Symptoms and Diagnostic Reasoning: Heddy Ramiro Case

Summary of Case Study

8-year-old Heddy Ramiro presents to your clinic with her mother who is wondering if anything can be done about Heddy’s nasal congestion and cough.

Symptom Analysis Questions

In order to identify the possible causes of illness, the doctor has to ask the child and her caretaker for information pertaining the incident. Here are several important factors to ask about during the visit (What questions will the doctor ask about, 2015):

• Duration: For how long did the child have nasal congestion and cough? Did she have it before? What was the cause of it last time?
• Severity: How bad are the symptoms? Are they constant, or infrequent?
• Location: Besides the nose and throat, what other parts of the body are affected? How deep is a cough?
• Causes: What triggers the coughing? Are there any factors that make the coughing better or worse?
• Associated symptoms: Were there any additional symptoms, like fever, headache, cold skin, dizziness, and weakness, etc.?
• Timing: How soon was the patient brought to receive medical attention? When did the first symptoms appear? Did the severity of the symptoms change overtime?
• Past medical history: Does the child have any current medical problems? If so, what are they? Was Heddy ever hospitalized? Did she ever undergo X-Ray tests?
• Past surgical history: If the child ever received an operation which could potentially influence the nasal canal congestion, it should be asked about.
• Medications: Ask about what medications the child is currently receiving.
• Allergies: Find out if Heddy has any allergies or adverse reactions. These factors may have contributed to her disease.
• Smoking, drug, and alcohol history: Although it is unlikely for the child to be smoking at such a young age, but it is possible that her parents are, turning their child into a passive smoker.
• Screening tests: Find out of the child had any screening tests to check for possible diseases, and what the results were.

Focused History of Presenting Illness

Here is the list of focused history questions:

• Medical Hx: lung problems, lung murmurs and sounds, infections, chronic respiratory diseases, influenza, surgeries, tonsillitis?
• Medications: List the prescript medications the child is taking, over-the-counter standard solutions to common cold, complementary and supplementary medicines. – Allergies: List any allergies to drugs, food, or influenced by the environment, such as allergies to pollen, animals, smoke, chemical compounds, etc.
• Family history: Does the family have a predisposition to respiratory diseases? Hereditary diseases? Allergies?
• Personal and Social history: Analyze the situation at home, environmental exposure to toxins, smoking in the family, flowers and plants available at home, any house animals, aerosols, etc.
• Screening: State if the patient had recently undergone any of these tests: laryngoscopy, Biopsy, X-Ray, Spirometry, Allergy tests, Sputum test of Pulmonary Function tests.
• Explanatory Model: Ask the patient and her parent what could have caused the disease.

Review of Systems

Aside from the reported ailments, such as the congested nasal tract and cough, the doctor must check and identify any abnormalities o the child’s systems. These are:

• General: Anxiety, weight loss or gain, appetite, fatigue, weakness, fever
• Skin: Sweating, color changes, swelling?
• Respiratory: SOB, cough, hemoptysis, DOE, wheezing?
• Cardiovascular (CV): previously reviewed above. Anything else going on?
• Gastrointestinal (GI): nausea, vomiting, trouble swallowing, heartburn, appetite, change in bowel habits, food intolerance, excessive belching or passing gas?

Physical Examination

After initial and in-depth questions were answered, the doctor must proceed with the physical examination. Although the number of examination procedures may vary from one case to another, these are the general procedures in case of respiratory and lung diseases:

• VS and general appearance, level of distress, Height, weight (gain or loss) Body Mass Index (BMI).
• Inspect and palpate skin and nails. Inspect eyes and eyelids. Conjunctiva, mucous membranes, soft palate, lips and tongue for central cyanosis.
• Carotid and jugular vein assessment. Trachea midline. Observe for Jugular venous distention (JVD), palpate carotid pulses (after auscultation) and lymph nodes.
• Auscultate carotids.
• Inspect and palpate thorax heaves, thrills, and point of maximal impulse (PMI). Chest expansion symmetry.
• Auscultate heart and lungs.
• Percuss lungs.
• Palpate all peripheral pulses and assess lower extremities for peripheral vascular disease, edema.
• Inspect, auscultate and palpate abdomen for abdominal pulsations, aortic bruits, pain, masses.
• Inspect extremities.

