Please provide an example of a case study with the provided presenting complaint specific to each of these systems. This case should present the clinical approach and decision-making process involved in diagnostic reasoning and therapeutic decision-making. You will present a Fictitious Illustrative Case presentation on the following topics Include the following in each case: Subjective data- questions to be asked Objective data- Expected physical findings Differential Diagnosis Cannot miss the diagnosis Final Diagnosis Clinical Guidelines for specific diagnosis Treatment Follow-up Prognosis

Title: Case Study Analysis: Diagnostic Reasoning and Therapeutic Decision-Making

Fictitious Illustrative Case Presentation

Subjective Data:
Patient Complaint: Shortness of breath and persistent cough

General Inquiry:
1. How long have you been experiencing shortness of breath and a persistent cough?
2. Was it sudden onset or gradual?
3. Do you have any other accompanying symptoms such as chest pain, fever, or weight loss?
4. Have you traveled recently? Any exposure to chemicals or allergens?

Objective Data:
Physical Findings:
1. Respiratory rate: Increased (tachypnea)
2. Oxygen saturation: Decreased
3. Lung auscultation: Presence of crackles or wheezing
4. Chest X-ray: Infiltrates or consolidation
5. Spirometry: Decreased Forced Expiratory Volume in 1 second (FEV1)

Differential Diagnosis:
1. Asthma – Based on history, presence of wheezing and reduced lung function
2. Chronic obstructive pulmonary disease (COPD) – Based on history, long-standing smoking history, and reduced lung function
3. Pneumonia – Based on acute onset, fever, and presence of infiltrates on chest X-ray
4. Pulmonary embolism – Based on acute onset, risk factors, and clinical presentation

Cannot Miss Diagnosis:
Acute Exacerbation of Asthma:
– Presence of wheezing, tachypnea, reduced FEV1, and possible response to bronchodilators.
– Immediate management with administration of short-acting bronchodilators and steroids.

Final Diagnosis:
Acute Exacerbation of Asthma:
– Obtained through a comprehensive assessment of clinical history, physical examinations, and diagnostic tests.
– Patient meets the criteria for asthma exacerbation based on the presence of subjective data, objective findings, and differential diagnosis.

Clinical Guidelines for Specific Diagnosis:
1. Global Initiative for Asthma (GINA) guidelines:
– Comprehensive assessment of symptoms, lung function tests, and response to treatment for diagnosing and managing asthma.

1. Short-acting bronchodilators:
– Rapid symptom relief and improvement of lung function.
– E.g., Salbutamol via inhalation.

2. Steroids:
– For anti-inflammatory effect and reduction of airway inflammation.
– E.g., Oral prednisolone.

3. Long-acting bronchodilators:
– Sustained bronchodilation for maintenance of lung function.
– E.g., Formoterol via inhalation.

4. Inhaled Corticosteroids:
– Prevention of recurrent exacerbations and long-term control of asthma symptoms.
– E.g., Budesonide via inhalation.

1. Regular follow-up visits:
– Evaluation of asthma control, identification of triggers, and adjustment of treatment as needed.
– Sequential lung function tests to monitor response to treatment.

With appropriate management and adherence to treatment, the prognosis for asthma exacerbation is generally good. However, factors such as smoking, poor treatment compliance, and exposure to allergens or irritants can influence the long-term prognosis.

In conclusion, this case study focused on a patient presenting with the complaint of shortness of breath and persistent cough. Through a comprehensive assessment of subjective and objective data, a systematic diagnostic reasoning process was conducted to arrive at a final diagnosis of Acute Exacerbation of Asthma. The treatment plan was based on clinical guidelines for managing asthma exacerbation, with regular follow-up visits and monitoring of lung function. The prognosis was deemed positive with appropriate management and adherence to treatment.