Discussion Peer/Participation Prompt Due Sunday by 11:59 pm
Instructions:
Please respond to two peers’ posts regarding their differential diagnosis list and/or plan.
What did you find interesting about their response?
How did their differential diagnosis list or plan compare to yours?
Do you agree with their plan and recommendations?
Responses need to address all components of the question, demonstrate critical thinking and analysis and include peer-reviewed journal evidence to support the student’s position.
Please be sure to validate your opinions and ideas with citations and references in APA format.
I will provide both peer post for response please use updated references for each separate post
peer#1
Sarah Johnson
Jun 27, 2022Jun 27 at 1:37pm
Week 8 DB
Our patient is an 11 year old female who is following up after a hospitalization for asthma
Pertinent Positives
Pertinent positives include camping trip with girl scout trip that included hiking, camping, and campfires in evening. Symptoms began with shortness of breath and wheezing around campfire but then increased to being unable to catch her breath during the day and had increasing asthma attacks. She has known asthma and used her proair inhaler. She was hospitalized for 2 days for acute respiratory distress, started on continuous nebulizer treatments, Medrol dose pack, and azithromycin 500 mg PO daily-2 days remaining. Using Mucinex 1-2 tables PRN secretions Currently using inhaler twice daily, has nonproductive intermittent cough. Her family history is positive for hypertension and DM. Her bilateral nasal turbinates are slightly swollen but patent. Her mother feels her asthma has not been under control since leaving the hospital.
Pertinent Negatives
Pertinent negatives include: no current chest tightness or SOB, no exposure at home to tobacco, illicit drugs, or alcohol. She is negative for fever, chills, loss of appetite, difficulty sleeping. Her physical exam is normal including negative for nasal congestion, no SOB, no difficulty breathing, wheezing, pain on inspiration, reflux, joint pain, weakness, numbness, mood changes, anxiety, polydipsia, polyphagia, and seasonal allergies. Her physical exam is negative for acute distress, eye exam negative, ENT exam shows midline septum, pink moist mucous membranes, no inflammation or lesions to throat, tonsils WNL. Her cardiovascular exam is negative for murmurs, gallops, rubs. She has no cyanosis, clubbing, or edema with normal capillary refill. Her lungs are negative for wheezing and rhonchi and are clear bilaterally. Her chest rise is symmetrical, she is negative for use of accessory muscles. Her GI exam is negative for tenderness and distention. Her musculoskeletal exam is normal and she is negative for tenderness, joint instability. Her skin is negative for scaling, redness, breaks on skin. Her neuro exam is normal, her psychiatric exam is normal. Lymph nodes are negative for swelling.
Other Information
Other information I would want includes: known triggers such as outdoors, do symptoms increase with exercise, if they have an asthma action plan, and what seems to help her symptoms and worsen symptoms. I want to know how many days per week she has an attack and if she has ever seen an allergist since her asthma seems to be exacerbated outdoors (Sawicki & Haver, 2021). I would also want to know if she was taking any allergy medication while up at camp-even though she specified no seasonal allergies, this would be important to rule out. It would be helpful to have immunization information as well to determine if she is current on vaccination schedule including influenza. It would be important to see the patient use her inhaler to ensure correct usage (Global Initiative for Asthma, 2022).
Differential Diagnoses
Moderate persistent asthma with acute exacerbation J45.41
Allergic rhinitis J30.9
Cystic Fibrosis E84.0
Diagnostics
This patient was diagnosed with asthma at some point in the past, however if records are not available, it would be good to ensure this diagnosis is accurate. Studies that could be considered are CBC to ensure patient is not anemic, sweat test to rule out cystic fibrosis, and pulmonary function testing (Garzon-Maaks et al., 2020).
Plan for Priority Diagnosis
Therapeutics
GINA guidelines recommend treatment with both inhaled corticosteroid and short acting beta agonist inhalers (Global Initiative for Asthma, 2022). This patient needs to be started on an inhaled corticosteroid (also known as an ICS). Prescriiption will be written for budesonide aerosol powder 180 mcg/day (Garzon-Maaks et al., 2020).
