Cough and Shortness of Breath: A Case Study

Biodata

Name: LN

Age: 16 Years

Gender: Female

Reasons for Encounter: Episodes of cough and shortness of breath

Cough and Shortness of Breath: A Case Study

LN, a 16-year-old female, presents to the clinic accompanied by her mom with complaints of episodes of cough, shortness of breath, and chest tightness for the past three weeks. The shortness of breath started suddenly and has been persistent during this period. It worsens when she engages in physical activity and improves slightly when she rests, as she needs to take a break to catch her breath.

She also reports a persistent cough that began suddenly three weeks ago. The cough is not productive. It tends to worsen at night without any specific trigger or relieving factor mentioned. Additionally, she experiences chest tightness, which she describes as a sensation of something squeezing her chest. She mentions that this is not the first time she has had similar symptoms. Along with these respiratory complaints, she also has a history of runny nose and nasal congestion.

Past Medical History

Past Medical Conditions: Eczema, Reactive Airway Disease

Hospitalizations/surgeries: No Previous Hospitalization or surgeries

Medications: No Medications

Allergies: No known allergies to medications, foods, or environmental triggers.

Preventive Health: Vaccinations are up-to-date

Social History:

The patient denies tobacco use. Reports secondhand smoke from her neighbors. No alcohol use. She does not engage in regular exercises

Review of Systems

General: Patient denies pain, fevers, chills, fatigability, weakness, night sweats, and weight loss

HEENT: Head: No reported headaches or head injuries. Eyes: No visual changes, blurriness, or eye pain. Ears: No reported ear pain, discharge, or hearing loss. Nose: Complaints of runny nose and nasal congestion. Throat: No reported sore throat or difficulty swallowing.

Cardiovascular: No reported chest pain or discomfort. No reported palpitations. Reports episodes of shortness of breath, which are exacerbated on ambulation and relieved slightly with rest. No reported limb edema, no orthopnea, no paroxysmal nocturnal dyspnea. No syncope

Respiratory: Complains of shortness of breath with ambulation. Complains of nonproductive cough

Gastrointestinal: No reported loss of appetite or weight loss. No reported nausea, vomiting, or abdominal pain. No reported diarrhea, constipation, or changes in bowel movements.

Genitourinary: No reported issues with urination frequency, urgency, or pain. No reported burning sensation during urination. No reported incontinence.

Musculoskeletal/Osteopathic Structural Examination: No reported joint pain, swelling, or stiffness. No reported weakness, limitations in joint movement, or stiffness. No reported back pain or spinal deformities. No reported history of recent fractures or musculoskeletal injuries.

Neurologic: No complaints of dizziness, headaches, seizures or convulsions, numbness, or tingling sensations. No changes in consciousness

Integumentary/Breast: Skin: Reports eczema, no reported hair loss or changes in hair texture. No reported changes in nail appearance or texture. No reported breast lumps, nipple discharge, or breast pain.

Lymphatic: No reported easy bruising and bleeding. No swelling, tenderness, or palpable lymph nodes. No excessive sweating during the night, no frequent or recurrent infections

Psychiatric: Complains of being stressed. Denies anxiety, depressive, or psychotic symptoms.

Endocrine: Denies weight changes, fatigue, or neck swelling. Denies heat or cold intolerance. Denies polyuria and polydipsia. No reported changes in sexual desire or libido, no reported irregularities or changes in menstrual cycles, no excessive sweating, and no changes in hair growth patterns.

Physical Examination

Constitutional Findings:

Weight: 150 lbs.; Height: 65″; BMI: 24.9 kg/m2

General Appearance: LN appears sick-looking and is in obvious respiratory distress. She is well-kempt, alert, and oriented to time, place, and person.

No pallor, jaundice, cyanosis, lymphadenopathies, edema, or dehydration was noted.

Vital Signs:

Temperature: 37.0°C (98.6°F) (Oral)

Oxygen Saturation: 94% on room air

Pulse: 88 beats/minute, regular rhythm, normal strength

Respiratory Rate: 26 breaths per minute, regular rhythm, with labored effort

Blood Pressure: Left 112/82 mm Hg, Right 114/80 mm Hg

HEENT/Neck Examination for LN: Head: Normocephalic, no signs of trauma or deformities. No tenderness on palpation. Eyes: Pupils are equal, round, and reactive to light (PERRLA). Extraocular movements are intact. Conjunctiva and sclera are clear. No jaundice or pallor was observed. Ears: No tenderness or swelling around the ears. No discharge from the ears. Nose: Nasal mucosa appears congested. No nasal discharge or bleeding observed. Throat/Oral Cavity: Oropharynx appears normal. No tonsillar enlargement or erythema. No ulcers or lesions observed. No exudates or tonsillar masses noted. Neck: No lymphadenopathy palpated. Full range of motion without discomfort. No neck stiffness or masses noted.

Cardiovascular: S1 and S2 sounds heard. No murmurs, rubs, or gallops. Quarter-size Point of maximal impulse (PMI) positive.

Chest/Respiratory Examination for LN: Inspection: The patient is in obvious respiratory distress, characterized by labored breathing and evident subcostal retractions. No chest deformities or asymmetry noted. Palpation: Chest expansion is bilaterally equal. No tenderness or masses detected. Percussion: Percussion notes are resonant bilaterally. Auscultation: Reduced air outflow with expiratory wheezing present. No crackles, rhonchi, or rubs present.