Hypotheses

Four hypothetical diseases match the initial descriptions given in the case study. These are:

• The common cold
• Bronchitis
• Child asthma
• Laryngitis.

Common Cold

Common Cold is one of the most frequent diseases ever encountered by health professionals. The symptoms of this disease include (Common cold diagnosis, 2016):

• A dry or a wet cough
• A runny nose or a nasal congestion
• A sore throat

Sometimes, the common cold is followed by fatigue, headaches, muscle aches, general weakness, and loss of appetite. Coughing and a sore throat are present in every second case. Fever is much less frequent, especially among adults. Young children and adults with a weak immune system may be more susceptible to it, which is why it is important to find out whether the child has a fever or not. Fever might be an indication of influenza – a disease that bears many similarities to the common cold. However, they are not the same, as the common cold is considered a much milder disease that does not endanger a person or requires hospitalization (Common cold diagnosis, 2016).

Patients tend to exaggerate their symptoms when they are infected with a rhinovirus. The findings are, usually, less drastic than they are portrayed to be. Temperature measurements vary between 36.6 °C and 37°C, very rarely going up to 39°C, usually in infants and young children. The nose tends to be red and moist, dripping nasal fluids. The discharge is typically clear, however, yellow or green colors are not uncommon. Usually, the color of nasal fluids turns white after a couple of days, filled with dead white blood cells. These are not signs of a viral infection unless they appear for longer than a week. Alternatively, the nasal canal is congested, and the patient has trouble breathing through it (Common cold diagnosis, 2016).

Even if a case of a sore throat is present during the initial examination, the pharynx often appears to be normal, without any visible exudate, ulceration, or erythema. If any damage is present, it is usually in the form of a marked erythema, edema. In that case, small vesicles could be found in the oropharynx. Should conjunctivitis or polyps be found in the nasal mucosa, the doctor must consider infection with adenovirus, herpes simplex, mononucleosis, diphtheria, or GAS. Cervical lymph nods are mildly enlarged. It is likely to find rhonchi during the auscultation examination of the chest (Common cold diagnosis, 2016).

Bronchitis

Bronchitis often develops from a simpler respiratory infection, such as the common cold or influenza, if those are left untreated for a period of time. During bronchitis, the patient suffers an inflammation of bronchial tubes. This interferes with breathing. The coughing is deep and often followed by thickening mucus, which may be of white, yellow, or green color.

Common symptoms include (Bronchitis, 2014):

• Deep coughing
• Production of sputum of various colorations, in rare cases outlined with red blood. Sometimes this happens when a patient tries to cough too hard.
• Feelings of discomfort and mild pain in the chest area
• Fatigue and shortness of breath
• Mild fever, freezing.

Findings during the physical examination in acute bronchitis can vary greatly. Sometimes, pharyngeal erythema can be found, while in other cases investigations reveal localized lymphadenopathy, rhinorrhea, murmurs and wheezes that change their position and intensity after successfully coughing out mucus, coarse rhonchi, etc. In severe cases, high-pitched sounds within the lungs, diffuse diminution, wheezes, and inspiratory stridor can be observed. They indicate the obstruction of the trachea, or a major bronchus, which is dangerous. These findings often justify vigorous coughing and suctioning. In particularly dangerous cases, intubation and tracheostomy are required (Bronchitis, 2014).

