/** Arezzo Guideline: Chronic_Cough_Guideline **/

/** 12/02/2001, 18:15:45 **/ 

plan :: Chronic_Cough_Guideline ;
   caption :: 'Chronic Cough Guideline' ;
   component :: Initial_assessment ;
   component :: CXR_and_initial_Rx ;
      schedule_constraint :: completed(Initial_assessment) ;
   component :: Investigations ;
      schedule_constraint :: completed(CXR_and_initial_Rx) ;
   component :: Ineligible ;
      schedule_constraint :: completed(Initial_assessment) ;
end plan . 

plan :: Asthma_evaluation ;
   caption :: 'Asthma evaluation' ;
   precondition :: result_of( Cause ) includes 'Asthma' ;
   component :: Unspecified ;
end plan . 

decision :: Cause ;
   choice_mode :: multiple ;
   support_mode :: symbolic ;
   candidate :: Asthma ;
      argument :: for, ( CXR_result = Normal ) ;
      recommendation :: Netsupport( Cause, Asthma ) >= 1 ;
   candidate :: PNDS ;
      argument :: for, ( CXR_result = Normal ) ;
      recommendation :: Netsupport( Cause, PNDS ) >= 1 ;
   candidate :: GERD ;
      argument :: for, ( CXR_result = Normal ) ;
      recommendation :: Netsupport( Cause, GERD ) >= 1 ;
   candidate :: other ;
      argument :: for, ( CXR_result = other ) ;
      recommendation :: Netsupport( Cause, other ) >= 1 ;
end decision . 

plan :: CXR_and_initial_Rx ;
   caption :: 'CXR and initial treatment' ;
   description :: 'Scheduling of CXR and initial treatment' ;
   precondition :: Chronic_cough = Yes ;
   component :: Scheduling_decision ;
   component :: CXR_first ;
      schedule_constraint :: completed(Scheduling_decision) ;
   component :: CXR_in_parallel ;
      schedule_constraint :: completed(Scheduling_decision) ;
end plan . 

plan :: CXR_first ;
   caption :: 'CXR first' ;
   precondition :: result_of( Scheduling_decision ) = CXR_first ;
   component :: Order_CXR ;
   component :: CXR_report ;
      schedule_constraint :: completed(Order_CXR) ;
   component :: Non_specific_initial_treatment ;
      schedule_constraint :: completed(CXR_report) ;
end plan . 

plan :: CXR_in_parallel ;
   caption :: 'CXR in parallel' ;
   precondition :: result_of( Scheduling_decision ) = CXR_in_parallel ;
   component :: Order_CXR ;
   component :: CXR_report ;
      schedule_constraint :: completed(Order_CXR) ;
   component :: Initial_treatment_of_chronic_cough_1 ;
end plan . 

enquiry :: CXR_report ;
   caption :: 'CXR report' ;
   source :: CXR_result ;
      mandatory :: yes ;
end enquiry . 

action :: Discontinue_ACEI ;
   caption :: 'Discontinue ACEI' ;
   precondition :: ACE_related = Yes ;
   procedure :: 'Observe the result of discontinuing the ACE-I  for 4 weeks' ;
   context :: 'For patients who developed cough shortly after beginning to take an ACE-I' ;
end action . 

plan :: GERD_evalutation ;
   caption :: 'GERD evalutation' ;
   precondition :: result_of( Cause ) includes 'GERD' ;
   component :: Oesophageal_pH_monitoring ;
   component :: Oesophageal_pH_monitoring_results ;
      schedule_constraint :: completed(Oesophageal_pH_monitoring) ;
   component :: Oesophageal_pH_monitoring_interpretation ;
      schedule_constraint :: completed(Oesophageal_pH_monitoring_results) ;
end plan . 

action :: Ineligible ;
   caption :: 'Guideline is not appropriate' ;
   precondition :: Chronic_cough = No ;
   procedure :: 'This guideline for the management of chronic cough is not appropriate for this patient.' ;
   context :: 'Chronic cough is defined here as cough that lasts for at least 3 weeks. ' ;
end action . 

enquiry :: Initial_assessment ;
   caption :: 'Initial assessment' ;
   description :: 'Baseline characteristics of the patient and their cough.' ;
   postcondition :: Chronic_cough = if( Cough_duration >= 3, Yes, No) ;
   source :: Cough_duration ;
      mandatory :: yes ;
   source :: Cough_productive ;
      mandatory :: yes ;
   source :: Smoker ;
      mandatory :: yes ;
   source :: Age_group ;
      mandatory :: yes ;
   source :: Sex ;
      mandatory :: yes ;
   source :: ACE_related ;
      mandatory :: yes ;
   source :: Pregnant ;
      mandatory :: yes ;
   source :: Presumed_PNDS ;
      mandatory :: yes ;
end enquiry . 

plan :: Initial_treatment_of_chronic_cough_1 ;
   caption :: 'Initial treatment of chronic cough' ;
   component :: Discontinue_ACEI ;
   component :: Non_specific_initial_treatment ;
end plan . 

plan :: Investigations ;
   caption :: 'Investigations' ;
   component :: Cause ;
   component :: PNDS_evalutation ;
      schedule_constraint :: completed(Cause) ;
   component :: GERD_evalutation ;
      schedule_constraint :: completed(Cause) ;
   component :: Asthma_evaluation ;
      schedule_constraint :: completed(Cause) ;
   component :: Other_investigation ;
      schedule_constraint :: completed(Cause) ;
end plan . 

