You are working with Dr. Nancy Law in a community clinic. Today she is scheduled to see a new patient, Sunita Patel, with a report of a cough for eight weeks.

Dr. Law asks you to do a focused history and physical exam and develop a working differential before presenting Sunita’s story to her.

You begin by picking up Sunita’s chart and reviewing the nurse’s intake information:

Patient: Patel, Sunita

Patient new to practice. Recently moved to area. Old records are being faxed from prior PCP.

Age: 6 years

Chief concern: Coughing for eight weeks. No improvement and maybe worsening. Mom concerned.

Vital signs:

Temperature is 37.6 C (99.68 F)

Pulse is 92 beats/minute?

Respiratory rate is 18 breaths/minute?

Oxygen saturation is 99% ?

Weight is 22 kg (50th percentile)

Height is 118 cm (50-75th percentile)

• Medications: None

Allergies: No medication, food, or environmental allergies

• Chronic cough

Sunita’s report of cough for eight weeks meets the definition of chronic cough (daily cough lasting > 4 weeks).

• Sunita’s age

The causes of chronic cough in a school-aged child are different from those in infants and toddlers.

• While many of the causes are similar, infants are more likely to have anatomic malformations (e.g., congenital vocal cord abnormalities, laryngotracheomalacia, vascular ring, laryngeal web, tracheal stenosis, or tracheoesophageal fistula) causing their cough.

In toddlers, a foreign body aspiration must also be considered.

• New to the practice and presently on no medications

Because you do not have old records, you are not yet sure if Sunita’s prolonged history of cough is a new or a recurrent problem; however, the fact that she is presently on no medications suggests that this may be a new problem.

• You notice that the family has recently moved to the area. Could this be related to her cough?

Appropriate growth parameters

Recognizing that you only have today’s measurements, you note that Sunita appears to be growing well.

Normal vital signs

Sunita’s current lack of fever, normal respiratory rate (normal range: 12–20 breaths per minute), and normal pulse oximetry reassure you that she is not in need of immediate medical intervention.

They also contribute to your diagnostic thinking.

When you enter the room and introduce yourself to Sunita and her mother, Sunita looks up from her drawing and gives you a bright smile. You notice that Sunita appears to be a well-nourished girl who is sitting comfortably next to her mother, in no apparent distress.

You introduce yourself to Mrs. Patel and Sunita, sit down next to the little girl, and say, “Hello, Sunita!” What a terrific drawing!” She smiles and tells you it is a picture of her dog.

You then say, “I hear you have had a cough lately.”

• You note that Sunita is speaking in full sentences without shortness of breath.

You continue your history by asking a focused review of systems and learn the following:

Constitutional: No fevers associated with the cough. No weight loss. Good appetite.

Skin: Patient has mild eczema. No new rashes associated with this cough.

• Head: No headaches. More nasal congestion since moving here. Had some sneezing during the early autumn.
• Throat: No sore throat. No change in Sunita’s voice. No history of choking.
• Respiratory: Cough is sometimes triggered by laughing or crying. No shortness of breath. No wheezing. No chest pain.

Cardiac: No palpitations.

Gastrointestinal: No stomach aches. No vomiting or diarrhea.

Past medical history:

• Born in India and moved to the U.S. when she was one year old.
• Born full term without complications.

Past history significant for mild eczema and two episodes of otitis media as a toddler.

No history of hospitalizations, pneumonia, or wheezing.

Normal growth and development. Immunizations up-to-date.

• No medication allergies.

Family History:

Asthma (mother and cousins).

No other chronic pulmonary conditions or infections.

• No one with recurrent infections.
• Social History:

In first grade and enjoys school.

Family moved to the area about three months ago. They live in a single-family home.

There are no smokers in the house. They have one dog. There are carpets in the bedrooms.

Sunita lives with her parents, 9-year-old brother, paternal grandmother.

Grandmother is from India and moved to the United States three months ago when they moved into the new house.

Mrs. Patel notes that there is a lot of tuberculosis in the area of India where the grandmother lived, but the grandmother recently had a negative tuberculin skin test (TST) and has not had a cough. Tuberculosis is an unlikely cause of Sunita’s cough, but placing a TST or ordering an Interferon Gamma Release Assay (IGRA) would be reasonable to consider.

SUMMARY STATEMENT

Sunita is a 6-year-old girl with chronic nasal congestion and a history of eczema who presents with a chronic cough that is often worse at night, with exercise, and with exposure to cold air. She has no fever, shortness of breath, or history of wheezing, but has a family history of asthma.

The ideal summary statement concisely highlights the most pertinent features without omitting any significant points. The summary statement above includes:

Epidemiology and risk factors: Sunita is 6 years old and has a family history of asthma.

Key clinical findings about the present illness using qualifying adjectives and transformative language:

Chronic nasal congestion and PMH of eczema

Chronic (i.e > 4 weeks) of cough

Worsens at night, with exercise, and exposure to cold air

No fever, shortness of breath, or wheezing

You step out briefly to allow Sunita to change into a gown. You then come back into the room and wash your hands. Sunita is sitting patiently on the examination table.

General assessment: Well-nourished and in no acute respiratory distress. Dark circles under both eyes with some creases below both eyes.

Skin: Dry skin but no obvious patches of eczema.

Hands: No evidence of distal cyanosis or digital clubbing.

Nose: Transverse nasal crease. Turbinates somewhat pale and edematous. Clear nasal secretions.

No sinus tenderness when the frontal sinuses are palpated. No facial tenderness.

