Marcia Alvarez: The Case

HPI:

Marcia Alvarez is a 21-year-old female patient who is seen in follow up by her physician for persistent cough and shortness of breath.

Six weeks ago, she sought care for nasal congestion, runny nose and cough. At that time, she was prescribed fluticasone nasal spray and oral loratadine, but she continued to cough. Her cough is always worse at night and sometimes she can’t seem to stop coughing and occasionally wheezes. During one of those episodes she borrowed her aunt’s albuterol inhaler and reports it provided some relief.

ROS:

No fever or chills.  She has had intentional weight loss through Weight Watchers. She does not think her symptoms are any different at work then at home or elsewhere. No rashes or joint pain.

PMHx:

• Obesity, BMI 31
• Allergic rhinitis usually seasonal and worst in the spring and fall. 

Medications:

• Fluticasone nasal spray
• Loratadine 10 mg po daily

Allergies:

• NKDA

Family History:

Her mom has a history of nasal allergies. Her sister has a history of asthma as a child.  Maternal uncle and cousin who both had leukemia. Not much is known about their history because that branch of the family lives in Puerto Rico. 

SHx:

Miss Alvarez moved to Kentucky from Puerto Rico with her family when she was 12 years old. She is currently a part-time student at the University of Louisville. Ms. Alvarez works full-time at a preschool and has a pet cat. She lives in an apartment and does not have concerns about exposure to mold, insect or rodent infestation. She does not smoke or have second-hand smoke exposure. She does not drink alcohol or use any drugs.

Exam:

HEENT: normal nasal and throat mucosa, no JVD, TM’s clear, eyes clear

Chest: diffuse, high-pitched expiratory wheezes throughout all lung fields, increased expiratory time. No murmurs, S1 S2 normal

Abdomen: No organomegaly or tenderness, normal bowel sounds

MSK: no joint swelling or deformities, normal range of motion

Skin: no rashes

The physician sends Ms. Alvarez over to the diagnostics lab for pulmonary function testing with and without albuterol. Her flow volume loop is shown.