You are working with Dr. Nancy Law in a community clinic. Today she is scheduled

You are working with Dr. Nancy Law in a community clinic. Today she is scheduled to see a new patient, Sunita Patel, with a report of a cough for eight weeks.
Dr. Law asks you to do a focused history and physical exam and develop a working differential before presenting Sunita’s story to her.
You begin by picking up Sunita’s chart and reviewing the nurse’s intake information:
Patient: Patel, Sunita
Patient new to practice. Recently moved to area. Old records are being faxed from prior PCP.
Age: 6 years
Chief concern: Coughing for eight weeks. No improvement and maybe worsening. Mom concerned.
Vital signs:
Temperature is 37.6 C (99.68 F)
Pulse is 92 beats/minute
Respiratory rate is 18 breaths/minute
Oxygen saturation is 99%
Weight is 22 kg (50th percentile)
Height is 118 cm (50-75th percentile)
Medications: None
Allergies: No medication, food, or environmental allergies
cute versus Chronic Cough
< 4 weeks > 4 weeks
Acute symptoms are most commonly due to an infectious cause (viral upper respiratory infection or viral or bacterial pneumonia) or a clear precipitating event (e.g., trauma or choking).
Children can have 5 to 8 upper respiratory infections a year, and the cough can last on average for up to 3 weeks with 10% lasting up to 25 days.
Causes are many and can include infection, inflammation, and irritation, anatomic or psychogenic. Rarely the cough may be due to cardiac or gastrointestinal conditions.
A viral upper respiratory infection can induce airway reactivity in a healthy host for weeks; cough may persist long after other symptoms have subsided.
An aspirated foreign body lodged in the airway can cause recurrent and chronic cough.
Asthma (A)
The features of Sunita’s cough as well as her past history, family history, and the finding of end-expiratory wheezing on exam all support a diagnosis of asthma.
Allergies (B)
Chronic nasal congestion, particularly in the context of a move to a new home, plus allergic shiners, clear nasal secretions, and edematous (“boggy”) turbinates are consistent with a diagnosis of environmental allergies.
The following are less likely:
Atypical or viral pneumonia (C)
Sunita’s course is prolonged relative to what you would expect for infectious pneumonia.
Sinusitis (E)
Signs and symptoms of acute bacterial sinusitis in younger children include:
URI symptoms with persistent illness (nasal discharge of any kind), daytime cough, or both lasting for more than 10 days but less than 30 days.
Worsening cough (or new onset of nasal discharge, daytime cough, or fever after initial improvement).
Severe symptoms (high fever and purulent nasal discharge) for at least 3 days.
Tuberculosis (F)
Although Sunita’s grandmother moved from an area where tuberculosis is endemic, she does not have any symptoms, and her TST was negative.
Asthma is a chronic disorder of the airways that involves a complex interaction of airflow obstruction, bronchial hyper-responsiveness, and underlying inflammation.
It is the most common chronic disease in children in developed countries. Epidemiologic risk factors include sex (males have higher prevalence), race/ethnicity (higher among non-Hispanic Black children), and socioeconomic status (higher among children whose family income is below the federal poverty level).
Diagnosis requires:
Symptoms of recurrent airway constriction by history and exam
Demonstration that airway constriction is at least partially reversible
Exclusion of other causes of airway obstruction
Dr. Law sends prescriptions for beclomethasone, albuterol, and loratadine to the pharmacy.
You ask Dr. Law about the relationship between allergies and asthma.
Aeroallergens and Asthma
Patients with asthma often have inhalational allergies as a common trigger for their asthma.
The most common indoor aeroallergens that are responsible for sensitizing susceptible people include:
House dust mites
Animal dander
Common outdoor aeroallergens include fungi and some grass and ragweed pollens.
The approach to the treatment of allergies in children varies somewhat among doctors and from one area of the country to the other.
Exposure Avoidance
Reducing exposure to known outdoor and indoor allergens—such as cigarette smoke or wood smoke from a stove—is a good strategy. In an individual who already demonstrates sensitivity to some environmental allergens, the risk of becoming sensitized to other environmental allergens is greater. The decision to recommend changes to the indoor environment (e.g., removing carpets or pets) should be individualized. The expense and effort involved in implementing indoor environmental allergen controls may be greater than any potential benefit.
Medications are frequently included in the management of environmental allergies.
Typical options include oral antihistamines, leukotriene receptor antagonists, and topical nasal steroids.
Antihistamines (H1 antagonists) are safe and effective for controlling the symptoms of sneezing, nasal pruritus, and rhinorrhea, particularly associated with intermittent or short-term seasonal allergies. Newer antihistamines are available that are significantly less sedating than the earlier antihistamines.
