CASE STUDY 1: ADULT ONSET ASTHMA
CASE STUDY 1: ADULT ONSET ASTHMA
CASE STUDY 1: Adult Onset Asthma
Irene Pocasangre, RN, BSN, PHN, FNP-S
Mervyn M. Dymally School of Nursing Charles R. Drew University of Medicine and Science June 30th 2020
This paper was written for NUR 620 Physical Assessment taught by Nancy Diago
This case study takes place in an Urgent Care (UC). The patient that self presented to the UC consist of the following given scenario:
A 25-year-old previously well woman presents to your office with complaints of episodic shortness of breath and chest tightness. She has had the symptoms on and off for about 2 years but states that they have worsened lately, occurring two or three times a month. She notes that the symptoms are worse during the spring months. She has no exercise-induced or nocturnal symptoms. The family history is notable for a father with asthma. She is single and works as an administrative assistant in a high-tech firm. She lives with a roommate, who moved in approximately 2 months ago. The roommate has a cat. The patient smokes occasionally when out with friends and drinks socially but has no history of illicit drug use.
Pertinent PE findings include the following: VS 115/80 HR 84 RR 22 T 98.6 O2 sat 95% room air. Pertinent physical examination is notable for mild end-expiratory wheezing. The rest of the PE findings are unremarkable.
Case Study 1: Adult Onset Asthma
PATIENT INFORMATION: W.E. is a 25-year-old woman who self-presented to Urgent Care (UC) for medical services.
CHIEF COMPLAINT: Patient states “I have been having more episodes of shortness of breath and chest tightness”.
HISTORY OF PRESENT ILLNESS: W.E. self presented to UC stating that she has been experiencing shortness of breath and chest tightness on and off for about 2 years now. However, symptoms have been increasing in frequency. She reports experiencing these symptoms two to three times a month. Symptoms appear to be worst during the spring months. Currently, W.E. denies worsening symptoms when exercising or at nighttime. Denies identification of triggers at this time. Patient reports that it is difficult to catch her breath, symptoms have resolved with no interventions. However, the increase in number of episodes a month is worrisome enough to have her come in today.
ALLERGIES: No known food or drug allergies.
PAST MEDICAL HISTORY: Denies any medical history, accidents, or any past hospitalizations. Reports that Immunization status is up to date, Influenza vaccine last received on 12/15/2019.
PAST SURGICAL HISTORY: Patients denies any previous surgeries.
FAMILY HISTORY: Mother is reported to be well and alive with no medical history.
Father has a history of asthma. Denies family history of Hypertension, Diabetes, Heart Disease or Cancers.
SOCIAL HISTORY: Works as an administrative assistant in a high-tech firm. Usually works long hours, but the pay is adequate for the job. Patient reports being single. Lives with roommate and roommates’ cat, as of two months ago. Father, mother and younger brother live 20 minutes away, parents are very supportive. Smokes occasionally when out with friends, drinks socially, denies drug use.
SEXUAL HISTORY: Currently practicing celibacy. Last Pap smear almost 4 years ago.
MEDICATIONS: Denies taking any medications.
REVIEW OF SYSTEMS:
Constitutional: Denies chills, fever, fatigue, weakness, weight changes, headaches, malaise, or night sweats.
Skin: No rash, discoloration, itching, pruritus, lumps/bumps, nail, or hair changes.
Head: No headache, dizziness, lightheadedness, or vertigo.
Eyes: No changes in vision, eye pain, tearing, eye discharge.
Ears: No ear pain, discharge, ear fullness, tinnitus, or hearing loss.
Nose/Sinuses: No congestion, nasal discharge, epistaxis, sinus pain, sneezing,
Oral: No sores, dental cavities, gum lesions or gingivitis, gum bleeding.
Throat/Neck: No sore throat, hoarseness, dysphagia, neck pain, or neck swelling.
Cardiovascular: (+)Occasional chest pain and shortness of breath. Denies palpitations, orthopnea, or worsening symptoms at nighttime.
