This week’s case study discusses the respiratory complaints of a 40-year-old patient. By the appropriate medical history subjectively and objectively, we are able to diagnose and treat the patient appropriately diagnosis.
What is your primary diagnosis for Michelle given the pattern of occurrence of symptoms, exam results, and recent history? Include the rationale and a reference for your diagnoses.
Primary Diagnosis: Asthma (J45.21)
Asthma is a chronic inflammatory respiratory disorder which creates airway constriction and hyperresponsiveness of the bronchi. Airway narrowing causes inflammation and hyperresponsiveness causes an increase in mucus production (Hollier, 2018). Asthma is classified as a reversible airway obstruction (Hollier, 2018). The WHO describes asthma as a lung condition that causes sporadic breathing conditions of varying severity.
Michelle’s PFT’s, show remarkable airway obstruction, her FEV1/FVC ratio < 70%, and post bronchodilator shows an increase in FVC of >15%, which suggests reversibility (Hollier, 2018). She is showing mild persistent asthma due to her symptoms occurring more than 2 times as week. She complains of feeling short of breath at times on work days and a slight wheeze is noted on inspiration and forced expiration which is not cleared with cough. Additionally, Michelle has a history of seasonal allergies and eczema as a child. Both eczema and allergies are commonly seen in patients with asthma.
Michelle’s risk factors are her sex, history of atopy and allergen exposure, exercise and history of smoking confirms a diagnosis of mild persistent asthma (Hollier, 2018). Michelle’s sign and symptoms, her physical examination and risk factors are consistent with the common assessment finding for mild persistent asthma (Hollier, 2018).
What is your first-line treatment plan for Michelle including medications, labs, education, referrals, and follow-up? Identify the drug class of each medication you prescribe and exactly what symptom it is targeted to address.
Treatment Plan for Michelle includes:
Medications:
According to the National Asthma Education and Prevention Program inhaled corticosteroids (ICS) are the preferred long term control therapy for all ages (NHLBI, 2020). The goal of asthma treatment is to reduce impairment and maintain normal lung function.
A combination of a long-acting beta2 agonist (LABA) and an ICS helps to decrease severe exacerbations (NHLBI, 2020).
(ICS) Flovent HFA 2 sprays (88 mcg/spray) two time a day
(SABA) – ProAir HFA 2 puffs q 4-6 hours prn bronchospasms
Drug Classification/Targeted Symptom
Flovent HFA – a inhaled corticosteroid with an anit0inflammatory action. This inhibits multiple cell types and mediator productions involved in the asthmatic response (Hollier, 2018).
ProAir HFA- is a Short-Acting Bronchodilator (SABA) which stimulates the beta 2 receptors in the lungs which causes bronchodilation. SABA’s are indicated as a rescue inhaler to reduce bronchospasm (Hollier, 2018).
Labs/Screenings
IgE testing to detect allergens. Allergy testing and the understating of what allergies cause triggers to help avoid exacerbations.
CBC (to screen for eosinophils), Methacholine challenge test and RAST (Radioallergosorbentest) (Hollier, 2018).
Provide Asthma Action plans. Peak Flow monitoring which is the basis for asthma action plan (Johnson & Theurer, 2014).
Education
Identify allergens and decrease exposure to allergens. Take all medications as prescribed to maintain normal lung function (NHLBI, 2020). Medication management and avoiding allergy triggers can help to decrease asthma exacerbations. Demonstrate proper use of spacers, inhalers and other medications. Initiate an Asthma Action Plan in order to determine severity of asthma, titrate medications and control exacerbations. Identify early signs and symptoms of asthma exacerbations. Know when to go to the Emergency Room when asthma is increasing in severity, there is no improvement or breathing difficulties. Keep a log of symptoms, exacerbations and outcomes after medication use. This log is important for the physician to see to help manage asthma (Hollier, 2018).
Referrals
Allergist- for diagnostic Allergen prick/droplet test
Pulmonology- if asthma is persistent and she experiences life-threatening exacerbation, hospitalization, or requires more than 2 doses of steroids annually. This may be an indication that she could be a candidate for immunotherapy (Hollier, 2018).
Follow-up
Follow up in 2 to 4 weeks after initiation of treatment to evaluate response to medications. Once stable, follow up every 3-6 months (Hollier, 2018).
Immunization
Pneumococcal pneumonia vaccine now then x 2 more doses at age 65 or older and the Influenza vaccine annually (CDC, 2018).
Address Michelle’s request for an antibiotic.
Michelle requires medication on over prescribing medications such as antibiotics that are not necessary. Michelle does not present with any symptoms of an infection. She is afebrile, denies sputum and purulent discharge from her sinus. She require education on the disease process of Asthma and her symptoms that are accompanied with asthma as well as education on infections that become resistant to antibiotics when they are used unnecessarily.
