Differential diagnoses

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• Peer response to Van
• A 7-year-old male patient accompanied his mother to the office with the chief complaint of coughing and wheezing for a week and right ear pain. The patient has a history of asthma and was out of an albuterol inhaler for a week, which he was using three times per day for the past week. Physical examination is significant for dry, scaly patches on their elbows and behind his knees. Based on this information, we can make some differential diagnoses and create a comprehensive care plan for the patient. 

Differential diagnoses 

Cough and wheezing for a week

• Asthma: This is the primary diagnosis of the cough. Coughing and wheezing are typical signs and symptoms of asthma (Cloutier et al., 2020). Additionally, the patient has a history of asthma, and the cough worsened to the point of being noticeable when he ran out of his albuterol last week. 

• Viral Upper respiratory tract infection (VURTI): Viruses are the most common cause of upper respiratory tract infection, which in turn is the most common cause of acute cough (Murgia et al., 2020). However, cough related to VURTIs is often accompanied by discomfort and loss of sleep but not wheezing (Murgia et al., 2020). Therefore, this diagnosis is unlikely 

• Community-acquired pneumonia: Patients with pneumonia often experience progressive cough, dyspnea, and even chest pain. The lung sounds may be crackles but not wheezing (Lim, 2022). Therefore, this diagnosis can also be ruled out. 

Right ear pain 

The patient complains of right ear pain. There are several potential diagnoses for ear pain; additional assessment and diagnostic tests are needed to narrow down the primary diagnosis. 

• Otitis media is the most common cause of ear pain (and the most likely diagnosis in this scenario). Patients with recent upper respiratory tract infections are at higher risk of otitis media. An examination with the otoscope should review a red, inflamed, and cloudy tympanic membrane (Earwood et al., 2018). 

• Otitis externa, swimmer’s ear, is more prevalent during the summer, especially if patients recently swam. During physical examination, patients usually experience pain while pulling on the external ear, and there might be some discharge (Earwood et al., 2018). 

• Foreign objects in the ear are most common in children and should be visible during examination with an otoscope (Earwood et al., 2018). 

Dry and scaly skin patches

• Atopic dermatitis typically appears as dry and scaly skin patches on the flexural surfaces of older children. It is also commonly accompanied by pruritus. These are similar signs and symptoms of the patient’s history of present illness. Therefore, this diagnosis is the primary diagnosis (Frazier & Bhardwaj, 2020). 

• Contact dermatitis is a hypersensitivity reaction that can occur at any age. It may cause pruritis but commonly appears as a rash at the site of exposure, which does not match the patient’s current signs and symptoms (Frazier & Bhardwaj, 2020). 

• Psoriasis is an autoimmune disorder that cause skin rash. It starts as an inflamed and erythematous rash, then turns into dry, scaly liver patches. However, it is less common in children (Frazier & Bhardwaj, 2020). 

Treatment plan 

Asthma

• The patient was using his albuterol inhaler three times per week. Therefore, providers can categorize his asthma as mild persistent asthma. For mild persistent asthma, the provider can prescribe low-dose, inhaled corticosteroids (ICS) daily with as-needed Short-Acting Beta-Agonists (SABAs) (Cloutier et al., 2020). 

• Prescription: Budesonide (Qvar 40 Redihaler), one puff, BID, for asthma prevention 

• Albuterol Sulfate, two puffs, Q4H PRN, for relief of asthma symptoms 

Otitis media 

• More information is needed to determine the appropriate treatment for this patient. If appropriate, the providers should consider observation for 48-72 hours if the condition is not severe (Gaddey et al., 2019). For example, if the patient’s ear pain is not accompanied by other signs and symptoms such as fever, sore throat, nausea, vomiting, etc, and the patient is not exposed to any risk factor that might complicate the conditions such as second-hand smoking (Gaddey et al., 2019).

• However, suppose the patient’s condition is severe and requires an antibiotic. In that case, other factors also have to be considered, such as if the patient is allergic to penicillin, whether the patient has taken any penicillin antibiotic in the past 30 days, and what is the patient weight to identify the best antibiotic treatment (Gaddey et al., 2019). If the assumed patient is not allergic to penicillin, has not taken any penicillin antibiotic in the past 30 days, weight 25 kg, and has severe otitis media, the provider can prescribe amoxicillin, 80mg/kg/day (in two divided doses), for ten days for the patient (Gaddey et al., 2019). The prescription would look like this: amoxicillin, 1000 mg, BID, for ten days, for otitis media treatment. 

Atopic dermatitis 

• To manage atopic dermatitis, the provider can recommend that the mother apply an emollient (moisturizer) twice per day and give the patient a lukewarm water bath for 5-10 minutes with a soap-free cleanser. This is the first line of treatment, and the provider should continue to monitor for flare-ups and continue treatment as appropriate (Frazier & Bhardwaj, 2020).  

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