JNP: The Journal for Nurse PractitionersA Breath of Uncertainty: Diagnostic Challenge in a Young Athlete

🧩 Diagnostic Reasoning Exercise / Teaching Case

A 14-year-old male soccer player presents with four weeks of exertional dyspnea worsening over two weeks, partially responsive to albuterol. Peak flows are within normal limits, lung and cardiac exams are unremarkable, and a recent well-visit was normal. His mother suspects exercise-induced asthma. A school transition, new team dynamics, and a psychiatric history dating to age 8 are noted but not initially volunteered.

Diagnostic Considerations

• Exercise-induced asthma and anxiety share significant symptom overlap in adolescents and absence of wheezing, normal peak flow, and negligible albuterol response shift the differential away from bronchoconstriction
• Albuterol’s adrenergic effects (tachycardia, jitteriness, restlessness) can independently worsen anxiety symptoms, creating a compounding diagnostic trap
• Private adolescent interview is a protocol-level practice standard; key psychosocial stressors (bullying, parental pressure, social displacement) were disclosed only after the parent left the room
• The GAD-7 and SCARED are validated, free screening instruments appropriate for primary care NPs evaluating adolescent anxiety; GAD-7 score of 7 supported mild generalized anxiety disorder in this case

Practice Pearls

• Recognize anxiety as a primary driver of somatic symptoms in adolescents when objective respiratory measures are normal and psychosocial stressors are present
• Consider that escitalopram is the only FDA-approved SSRI for pediatric GAD ages 7 and older; fluoxetine and sertraline carry strong off-label evidence; duloxetine is FDA-approved for this indication in the same age range
• Monitor all pediatric antidepressant initiations per the FDA Black Box Warning for clinical worsening and treatment-emergent suicidality, with dose titration every one to four weeks
• Refer to psychiatric NP when comorbidities are suspected or primary care management proves insufficient