References:
Asthma. (2020). Retrieved 12 January 2020, from https://www.who.int/news-room/q-a-detail/asthma (Links to an external site.)
Recommended Vaccines | Adults with Health Conditions | CDC. (2020). Retrieved 13 January 2020, from https://www.cdc.gov/vaccines/adults/rec-vac/health-conditions/index.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Ffeatures%2Fvaccineschronicconditions%2Findex.html (Links to an external site.)
Guidelines for the Diagnosis and Management of Asthma (EPR-3) | National Heart, Lung, and Blood Institute (NHLBI). (2020). Retrieved 12 January 2020, from https://www.nhlbi.nih.gov/health-topics/guidelines-for-diagnosis-management-of-asthma
Hollier, A. (2018) Clinical guidelines in primary care. (3rd ed.). Lafayette, LA: Advanced Practice Education Associates.
Johnson, J. D., & Theurer, W. M. (2014). A stepwise approach to the interpretation of pulmonary function tests. American Family Physicians, 89(5), 359-366. Retrieved from https://www.aafp.org/afp/2014/0301/p359.html (Links to an external site.)
Dr. M. and class,
Michelle is a pleasant women who presents to the clinic with a c/o shortness of breath. She is 40 years old and appears to be in no distress.
S:
CC – “I’ve been having a hard time breathing on and off lately.”
HPI –
Location – Respiratory
Durations – “on and off”
Characteristics – associated with shortness of breath
Aggravating Factors – occurs after a few hours at workplace (bakery)
Relieving Factors – when away from workplace
Treatment – none reported
Current Medication – Multivitamin, Zyrtec
Allergies – erythromycin causes severe GI upset; strawberries cause a rash; seasonal allergies (worst during spring season)
PMHx – seen in urgent care a few month ago d/t SOB from work – breathing tx & antibiotic provided; current on all vaccinations; eczema in childhood; allergy shots for seasonal allergies 10 years ago; cholecystectomy
Social History: Married with 3 children at home. Let go from advertising job 18 months – now working as Baker’s assistant at an Artisan Bread Bakery. Social alcohol drinker, formerly smoked 1 pack a week for 3 years when she was in her 20’s. Denies illicit drug use. Gets 6 to 7 hours of sleep per night. Gets in 4 to 5 days of exercise per week.
Family History: daughter with current sinus infection. Both parents deceased. Mother from CHF at age 80 – Father from lung cancer with mets to the brain at age 82 – PGM from unknown causes – PGF from a stroke at age 82 – MGM deceased at age 83 related to medical h/o HTN, atherosclerosis and several heart attacks – PGF from COPD at age 71.
ROS:
General – AAOx3; communicates appropriately in full sentences with no breathlessness.
HEENT – Head normo-cephalic; Hair thick and without hair loss; Sclera clear; Conjunctiva white; PERRLA, intact EOMs. Tympanic membranes intact and pearly gray and with light reflex. No tenderness to pinna and tragus; Nares patent with thin white exudate; Mucosa boggy and pale; Deviated septum noted; No tenderness to sinuses on palpation; Oropharynx pink, moist, with no lesions or exudate noted; Tonsils 1+ bilaterally; Teeth in good health with no cavities noted; Tongue midline, smooth, pink, with no lesions noted; No stiffness noted to neck. No cervical lymphadenopathy or tenderness on palpation; Thyroid small, firm and midline with no palpable masses noted.
Skin – Warm, dry, and intact; pale and pink with no cyanosis or pallor.
Respiratory – Clear bilateral lung sounds on auscultation; Respirations unlabored; Mild wheezing on inspiration and forced expiration, which does not clear with cough.
Cardiovascular – S1 and S2, normal rate and rhythm with no murmurs or displaced PMI. pulses equal bilaterally to all extremities; no peripheral edema noted.
Gastrointestinal – Abdomen soft and round; bowel sounds present in all quadrants. No organo-megaly noted on inspection and palpation.
A:
Moderate persistent occupational asthma
P:
Diagnostics –
Pulmonary Function Testing
Pre-Bronchodilator of FEV1/FVC 60%, FVC decreased
Post Bronchodilator of FEV1/FVC 75%
PE – Height of 5’10”; Weight of 140 lbs
Vital signs – BP 130/70, T 98.0, P 75, R 18 Sao2 98% on RA
Further diagnostics, medications, education, referral, and follow-up care is explained in detail in the answers to the following proposed questions.
- What is your primary diagnosis for Michelle given the pattern of occurrence of symptoms, exam results, and recent history? Include the rationale and a reference for your diagnoses.
