What is the chief complaint? “Shortness of breath and a…
- What is the chief complaint? “Shortness of breath and a nonproductive nocturnal cough“.
2. Based on the subjective and objective information provided what are your 3 top differential diagnosis listing the presumptive final diagnosis first?
Moderate Persistent Asthma (J45.4)
Seasonal Allergic Rhinitis (J30.2)
3. What treatment plan would you consider utilizing current evidence based practice guidelines?
The primary aim of asthma management is to achieve control of symptoms, to reduce the risk of future exacerbations and progressive loss of lung function. The first consideration is to ensure if the diagnosis of asthma is in fact correct. Evidence of airway obstruction on spirometry, especially if reversible with a bronchodilator, can confirm the diagnosis of asthma or assess the severity. Normal spirometry does not exclude the diagnosis. Moreover, young, or non-compliant patients are often unable to perform. Improvement on a trial of medications is often used to confirm the diagnosis in these. Moderate persistent asthma occurs when symptoms are daily with nighttime awakenings. These awakenings are greater or equal to 1 time per week but not nightly. General measures for treatment include symptom control, using spacers, a written asthma plan, avoidance of exposures, annual flu vaccines, and epi pen for anaphylaxis. Since the patient does not appear to be in acute stress administering a dose of a rescue inhaler, such as, Albuterol would be appropriate to asses for effectiveness. If the Albuterol aids in symptom control it is important to educate the patient on correct spacer technique with return demonstration. Adding an antihistamine, such as, Zyrtec, may be necessary if environmental factors are precipitating her asthma exacerbations. If asthma is not controlled by these interventions the patient may benefit from a Long acting beta agonists or an inhaled corticosteroid. Montelukast/singulair may also aid in control of persistent asthma.
Please just provide the rationale for your differentials and be more specific on medications that you would prescribe and how you would prescribe them.