Case Discussion: Pulmonary Part 1
What is your primary diagnosis for Michelle given the pattern of occurrence of symptoms, exam results, and recent history?
The primary diagnosis is mild to moderate persistent asthma with dyspnea associated with occupational circumstances. Asthma is a chronic inflammatory condition of the respiratory system distinguished by bronchial hyperresponsiveness, episodic exacerbations, and reversible airflow obstruction (Drake et al., 2019). Characteristic symptoms include reversible wheezing, cough, and dyspnea.
The diagnosis of asthma is made by a combination of the typical asthma symptoms with a simultaneous demonstration of reversible bronchial obstruction (Cloutier et al., 2020). Michelle has a history of asthma-related symptomatology, including dyspnea and chest tightness.
Furthermore, she has a history of seasonal allergies and even had eczema during her childhood. According to Drake et al. (2019), atopy is the cardinal risk factor for allergic asthma. Finally, her pre-PFT demonstrated an FEV1/FVC of 60%, while the post-PFT showed an FEV1/FVC of 75%, this increment exceeds 12% solidifying a diagnosis of asthma as per the 2019 Global Initiative for Asthma (GINA) guidelines (Mauer & Taliercio, 2020).
Additionally, allergic occupational asthma is a key diagnosis in her case. According to Tiotiu et al. (2020), this variant of asthma is considerably related to exposure to allergens in the workplace. Michelle’s episodes of shortness of breath and chest tightness mostly occur at the workplace. She feels relieved at home and is almost always symptom-free during the weekends.
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.
According to the 2020 GINA guidelines, asthma should be managed via a step-wise approach. However, for Michelle, who most likely has moderate persistent asthma, a combination of low-dose inhaled corticosteroid, and long-acting beta-agonist (ICS-LABA) is recommended (Reddel et al., 2022). For instance, Fluticasone/salmeterol: 2 puff PO Q12 hours. This combination alleviates the symptoms of asthma, including cough, difficulty in breathing, dyspnea, chest tightness, and wheezing.
Furthermore, fluticasone is an inhaled corticosteroid that reduces airway inflammation, irritation, and edema. On the other hand, salmeterol is a long-acting beta-agonist that principally dilates the airway alleviating the obstruction. Finally, a short-acting beta-agonist (SABA) as needed as a reliever medication is also recommended (Reddel et al., 2022). For instance, Albuterol sulfate: PROAIR HFA 2 puff PO every 4 to 6 hours as needed. This medication is a bronchodilator and relieves symptoms such as shortness of breath.
Currently, no laboratory tests are required for her case. Nevertheless, a skin prick test is elemental to potentially isolate the possible environmental triggers (Drake et al., 2019). a well-documented individualized daily self-management plan should be developed. This action plan ought to be shared with the patient. Her education requires a multidisciplinary approach.
Michelle should be educated on self-management, self-monitoring techniques, medication use, inhaler use, and environmental control measures (Drake et al., 2019). Additionally, she should be enlightened on the side effects of medication and potential drug-drug interactions. At the moment, no referral is required, but in the event of worsening symptoms or an increase in exacerbations, it is worth it. Finally, she should follow up in 2 weeks to monitor the side effects and efficacy of medications and then quarterly to monitor asthma control and possible adjustments.
Currently, Michelle does not require any antibiotics. According to Mauer and Taliercio (2020), antibiotics are advocated for during acute asthma exacerbation but only during lung infections suggested by pneumonia, fever, and purulent sputum. Finally, her exacerbation is principally due to a viral infection putting antibiotics at a greater risk of worsening her condition.
Cloutier, M. M., Baptist, A. P., Blake, K. V., Brooks, E. G., Bryant-Stephens, T., DiMango, E., Dixon, A. E., Elward, K. S., Hartert, T., Krishnan, J. A., Lemanske, R. F., Jr, Ouellette, D. R., Pace, W. D., Schatz, M., Skolnik, N. S., Stout, J. W., Teach, S. J., Umscheid, C. A., & Walsh, C. G. (2020). 2020 Focused Updates to the Asthma Management Guidelines: A Report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group. The Journal of Allergy and Clinical Immunology, 146(6), 1217–1270. https://doi.org/10.1016/j.jaci.2020.10.003
Drake, S. M., Simpson, A., & Fowler, S. J. (2019). Asthma diagnosis: The changing face of guidelines. Pulmonary Therapy, 5(2), 103–115. https://doi.org/10.1007/s41030-019-0093-y
Mauer, Y., & Taliercio, R. M. (2020). Managing adult asthma: The 2019 GINA guidelines. Cleveland Clinic Journal of Medicine, 87(9), 569–575. https://doi.org/10.3949/ccjm.87a.19136
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Tiotiu, A. I., Novakova, S., Labor, M., Emelyanov, A., Mihaicuta, S., Novakova, P., & Nedeva, D. (2020). Progress in occupational asthma. International Journal of Environmental Research and Public Health, 17(12), 4553. https://doi.org/10.3390/ijerph17124553