Education
Education should be provided both orally and in writing on how to use the inhaled corticosteroid as well as the albuterol inhaler. NSAIDS such as ibuprofen should be avoided as they can worsen asthma. An asthma action plan should be developed and written for all patients with asthma as well as a supply of medications for both home and school (Global Initiative for Asthma, 2022). She should also always rinse her mouth after the use of her inhaled corticosteroid to prevent thrush (Garzon-Maaks et al., 2020).
Collaboration
I would also refer this patient to an allergist as her symptoms increased while being outside in both campfire smoke and hiking.
References
Garzon-Maaks, D. L., Starr, N. B., Brady, M. A., Gaylord, N. M., Driessnack, M., & Duderstadt, K. (2020). Burns’ pediatric primary care (7th ed.). Elsevier.
Global Initiative for Asthma. (2022). Global strategy for asthma management and prevention [PDF]. https://ginasthma.org/wp-content/uploads/2022/05/GINA-Main-Report-2022-FINAL-22-05-03-WMS.pdf (Links to an external site.)
Sawicki, G., & Haver, K. (2021). Acute asthma exacerbations in children younger than 12 years: Overview of home/office management and severity assessment (R. A. Wood, G. Redding, & E. TePas, Eds.). UpToDate. Retrieved June 20, 2022, from https://www.uptodate.com/contents/acute-asthma-exacerbations-in-children-younger-than-12-years-overview-of-home-office-management-and-severity-assessment?search=asthma%20exacerbation%20in%20children%26source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1 (Links to an external site.)
peer#2
Nick Castaneda
Jun 27, 2022Jun 27 at 10:53pm
Pertinent Positives:
Hospitalized for two days due to asthma exacerbation after camping trip/campfire
The mother reports symptoms are uncontrolled since hospital discharge
Using inhaler BID
Still having a nonproductive cough
History of 4 previous hospitalizations due to asthma
Mother with history of HTN Father with DM.
Pertinent negatives:
Physical exam wnl
ROS wnl
Additional information that should be asked can include:
Are the patients familiar with what their asthma triggers are? Any allergies to animals, dust, foods, pollen? Is the patient familiar with how to prevent future attacks? The patient’s immunization history should be asked. Are they flu vaccinated or COVID? Any family history of allergies, sinusitis, nasal polyps, or asthma? The patient should also be asked what else helps besides inhaler use. Their exacerbations history, including rapidity of onset, duration, frequency, severity, number of exacerbations in a year, and usual pattern management?
Differential diagnoses can include allergic rhinitis, sinusitis, vocal cord dysfunction, or viral bronchiolitis. Viral bronchiolitis causes bronchioles to become acutely injured and inflammatory. A viral infection is to blame for it, most commonly respiratory syncytial virus. Although this disorder can affect people of any age, tiny infants are often the only ones who show significant symptoms. In this instance, the patient is already 11 years old. This might also show signs of respiratory distress such as tachypnea, nasal flare-ups, and retractions.
The ultimate goal is to prevent symptoms and minimize morbidity from acute episodes. It should be like this patient’s asthma is not currently controlled. It sounds like this patient has mild persistent asthma, and their treatment plan needs to be stepped up. They’re now using their SABA BID. Inhaled short-acting beta-2 agonists are the standard emergent treatment for acute asthma exacerbations. Treating children with a moderate-to-severe asthma exacerbation with ipratropium bromide and a beta-agonist is recommended. Long-acting beta-adrenergic drugs found in certain inhalers or MDI should be used for maintenance treatment. These drugs will aid bronchodilation to facilitate easier breathing (Billington, 2017).
Reference:
Billington, C. K., Penn, R. B., & Hall, I. P. (2017). β2 Agonists. Handbook of experimental pharmacology, 237, 23–40. https://doi.org/10.1007/164_2016_64
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