Case #19

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Chief Complaint

Ms. A.J., a 30 year old female presents for the first time to your office because she has recently had difficulty keeping up with her friends in her bi-weekly volleyball game. She had a “cold” 5 weeks ago (stuffy nose, cough, sore throat), which have gotten better except for the persistent cough. The cough is productive of green phlegm and she gets short of breath with exertion. She tells you that she thinks she’s got “bronchitis,” because she got bronchitis frequently as a child. She is here requesting antibiotics because that’s what her doctor “always” gave her for the bronchitis. She has recently tried over the counter inhalers, but finds they offer little relief of her symptoms. She does not smoke. She coughs daily and is awakened from sleep at least one or two nights a week with cough. Her cough is worsened by cold weather and she is noticing decreased exercise tolerance over the past several months. She volunteers, “I do NOT have asthma.”

Review of systems is otherwise negative. There is no personal history of asthma. She thinks her mom had asthma and her brother has “allergies.” She has never been hospitalized. She denies any allergies to medication or environmental allergens. The patient denies symptoms of GERD.
  1. Does this patient have a chronic cough?
  2. What is the differential diagnosis of chronic cough? (Think broadly)

Physical Examination

On exam:

General: She is a neatly dressed white female appearing her stated age and in no respiratory distress.

Vitals: BP 110/70 RR 12 HR 68 T 97.5 Ht: 6’1” Wt: 190 lbs

HEENT: PERRL, EOMI, anicteric sclera, tympanic membranes visualized bilaterally, clear nasal discharge noted, nasal mucosa pink and without inflammation. No frontal or maxillary sinus tenderness. Pharynx without erythema, tonsils without exudate. Neck is supple, without adenopathy, no thyromegaly

CV: Heart rate regular without m/r/g

LUNGS: Clear to ausculation in all fields bilaterally

ABD: soft, positive bowel sounds, non-tender, non-distended, no masses, guarding, organomegaly

GU/RECTAL: deferred

EXTREMITIES: without clubbing, cyanosis, edema

  1. What tests would you like to order?

Test Results

Chest x-ray: showed no infiltrate, no mass, no cardiomegaly or increased vascular markings. The patient’s peak flow is 350 (expected is 630).
  1. What is peak flow and how would you interpret the patient's peak flow results?
  2. Define Asthma
  3. There are no wheezes on A.J. 's lung exam, does that exclude asthma?
  4. How is asthma diagnosed?
  5. Does this patient have asthma?
  6. Why is asthma a public health concern?
  7. What are the risk factors for death from asthma?
  8. What causes asthma?
A.J. read about the recent outbreak of Pertussis and wonder if she has the disease. The patient’s vaccination records are obtained and the patient is fully vaccinated against Pertussis. 
  1. Is it possible that A.J. has Pertussis? What are the symptoms of Pertussis?
  2. What should you do for this patient?
  3. The patient says she already has Primatene Mist (an over the counter inhaler) at home. Can’t she just continue to use this instead? What’s the difference between OTC inhalers and albuterol (prescription only)?

Follow-up

The cough cleared quickly with the regimen you prescribed and she cancelled her 2 weeks follow up visit.

Six months later, A.J. presented to the office reporting that she continues to have wheezing with exercise and it is taking increasingly longer to get rid of the “winded” feeling she gets. The wheezing episodes occur about 2-3 times a week. She also wakes occasionally from sleep short of breath. She notices that her symptoms have worsened since the weather has gotten colder. Her exam is unremarkable except for expiratory wheezes.

 
  1. You tell the patient that she has mild-persistent asthma. What does that mean?
  2. What treatment should A.J. receive?
  3. What are the five classes of medications (not including oxygen) that are used for asthma and what is their purpose?
  4. How can A.J. assess the severity of her asthma at home?
  5. A.J. is concerned about the steroids and asks about the risks and benefits. What do you tell her?
  6. What is your short-term goal for A.J.?
A.J. agrees to your plan (a low dose inhaled steroid 2 puffs QID and albuterol 2 puffs q4hours prn) You also give A.J. a peak flow meter and teach her how to use it and to record her daily readings.  You see A.J. in follow up in one month’s time and ask how she’s been doing.  She states that she feels much better and has symptoms only about once a week.  Her peak flows on most days are more that 540, although on a few particularly cold days, her peak flows were only about 400.
  1. What now and what are your long-term goals for A.J.?
  2. How will A.J. know when her inhalers are empty?
  3. The patient says that she thinks her mom had asthma and that her brother has “allergies.” Is her asthma related to environmental allergens? How can you tell?
  4. How can we ensure that the patient will be compliant with their asthma therapy?

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This page was last updated on April 24, 2006
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