Respiratory: (+) Occasional shortness of breath, trouble breathing, and wheeze. No cough, congestion or hemoptysis.
Gastrointestinal: no abdominal pain, nausea, vomit heartburn, changes in bowel habits or blood in stools.
Genitourinary: No dysuria, hematuria, urinary frequency, incontinence, genital discharge.
Musculoskeletal: No leg pain, cramps, joint pain, joint stiffness, swelling, redness or weakness.
Neurological: No headaches, seizures, tremors, numbness, or tingling.
Endocrine: No polyphagia, polydipsia, polyuria, denies intolerance to heat or cold.
Hematological: No easy bruising
Psychiatric: No anxiety, feeling of sadness, mood swings, insomnia.
General Survey: Patient is awake, alert, oriented, not in acute respiratory distress.
VS: BP: 115/80 mmHg HR: 84/min RR: 22/min Temp: 98.6F (oral) O2 sat 95% room air
Hgt: 5’5” Wgt:120 lbs BMI: 21.6
Skin: Intact, pink, warm, moist, free of rashes, no atypical pigmentation.
Head: Normocephalic/atraumatic, even hair distribution, no scalp lesions or bald spots, no scalp tenderness or palpable mass.
Eyes: no ptosis, pink palpebral conjunctivae, anicteric sclerae, pupils equally reactive to light and accommodation (PERRLA), (+) intact extraocular muscles (EOM’), (+) red orange reflex bilaterally, fundoscopic findings shows no papilledema, no retinal hemorrhages, blood vessels appear normal with sharply demarcated optic disc.
Ears: normal pinna, no lesions, no tragal tenderness, otoscopy showed non erythematous ear canal, minimal cerumen, no aural discharge, tympanic membrane pearly gray, good cone of light, no bulging or retraction, bilaterally.
Nose/Sinus: nasal septum midline, nostrils patent bilaterally, no nasal discharge, no inflammation, pink nasal mucosa, no bogginess noted, no tenderness over frontal and maxillary sinuses.
Oral/Throat: pink moist oral mucosa, no oral lesion, good dentition, no dental caries, no halitosis, no gum lesions, swelling or bleeding. Pink pharyngeal wall, no airway obstruction
Neck: supple, no tenderness, no stiffness, carotid pulse with normal upstroke, no bruit appreciated. Trachea midline, thyroid normal size and consistency, no palpable mass, no JVD.
Cardiac: normal rate regular rhythm, no heaves, no thrills, S1 and S2 sounds normal, no gallops, clicks or rubs. PMI best appreciated on the 5th ICS-MCL, no murmur. No edema to extremities.
Lungs: respiratory effort even with noted tachypnea. No intercostal or supraclavicular retractions, symmetrical chest expansion, equal tactile fremitus bilaterally, resonant on percussion with noted hyperresonance or dullness. End expiratory wheezing with prolongation of expiratory phase noted. No ronchi, no rales.
Abdomen: flat, nontender and nondistended. No skin discoloration, no visible lesion, flat umbilicus, normoactive bowel sounds, liver span 6.5 cm, spleen non palpable, no mass
Genitalia: Deferred per patient request.
Extremities: no rashes, no abnormal pigmentation, no edema, no swelling, no deformity, pulse full and equal on all extremities, good range of motion, muscle strength 5/5 on all extremities.
Neurologic: alert, oriented to time, and place, responds appropriately to questions and follows simple commands, CN I – XII intact, good coordination and balance, no gross or fine motor deficits.
PRIMARY DIAGNOSIS: Adult Onset Asthma
The patient in this case study presented with adult onset asthma. Adult onset asthma is noted during physical examination with symptoms of end-expiratory wheezing and slightly tachypneic with respiration of 22. Although SaO2 is 95%, it is noted to be low normal for a fairly healthy 25-year-old. Subjective information includes chest tightness and shortness of breath. These symptoms demonstrate bronchial hyperresponsiveness and strongly suggest a diagnosis of adult onset asthma. The roommate’s cat may be a trigger or allergen for this specific patient. Exposure to allergens can initiate a cascade of cellular activation events in the airway leading to acute and chronic inflammatory response resulting in the release of cytokines and other mediators (Asthma and Allergy Foundation of America. 2020). Mediators cause increase airway inflammation, air way hyperresponsiveness and asthma symptoms. The cascading events can result in permanent changes in both structure and function of the airway.
