Presenting Complaints

The patient presents with a chief complaint of wheezing and shortness of breath that has been worsening over the past 2 weeks.

History of Presenting Complaint

The patient reports that he has been experiencing intermittent episodes of wheezing, chest tightness, and shortness of breath, particularly with physical activity. The symptoms seem to be worse at night and in the early morning hours. He denies any recent upper respiratory tract infections, but mentions that he has been exposed to increased pollen levels in his neighborhood over the past few weeks due to the changing seasons.

Significant Positives & Negatives For Differentials

Asthma

Positives:

• Episodic wheezing and shortness of breath
• Symptoms worse with physical activity and environmental triggers (pollen)
• Family history of asthma

Negatives:

• No recent respiratory infection
• Young age of patient

Viral or Bacterial Respiratory Infection

Positives:

• Wheezing and shortness of breath
• Potential for acute onset of symptoms

Negatives:

• No reported recent upper respiratory tract infection
• Symptoms not resolving over time

Allergic Rhinitis with Bronchospasm

Positives:

• Wheezing and shortness of breath
• Symptoms associated with environmental triggers (pollen)

Negatives:

• No reported nasal congestion, rhinorrhea, or other typical allergic rhinitis symptoms

Exercise-Induced Bronchoconstriction

Positives:

• Wheezing and shortness of breath with physical activity

Negatives:

• Symptoms not limited to only exercise
• Symptoms also present at rest

Chronic Obstructive Pulmonary Disease (COPD)

Positives:

• Wheezing and shortness of breath

Negatives:

• Young age of patient
• No reported history of smoking or other risk factors for COPD

Past Medical History

The patient has no significant past medical history. He reports no prior hospitalizations or surgeries.

Drug/Medication History

The patient is not taking any regular medications. He occasionally uses over-the-counter cough/cold remedies when he has symptoms, but cannot recall the specific names of the products.

Social History

The patient is a university student who lives in an apartment with two roommates. He does not smoke and denies any recreational drug use. He enjoys playing recreational sports, such as soccer, a few times per week.

Family History

The patient's mother has a history of asthma, but the rest of his family members are healthy with no known respiratory conditions.

Systems Review

• Respiratory: Wheezing, chest tightness, shortness of breath with exertion
• Cardiovascular: No chest pain, palpitations, or edema
• Gastrointestinal: No nausea, vomiting, or abdominal pain
• Neurological: No headaches, dizziness, or changes in vision
• Musculoskeletal: No joint pain or muscle weakness

Ideas, Concerns & Expectations

The patient is concerned that he may have developed some form of respiratory condition, as the symptoms have been interfering with his daily activities and exercise routine. He is hoping the doctor can provide a diagnosis and appropriate treatment to help manage his symptoms.

Case Presentation

Based on the presented case information and the detailed analysis of the differentials, the most likely diagnosis is asthma. The patient's episodic wheezing and shortness of breath, particularly with physical activity and environmental triggers, along with the family history of asthma, strongly support this diagnosis. While other differentials should still be considered and ruled out, the clinical picture is most consistent with asthma at this time.