Case Study on Asthma
John is a 13 yr old male who presents to your clinic accompanied by his mother with complaint of productive cough, chest and nasal congestion and intermittent chills x 7 days. He reports symptoms initially started with mild nasal congestion, clear runny nose and sorethroat, but got worse the past few days. He now has chest congestion, productive cough with greenish-yellow sputum, chills, and mild headache x 2 days. OTC meds for cold have not helped. He denies any known sick contact.
Mother further reports she noticed John has been wheezing more the past 2 months. He used to use his albuterol inhaler about once a month but now uses it 3-4 times a week. Both John and his mom reported nighttime dry cough and wheezing which occurs about 1-2 times a week
Past Medical History: Asthma, Allergic rhinitis, Atopic dermatitis
Medication History: Albuterol HFA prn, Zyrtec 10mg QD, Tylenol 500mg -1tab prn for headache and chills.
Family Medical History: Father: HTN; Mom: healthy. 3 siblings-all healthy
Drug Allergy: NKDA
Social History: Denies alcohol or cigarette use. Denies illicit drug use. Occupation: Student.
Vaccination: Up to date
Physical Exam
Gen: Slightly lethargic, otherwise in no acute distress
V/S: BP: 124/72, HR: 110, T: 101.3(oral), RR: 22, wt: 132lbs, Ht: 66inches
HEENT: Nasal mucosa erythematous, mild nasal congestion, tonsils and pharynx normal, slight postnasal drainage, light green nasal discharge.
CV: Normal S1& S2, rhythm regular
Resp: regular. Mild expiratory wheezing bilaterally to auscultation. No use of accessory muscles. 02 saturation: 95%
Abd: Soft, non-distended, non-tender, bowel sounds + and normal x 4 quadrants, no masses palpated.
Neuro/Psych: alert and oriented X 3. CN II-XII grossly intact. Good eye contact, speech clear and goal oriented. Affect normal.
Skin: Normal, no lesions.
Diagnostic Tests: In-house: CBC with diff and CXR
Labs/X-ray
L.C’s values
WBCs
12,000
Neutrophil
8,500
Lymphocyte
4,500
Platelet
190, 000
Hemoglobin
14
HCT
38%
CXR Result
Consolidation in left upper lobe
Case Questions:
1. What is/are the diagnoses: Support with literature evidence and interpretation of data presented in the case study. Discuss the pathophysiology of the selected diagnosis.
2. Present and briefly discuss(rationale) 3 differential diagnoses for this patient.
3. Discuss plan of care for this patient-pharmacological, education, referral, and need for further diagnostic testing if any. Your thoughts about his asthma?.
4. Support plan of care/intervention with literature evidence.
FNP Pediatric Health Case Study
Student’s Name
Institutional Affiliations
FNP Pediatric Health Case Study
Respiratory infections are common among pediatrics and adolescents. Some patients might have more than one respiratory disease at the same time. To ensure an accurate diagnosis and proper treatment, the healthcare professional must carefully evaluate the patient’s symptoms, past medical history, and objective data of the patient in order to identify pertinent positives and pertinent negatives for specific respiratory illnesses (Posteraro et al., 2021). This paper will describe the diagnosis and treatment plan for a 13-year-old male patient presenting to the clinic accompanied by his mother with complaints of productive cough, chest and nasal congestion, and intermittent chills x 7 days.
Primary Diagnosis
The primary diagnosis for the patient is asthma which co-occurs with bacterial pneumonia. Both asthma and pneumonia are respiratory conditions commonly diagnosed in children and adolescents. Both conditions cause chest congestion, nasal congestion, and difficulty breathing. A productive cough that is characterized by greenish-yellow sputum in patients with asthma is a sign of infection (Pabreja et al., 2017). Such infections usually worsen asthma symptoms in patients who already have asthma. John’s young age is a risk factor for pneumonia and asthma. His past medical history indicates that he has had asthma before. Intermittent chills that have lasted for more than 2 days, wheezing that has persisted for the past two months, nighttime dry cough, light green nasal discharge, and greenish-yellow sputum are positive symptoms of pneumonia. The presence of pneumonia infection is further evidenced by elevated levels of white blood cells and neutrophils (Wu et al., 2021). Lung x-ray results for patients with pneumonia usually reveal consolidation in the left upper lobe of the lungs as observed in John’s case (Sharma, 2021). Initially, John used to use his albuterol inhaler about once a month but now uses it 3-4 times a week, an indication that his asthma has worsened in the recent past.
