In the scenario presented to us in the Bate’s video, we saw Devin, a 14-year-old male patient with a chief complaint of cough, trouble breathing, and a recent cold. He reports that he cannot catch his breath and that his chest felt as if it was closing in on him. Devin’s mother gives a brief history of his current symptoms reporting a subjective fever and coughing episodes that occur two times were week on average. She also explains that he has been suffering from dry skin with rashes and patches to his body.
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What preliminary diagnoses are you considering at this time?
- Childhood asthma
- Pneumonia
- Vital upper respiratory infection
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What areas of physical examination are important for this patient?
- Vital signs: normal temperature, heart rate 90 bpm, respirations 20/min, blood pressure 120/75 mmHg, height: 5’3, weight: 69 kg, BMI: 27
- Skin inspection: dry with rashes and patches (commonly seen in patients with asthma)
- Pharynx (tonsils): enlarged (can be contributed to obesity and results in snoring)
- Lungs: intercostal retractions present, bilateral expiratory wheezing with prolonged inspiratory expiratory ratio with use of accessory muscles
- Heart: normal assessment
- Abdomen: normal assessment
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What are your three diagnostic considerations in order of priority?
- Childhood asthma: Due to Devin’s recent symptoms of a cold, this may trigger an asthma exacerbation. His positive history of a nighttime cough, intermittent shortness of breath, and trouble breathing with exercise can help point to this diagnosis. Identifying if he has been experiencing nocturnal symptoms that contribute to sleep disturbances and daytime sleepiness can also be associated with acute asthma exacerbations (Trivedi & Denton, 2019).
- Bacterial or Community acquired pneumonia: Common symptoms for bacterial pneumonia include a productive cough, fever, chest pain, fatigue, and shortness of breath (Nathan et al., 2020). At this time, bacterial pneumonia can be ruled out as Devin has not been experiencing most of these symptoms.
- Upper respiratory infection: In viral URIs, an individual may exhibit nasal congestion, cough, rhinorrhea, sneezing, low-grade fever, etc. (Mann et al., 2021). Devin seems to have experienced a few of these symptoms which may have triggered an acute asthma exacerbation.
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List three next steps in your diagnostic workup
- Pulse oximetry: Determines if oxygen saturation is within normal limits.
- Chest x-ray: Confirms if there is consolidation (can help rule out pneumonia). In Devin’s case a chest radiograph would not be warranted because of he does not display the symptoms associated with pneumonia.
- Peak flow meter: Is commonly used in individuals with chronic asthma and can be useful when assessing pulmonary function.
As a nurse practitioner it is essential we conduct an in-depth and comprehensive assessment to determine the cause of Devin’s symptoms. Differential diagnoses and ruling out other causes can help steer us towards an accurate diagnosis of childhood asthma and identify proper interventions when treating this condition. A step-by-step approach is necessary to prevent us from missing any crucial information, both subjective and objective, during the interview and assessment processes.
