Patient Name: Patel, Sunita
Age: 6
Chief Compliant: Coughing for 8 weeks. No improvement and maybe worsening.
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
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
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.
Physical Exam
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
Asthma (A)
- The features of Sunita’s cough as well as her past history, family history, and the finding of end-expiratory wheezing on exam all support a diagnosis of asthma.
Allergies (B)
- Chronic nasal congestion, particularly in the context of a move to a new home, plus allergic shiners, clear nasal secretions, and edematous (“boggy”) turbinates are consistent with a diagnosis of environmental allergies.
The following are less likely:
Atypical or viral pneumonia (C)
- Sunita’s course is prolonged relative to what you would expect for infectious pneumonia.
Sinusitis (E)
Signs and symptoms of acute bacterial sinusitis in younger children include:
- URI symptoms with persistent illness (nasal discharge of any kind), daytime cough, or both lasting for more than 10 days but less than 30 days.
- Worsening cough (or new onset of nasal discharge, daytime cough, or fever after initial improvement).
- Severe symptoms (high fever and purulent nasal discharge) for at least 3 days.
Main Diagnosis: Asthma
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
Expectations
Essay APA format
- Brief introduction of case study
- 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
- A specific treatment plan supported by recent clinical guidelines.
- Length: A 700 words, not including references and title page
- Citations: At least one high-level scholarly reference in APA format from within the last 5 years
Grading RURBIC
Identifies main diagnosis with rationale: Identifies main diagnosis and rationale for selection based on cues, problem statement, history and physical findings from the case. The main diagnosis is supported by clinical guidelines or peer-reviewed references.
Two differential diagnoses in addition to main diagnosis: Clearly identifies two differential diagnoses for patient presentation with brief rationale for not being main diagnosis. Rationale is supported with clinical guidelines or peer-reviewed references.
Diagnostic Plan: Identifies the lab, radiology, or other tests needed for the main diagnosis based on most recent clinical practice guidelines or peer reviewed resources. Did not include excessive or non-pertinent tests.
Treatment Plan: Lists the elements of an initial treatment plan for the main diagnosis. Includes medication name, dosage and frequency; patient/family education; appropriate follow up plan; and hospitalizations and consults when appropriate based on appropriate clinical practice guidelines.
Peer reviewed references and clinical guidelines: The student uses at least TWO published clinical guidelines or evidence from peer reviewed professional journals that are not textbooks. The student uses primary sources (the guidelines themselves or the original published work). The chosen supportive literature is written for providers and was published in the last 5 years, or last 10 years if the guideline has not been updated.