From the Guidelines
The patient should proceed with the nerve conduction study to evaluate the function of the ulnar nerve, and in the meantime, avoid prolonged elbow flexion, direct pressure on the elbow, and try sleeping with arms straight rather than bent to prevent further compression. Regarding the nighttime cough, since PFT results are pending and previous recommendations suggested GERD treatment, the patient should elevate the head of the bed 6-8 inches, avoid eating 3 hours before bedtime, and consider an OTC proton pump inhibitor like omeprazole 20mg daily for 2 weeks, as recommended by the ACCP evidence-based clinical practice guidelines 1. The patient's symptoms of catching in the back of the throat and cough at night when laying down are consistent with GERD, and the guidelines suggest that an empiric trial of medical antireflux therapy is recommended in patients who meet the clinical profile predicting that silent GERD is the likely cause of chronic cough or in patients with chronic cough who also have prominent upper GI symptoms consistent with GERD 1. Some key points to consider in the management of the patient's cough include:
- Dietary and lifestyle modifications, such as avoiding trigger foods and elevating the head of the bed, as recommended by the guidelines 1
- Acid suppression therapy, such as omeprazole, which may be effective in reducing symptoms of GERD-related cough 1
- The addition of prokinetic therapy, which may be beneficial in enhancing gut motility and reducing symptoms of GERD-related cough 1
- The patient should follow up to discuss PFT results and determine if further GERD treatment or pulmonology referral is needed, as the guidelines recommend assessing the response to therapy within 1 to 3 months 1. It is also important to note that if empiric treatment fails, it cannot be assumed that GERD has been ruled out as a cause of chronic cough, and further objective investigation for GERD may be necessary, as recommended by the guidelines 1.
From the Research
Patient Symptoms and History
- The patient reports infrequent numbness in their pinkie finger, occurring once a day, with possible positional factors contributing to the symptom.
- The patient denies any injury to the left pinkie finger.
- The patient has a history of being referred to pulmonology for a cough at night when laying down and was advised to treat GERD if symptoms persisted.
- The patient reports changing their diet but still experiences a sensation of catching in the back of their throat and a cough at night when laying down.
Screening and Diagnosis
- The patient is due for colorectal cancer screening at 45 unless concerns arise earlier.
- The onset of numbness in the pinkie finger started 2 or 3 weeks ago, characterized by a pins and needles sensation with no pain.
- The patient reports no radiation of symptoms and no associated symptoms.
- The timing of the numbness is worse at night, with uncertain exacerbating factors and a pain scale of 0/10.
Relevant Studies
- A study on empirical treatment of outpatients with gastroesophageal reflux disease with proton pump inhibitors found that short-term empirical PPI treatment can provide effective relief of GERD symptoms in most patients 2.
- Nerve conduction studies (NCS) are an important tool in evaluating neuromuscular disease, enabling the quantitative assessment of peripheral nerve and muscle function 3, 4, 5.
- A study comparing omeprazole with fluoxetine for treatment of patients with heartburn and normal endoscopy who failed once daily proton pump inhibitors found that fluoxetine was superior to omeprazole for improving symptoms 6.
Potential Next Steps
- The patient was offered a nerve conduction study, which could help identify the physiological source of the patient's symptoms.
- The patient declined a neurology referral at this time.
- The patient's PFT results are being obtained, which may provide further insight into their symptoms.