Based on subjective and objective information provided what are your three top differential diagnosis listing the presumptive final diagnosis first.

1. What is the chief complaint?

“Shortness of breath and a nonproductive nocturnal cough”

The chief complaint is the patient’s reason for the visit, given in the patient’s own words, that guides the opening questions of the interview and begins the history taking portion of the exam (Goolsby & Grubbs, 2015).

2. Based on subjective and objective information provided what are your three top differential diagnosis listing the presumptive final diagnosis first:

Asthma (Moderate persistent asthma, uncomplicated- J45.40): Moderate persistent asthma is given as a diagnosis as there is not full clarity in nocturnal awakenings of seven nights weekly (an indicator of severe persistent asthma) and the adolescent is not in acute distress. In moderate persistent asthma the adolescent suffers with symptoms daily and nocturnal awakenings more than once weekly but not seven nights weekly. Activities of daily living are somewhat impacted but the adolescent is rarely acutely in distress and is still able to function at a near normal level. Definitive level of severity is made based on forced expiratory volume and peak expiratory flow (NHLBI, 2012).

Allergic rhinitis (Other allergic rhinitis- J30.89): Allergic rhinitis (AR) is the most common chronic disease in the pediatric population of the US. In this patient, with a known history of seasonal rhinitis, she may be suffering from chronic inflammation of the upper airways due to AR resulting in airway narrowing and cough (Gurgel, Lin, & Seidman, 2015).

Bronchitis (Bronchitis, not specified as acute or chronic- J40): Bronchitis is the result of inflammation of the trachea and large airways not associate with an infectious process. In bronchitis, symptoms may last weeks to months, be exacerbated by activity and allergen, and worsen in the evening (Kinkade & Long, 2016).

 

3. What treatment plan would you consider utilizing current evidence based practice guidelines?

Current evidence based clinical guidelines recommend a stepwise approach to asthma management:

• First the clinician must diagnose severity level based on provided clinical guidelines as was done above. Next the provider must initiate treatment for control. For adolescents older than 12 years of age beginning treatment for moderate persistent asthma includes a combination approach utilizing a low dose inhaled corticosteroid and a long acting beta-agonist. To ease dosing and increase adherence this combination is readily available in combined forms as: fluticasone/salmeterol, budesonide/formoterol, and mometasone/formoterol. Initial dosing for this adolescent may include:

fluticasone/salmeterol- 1 inhalation twice daily OR budesonide/formoterol- two inhalations twice daily OR

mometasone/formoterol- two inhalations twice daily.

• Next the clinician must educate the adolescent and parent on trigger identification and trigger avoidance. Continuation of seasonal allergy treatment must continue and allergy testing may prove prudent to assist in trigger identification and management. Further, education must include the step wise approach that will be used on this adolescent. This approach will include combination treatment until control is gained with the goal to step down to a stage two level of medication (i.e. single low dose inhaled corticosteroid usage daily). Final education must include red flag warnings and when to seek emergency medical treatment (e.g. cyanosis, changes in LOC, unrelieved SOB).
• Finally, at this initial visit, an asthma plan must be made that includes the adolescents wishes for outcome, the parent’s wishes for outcomes, and the providers goals for outcomes.

(Avena-Woods, Li, Pisano, & Rehman, 2017; and NHLBI, 2012)

Avena-Woods, C. Li, J., Pisano, M., & Rehman, A. (2017). Treating asthma in the pediatric population. Respiratory 42(2): 16-20 Goolsby, M & Grubbs, L. (2015). Assessment and clinical decision-making: An overview. In M.

Goolsby and L. Grubbs (editors) Advanced assessment: Interpreting findings and formulating differential diagnoses (3^rd edition, p. 1-11). Philadelphia, PA: F.A. Davis Company Gurgel, R., Lin, S., & Seidman, M. (2015). Clinical practice guideline: Allergic rhinitis.Otolaryngology Head and Neck Surgery 152(1S): S1-S43. doi: 10.1177/0194599814561600 Linkade, S. & Long, N. (2016). Acute Bronchitis. American Family Physician 94(7): 560-565 National Heart, Lung, and Blood Institute (2012). Asthma care quick reference: Diagnosing and managing asthma. Quick reference based on the Expert Panel Report. U.S. Department of Health and Human Services: National Institutes of Health. Retrieved August 21, 2019 from https://www.nhlbi.nih.gov/files/docs/guidelines/asthma_qrg.pdf