Gastrointestinal Examination: No distension, therapeutic marks, or dilated veins noted. Abdomen is soft and non-tender upon palpation. No organomegaly or masses palpable. Bowel sounds are normal and active in all quadrants.

Genitourinary Examination: Inspection reveals normal appearance of the external genitalia. No redness, swelling, or lesions observed.

Musculoskeletal/Osteopathic Structural Examination: Full range of motion in all joints without pain or limitations. No joint swelling or tenderness. No signs of deformities or abnormalities in posture.

Neurologic Examination: Cranial nerves are intact with no focal deficits. Sensation is intact in all extremities. Normal muscle strength and coordination. No tremors or involuntary movements.

Differential Diagnosis (DDx)

  1. Asthma exacerbation: Given the patient’s history of reactive airway disease, acute onset of shortness of breath, cough, and chest tightness, asthma exacerbation is a likely differential diagnosis.
  2. Allergic rhinitis: The associated history of runny nose and nasal congestion may suggest allergic rhinitis as a possible contributing factor to the respiratory symptoms (Dhingra & Dhingra, 2021)
  3. Upper respiratory tract infection (URTI): The presence of cough, nasal congestion, and runny nose could be indicative of a viral URTI, which can cause respiratory symptoms.
  4. Gastroesophageal reflux disease (GERD): GERD can present with symptoms such as chronic cough and chest tightness. It could be considered as a differential diagnosis, especially if there is a history of acid reflux symptoms.
  5. Tuberculosis (TB): Given the persistent cough and shortness of breath, TB should be considered as a potential differential diagnosis, especially if there are risk factors or known exposure.
  6. Viral pneumonia: The patient’s acute respiratory symptoms and the possibility of viral upper respiratory infection make viral pneumonia a potential differential diagnosis.
  7. Bacterial pneumonia: Bacterial pneumonia can occur simultaneously with asthma, as individuals with asthma are potentially more susceptible to respiratory infections.

Differential Diagnosis Ranking:

  1. Asthma exacerbation (Lead Diagnosis)
  2. Allergic rhinitis (Alternate Diagnosis)
  3. Upper respiratory tract infection (URTI) (Alternate Diagnosis)
  4. Gastroesophageal reflux disease (GERD) (Alternate Diagnosis)
  5. Tuberculosis (TB) (Alternate Diagnosis)
  6. Viral pneumonia (Alternate Diagnosis)
  7. Bacterial pneumonia (Alternate Diagnosis)

Must Not Miss (MNM) Diagnoses:

  1. Status asthmaticus: This is a severe and potentially life-threatening form of asthma exacerbation that requires immediate medical attention (Agnihotri & Saltoun, 2019). It is important to consider this as a Must Not Miss diagnosis due to the patient’s acute and persistent respiratory distress.
  2. Pneumothorax: Although not specifically evident in the case scenario, the presence of acute respiratory distress and chest tightness raises the possibility of pneumothorax, especially if there is a history of trauma or risk factors.

Management Plan

Diagnostic tests:

  1. Pulmonary Function Tests (PFTs): PFTs can help assess lung function and confirm the diagnosis of asthma. They can also provide baseline measurements for future comparisons. The most important PFT in LN’s case is spirometry
  2. Chest X-ray: A chest X-ray helps to evaluate the lungs and detect any abnormalities, such as pneumonia or other pulmonary conditions

Medications and other Treatment Interventions

  1. Oxygen therapy: Due to the patient’s low oxygen saturation of 94%, oxygen supplementation is necessary. In this case, the patient can receive oxygen via nasal prongs at a flow rate of 2-4 L/minute or an oxygen face mask at a flow rate of 4-6 L/minute.
  2. Nebulization with Albuterol or Combivent can also be administered to alleviate the patient’s distress and improve symptoms.
  3. Albuterol inhaler (ProAir HFA): 2 puffs (90 mcg/puff) every 4-6 hours as needed for acute relief of asthma symptoms. This is a short-acting bronchodilator that helps to open the airways.
  4. Inhaled corticosteroid (Fluticasone propionate, brand name Flovent): 1-2 inhalations (100-250 mcg per inhalation) twice daily for maintenance therapy to reduce airway inflammation (Beasley et al., 2019). This helps to prevent asthma exacerbations and control symptoms. Prescription required.
  5. OTC antihistamine (e.g., cetirizine, brand name Zyrtec): 10 mg orally once daily for relief of allergic rhinitis symptoms. This can help manage nasal congestion and runny nose.

Suggested Consults/Referrals:

Pulmonology Consultation: Referral to a pulmonologist for further evaluation and management of asthma, especially if the symptoms persist despite initial treatment or if there are concerns about disease severity or control.

Client Education:

  1. Educate the patient and family about asthma triggers and the importance of avoiding exposure to them (e.g., secondhand smoke, allergens).
  2. Teach proper inhaler technique for both the albuterol inhaler and inhaled corticosteroid to ensure optimal medication delivery.
  3. Emphasize the importance of adhering to the prescribed medication regimen, including regular use of the inhaled corticosteroid for long-term control of asthma.
  4. Provide education on recognizing and managing asthma exacerbations, including when to seek immediate medical attention.

Follow-up:

The patient should come back in 2 weeks for assessment of the response to treatment, adjustment of medications if needed, and reinforcement of education. The patient should seek medical attention sooner if there is worsening shortness of breath, chest pain or if symptoms do not improve with prescribed medications.

References