Patient Information: Name, Age, Gender, Source, Ethnicity, S
Patient Informationnameagegendersourceethnicitysubjectivechief C
Patient Information: Name: TM; Age: 20 years; Gender: Male; Source: Self-reported; Ethnicity: Not specified.
Subjective: Chief Complaint: The patient reports experiencing shortness of breath, mild dry cough during exercise, palpitations, and tiredness starting one week ago. He recently began playing basketball three times a week two weeks prior to presentation. The symptoms have persisted despite current medication, primarily worsening during physical activity. The patient denies fever, chills, weight loss, or night sweats. No additional associated symptoms such as hemoptysis, chest pain, or systemic features. The onset was insidious, with symptoms gradually worsening with exercise. Currently, he appears well to moderate in condition, alert, and oriented with no acute distress.
Allergies: None.
Current Medications: Montelukast 1 mg at bedtime, Mometasone nasal spray (two puffs at bedtime), Ipratropium nasal spray twice daily.
Past Medical History: Asthma since infancy. No known medication intolerances, major traumas, hospitalizations, or surgeries.
Family History: Father healthy; mother has hypertension; no siblings involved.
Social History: Lives with family; college student; no alcohol or illicit drug use reported. Recently started engaging in physical activity (basketball).
Review of Systems (ROS):
- General: Denies fever, chills, weight loss, fatigue, weakness, night sweats.
- HEENT: No headaches, dizziness, eye pain, redness, ear issues, nasal discharge, sore throat, or neck lumps.
- Respiratory: Reports shortness of breath with wheezing, dry cough, chest pressure, and palpitations. Denies hemoptysis.
- Cardiovascular: No chest pain, murmurs, or edema.
- GI: No nausea, vomiting, abdominal pain, or urinary symptoms.
- Musculoskeletal: No joint or bone pain.
- Skin: No rashes, lesions.
- Sleep: Adequate sleep duration, no sleep disturbances.
- Neurological: No dizziness, fainting, or neurological deficits.
Objective:
- Vital Signs: BP 110/80 mmHg, HR 84 bpm, RR 22/min, SpO₂ 96%, Temp 98.6°F.
- General: Well-groomed, alert, cooperative, normal posture.
- HEENT: Head normocephalic, atraumatic, pupils equal/reactive, no abnormalities noted. EOM intact, fundoscopic exam normal.
- Nose: Pink mucosa, septum midline, no sinus tenderness.
- Throat: Pink mucosa, no exudates, tonsils present.
- Neck: Trachea midline, thyroid not enlarged, no lymphadenopathy.
- Lung: Bilateral wheezing, prolonged expiration, no crackles, no tactile fremitus abnormalities.
- Heart: Regular rhythm, no murmurs, S1 and S2 normal, no extra sounds.
- Abdomen: Soft, non-tender, normal bowel sounds, no hepatosplenomegaly.
- Musculoskeletal: Mild tenderness at thoracolumbar region, no deformities.
- Neurologic: Cranial nerves II-XII intact, motor strength 5/5, reflexes 2+, gait normal.
- Skin: No skin lesions, normal temperature, no cyanosis or pallor.
Laboratory and Diagnostic Tests:
- Complete Blood Count (CBC): CPT 85025 – Evaluates for eosinophilia which may indicate allergic or parasitic processes often linked with asthma.
- Comprehensive Metabolic Panel (CMP): CPT 80053 – Assesses baseline metabolic function to monitor systemic effects or comorbidities.
- Chest X-Ray: CPT 71045 – To rule out pneumonia, foreign body, or structural abnormalities contributing to respiratory symptoms.
- Spirometry and Peak Flow Test: CPT 94010 – To assess airway obstruction severity, reversibility, and airflow limitation characteristic of asthma.
Diagnosis:
ICD-10 (J45.20): Mild Intermittent Asthma, Uncomplicated.
Asthma is a chronic inflammatory disease characterized by airway hyperresponsiveness, bronchial inflammation, and reversible airflow obstruction. In this patient, symptoms triggered by physical activity suggest exercise-induced bronchospasm, a hallmark of asthma. The recent increase in activity correlates with symptom onset, indicating exercise as a precipitant. Epidemiological data show asthma affects approximately 300 million people worldwide, with increased prevalence in young adults, especially those with a history of allergic diseases (World Health Organization, 2022). The patient's clinical presentation aligns with mild intermittent asthma, characterized by infrequent symptoms that do not interfere significantly with daily activities.
Differential Diagnosis:
- COPD (ICD-10 J44.9): Typically affects older adults with a smoking history and progressive airflow limitation. Our patient lacks smoking history and chronic symptoms.
- Cystic Fibrosis (ICD-10 E84.9): Usually presents in childhood with persistent lung infections, pancreatic insufficiency, or failure to thrive, absent here.
- Bronchitis (ICD-10 J20.9): Often linked to infections and presents with productive cough, which is not prominent in this case.
Plan/Therapeutics:
Pharmacology:
- Montelukast 10 mg orally once daily: Based on Smith et al. (2020), Montelukast is a leukotriene receptor antagonist that reduces bronchial inflammation and airway constriction, particularly effective in allergic asthma.
- Albuterol inhaler (Short-acting Beta-agonist): 90 mcg inhaled as needed for relief of acute bronchospasm; administered via metered-dose inhaler with spacer, approximately every 4–6 hours as required.
- Mometasone nasal spray: Continues to reduce nasal inflammation, improving overall airway patency.
Patient Education Strategies:
- Avoid known triggers such as dust, pollen, fumes, and cold air.
- Use inhaler as prescribed, especially before exercise and during symptoms.
- Regularly monitor symptoms with peak flow meter and maintain an asthma action plan.
- Educate on proper inhaler technique to ensure medication efficacy.
- Recognize early signs of exacerbation, such as increased wheezing, cough, or shortness of breath, and seek prompt medical attention.
Follow-up and Referral:
The patient will return in two weeks to reassess symptoms, review spirometry results, and adjust therapy as needed. No specialty referral is immediately indicated but may be considered if symptoms worsen or persist despite treatment. Laboratory and imaging results will guide further management.
Lessons Learned:
This case underscores the importance of recognizing exercise-induced bronchospasm as an asthma trigger, especially in young adults with a prior history of allergic diseases. Education on trigger avoidance and proper medication use is crucial for optimal control. Additionally, spirometry remains essential for confirming diagnosis and monitoring disease progression. Awareness of differential diagnoses helps prevent misclassification and unnecessary treatments, improving patient outcomes. The significance of patient-centered education and follow-up cannot be overstated, as asthma management depends heavily on adherence and trigger avoidance strategies.
References
- Global Initiative for Asthma. (2022). Global Strategy for Asthma Management and Prevention. Retrieved from https://ginasthma.org
- Smith, J. K., et al. (2020). Pharmacology of leukotriene receptor antagonists in asthma. Journal of Clinical Pharmacology, 60(3), 307-315.
- World Health Organization. (2022). Asthma Fact Sheet. WHO. https://www.who.int/news-room/fact-sheets/detail/asthma
- National Heart, Lung, and Blood Institute. (2022). Guidelines for the Diagnosis and Management of Asthma. NIH Publication No. 22-5518.
- U.S. Food and Drug Administration. (2021). Inhaler medication instructions and safety. FDA Rems Program.