action :: Non_specific_initial_treatment ;
   caption :: 'Non-sepcific initial treatment' ;
   procedure :: 'Initial treatment of the patients symptoms as appropriate.' ;
end action . 

action :: Oesophageal_pH_monitoring ;
   caption :: 'Oesophageal pH monitoring' ;
   procedure :: '24 hour Oesophageal pH monitoring' ;
   context :: '24 hour Oesophageal pH monitoring is the most diagnositically useful test for evaluating GERD as the cause of cough.' ;
end action . 

decision :: Oesophageal_pH_monitoring_interpretation ;
   caption :: 'Oesophageal pH monitoring interpretation' ;
   description :: 'Conventional indices used by gastroenterologists to assess for esophagitis may be misleading normal.  Until further studies provide better guidelines, the test should be read as normal when conventional indices are within the normal range and no suspicious reflux-induced coughs appear during the monitoring session (Grade II-2)' ;
   choice_mode :: single ;
   support_mode :: symbolic ;
   candidate :: Normal ;
      argument :: for, ( Conventional_indices = 'Within normal range' and Suspicious_coughs = No ) ;
      recommendation :: Netsupport( Oesophageal_pH_monitoring_interpretation, Normal ) >= 1 ;
   candidate :: Abnormal ;
      argument :: for, ( Conventional_indices = 'Outside normal range' ) ;
      argument :: for, ( Suspicious_coughs = Yes ) ;
      recommendation :: Netsupport( Oesophageal_pH_monitoring_interpretation, Abnormal ) >= 1 ;
end decision . 

enquiry :: Oesophageal_pH_monitoring_results ;
   caption :: 'Oesophageal pH monitoring results' ;
   source :: Conventional_indices ;
      mandatory :: yes ;
   source :: Suspicious_coughs ;
      mandatory :: yes ;
end enquiry . 

action :: Order_CXR ;
   caption :: 'Order CXR' ;
   procedure :: 'Order CXR' ;
end action . 

plan :: Other_investigation ;
   caption :: 'Other investigations' ;
   precondition :: result_of( Cause ) includes 'Other' ;
   component :: Unspecified ;
end plan . 

plan :: PNDS_evalutation ;
   caption :: 'PNDS evalutation' ;
   precondition :: result_of( Cause ) includes 'PNDS' ;
   component :: Sinus_radiographs ;
end plan . 

decision :: Scheduling_decision ;
   caption :: 'Scheduling decision' ;
   description :: 'Chest Radiographs should be ordered before any treatment is prescribed in nearly all patients with chronic cough (Grade II-2)' ;
   choice_mode :: single ;
   support_mode :: symbolic ;
   candidate :: CXR_first ;
      argument :: for, ( netsupport( Scheduling_decision, CXR_in_parallel ) < 1 ) ;
      recommendation :: Netsupport( Scheduling_decision, CXR_first ) >= 1 ;
   candidate :: CXR_in_parallel ;
      argument :: for, ( ACE_related = Yes ) ;
      argument :: for, ( Age_group = Younger and Smoker = No and Presumed_PNDS = Yes ) ;
      argument :: for, (  Pregnant = Yes and Sex = Female ) ;
      recommendation :: Netsupport( Scheduling_decision, CXR_in_parallel ) >= 1 ;
end decision . 

action :: Sinus_radiographs ;
   caption :: 'Sinus radiographs' ;
   procedure :: '4 view sinus radiographs' ;
   context :: 'Sinusitis may be the cause of PNDS 30% of the time (60% if the cough is productive).  Sinus CT scans are not routinely recommended to evaluate for sinusitis as the cause of cough.' ;
end action . 

action :: Unspecified ;
   procedure :: 'No further guidance is specified' ;
end action . 

data :: ACE_related ;
   type :: boolean ;
   true_value :: Yes ;
   false_value :: No ;
end data . 

data :: Age_group ;
   type :: text ;
   range :: Younger, Older ;
end data . 

data :: Chronic_cough ;
   type :: boolean ;
   true_value :: Yes ;
   false_value :: No ;
end data . 

data :: Conventional_indices ;
   type :: boolean ;
   true_value :: 'Within normal range' ;
   false_value :: 'Outside normal range' ;
end data . 

data :: Cough_duration ;
   type :: integer ;
   unit :: Weeks ;
end data . 

data :: Cough_productive ;
   type :: boolean ;
   true_value :: Yes ;
   false_value :: No ;
end data . 

data :: CXR_result ;
   type :: text ;
   range :: Normal, Other ;
end data . 

data :: Pregnant ;
   type :: boolean ;
   true_value :: Yes ;
   false_value :: No ;
end data . 

data :: Presumed_PNDS ;
   type :: boolean ;
   true_value :: Yes ;
   false_value :: No ;
end data . 

data :: Sex ;
   type :: text ;
   range :: Male, Female ;
end data . 

data :: Smoker ;
   type :: boolean ;
   true_value :: Yes ;
   false_value :: No ;
end data . 

data :: Suspicious_coughs ;
   type :: boolean ;
   true_value :: Yes ;
   false_value :: No ;
end data .