10/9/24, 11:12 Paisley Ward i
AM Human
Paisley Ward 16 year old
HPI: Patient with cough for the last 3 weeks and shortness of breath that started 3
days ago. Cough is persistent and worse at night. Denies coughing up sputum. She is
not currently taking anything to relieve symptoms. Shortness of breath occurs just
while walking and mother expresses that it also occurs while she is talking. Relief of
shortness of breath occurs when patient rests for a few minutes. Shortness of breath
reportedly only lasts about a minute per patient. Reports that 3 weeks ago had
congestion and runny nose that has now subsided. Other reported symptom includes
chest tightness/heaviness however does deny chest pain. Patient reports that
neighbors smoke within the building and she is able to smell it throughout the
building. Patient denies any allergies or pets within the home. Patient has a history of
reactive airway along with shortness of breath in the past that has self-resolved and a
history of eczema. She has also been experiencing more stress lately due to her parents
hectic work schedules.
Differential Diagnosis:
• Acute asthma exacerbation
• Paradoxical vocal cord movement
• Bacterial pneumonia
• Viral pneumonia
• Panic disorder
Problem Statement: P.W. is a 16-year-old female who presents with a 3 week history of
non-productive cough and 3 day history of shortness of breath. Cough is worse at night
and shortness of breath occurs while talking and walking. Relieving factors include
rest. Denies prescriptions and OTCs. She reports associated chest tightness. Past
medical history is pertinent for reactive airway. Upon exam, breathing is labored with
expiratory wheezes, tachypnea, and subcostal retractions. Recent stressors include
parents work schedules. She also is exposed to secondhand smoke within her housing
building. Recent 3-week history of congestion and runny nose but denies fevers. On
physical exam, patient has labored breathing with tachypnea, respirations of 26 per
minute, bilateral expiratory wheezing, and subcostal retractions.
Testing:
• X-ray chest PA and lateral view
• Peak expiratory flow rate (PEFR)
Management Plan
Diagnostic Tests
• X-ray chest PA and lateral view showed pulmonary hyperinflation and normal
cardiac silhouette
about:bl 1
AM Human
Paisley Ward 16 year old
HPI: Patient with cough for the last 3 weeks and shortness of breath that started 3
days ago. Cough is persistent and worse at night. Denies coughing up sputum. She is
not currently taking anything to relieve symptoms. Shortness of breath occurs just
while walking and mother expresses that it also occurs while she is talking. Relief of
shortness of breath occurs when patient rests for a few minutes. Shortness of breath
reportedly only lasts about a minute per patient. Reports that 3 weeks ago had
congestion and runny nose that has now subsided. Other reported symptom includes
chest tightness/heaviness however does deny chest pain. Patient reports that
neighbors smoke within the building and she is able to smell it throughout the
building. Patient denies any allergies or pets within the home. Patient has a history of
reactive airway along with shortness of breath in the past that has self-resolved and a
history of eczema. She has also been experiencing more stress lately due to her parents
hectic work schedules.
Differential Diagnosis:
• Acute asthma exacerbation
• Paradoxical vocal cord movement
• Bacterial pneumonia
• Viral pneumonia
• Panic disorder
Problem Statement: P.W. is a 16-year-old female who presents with a 3 week history of
non-productive cough and 3 day history of shortness of breath. Cough is worse at night
and shortness of breath occurs while talking and walking. Relieving factors include
rest. Denies prescriptions and OTCs. She reports associated chest tightness. Past
medical history is pertinent for reactive airway. Upon exam, breathing is labored with
expiratory wheezes, tachypnea, and subcostal retractions. Recent stressors include
parents work schedules. She also is exposed to secondhand smoke within her housing
building. Recent 3-week history of congestion and runny nose but denies fevers. On
physical exam, patient has labored breathing with tachypnea, respirations of 26 per
minute, bilateral expiratory wheezing, and subcostal retractions.
Testing:
• X-ray chest PA and lateral view
• Peak expiratory flow rate (PEFR)
Management Plan
Diagnostic Tests
• X-ray chest PA and lateral view showed pulmonary hyperinflation and normal
cardiac silhouette
about:bl 1
