NR 603 Week 2:
Case Discussion
Pulmonary – Part 1
1. 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.
Diagnosis: Mild to moderate persistent asthma with episode of shortness of
breath (SOB) related to occupational problems/ work circumstances.
ICD code: J45.30 and Z56.9
Asthma
Asthma is a chronic airway inflammation characterize by respiratory
symptoms such as SOB, coughing, wheezing and tightness of the chest,
along with a variable of expiratory airflow limitation. A diagnosis of asthma
be confirmed by a history of various respiratory symptoms and pulmonary
function test (PFT). A diagnosis of asthma can be diagnosed by the patient
past respiratory symptoms and a FEV1 greater than 12% difference between
a pre-and-post PFT (GINA, 2020).
Rationale:
The patient has a history of seasonal allergies, recent episodes of SOB and a
few months ago visited an urgent care for her SOB. The patient’s physical
exam presents slight wheezing on inspiration and forced expiration with
wheezing that does not clear with forceful coughing. The patient pre-PFT
resulted in a FEV1/FVC of 60% and the post- PFT resulted in a FEV1/FVC
of 75%, which is greater than 12% improvement indicating a diagnosis of
asthma as per the GOLD guidelines (GINA, 2020).
Occupational asthma is an exposure of substance(s) that causes an
exacerbation or contribute to worsening of preexisting condition in the
workplace. Classic symptoms of occupational asthma may include
coughing, difficulty breathing, wheezing, and tightening of the chest (Bepko
and Mansalis, 2016).
Rationale:
HPI: The patient reports SOB mostly occurs at work and resolves before
arriving home. Upon returning to work, the patient reports her SOB returns.
The episodes of SOB do not occur on the weekends. Based on her HPI the
patient symptoms are associated with occupational asthma.
, 2. 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.
Medications
Based on the GINA guidelines, Michelle should be started on a following medication:
1. Low dose corticosteroid and long-acting-beta-agonist (ICS-LABA): (GINA, 2020)
● Advair (Fluticasone/salmeterol): 2 puff PO Q12 hours. Disp #:1
Advair is a combination drug of fluticasone and salmeterol used to treat respiratory
symptoms such as SOB, wheezing, tightness of the chest, difficulty breathing due to asthma.
Fluticasone is a corticosteroid that helps by reducing irritation and swelling of the airway.
Salmeterol is a long-acting-beta-agonist (LABA) that helps relax and open an air passage to
the lungs. Short acting-beta-antagonist (SABA): A SABA as-needed for severe uncontrolled
asthma exacerbations (U.S. NLOM, 2020).
2. Short-acting-beta-agonist (SABA) (GINA, 2020)
● Albuterol sulfate: PROAIR HFA 108 mcg/puff Sig: 2 puff PO Q4-6 hours as
needed for SOB. Disp #: 1
PROAIR FA is an aerosol inhalator that treat and prevents bronchospasm and exercise-
induced bronchospasm (FDA, 2019).
Plan of Treatment:
1. Action plan:
An action plan will be created, and a written copy will be provided. The patient will be
educated on steps to follow if asthma symptoms worsen and when to seek emergency care
(GINA, 2020).
2. Allergy skin prick test:
Since the patient has environment allergic asthma exacerbation triggers an allergy skin prick
(epicutaneous) test is recommended to help identify possible environmental asthma
exacerbation triggers (If the clinic does not offer the allergy skin prick test, a referral will be
needed (Quirt, J., Hildebrand, K.J., Mazza, J. et al., 2018).
Labs:
No labs are needed at this time.
Education:
● Michelle will be educated on the proper use of antibiotic. (Details listed below.)
Case Discussion
Pulmonary – Part 1
1. 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.
Diagnosis: Mild to moderate persistent asthma with episode of shortness of
breath (SOB) related to occupational problems/ work circumstances.
ICD code: J45.30 and Z56.9
Asthma
Asthma is a chronic airway inflammation characterize by respiratory
symptoms such as SOB, coughing, wheezing and tightness of the chest,
along with a variable of expiratory airflow limitation. A diagnosis of asthma
be confirmed by a history of various respiratory symptoms and pulmonary
function test (PFT). A diagnosis of asthma can be diagnosed by the patient
past respiratory symptoms and a FEV1 greater than 12% difference between
a pre-and-post PFT (GINA, 2020).
Rationale:
The patient has a history of seasonal allergies, recent episodes of SOB and a
few months ago visited an urgent care for her SOB. The patient’s physical
exam presents slight wheezing on inspiration and forced expiration with
wheezing that does not clear with forceful coughing. The patient pre-PFT
resulted in a FEV1/FVC of 60% and the post- PFT resulted in a FEV1/FVC
of 75%, which is greater than 12% improvement indicating a diagnosis of
asthma as per the GOLD guidelines (GINA, 2020).
Occupational asthma is an exposure of substance(s) that causes an
exacerbation or contribute to worsening of preexisting condition in the
workplace. Classic symptoms of occupational asthma may include
coughing, difficulty breathing, wheezing, and tightening of the chest (Bepko
and Mansalis, 2016).
Rationale:
HPI: The patient reports SOB mostly occurs at work and resolves before
arriving home. Upon returning to work, the patient reports her SOB returns.
The episodes of SOB do not occur on the weekends. Based on her HPI the
patient symptoms are associated with occupational asthma.
, 2. 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.
Medications
Based on the GINA guidelines, Michelle should be started on a following medication:
1. Low dose corticosteroid and long-acting-beta-agonist (ICS-LABA): (GINA, 2020)
● Advair (Fluticasone/salmeterol): 2 puff PO Q12 hours. Disp #:1
Advair is a combination drug of fluticasone and salmeterol used to treat respiratory
symptoms such as SOB, wheezing, tightness of the chest, difficulty breathing due to asthma.
Fluticasone is a corticosteroid that helps by reducing irritation and swelling of the airway.
Salmeterol is a long-acting-beta-agonist (LABA) that helps relax and open an air passage to
the lungs. Short acting-beta-antagonist (SABA): A SABA as-needed for severe uncontrolled
asthma exacerbations (U.S. NLOM, 2020).
2. Short-acting-beta-agonist (SABA) (GINA, 2020)
● Albuterol sulfate: PROAIR HFA 108 mcg/puff Sig: 2 puff PO Q4-6 hours as
needed for SOB. Disp #: 1
PROAIR FA is an aerosol inhalator that treat and prevents bronchospasm and exercise-
induced bronchospasm (FDA, 2019).
Plan of Treatment:
1. Action plan:
An action plan will be created, and a written copy will be provided. The patient will be
educated on steps to follow if asthma symptoms worsen and when to seek emergency care
(GINA, 2020).
2. Allergy skin prick test:
Since the patient has environment allergic asthma exacerbation triggers an allergy skin prick
(epicutaneous) test is recommended to help identify possible environmental asthma
exacerbation triggers (If the clinic does not offer the allergy skin prick test, a referral will be
needed (Quirt, J., Hildebrand, K.J., Mazza, J. et al., 2018).
Labs:
No labs are needed at this time.
Education:
● Michelle will be educated on the proper use of antibiotic. (Details listed below.)