The primary diagnosis for Michelle is occupational asthma (OA). Due to Michelle’s recent career change to working in a bakery, this type of asthma is often referred to as baker’s asthma. It is caused by the exposure to flour dust-like enzymes, proteins, and additives used by bakers. This type of exposure to harmful substances may cause an allergic reaction, especially given Michelle’s history of seasonal allergies (Stobnicka, & Górny, 2015). Based on Michelle’s PFT results of an FEV1/FVC of 60%, her asthma severity is considered moderate. An obstructive ventilatory defect can be defined as an FEV/FVC ratio of less than 0.70. The increase of FEV1/FVC to 75% post bronchodilator challenge is greater than 12% and is considered a positive bronchodilator response for disease reversibility (Ponce & Sharma, 2019). Moderate persistent asthma can also be diagnosed based on Michelle experiencing symptoms of asthma daily at work (Falk, Hughes, & Rodgers, 2016).
- What is your first-line treatment plan for Michelle including medications, labs, education, referrals, and follow-up? Identify the drug class of each medication you prescribe and exactly what symptom it is targeted to address.
Patients with OA must be managed and educated on controlling their exposure to triggers, as well as pharmacotherapy according to guidelines. Michelle must be encouraged to remove herself from the bakery and find other employment. Further diagnostics may be done, such as referral to allergist for diagnosis by a skin prick test, in order to identify the affecting allergen.
The gold standard in asthma therapy begins with a low-dose inhaled corticosteroids (ICS) as a controller together with an as needed Short-acting beta-2-agonist (SABA). Low dose ICS, such as Budesonide DPI (Pulmicort), can be started at a dose of 180 mcg twice daily (Falk et al., 2016). These medications decrease the inflammatory response of an overactive immune system and effectively decrease the airways hyper-responsiveness. Side effects for ICSs include nasopharyngitis, headache, bronchitis, sinusitis, influenza, pharyngitis, respiratory tract infection, tooth and back pain, viral gastroenteritis, abdominal pain, cough, oropharyngeal candidiasis and pain, dysphonia, rhinitis, and throat soreness (Sharma, Hashmi, & Chakraborty, 2019). A SABA, such as Albuterol DPI, can be used for episodes of acute exacerbation by administering 2 puffs of 180 mcg every 4 to 6 hours as needed (Falk et al., 2016). SABAs work to decrease symptoms of wheezing, cough and shortness of breath. Side effects for SABAs include tremor, nausea, fever, bronchospasm, vomiting, headache, dizziness, cough, dry mouth, sweating, chills, and dyspepsia. Michelle can attempt to avoid some of the side effects of her prescribed medications by rinses her mouth with water after each use (Sharma et al., 2019)
Follow-up therapy is aimed at achieving the treatment goal of maximum freedom of symptoms and optimal quality of life. Michelle must be encouraged to follow her treatment plan and regularly continue to follow-up for pulmonary function testing. A questionnaire, such as the Asthma Control Test (ACT), can help evaluate therapeutic efficacy related to symptom control. The initial follow up should be in 4 weeks, with continued follow-up in intervals of 3 to 6 months, based on treatment efficacy and severity of symptoms (Horak et al., 2016).
- Address Michelle’s request for an antibiotic.
Based on Michelle’s history and presenting symptoms, she does not need to be put through any further testing or treatment options. Her concern for antibiotic therapy should be acknowledged and she should be educated on her new diagnosis of asthma. She must understand that antibiotic therapy is not appropriate at this time, as there are no signs of infection. Instructions on reporting symptoms of infection should be provided as asthma may be associated with an increased susceptibility to respiratory infections (Patella, Bocchino, & Steinhilber, 2015).
References:
Falk, N.P., Hughes, S. W., & Rodgers, B.C., (2016). Medications for Chronic Asthma. Retrieved from https://www.aafp.org/afp/2016/0915/p454.pdf (Links to an external site.)
Horak, F., Doberer, D., Eber, E., Horak, E., Pohl, W., Riedler, J., … Studnicka, M. (2016). Diagnosis and management of asthma – Statement on the 2015 GINA Guidelines. Wiener klinische Wochenschrift, 128(15-16), 541–554. doi:10.1007/s00508-016-1019-4
Patella, V., Bocchino, M., & Steinhilber, G., (2015). Asthma is Associated with Increased Susceptibility to Infection. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/27427119 (Links to an external site.)
Ponce, MC., & Sharma, S., (2019). Pulmonary Function Tests. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK482339/
Sharma, S., Hashmi, MF., Chakraborty, RK., (2019). Asthma Medications. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK531455/
Stobnicka, A., & Górny, R. L. (2015). Exposure to flour dust in the occupational environment. International journal of occupational safety and ergonomics : JOSE, 21(3), 241–249. doi:10.1080/10803548.2015.1081764