Pathophysiology
The pathophysiology of bacterial pneumonia entails inflammation of lung parenchyma cells. Cough reflexes are impaired in the affected patients leading to repeated coughs. Bacterial activities in the airways trigger the formation of greenish yellow sputum that is usually produced when the patient is coughing (Posteraro et al., 2021). The body considers these bacteria are foreign substances. As a result, it produced increased levels of macrophages to help clear these substances from the airway. This explains why affected patients usually have elevated levels of white blood cells and neutrophils. The inflammation of lung parenchyma cells usually results in the production of exudates, abscess formation, and cell necrosis (Posteraro et al., 2021). These usually appear as consolidation in the left upper lobe of the lungs on an x-ray radiograph (Sharma, 2021).
Differential Diagnoses
Primary diagnosis: Asthma and bacterial pneumonia
Differential diagnoses:
- Atelectasis:
- Bronchitis:
- Chronic obstructive pulmonary disease:
Plan of Care
Pharmacological treatment:
- Continue Albuterol HFA prn for asthma symptoms, Zyrtec 10mg QD for allergy, and Tylenol 500mg -1tab prn for headache and chills.
- Add doxycycline to the current medication regimen for pneumonia symptoms (Lee et al., 2021).
Patient education:
Educate the patient to adhere to medication and keep warm (Posteraro et al., 2021).
Referral:
- Refer the patient to a pulmonologist to assess the degree of respiratory damage caused by the conditions and to examine if the patient has other complications (Janssen et al., 2021).
Need for further diagnostic testing:
- Perform a bacterial culture in order to establish the type of bacteria that is causing pneumonia in the patient (Posteraro et al., 2021).
Thoughts about the asthma:
- John’s asthma symptoms are exacerbated by bacterial pneumonia. An improvement in symptoms should occur after two weeks of medication use.
References
Janssen, S., Spruit, M. A., Antons, J. C., Djamin, R. S., Abbink, J. J., van Helvoort, H., & van ‘t Hul, A. J. (2021). “Can Do” Versus “Do Do” in Patients with asthma at first referral to a pulmonologist. The Journal of Allergy and Clinical Immunology. In Practice, 9(3), 1278–1284. https://doi.org/10.1016/j.jaip.2020.09.049
Lee, H., Choi, Y. Y., Sohn, Y. J., Kim, Y. K., Han, M. S., Yun, K. W., Kim, K., Park, J. Y., Choi, J. H., Cho, E. Y., & Choi, E. H. (2021). Clinical efficacy of doxycycline for treatment of macrolide-resistant Mycoplasma pneumoniae pneumonia in children. Antibiotics (Basel, Switzerland), 10(2), 192. https://doi.org/10.3390/antibiotics10020192.
Pabreja, K., Gibson, P., Lochrin, A. J., Wood, L., Baines, K. J., & Simpson, J. L. (2017). Sputum colour can identify patients with neutrophilic inflammation in asthma. BMJ Open Respiratory Research, 4(1), e000236. https://doi.org/10.1136/bmjresp-2017-000236.
Posteraro, B., Cortazzo, V., Liotti, F. M., Menchinelli, G., Ippoliti, C., De Angelis, G., La Sorda, M., Capalbo, G., Vargas, J., Antonelli, M., Sanguinetti, M., De Pascale, G., & Spanu, T. (2021). Diagnosis and treatment of bacterial pneumonia in critically ill patients with COVID-19 using a multiplex PCR assay: A large Italian hospital’s five-month experience. Microbiology Spectrum, 9(3), e0069521. https://doi.org/10.1128/Spectrum.00695-21.
Sharma, R. (2021). Left upper lobe consolidation. https://radiopaedia.org/articles/left-upper-lobe-consolidation
Wu, J., Wang, X., Zhou, M., Chen, G. B., Du, J., Wang, Y., & Ye, C. (2021). The value of lymphocyte-to-monocyte ratio and neutrophil-to-lymphocyte ratio in differentiating pneumonia from upper respiratory tract infection (URTI) in children: a cross-sectional study. BMC Pediatrics, 21(1), 545. https://doi.org/10.1186/s12887-021-03018