Provide a case scenario of a 28‑year‑old female school teacher with a three‑year history of episodic wheezing, chest tightness, cough and dyspnea that worsen at night and with exposure to dust, strong odors, and exercise, and who shows reversible airway obstruction on spirometry.

Case Scenario: Bronchial Asthma in a Young Adult

A 28-year-old female school teacher presents with a three-year history of episodic wheezing, chest tightness, nocturnal cough, and dyspnea that worsens with exposure to classroom dust, strong cleaning chemical odors, and when playing recreational sports, with spirometry demonstrating reversible airway obstruction. 1, 2

Clinical Presentation

Chief Complaint:

• Recurrent episodes of shortness of breath and wheezing over the past 3 years 1

History of Present Illness:

• The patient reports variable and intermittent respiratory symptoms including wheezing, chest tightness, cough (particularly worse at night, often awakening her), and difficulty breathing 1
• Symptoms are trigger-provoked, specifically worsening with:
  • Exposure to chalk dust and classroom allergens 1, 3
  • Strong odors from cleaning chemicals used in the school 1
  • Exercise, particularly when jogging or playing tennis 1, 4
  • Viral upper respiratory infections 1
  • Changes in weather, especially cold air 3
• Nocturnal symptoms occur 2-3 times per week, disrupting her sleep 1
• She notes dramatic improvement in symptoms after using an over-the-counter inhaler borrowed from a friend 1

Past Medical History:

• Childhood eczema (resolved) 1, 3
• Allergic rhinitis diagnosed at age 15, currently managed with antihistamines 1, 5

Family History:

• Mother has asthma 1, 3
• Father has seasonal allergies 1

Social History:

• Non-smoker 1
• Works as an elementary school teacher with daily exposure to dust and cleaning products 1
• Lives in an older apartment building with visible mold in bathroom 1

Physical Examination

Vital Signs:

• Temperature: 98.6°F
• Heart rate: 78 beats/min (at rest) 6
• Respiratory rate: 16 breaths/min
• Blood pressure: 118/72 mmHg
• Oxygen saturation: 98% on room air 6

General Appearance:

• Well-appearing, no acute distress 1

Upper Respiratory Tract:

• Mild nasal mucosal swelling and clear secretions consistent with allergic rhinitis 1, 3
• No nasal polyps visualized 1

Chest Examination:

• Bilateral polyphonic expiratory wheezes heard during forced exhalation 1, 4
• No wheezing during quiet breathing 1
• No use of accessory muscles 6
• Normal chest wall configuration, no hyperexpansion 1

Skin:

• No active eczema or dermatitis 1

Cardiovascular and Other Systems:

• Normal examination 1

Diagnostic Testing

Spirometry (Baseline):

• FEV₁: 2.4 L (78% predicted) indicating airflow obstruction 1, 2
• FEV₁/FVC ratio: 0.68 (reduced, confirming obstructive pattern) 1, 2

Post-Bronchodilator Spirometry (after inhaled albuterol):

• FEV₁: 2.8 L (91% predicted) 1, 2
• Improvement of 400 mL and 17% from baseline, demonstrating reversible airflow obstruction and confirming the diagnosis 1, 2

Additional Testing:

• Chest X-ray: Normal, no infiltrates or other pathology 2, 3
• Peak expiratory flow monitoring over 2 weeks: Diurnal variation of 25%, with lowest readings in early morning 1

Clinical Reasoning

This case demonstrates the cardinal diagnostic features of asthma: 1

• Episodic symptoms of airflow obstruction including wheezing, chest tightness, cough, and dyspnea that are variable and intermittent rather than continuous 1, 7
• Trigger-provoked symptoms with clear worsening from exercise, allergens (dust), irritants (chemical odors), and viral infections 1, 4, 3
• Nocturnal worsening with symptoms awakening the patient from sleep 1
• Reversible airflow obstruction documented objectively by spirometry showing >12% and >200 mL improvement in FEV₁ after bronchodilator 1, 2
• Atopic background with personal history of eczema and allergic rhinitis, plus family history of asthma 1, 3, 5

Key diagnostic confirmation: The spirometry results are critical, as they provide objective evidence of both obstruction (reduced FEV₁/FVC ratio) and reversibility (significant improvement post-bronchodilator), which are essential for establishing the diagnosis in patients 5 years and older 1, 2, 3

Important caveats: Physical examination between episodes may be completely normal and does not exclude asthma—this patient had wheezing only with forced exhalation, which is typical 1, 3. The presence of polyphonic wheezing with exercise is a cardinal sign of asthma 4.

Differential Diagnoses Excluded

• COPD: Unlikely given young age, no smoking history, and significant reversibility on spirometry 2, 3, 8
• Vocal cord dysfunction: Would not show obstructive pattern on spirometry or bronchodilator reversibility 2, 3
• Chronic bronchitis: Would present with continuous productive cough rather than variable, intermittent symptoms 4, 8
• Cardiac disease: Normal cardiovascular examination and chest X-ray, symptoms clearly trigger-related 2, 3

Diagnosis

Bronchial asthma, moderate persistent (based on nocturnal symptoms 2-3 times per week and FEV₁ 78% predicted at baseline) 1