A doctor must check for a sustained heave along the left sternal border. It may be an indication of right ventricular hypertrophy. People with chronic bronchitis tend to have it. Check the fingers – any clubbing or peripheral cyanosis could be a sign of cystic fibrosis. Mycoplasmal pneumonia is usually followed by bullous myringitis. Conjunctivitis, rhinorrhea, and adenopathy are common signs of adenoviral infection (Bronchitis, 2014).

Child Asthma

Asthma is a very common disease in children and is viewed as a source of most chronic respiratory ailments. Although asthma can happen at any age, most afflictions begin before age 5. Many factors contribute to the development of asthma, among them being the genetic predisposition, race, hereditary vulnerability, allergies, exposure to aerosols and tobacco smoke, and many others. The most common symptoms of asthma are (Asthma in children and infants, 2016):

• Frequent coughing, which may occur during sleep, talking, eating, or physical activities, for no apparent reason. Often, coughing may be the only symptom of asthma.
• Low stamina. Children afflicted with asthma are typically weaker and less resilient than their healthy counterparts. Asthmatics need more rest to catch their breath.
• Rapid, shallow breathing patterns
• Chest pains and feelings of tightness when breathing
• Whistles and wheezes during breathing, particularly when the air leaves the lungs
• Shortness and loss of breath
• Dark circles and bags under the eyes
• Constant tension around the neck or chest
• Headaches that occur due to poor oxygen supply
• General fatigue and weakness of the body
• Poor appetite, no desire for food.

What makes asthma harder to detect is the fact that symptoms vary greatly from person to person and from time to time. They can be easily confused with the common cold or other respiratory diseases.

Manifestations of asthma differ based on how acute the disease is. It is very important to diagnose the level of acuity with precision, as a wrong diagnosis may endanger the patient’s life. Examination findings depend on whether the manifestations of asthma are mild, moderate, or severe. The worst-case scenario is an imminent respiratory arrest, which may lead to death (Asthma in children and infants, 2016).

• Mild episodes: the patient is breathless after physical activities, heart rate is at 100 beats per minute, an exaggerated pulse is not present. Wheezes are present during the inspection of the chest, and oxyhemoglobin saturation with room air is below 95%. The patient is capable of breathing while lying down and can talk in sentences.
• Moderate episodes: Respiratory rate is increased, and breathing is often forceful. Heartbeat rate varies between 100-120 beats per minute. Exaggerated pulse is present. The patient may experience a short of breath while talking and has to assume a sitting position in particularly severe incidents. Oxyhemoglobin saturation is between 90-95%
• Severe episodes: the patient is breathless even when not doing anything, is agitated, and can barely talk, often communicating in words rather than sentences. Breathing rate is over 30 breaths per minute, and heartbeat rate is way above 120 bpm. Oxyhemoglobin saturation rate is 81-90%. In order to keep breathing, the patient is forced to hunch forward, removing any pressure from the chest.

Laryngitis

Laryngitis is often called the disease of talkative people. It occurs when a person’s vocal cords or voicebox becomes inflated due to a viral infection, damage, or overuse. Depending on the nature of the infection, it can be chronic, or short-term.

Common symptoms of laryngitis are (Laryngitis, 2016):

• Weakened voice
• Dry or a sore throat
• Dry cough
• Scratchy and irritated feelings around the throat

While these symptoms are always present, laryngitis is also followed by fever, nasal congestion, and a cough, which means that this disease is also a likely diagnosis for Heddy, especially if she is a talkative child.

Laryngitis is fairly easy to diagnose based solely on the symptoms, which differ largely from most other upper respiratory system diseases. Physical examination of the larynx is not always necessary. Still, should the doctor decide to proceed with the examination, a patient would have to be examined thoroughly. Laryngoscopy, however, should be performed at all times, in order to make sure there are no signs of cancer, papillomas, vocal nodules, etc. The patient may not experience any other signs of illness aside from the upper respiratory tract inflation. A mirror is used to perform a visual examination of the larynx. Otherwise, a flexible tube with a camera called the nasolaryngoscope can be used to view erythema and edema of the vocal cords, irregularities of the surface contour, and the vocal cords. The doctor must make sure there is no airway obstruction, and analyze mobility of the vocal cords (Laryngitis, 2016).

