Asthma: Initial Inspection, Diagnosis, Treatment

Chief Complaint

Asthma is the chief complaint. The 15-year old girl has a history of allergies but her claims do not suggest presence of allergies.  People with allergies tend to have itchy eyes and skin, nasal congestion, sneezing, wheezing, and rash. The girl has not shown these symptoms. Her eyes, head, nose, ears, and throat are normal.  However, there is a decrease in air movement in her chest and high-pitched whistling on expiration in all her lobes. Asthma is a condition whereby the airways of a person narrows, swells, and produces extra mucus. The fact that the girl has shortness of breath and a nonproductive nocturnal cough clearly shows that the girl has asthma. The presence of asthma is also proved by the girl’s claims that she used to only have shortness of breath during extreme exercise. Asthma symptoms vary from person to person. Some people can have infrequent asthma attacks and show symptoms at certain times like when they are exercising (Horak et al. 2016), which is the case with this 15-year old girl.

Differential Diagnosis Listing

It is possible to confuse one illness with another. It is thus important to be careful while diagnosing an illness. In this case, I have based my conclusion on the girl’s complain of shortness of breath and a nonproductive nocturnal cough, attacks during extreme exercise, and a decrease in air movement in her chest and high-pitched whistling on expiration in all of her lobes.

Treatment Plan

There is no cure for asthma and so it will be important to develop a treatment plan that will enable the girl live successful with the condition (Bacharier et al., 2008; Rai et al., 2007). My treatment plan will involve vaccination for pneumonia and influenza and education of the girl on asthma triggers and importance of avoiding them, importance of taking prescribed medication, and how to monitor her breath, and identify and treat attacks. Furthermore, I will also give her a quick-relief inhaler and educate her and her parents on how to use it.