Adolescent asthma case scenario guide: ranked differential

The case is a classic presentation written to be recognized, and the three questions grade three different skills. The chief complaint is a discipline check: it is what the patient came in saying — shortness of breath and a nonproductive nocturnal cough — captured in her terms, not your diagnostic translation of them. The differential question specifies its own format precisely: three diagnoses, ranked, presumptive final diagnosis first, and the ranking must be argued from the case's paired subjective and objective findings. Asthma leads on the classic cluster — exercise-triggered symptoms progressing to continuous, nocturnal timing, the atopic history (seasonal allergies, a mother with eczema and allergies), and expiratory wheeze with decreased air movement on a resonant chest. The atopic thread is the case's quiet gift: personal seasonal allergies plus a first-degree relative with eczema is textbook atopy, and naming that pattern shows the examiner you read the family history as data.

The competing two need to be genuine contenders you then beat: vocal cord dysfunction mimics asthma's wheeze and dyspnea but localizes to the larynx and resists bronchodilators; exercise-induced bronchoconstriction alone fails to explain the now-continuous and nocturnal course; a chronic-infection picture like bronchiectasis founders on the dry cough, absent fever and clean history. Each differential earns its place with its supporting findings and is demoted by its negative ones — that support-and-demote structure is what the question's format is really asking for. Write each contender in the same three-beat shape — what it explains, what it fails to explain, why it ranks where it does — and the ranking argument becomes visible instead of implied, which is precisely what the presumptive-first format exists to grade. Filler differentials with no mimicry value (pneumonia with no fever, cardiac disease at fifteen with normal vitals) waste a slot the mimics deserve.

The treatment plan question names its standard — current evidence-based practice guidelines — which for asthma means the stepwise framework: confirm the diagnosis objectively with spirometry before and after bronchodilator (with bronchoprovocation testing where baseline spirometry is normal), then classify severity from the symptom frequency and nocturnal pattern the case describes, and step therapy accordingly. This presentation — symptoms now continuous, nocturnal cough — argues persistent asthma, which under current guidelines means an inhaled corticosteroid-containing controller rather than a short-acting bronchodilator alone; writing the plan as diagnostic workup, controller and reliever pharmacotherapy with doses, and the non-drug tier keeps it in guideline shape. The non-drug tier is where adolescent-specific care shows: inhaler technique teaching and an asthma action plan, trigger identification with allergy referral given her atopy, school and activity planning that keeps her exercising rather than benched, and scheduled follow-up to reassess control.

A cleaning note this record makes unavoidable: it circulated answer-first — a completed student write-up (differentials, drug doses, follow-up schedule) ahead of the actual prompt — and that answer is excluded from the brief above. Beyond the originality hazard of leaning on it, its clinical choices are not all defensible against current guidance (daily oral corticosteroids as maintenance for this presentation would be a step-therapy error), which is the practical argument for working from the guidelines rather than the circulating answer: the assignment's own standard is current evidence-based practice, and the guidelines are where that lives. Cite the strategy document and the federal overview by name in the plan, because the question's own phrasing makes the guideline citation part of the answer rather than decoration.