APA format, 2 pages, 3 references
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?
Expert Solution Preview
Introduction:
The presented case study highlights a common complaint in adolescent clients and requires a systematic approach to arrive at a diagnosis. As a medical professor, it is crucial to train medical college students in developing a clinical reasoning process to identify and manage patients’ health conditions successfully. This assignment aims to evaluate students’ ability to use history taking and physical examination skills to develop a differential diagnosis and treatment plan for a 15-year-old female presenting with shortness of breath and cough.
1. What is the chief complaint?
The chief complaint of the 15-year-old female 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 presented symptoms and examination findings require a differential diagnosis to identify the underlying cause. The top three differential diagnoses are:
1. Asthma: Asthma is a prevalent respiratory condition in adolescents, characterized by recurrent episodes of shortness of breath, cough, and wheezing. The patient’s symptoms of nocturnal cough and shortness of breath with decreased air movement and high-pitched whistling on expiration in all lobes support this diagnosis.
2. Bronchitis: Bronchitis is inflammation of the bronchi, leading to cough with or without sputum production, dyspnea, and wheezing. The patient’s symptoms of cough and shortness of breath with decreased air movement support this diagnosis.
3. Foreign body aspiration: Foreign body aspiration is common in adolescents who have a habit of putting foreign objects in their mouth. The patient’s symptoms and examination findings are not typical of foreign body aspiration, but the possibility cannot be ruled out without further investigations.
The presumptive final diagnosis is asthma based on the patient’s symptoms, examination findings, and common presentation in adolescents.
3. What treatment plan would you consider utilizing current evidence-based practice guidelines?
The treatment plan for asthma in adolescents involves identifying and avoiding triggers, regular exercise, and prescription of medications such as inhaled corticosteroids, short-acting beta-agonists, and leukotriene modifiers. The following treatment plan can be considered based on current evidence-based practice guidelines:
1. Prescribe inhaled corticosteroids (ICS), such as beclomethasone or fluticasone, for long-term control of asthma.
2. Prescribe a short-acting beta-agonist (SABA), such as albuterol, for quick-relief of symptoms.
3. Advise the patient to avoid triggers, such as smoke, allergens, and exercise-induced asthma.
4. Educate the patient and family about proper inhaler techniques and adherence to medication.
5. Schedule follow-up visits to monitor the effectiveness of treatment and adjust the treatment plan accordingly.
Conclusion:
The presented case study demonstrates the importance of a systematic approach to diagnose and manage common conditions in adolescent clients. Medical college students should use history taking and physical examination skills to develop a differential diagnosis and treatment plan based on current evidence-based practice guidelines. Effective communication skills and patient education are critical in managing chronic conditions like asthma in adolescent clients.