Leukotriene receptor antagonists may be useful in the treatment of both asthma and allergic rhinitis.
Topical nasal steroids are the most effective pharmacologic agents for the treatment of allergic rhinitis, but may not be indicated for short-term symptoms of seasonal allergies.
Examples of Control Measures for Environmental Allergies
Animal Dander
Remove pets with fur or hair from the home, or, at a minimum, keep animals out of the patient’s bedroom and carpeted rooms within the home.
House Dust Mites
Encase mattresses and pillows in an allergen-impermeable cover.
Wash non-encased pillows, sheets, blankets, and any special stuffed animal weekly in water hotter than 130 F (54.5 C).
Remove all other stuffed animals from the child’s bed. Placing toys weekly in the dryer or freezer may help.
Remove carpet from the child’s bedroom, if possible, and damp mop wood or vinyl floor weekly.
If not possible, vacuum the child’s bedroom carpet twice per week with the child out of the room.
Reduce humidity to < 60% (ideally 30%–50%). Eliminate any cockroaches. Use poison bait or traps to control pests (chemical sprays may irritate asthma). Do not allow food in patient's bedroom. Do not leave food or garbage exposed. Indoor Mold Fix all leaks and eliminate water sources associated with moldy growth. Clean moldy surfaces. The child should avoid damp rooms such as basements. Dehumidify the basement to below 60% humidity, if possible. Outdoor Mold Try to keep windows closed; stay indoors when pollen and mold spore counts are highest (midday and afternoon), if possible. Smoke, Strong Odors, and Sprays Do not allow smoking in the child's home, family vehicle, daycare center, or school. Avoid strong odors, perfume, and sprays whenever possible. Sunita and her family return a few weeks later. You ask Sunita, "How has your cough been? Have you had any trouble using your inhalers?" "I'm coughing a lot less! That medicine for my allergies tastes okay, but not great. Have you ever tried it? Blah. The puffer medicines are okay too, but the one in the red container (albuterol) makes me kinda jumpy." Mrs. Patel confirms Sunita's coughing seems to be much better. She has been awakened at night due to her cough only once in the past few weeks. She has used her albuterol inhaler twice. Mrs. Patel says she feels fairly confident about Sunita's treatment plan, though somewhat concerned that her daughter might be limited by having a chronic illness. Dr. Law explains that the goal of asthma management is to allow full participation in all activities, with no limitations—and that they will work together to adjust Sunita's treatment as needed to make sure she can do everything she wants to do. Given that Sunita is doing well, Dr. Law recommends continuing her current medication plan and returning for another visit in 4 weeks to assess her asthma control. Sunita and her mother thank you for helping in her care. Sunita gives you a drawing as a parting gift. collapseDEEP DIVEGuidelines for Referral to an Asthma Specialist This is the final page of the case. We value your perspective on the learning experience. After completing three required feedback ratings you can finish the case and access the case summary. Dr. Law agrees that Sunita likely has asthma. To confirm the diagnosis, she arranges for Sunita to have spirometry testing later that day and schedules a follow-up visit the next morning. She asks you to read about asthma and to review the NHLBI Asthma Care Quick Reference. Dr. Law also mentions an additional resource from the Global Initiative for Asthma (GINA) which varies slightly compared to NHLBI for adults and children ages 6 and up. However, Dr. Law notes her institution primarily utilizes the NHLBI guidelines to initiate asthma management in pediatric patients. TEACHING POINT Asthma Severity and Control The NIH asthma classification system provides a broadly accepted and consistent definition of asthma, allowing for improved communication regarding its diagnosis and management among health care providers caring for patients with this chronic condition. During a patient's initial presentation, the emphasis is on assessment of asthma severity, as a guide to starting therapy. Once treatment is initiated, the emphasis changes to assessment of asthma control, as a guide to maintaining or adjusting therapy. Assessment of severity and control varies with the age of the patient and relies primarily on consideration of asthma-related impairment: Frequency of daytime symptoms Frequency of nighttime awakenings related to asthma Interference with activity Pulmonary function (if available) Use of short-acting beta2-agonist medications (SABA) (if patient is already using medications) A primary goal in classifying severity is to determine whether a patient's asthma is intermittent or persistent. Asthma severity classification based on history of impairment in a school-age child: History Classification Treatment Daytime sx ≤ 2 days/week Intermittent Quick relief (SABA) as needed Nighttime awakening < 2 times/month Intermittent Quick relief (SABA) as needed No interference with activity Intermittent Quick relief (SABA) as needed More frequent symptoms, more interference with activity Persistent Daily controller + quick relief as needed Persistent asthma is further classified as mild, moderate, or severe. See the GINA Pocket Guide for Asthma Management and Prevention for additional details.