This week you learned about common conditions in the adolescent client. Please review the following case study and answer the following questions.
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?
Please used APA format and no later then 2013 references.
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Introduction:
The chief complaint of a fifteen-year-old female presenting to the clinic is shortness of breath and a nonproductive nocturnal cough. This case study provides subjective and objective information about the patient’s medical history, symptoms, and examination findings. Based on this information, we will identify the chief complaint, list three top differential diagnoses, and propose a treatment plan utilizing current evidence-based practice guidelines.
Answer:
1. The chief complaint:
The chief complaint of the fifteen-year-old female is shortness of breath and a nonproductive nocturnal cough.
2. Three top differential diagnoses:
a. Presumptive final diagnosis: Asthma – Given the patient’s symptoms of shortness of breath and nonproductive nocturnal cough, along with a family history of allergies and eczema, asthma is a likely differential diagnosis. The high-pitched whistling on expiration and decreased air movement on chest auscultation are also consistent with asthmatic findings.
b. Differential diagnosis 1: Allergic rhinitis – Considering the patient’s history of seasonal allergies and current use of nasal steroid spray, allergic rhinitis could be a possible differential diagnosis contributing to the respiratory symptoms. However, the absence of upper respiratory symptoms and the findings on chest auscultation make asthma a more likely diagnosis.
c. Differential diagnosis 2: Vocal cord dysfunction – Vocal cord dysfunction can present with symptoms of stridor, cough, and dyspnea. However, the high-pitched whistling on expiration and decreased air movement on chest auscultation suggest a primary pulmonary pathology as the underlying cause.
3. Treatment plan utilizing current evidence-based practice guidelines:
The treatment plan for the presumptive final diagnosis of asthma would include:
a. Stepwise approach to pharmacotherapy: Based on guidelines, treatment for asthma starts with a short-acting beta-agonist (SABA) as a rescue medication. Inhaled corticosteroids (ICS) are recommended as the preferred long-term controller medication for persistent asthma. Therefore, prescribing a low-dose ICS, such as beclomethasone or fluticasone, would be appropriate.
b. Use of peak flow monitoring: In order to assess asthma control and adjust medication dosage, peak flow monitoring can be utilized. Patient education on peak flow monitoring techniques and monitoring their peak flow readings at home should be provided.
c. Avoidance of triggers and allergens: Identifying triggers like allergens or irritants that worsen asthma symptoms and advising the patient to avoid them is an important aspect of asthma management.
d. Education on proper inhaler technique: Ensuring the patient knows how to correctly use the prescribed inhaler device is crucial. This includes correct inhalation technique and understanding the importance of regular use to achieve asthma control.
Conclusion:
Through this case study, we have identified the chief complaint as shortness of breath and a nonproductive nocturnal cough. The three top differential diagnoses, with the presumptive final diagnosis first, include asthma, allergic rhinitis, and vocal cord dysfunction. The proposed treatment plan is based on current evidence-based practice guidelines and includes a stepwise approach to pharmacotherapy, peak flow monitoring, avoidance of triggers and allergens, and proper education on inhaler technique.