• Posterior pharynx: Tonsils normal in size. No oral lesions. No erythema.
• Focused examination of her head, eyes, and ears shows no additional abnormalities.
• Cardiac: Regular, rate, and rhythm with no murmurs.
• Abdomen: Benign. Soft, nontender.
• Neurologic and developmental exams: Grossly normal.
• Neck: Trachea midline. No significant lymphadenopathy. No use of accessory muscles of respiration.

Lungs: No evidence of retractions or a hyperinflated thorax. No changes to percussion or E-to-A changes. Normal I:E ratio. End-expiratory wheezing. No use of accessory muscles.

DIFFERENTIAL DIAGNOSIS

• Now that you have completed Sunita’s physical exam, you consider what information you will present to Dr. Law. Based on Sunita’s history and physical findings, what do you think are the most likely diagnoses? Asthma and Allergies.
• PRESENTING TO THE ATTENDING
• You summarize Sunita’s history, exam findings, and your differential diagnosis for Dr. Law, making sure to provide evidence to support your thought process.

“Sunita is a 6-year-old girl with eczema, who moved to the area three months ago. She is here today with a cough for two months that is worse at night, with activity, and with the colder weather. Since moving into her new house, she has also had nasal congestion. There is a family history of asthma. Her social history is pertinent for a dog in the home and carpets, but no smokers. Her grandmother recently came to live with them from India and had a normal TST.

“Her vital signs are normal. Her physical exam findings are notable for allergic shiners, clear nasal secretions, and boggy nasal turbinates but a normal oropharynx. Her lung exam is significant for diffuse, bilateral mild end-expiratory wheezing but she was not in respiratory distress and was able to speak in full sentences. She was not coughing during my exam.

• “My assessment is that Sunita likely has asthma, with environmental allergies playing a role. The onset of symptoms after a move to a new environment, her history of eczema, and the family history of asthma all fit. Sunita’s symptoms worsen in response to typical asthma triggers. She has physical findings typical of allergic rhinitis as well as wheezing on exam.”
• Dr. Law notes that you’ve made a compelling argument to support your assessment. She returns with you to the exam room and confirms the key elements of your history and exam.
• DIAGNOSIS
• Asthma is a chronic disorder of the airways that involves a complex interaction of airflow obstruction, bronchial hyper-responsiveness, and underlying inflammation.
• It is the most common chronic disease in children in developed countries. Epidemiologic risk factors include sex (males have higher prevalence), race/ethnicity (higher among non-Hispanic Black children), and socioeconomic status (higher among children whose family income is below the federal poverty level).

Diagnosis requires:

Symptoms of recurrent airway constriction by history and exam

Demonstration that airway constriction is at least partially reversible

Exclusion of other causes of airway obstruction

Dr. Law agrees that Sunita likely has asthma. She notes that a radiograph is not indicated, per the NHLBI guidelines. To confirm the diagnosis, she arranges for Sunita to have spirometry testing later that day and schedules a follow-up visit the next morning.

She asks you to read about asthma and to review the NHLBI Asthma Care Quick Reference. Dr. Law also mentions an additional resource from the Global Initiative for Asthma (GINA) which varies slightly compared to NHLBI for adults and children ages 6 and up. However, Dr. Law notes her institution primarily utilizes the NHLBI guidelines to initiate asthma management in pediatric patients.

TREATMENT

• Based on your classification, which of the following medications could be used in treatment?
• A. Short-acting beta2-agonist (albuterol)
• B. Inhaled corticosteroid
• C. Leukotriene modifier

D. Combined Long-acting beta2-agonist and inhaled corticosteroid (LABA-ICS)

TESTING

The next morning you review Sunita’s pulmonary function tests (PFTs—see image above). The results show a mild, reversible obstructive defect, consistent with the diagnosis of asthma.

MANAGEMENT

Sunita and her mother return that afternoon to clinic.

Dr. Law explains that Sunita’s history, exam, and PFT results all suggest a diagnosis of asthma:

“Asthma involves inflammation—or irritation and swelling—of the airways in the lungs. The inflammation can cause the airways to get tight or narrow, leading to cough, wheezing, and difficulty breathing.”

Dr. Law recommends that Sunita start treatment with a low-dose inhaled corticosteroid twice a day to keep the inflammation under control and albuterol as needed to relax the airways.

She then discusses an Asthma Action Plan for Sunita (See an example of an asthma action plan).

Because Sunita has signs and symptoms of allergies, Dr. Law also recommends starting an oral antihistamine.

She asks to see Sunita in one month but advises the family to return sooner if Sunita develops signs of respiratory distress.

ALLERGIES

Dr. Law sends prescriptions for beclomethasone, albuterol, and loratadine to the pharmacy.

You ask Dr. Law about the relationship between allergies and asthma.

FOLLOW-UP

Sunita and her family return a few weeks later.

You ask Sunita, “How has your cough been? Have you had any trouble using your inhalers?”

Mrs. Patel confirms Sunita’s coughing seems to be much better. She has been awakened at night due to her cough only once in the past few weeks. She has used her albuterol inhaler twice.

Mrs. Patel says she feels fairly confident about Sunita’s treatment plan, though somewhat concerned that her daughter might be limited by having a chronic illness.

Dr. Law explains that the goal of asthma management is to allow full participation in all activities, with no limitations—and that they will work together to adjust Sunita’s treatment as needed to make sure she can do everything she wants to do.

Given that Sunita is doing well, Dr. Law recommends continuing her current medication plan and returning for another visit in 4 weeks to assess her asthma control.

Sunita and her mother thank you for helping in her care. Sunita gives you a drawing as a parting gift.

Essay Elements:

One to three pages of scholarly writing in paragraph format, not counting the title page or reference page

Brief introduction of the case

Identification of the main diagnosis with supporting rationale

Identification of at least two additional differential diagnoses with brief rationale for why these were ruled out

Diagnostic plan with supporting rationale or references