Presenting Complaints

• 14-year-old male patient presenting with 2 days of wheezing and shortness of breath.

History of Presenting Complaint

• The patient began experiencing wheezing and difficulty breathing 2 days ago. The symptoms started gradually and have been worsening over the past 48 hours.
• The wheezing is worse with physical activity and at night. He also reports a mild, dry cough.
• He denies any fever, chest pain, or recent illnesses.
• The patient states he has had similar episodes of wheezing in the past, but this is the worst it has been.

Significant Positives & Negatives For Differentials

Asthma

Positives:

• Recurrent episodes of wheezing and shortness of breath
• Worsening of symptoms with physical activity and at night
• Family history of asthma
• Lack of fever, productive cough, or other concerning symptoms

Negatives:

• Sudden onset of symptoms (may suggest foreign body aspiration)
• Presence of fever or focal lung findings (may suggest pneumonia)
• Productive cough (may suggest bronchitis)

Pneumonia

Positives:

• Fever
• Productive cough
• Focal lung findings on exam

Negatives:

• Lack of fever
• Isolated wheezing without productive cough

Bronchitis

Positives:

• Productive cough

Negatives:

• Lack of productive cough
• Isolated wheezing without productive cough

Foreign Body Aspiration

Positives:

• Sudden onset of wheezing
• History of choking or gagging

Negatives:

• Gradual onset of symptoms
• No history of choking or gagging

Past Medical History

• No known medical conditions
• No prior hospitalizations
• Up-to-date on all childhood vaccinations

Drug/Medication History

• No regular medications
• No known drug allergies

Social History

• Lives at home with parents and younger sister
• Attends middle school, does well academically
• Denies smoking, vaping, or recreational drug use
• Enjoys playing soccer and basketball

Family History

• Mother has asthma
• No family history of other respiratory or allergic conditions

Systems Review

• Respiratory: Wheezing, shortness of breath, mild dry cough
• Cardiovascular: Denies chest pain, palpitations
• Gastrointestinal: Denies nausea, vomiting, abdominal pain
• Genitourinary: Denies dysuria, hematuria
• Musculoskeletal: Denies joint pain, swelling
• Neurological: Denies headaches, dizziness, seizures
• Skin: Denies rashes, hives

Ideas, Concerns & Expectations

• Patient and family are concerned about the worsening wheezing and shortness of breath, as the patient has experienced similar episodes in the past.
• They are hoping the doctor can provide treatment to relieve the symptoms and prevent future episodes.

Case Presentation

Based on the patient's history, physical exam findings, and the consideration of the key positives and negatives for each differential diagnosis, the most likely diagnosis is asthma. The recurrent episodes of wheezing and shortness of breath, worsening with physical activity and at night, along with the family history of asthma, strongly support this diagnosis. The lack of fever, productive cough, and other concerning symptoms make pneumonia and bronchitis less likely, while the gradual onset of symptoms and lack of a history of choking or gagging make foreign body aspiration less probable. Appropriate management would include bronchodilator medications, corticosteroids, and identification/avoidance of triggers.