NSG 6435 A fifteen-year-old female presents to your clinic complaining of shortness of breath and a nonproductive nocturnal cough

NSG 6435 A fifteen-year-old female presents to your clinic complaining of shortness of breath and a nonproductive nocturnal cough

NSG 6435 A fifteen-year-old female presents to your clinic complaining of shortness of breath and a nonproductive nocturnal cough

Case Scenario of an Asthma Patient

Case Overview

            The case scenario is of a 15-year-old female who presents with complaints of dyspnea, and a cough with no sputum that occurs at night. She reports that she used to have the symptoms only when she engages in extreme exercises, but lately, she has had the symptoms continuously. She reports no complaints in the respiratory, gastrointestinal, and urinary systems. In addition, she has a history of seasonal allergies, which she manages with nasal steroid spray and has no other relevant medical and surgical history. In her family history, the mother has a history of eczema and hypersensitivity reactions while the father has hypertension. On physical examination, she is in no distress. Vital signs include temperature of 98.6 F, pulse 80b/min, BP 120/80, and respiration rate of 20b/min. Auscultation of the chest reveals limited air flow and wheeze on expiration in the lungs. Chest percussion, reveals resonant lungs.

Chief Complaint

            The chief complaint is continuous dyspnea and a cough with no sputum production that mostly occurs at night.

Differential Diagnosis

1. Asthma: Asthma is a chronic reversible condition resulting from inflammation of airways. Inflammation causes airway hyperactivity, edema, and production of mucus, causing bronchoconstriction (Drake, Simpson & Fowler, 2019). The narrowing of the airways results to obstruction of airflow in the lungs and leads to intermittent asthmatic episodes. The hallmark symptoms of asthma are wheezing non-productive cough, and shortness of breath (Drake, Simpson & Fowler, 2019). Wheezing, which is the most typical symptom, is a musical high-pitched whistling sound that is heard during expiration. The risk factors for exacerbation of asthma symptoms are allergens, exposure to cold, exercise, stress, and medications such as aspirin (Drake, Simpson & Fowler, 2019). Asthma is a probable diagnosis as per positive subjective findings of a dyspnea and a cough with no sputum production that occurs with extreme exercises and at night. There are also positive objective findings of limited air flow and wheeze on auscultation.

2. Vocal cord dysfunction (VCD): VCD occurs when vocal cords are adducted when inhaling. The adduction results in airflow obstruction at the laryngeal level (Weinberger & Doshi, 2017). Symptoms of VCD include wheezing, cough, stridor, shortness of breath, voice hoarseness, and a sensation of throat tightness. On auscultation, stridor is perceived in the laryngeal area, and wheezing is heard on the chest (Weinberger & Doshi, 2017). The symptoms are unresponsive to corticosteroids and bronchodilators. VCD is a likely diagnosis based on the patient’s positive symptoms of dyspnea, cough, and wheezing. There are negative findings, however, of airflow obstruction on the laryngeal area.

NSG 6435 A fifteen-year-old female presents to your clinic complaining of shortness of breath and a nonproductive nocturnal cough
NSG 6435 A fifteen-year-old female presents to your clinic complaining of shortness of breath and a nonproductive nocturnal cough

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3.Bronchiectasis: The classic symptom is cough and prolonged daily production of mucopurulent sputum (Chalmers, Aliberti & Blasi, 2015). Other symptoms include shortness of breath, fever, chest pain, fatigue, and generalized body weakness. Physical findings include crackles, scattered wheeze, rhonchi, cyanosis, and muscle wasting (Chalmers, Aliberti & Blasi, 2015). Bronchiectasis is a probable diagnosis as per positive findings of shortness of breath, wheeze, and cough. However, there are negative findings of sputum production, chest pain, and fever.  

Treatment Plan

Workups

  • Pulmonary function testing to assess the severity of airway obstruction and to make an asthma diagnosis.
  • Methacholine challenge to assess airway hypersensitivity and guide in making an accurate diagnosis of asthma (Drake, Simpson & Fowler, 2019).
  • Provocative tests to assess the severity of airway obstruction when exposed to cold or during physical activities

Medications

a)Ventolin HFA aerosol inhaler 2 puffs QID. This is a bronchodilator that acts by relaxing bronchial smooth muscles to relieve bronchospasm (Lommatzsch & Stoll, 2016).  It prevents episodes of bronchospasm in exercise-related and nocturnal asthma.

b) Prednisolone 30 mg qDay. It acts by suppressing inflammatory receptors and reversing the inflammation process (Lommatzsch & Stoll, 2016). It is also used in the management of acute and chronic asthma to prevent exacerbation of asthma symptoms.

c) Beclomethasone inhalant 80mcg B.D. It is an anti-inflammatory drug that acts by inhibiting bronchoconstriction. It also relaxes bronchial smooth muscles resulting in Broncho-dilation.

Health Promotion

a). Allergen avoidance: I will offer health education on avoiding allergens such as cold, dust, and vigorous exercises to prevent exacerbation of asthma symptoms.

b). Medication adherence; health education will be offered on the importance of adhering to the drug regimen prescribed to prevent frequent asthma exacerbations.

c). Healthy diet; I will offer nutrition counseling on the importance of a healthy diet and advise the patient to take food having a high vitamin content and a lot of fruits to boost the immune system.

d). Exercises – I will advise the patient to engage in non-strenuous activities such as jogging, walking, and cycling. However, she will be advised not to engage in vigorous exercises and to rest when she experiences shortness of breath.

Referrals

Referral to an allergy specialist for a skin test that will help to identify specific allergens that trigger asthma exacerbations (Lommatzsch & Stoll, 2016). Identification of allergens will help in preventing the particular allergens.  

Follow-up

The first clinic follow up of the patient will be after two weeks to assess for improvement in the alleviation of asthma symptoms. After the first visit, I will schedule follow-ups after every three months to assess comorbid conditions and assess improvement.

References

Chalmers, J. D., Aliberti, S., & Blasi, F. (2015). Management of bronchiectasis in adults. European Respiratory Journal, 45(5), 1446-1462.

Drake, S. M., Simpson, A., & Fowler, S. J. (2019). Asthma Diagnosis: The Changing Face of Guidelines. Pulmonary Therapy, 1-13.

Lommatzsch, M., & Stoll, P. (2016). Novel strategies for the treatment of asthma. Allergo journal international, 25(1), 11-17.

Weinberger, M., & Doshi, D. (2017). Vocal cord dysfunction: a functional cause of respiratory distress. Breathe, 13(1), 15-21.