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CASE 2: PRESENTATION
196
SHORT CASE PRESENTATIONS
doi: 10.1053/prrv.2001.0132, available online at http://www.idealibrary.com on
doi: 10.1053/prrv.2001.0134, available online at http://www.idealibrary.com on
CASE 2: PRESENTATION
CASE 4: PRESENTATION
A 14-year-old girl was referred because of persistent asthmatic symptoms despite treatment with regular oral prednisolone. Asthma was diagnosed at the age of 2 years. She also had a history of hay fever and eczema. Two siblings had eczema. There were no pets at home and no-one smoked. She continued to have daily symptoms of wheeze and chest tightness requiring salbutamol despite prednisolone 5 mg alternate days, fluticasone 1 mg bd, salmeterol 100 mcg bd (both via an accuhaler) and montelukast 5 mg od. FEV1 was 27% predicted, increasing to 42% after bronchodilator. Following 2 weeks’ prednisolone (40 mg/day), FEV1 increased to 38% (52% after bronchodilator). Symptoms also improved, with use of salbutamol on only three of the last seven days.
A 6-year-old boy is brought to the Accident and Emergency department accompanied by his mother and maternal grandfather. He presents with cough, wheeze and shortness of breath which have progressively worsened since the onset of upper respiratory tract symptoms the day before. He had a similar episode when he was 8 months old which responded to a nebulised bronchodilator and has remained symptom-free since. While obtaining the history, the child’s 62-year-old grandfather mentioned that his general practitioner has recently started him on some inhalers for breathlessness and a mild wheeze brought on by walking to the local newsagent shop.
1. 2. 3.
What are the possible reasons for this girl’s poorly controlled asthma? What further investigations would you perform? What treatment changes would you suggest?
1.
2. 3.
What other information about the child would be helpful in establishing a diagnosis and deciding on appropriate treatment? What is the differential diagnosis for the child? What other questions would you like to ask the grandfather about himself? What is the differential diagnosis for the grandfather?
doi: 10.1053/prrv.2001.0133, available online at http://www.idealibrary.com on
4.
CASE 3: PRESENTATION
doi: 10.1053/prrv.2001.0139, available online at http://www.idealibrary.com on
A 12-year-old boy is referred to you because of therapyresistant exercise-induced asthma. He has had dyspnoea on exercise since approximately 12 months. There are no triggers inducing dyspnoea other than exercise. He sometimes wheezes when he is feeling short of breath. He has been using inhaled budesonide 800 µg daily and salbutamol prn, which is sometimes helpful and sometimes not. His physical examination at rest is unremarkable. He brings along a peak flow chart recorded at home (Fig. 1). 1. What is your interpretation of the peak flow diary? 2. What is the most likely diagnosis? 3. How would you proceed in making or excluding your likely diagnosis? peak flow (L /min)
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time (days)
Case 3. Figure 1.
CASE 5: PRESENTATION A 3-year-old child from India is brought to you because he has a mild cough and his grandfather, who moved with the family from Bombay to Houston, Texas, was diagnosed with pulmonary tuberculosis last month. The child has a 17 mm reaction to a tuberculin skin test. His chest radiograph reveals right-sided hilar adenopathy with a collapse-consolidation lesion of the right middle lobe. 1. What additional information or evaluations would you like to have before starting the child on antituberculosis therapy? 2. What treatment regimen would you start and how would you give it? 3. How would you follow the child on treatment?
SHORT CASE PRESENTATIONS
doi: 10.1053/prrv.2001.0132, available online at http://www.idealibrary.com on
doi: 10.1053/prrv.2001.0134, available online at http://www.idealibrary.com on
CASE 2: PRESENTATION
CASE 4: PRESENTATION
A 14-year-old girl was referred because of persistent asthmatic symptoms despite treatment with regular oral prednisolone. Asthma was diagnosed at the age of 2 years. She also had a history of hay fever and eczema. Two siblings had eczema. There were no pets at home and no-one smoked. She continued to have daily symptoms of wheeze and chest tightness requiring salbutamol despite prednisolone 5 mg alternate days, fluticasone 1 mg bd, salmeterol 100 mcg bd (both via an accuhaler) and montelukast 5 mg od. FEV1 was 27% predicted, increasing to 42% after bronchodilator. Following 2 weeks’ prednisolone (40 mg/day), FEV1 increased to 38% (52% after bronchodilator). Symptoms also improved, with use of salbutamol on only three of the last seven days.
A 6-year-old boy is brought to the Accident and Emergency department accompanied by his mother and maternal grandfather. He presents with cough, wheeze and shortness of breath which have progressively worsened since the onset of upper respiratory tract symptoms the day before. He had a similar episode when he was 8 months old which responded to a nebulised bronchodilator and has remained symptom-free since. While obtaining the history, the child’s 62-year-old grandfather mentioned that his general practitioner has recently started him on some inhalers for breathlessness and a mild wheeze brought on by walking to the local newsagent shop.
1. 2. 3.
What are the possible reasons for this girl’s poorly controlled asthma? What further investigations would you perform? What treatment changes would you suggest?
1.
2. 3.
What other information about the child would be helpful in establishing a diagnosis and deciding on appropriate treatment? What is the differential diagnosis for the child? What other questions would you like to ask the grandfather about himself? What is the differential diagnosis for the grandfather?
doi: 10.1053/prrv.2001.0133, available online at http://www.idealibrary.com on
4.
CASE 3: PRESENTATION
doi: 10.1053/prrv.2001.0139, available online at http://www.idealibrary.com on
A 12-year-old boy is referred to you because of therapyresistant exercise-induced asthma. He has had dyspnoea on exercise since approximately 12 months. There are no triggers inducing dyspnoea other than exercise. He sometimes wheezes when he is feeling short of breath. He has been using inhaled budesonide 800 µg daily and salbutamol prn, which is sometimes helpful and sometimes not. His physical examination at rest is unremarkable. He brings along a peak flow chart recorded at home (Fig. 1). 1. What is your interpretation of the peak flow diary? 2. What is the most likely diagnosis? 3. How would you proceed in making or excluding your likely diagnosis? peak flow (L /min)
500 450 400 350 300 1
2
3
4
5
6
7
8
9 10 11 12 13 14
time (days)
Case 3. Figure 1.
CASE 5: PRESENTATION A 3-year-old child from India is brought to you because he has a mild cough and his grandfather, who moved with the family from Bombay to Houston, Texas, was diagnosed with pulmonary tuberculosis last month. The child has a 17 mm reaction to a tuberculin skin test. His chest radiograph reveals right-sided hilar adenopathy with a collapse-consolidation lesion of the right middle lobe. 1. What additional information or evaluations would you like to have before starting the child on antituberculosis therapy? 2. What treatment regimen would you start and how would you give it? 3. How would you follow the child on treatment?