A 12-year-old girl arrives at your office with her mother for an evaluation of the child's cough. The mother reports that the child has a nocturnal nonproductive cough 2 to 3 times per month for the past 3 months associated with increasing episodes of shortness of breath that usually resolve spontaneously. However, during soccer games, the girl has recurrent episodes of cough and wheezing that are only relieved when she uses a friend's albuterol inhaler.
Past medical history reveals that the patient has had recurrent upper respiratory infections and had bronchitis 2 years ago. The patient has had no hospitalizations or emergency department visits. Current medications include diphenhydramine for her intermittent runny nose and an occasional puff from her friend's albuterol inhaler during soccer games.
Family history reveals that the girl lives with her mother, father, and older sister in a house on the outskirts of the community. The father had a history of seasonal hay fever as a child. Both parents are indoor and outdoor smokers. The mother reports that her husband has had some difficulties with episodic cough and shortness of breath, but has not seen a physician.
A review of systems reveals that the patient has numerous episodes of
- Sneezing,
- Itchy eyes, and
- Clear discharge from the nose.
You ask the mother to leave the examination room. This allows you to ask the patient confidentially if she has been smoking or is around friends who smoke. The patient states that neither she nor any of her friends smoke cigarettes or any other inhaled substances, such as marijuana. In addition, the patient has not reached menarche and she denies sexual activity. The patient has met developmental milestones and followed a 50th-percentile growth curve. She is a 7th grader doing well academically, with no school absences.
Physical examination reveals a young girl, who sits quietly and comfortably, in no apparent distress. Her vital signs are
- Temperature 98.6º F (37.0º C),
- Respiratory rate 17,
- Heart rate 82,
- Blood pressure 118/75 millimeter of mercury (mmHg).
No dyspnea or stridor is evident. Her skin color is normal, without cyanosis. Examination of the nares reveals boggy, red turbinates with moderate congestion, but no sinus tenderness or flaring. The tympanic membranes are mobile and without erythema or air/fluid levels. Inspection of the chest does not show accessory muscle use or intercostal, suprasternal, or supraclavicular retractions. The antero-posterior diameter does not seem to be increased. Pulmonary auscultation reveals inspiratory and expiratory wheezing scattered throughout both lung fields. Her peak expiratory flow rate (PEFR) reading is 285 liters per minute (L/min). You explain to the patient and her mother that her predicted normal should be 360 L/min (give or take 20%), which is the predicted normal PEFR for her age and build. The rest of the physical examination is unremarkable. The fingers are not clubbed, nor are the nail beds cyanotic.
Your primary working diagnosis for this patient is asthma.
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