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Week 2 DQ Shortness of Breath
A fifteen-year-old female presents to your clinic complaining of shortness of breath and a nonproductive nocturnal cough. She states she used to feel this way only with extreme exercise, but lately, she has felt this way continuously. She denies any other upper respiratory symptoms, chest pain, gastrointestinal symptoms, or urinary tract symptoms. Her past medical history is significant only for seasonal allergies, for which she takes a nasal steroid spray but is otherwise on no other medications. She has had no surgeries. Her mother has allergies and eczema, and her father has high blood pressure. She is the only child. She denies smoking and illegal drug use. On examination, she is in no acute distress and her vital signs are: T 98.6, BP 120/80, pulse 80, and respirations 20. Her head, eyes, ears, nose, and throat examinations are essentially normal. Inspection of her anterior and posterior chest shows no abnormalities. On auscultation of her chest, there is decreased air movement and high-pitched whistling on expiration in all lobes. Percussion reveals resonant lungs.
- What is the chief complaint?
- Based on the subjective and objective information provided what are your 3 top differential diagnosis listing the presumptive final diagnosis first?
- What treatment plan would you consider utilizing current evidence based practice guidelines?
Expert Solution Preview
Introduction: The case study describes a fifteen-year-old female with shortness of breath and a nonproductive nocturnal cough. This response will answer the three questions provided based on the subjective and objective information provided in the case study.
1. What is the chief complaint?
The chief complaint is shortness of breath and a nonproductive nocturnal cough.
2. Based on the subjective and objective information provided, what are your 3 top differential diagnoses listing the presumptive final diagnosis first?
The three top differential diagnoses are:
1. Asthma – The patient’s symptoms of shortness of breath and nonproductive cough, along with wheezing on auscultation, are indicative of asthma. These symptoms have worsened to be present continuously, which may indicate poorly controlled asthma.
2. Vocal cord dysfunction – The high-pitched whistling on expiration in all lobes may suggest vocal cord dysfunction. This condition can also cause shortness of breath, and a nonproductive cough, especially during exercise.
3. Allergic rhinitis – The patient’s past medical history of seasonal allergies, for which she takes a nasal steroid spray, increases the likelihood of allergic rhinitis. Allergic rhinitis can cause nasal congestion, which can lead to shortness of breath and nonproductive coughing.
Presumptive final diagnosis: Asthma
3. What treatment plan would you consider utilizing current evidence-based practice guidelines?
The treatment plan for asthma entails controlling symptoms and preventing exacerbations through the use of inhaled corticosteroids. Inhaled corticosteroids are the preferred first-line therapy for asthma control and are considered the most effective anti-inflammatory treatment. Additionally, the use of short-acting beta-agonists should be considered for rescue medication. Education on proper inhaler technique, trigger avoidance, and self-monitoring of symptoms should also be emphasized. The patient should be advised to follow up with their healthcare provider if symptoms persist or worsen.
