Visual diagnosis: an adolescent female who has persistent cough.

Abstract

1. William T. Scouten, MD* 2. Jeanette White, MD† 1. *National Capital Consortium Pediatric Residency Program, National Naval Medical Center/Walter Reed Army Medical Center, Washington, DC 2. †Pediatric Critical Care, Children’s National Medical Center, Washington, DC A previously healthy 17-year-old girl complains of a “dry and intermittent” cough for the past 1.5 months. The cough worsens when she is recumbent and does not respond to over-the-counter cough medications. The cough is not associated with fever, chills, nausea, vomiting, night sweats, or weight loss. She reports several episodes of posttussive chest pain. Recently prescribed treatments of albuterol and fexofenadine do not alleviate her symptoms, despite her clinical diagnoses of exercise-induced bronchospasm and allergic rhinitis. She is an accomplished basketball player; her cough does not diminish her athletic performance. The patient’s past medical history is remarkable for a cardiac murmur noted at birth that resolved by 2 years of age and for three episodes of pneumonia by 6 months of age. She has no drug or environmental allergies, her immunizations are up-to-date, and her growth and development are normal. She denies drug, alcohol, or tobacco use. Further review of a psychosocial history reveals minimal adolescent risk characteristics. For the past 6 years, she has lived in the southwest United States and spent the prior summer in northern California. She denies exposure to others who had chronic cough, tuberculosis, or lung diseases. She admits to watching bats on one occasion during vacation in the past year. On physical examination, the patient appears healthy and is in no apparent distress. Vital signs are: temperature, 36.8°C (98.2°F); respiratory rate, 22 breaths/min; pulse, 88 beats/min; blood pressure, 117/73 mm Hg; and pulse oximetry, 100% hemoglobin-oxygen saturation while breathing room air. The patient’s respirations are unlabored, and she has adequate air movement. Auscultation of the chest reveals decreased breath sounds over the left base and fine, end-inspiratory crackles within the midposterior left chest. There is no appreciable egophony. The remainder of the physical findings are normal. A complete blood count reveals a white …