Presenting Complaints

The patient presents with a chief complaint of wheezing and shortness of breath for the past 2-3 days.

History of Presenting Complaint

The patient, a 43-year-old male, reports that he has been experiencing episodes of wheezing and difficulty breathing for the past 2-3 days. The wheezing is worse at night and with exertion. He also notes a mild, dry cough. He denies any fever, chest pain, or recent changes in his voice. The symptoms seem to be triggered by exposure to dust or strong scents.

Significant Positives & Negatives For Differentials

Asthma Exacerbation

Positives:

• History of childhood asthma
• Wheezing and shortness of breath triggered by exposure to dust or strong scents
• Symptoms worse at night and with exertion
• Mild, dry cough
• No fever, chest pain, or other systemic symptoms

Negatives:

• Patient has been well-controlled for several years without needing asthma medications
• Lack of significant smoking history

COPD Exacerbation

Positives:

• Wheezing and shortness of breath
• Chronic respiratory condition

Negatives:

• Patient's age (43 years old) is younger than typical COPD presentation
• Lack of significant smoking history

Pneumonia

Positives:

• Respiratory symptoms like wheezing and shortness of breath

Negatives:

• Lack of fever or other systemic symptoms
• No chest pain or other signs of lower respiratory tract infection

Congestive Heart Failure

Positives:

• Wheezing and shortness of breath

Negatives:

• Lack of chest pain, edema, or other signs of heart failure
• No history of cardiovascular disease

Vocal Cord Dysfunction

Positives:

• Wheezing and shortness of breath

Negatives:

• Symptoms not specifically triggered by upper airway irritants
• Lack of hoarseness or voice changes

Past Medical History

The patient has a history of seasonal allergies and was diagnosed with asthma as a child, for which he used to take an albuterol inhaler as needed. However, he has not required any asthma medications for the past several years and considers himself to be well-controlled.

Drug/Medication History

The patient currently takes no regular medications. He occasionally uses over-the-counter antihistamines for his seasonal allergies.

Social History

The patient works as an office clerk and lives in a small apartment in a crowded urban area of India. He is a non-smoker and denies any significant occupational or environmental exposures.

Family History

The patient's mother has a history of asthma. There is no other significant family history of respiratory or allergic conditions.

Systems Review

Review of systems is otherwise unremarkable, with no fevers, chills, weight changes, or other concerning symptoms.

Ideas, Concerns & Expectations

The patient is concerned that his asthma may be worsening and is hoping for treatment to relieve his current symptoms.

Case Presentation

Based on the patient's history of childhood asthma, characteristic wheezing and shortness of breath symptoms triggered by environmental exposures, and lack of other concerning systemic symptoms, the most likely diagnosis is an asthma exacerbation. While other differential diagnoses were considered, the overall clinical picture is most consistent with an acute worsening of the patient's underlying asthma condition.