Pulmonary tuberculosis disease in adults: Clinical manifestations and complications. UpToDate. Retrieved April 19, 2025 from https://www.uptodate.com/contents/pulmonary-tuberculosis-disease-in-adults-clinical-manifestations-and-complications
Rose, C. (2025). Silicosis. UpToDate. Retrieved May 28, 2025 from https://www.uptodate.com/contents/silicosis
Treanor, J. J. (2020). Influenza viruses, including avian influenza and swine influenza. In J.E. Bennett, R. Dolin, & M. J. Blaser (Eds.), Mandell, Douglas and Bennett’s Principles and Practice of Infectious Diseases (9th ed., pp 2143-2168). Elsevier.
World Health Organization. (2025). Tuberculosis in Afghanistan. https://worldhealthorg.shinyapps.io/TBrief/?_inputs_&sidebarItemExpanded=null&sidebarCollapsed=true&iso2=%22AF%22&entity_type=%22country%22