Summary of Findings

The common cold is called that way for a reason – it is a colloquial name for a mild disease caused by over 200 similar viruses. The most common reasons for common cold are the rhinoviruses, responsible for about 40% of all cases of the disease, coronavirus – 20%, and parainfluenza – 10%. This disease rarely needs treatment at a hospital, and usually, passes in a few days. However, it can also be a gateway for more serious afflictions and should not be neglected. Statistics say that in the USA alone the population has over 1 billion colds a year. A stuffy or a runny nose, sore throat, mild fever, weakness, and mild headaches characterize the disease (Common cold diagnosis, 2016). While this is the most likely infection in Heddy’s case, other diagnoses must be ruled out prior to making this call.

Bronchitis is one of the most common diseases around the world. Around 5% of children have it at least once a year. The disease infects over 300 million people yearly. Mucous coughing, stuffy nose, sore throat, headaches and mild fever characterize this disease. While not very dangerous when treated, the disease can become worse and pose a threat if left alone. It often develops from simpler diseases, such as the common cold. 95% of all cases of acute bronchitis develop from a viral infection (Bronchitis, 2014).

In asthma, the lungs and respiratory channels become vulnerable to certain triggers and are easily inflamed, obstructing a person’s breathing. This is a potentially dangerous disease in its severe forms, as it can cause a respiratory arrest. It is most frequent among children. In order to understand if Heddy has it, the doctor must review her history and analyze any long-term symptoms that are reported. Smoking, aerosols, pollen, animals, dust and a myriad of other factors can trigger asthma. According to Asthma global report 2014, there are more than 340 million asthmatics in the world (Asthma in children and infants, 2016).

Laryngitis is a fairly common condition, which usually happens as a result of a viral infection of from mechanical irritation of the voicebox and the vocal cords. The disease itself can be treated at home and does not require hospitalization. It is easily recognizable, which is why many parents opt not to call a doctor when a child has it. It can pass without treatment, but treating it is strongly encouraged to prevent the disease from serving as a gateway for worse afflictions. Laryngitis often evolves from the common cold (Laryngitis, 2016).

Diagnostic Tests

There are a number of tests that could be used to identify respiratory symptoms diseases. These tests are common in medical hospitals around the world and are used in order to give a diagnosis with a great deal of precision. Depending on each of the diseases presented in this paper, tests would differ. However, some are universal for most of them. These are:

• Chest X-ray. A chest X-ray is used to identify bronchitis, pneumonia, and other conditions that may explain the coughing. This procedure is also required in case Heddy’s parents are avid smokers.
• Sputum tests. During this test, the doctor gathers the mucus one coughs up from the lungs. It is then analyzed, in order to identify the bacteria present, and the biological contains. These tests are used to understand what antibiotics a particular stem of the virus is resistant to. It is also helpful in analyzing allergies. Because of this, these tests are recommended in case of bronchitis and asthma.
• Pulmonary function tests. During this test, a patient blows into a spirometer, which allows measuring the volume of inhaled and exhaled air. This test also detects how quickly it enters and leaves lungs. This is a standard test used to diagnose asthma.
• Laryngoscopy. Standard procedure when diagnosing laryngitis. The doctor performs a visual examination of a person’s vocal cords using either a tiny mirror or a camera in a flexible tube, called the endoscope. During this test, the doctor can watch the motions of the cords as the patient speaks. This method is also used to detect other pathologies present in the larynx.

References

Asthma in children and infants. (2016). Web.

Bronchitis. (2014). Web.

Common cold diagnosis. (2016). Web.

Laryngitis. (2016). Web.

What questions will the doctor ask about your symptoms (and why?). (2015). Web.