Question

Case Study: A 12-year-old girl who presents to the walk-in clinic complaining of shortness of breath and dry cough that has been present for 3 weeks. It is worse at nighttime and with activity. When she plays soccer with her friends, she often feels tight in the chest after a few minutes of play. On further questioning, the patient admits to occasional episodes of shortness of breath and coughing over the last 2-3 years, but never this severe. These episodes usually occur in the fall and are triggered by high humidity and cigarette smoke. At times, the cough sounds like wheezing.

Question: Based on the clinical and/or laboratory presentation of this case, what is your final diagnosis? Why?

Answer 1

Features of foreign body aspiration include unexplained wheezing and asymmetric breath sounds, as well as air trapping in one lung indicating unilateral airway obstruction. The right main bronchus is the more commonly obstructed due to anatomy (it is wider and more vertical than the left). The most commonly aspirated foods are hot dogs, nuts, hard candy, grapes, and popcorn.

Croup includes subglottic aggravation, regularly giving inspiratory stridor and a "barky hack" (i.e., like a seal). This patient isn't noted to have either, and furthermore gives unbalanced wheezing and air catching that would not be normal in a person with croup.

While this patient presents with hack and expanded work of breathing, she is afebrile, and auscultation of the chest does not uncover snaps or diminished breath sounds/region of combination, which would be predictable with pneumonia. Furthermore, chest x-beam discoveries are not steady with a lobar or more diffuse pneumonia.

Acute bronchiolitis is a good thought, especially as this is the most common cause of wheezing in infant; however, if this were the diagnosis, the patient would most likely be febrile and chest x-ray would demonstrate scattered atelectasis and/or diffuse opacities from bronchial obstruction.

While the finding of wheezing is consistent with asthma, this patient has wheezing only on one side. Along those lines, chest x-ray in an asthmatic patient would demonstrate global air trapping with hyperinflated lungs, rather than unilateral findings.