Asthma is a common pulmonary condition defined by airway inflammation that causes inflammation to the respiratory tubes, tightening of respiratory smooth muscles, and episodes of brochoconstriction (Brashers, V., & Rote, N. 2018). The airways narrow resulting in an increase in resistance that manifest as episodes of coughing, shortness of breath, and wheezing (Brashers, V., & Rote, N. 2018). Airway capillaries may dilate and leak, increasing secretions, which in turn causes edema and impairs mucus clearance (Brashers, V., & Rote, N. 2018). The increase in mucus can cause plugs that block the airway. It can affect the trachea, bronchi, and bronchioles. In many healthy individuals the airway does not contribute to significant changes to airflow resistance. Loss of the epithelia’s barrier function allows allergens to penetrate, causing the airways to become hyperresponsiveness (Brashers, V., & Rote, N. 2018). The extent of inflammation along with the individual’s immunologic response will account for the level of hyperresponsiveness.
1. Acute Coronary Syndrome
Acute Coronary Syndrome (ACS) is a term that encompasses many cardiac diagnoses, which include STEMI, NONSTEMI, unstable angina, cardiac arrhythmia, and cardiac tamponade (Uptodate, 2020). These cardiac diseases can reduce blood flow to the heart causing changes in how the heart works. These changes can predispose individuals to heart attacks or even sudden death. These symptoms include chest pain, shortness of breath, nausea, vomit, dizziness, lightheadedness, fatigues, and sudden sweating (Uptodate, 2020). Many times, dyspnea might be the only presentation, especially in females, older adult, and diabetics. In this case, ruling out ACS is imperative. Heart failure can also mimic symptoms of asthma, however, this patient is too young and healthy to suspect heart failure at this time.
2. Pulmonary Embolism
Pulmonary Embolism (PE) occurs when there is a blockage in the pulmonary arteries by a blood clot that usually forms in other parts of the body, dislodges and travels upwards (Wedo, B., 2019). It usually forms in the deep veins of the upper and lower extremities. Symptoms can be very similar to that of asthma; symptoms include dyspnea at rest, tachypnea, anxiety, and pleuritic chest pain (Wedo, B., 2019). Symptoms can present acute or chronic. Diagnosis can be suspected if patient reports prolonged immobilization such as in prolonged bedrest due to surgery or illness or prolonged sitting during traveling, trauma to one of the extremities, bleeding abnormalities, pregnancy, use of birth control, or certain cancers. PE is not the proper diagnosis for this patient as patient denies recent immobilization as she continues to work as schedule, recent travel as she denies taking any vacations, denies being sexually active at this time with no need to take contraception, and denies any medical history. Physical examination did not observe edema, redness, tenderness to any of the 4 extremities. Chronic obstruction pulmonary disease can mimic symptoms of asthma; however, this patient does not seem to suffer from progressively worsening lung disease, cough and trouble breathing. The patient reports episode of shortness of breath and chest pain, increasing in frequency. Patient denies being a heavy smoker and physical assessment did not find signs of barrel chest.
An electrocardiogram (EKG) is a noninvasive, painless diagnostic procedure that measures electrical signals in the heart. It can detect irregular heart rhythms and identify causes of chest pain, shortness of breath, dizziness and fainting. The test consists of having small electrodes attached to specific areas in the chest and extremities while a technician records the signal. The procedure can take a few minutes, typically less than 10. This test can rule out emergent situations such as a ST-Elevation Myocardial Infarction (Papadakis, M & McPhee, S. 2020). Individuals presenting with chest pain or epigastric pain should have an EKG completed to rule out STEMI. This test can also help identify abnormal rhythms such as Atrial fibrillation.
2. Chest Radiography
Chest radiography (CXR) is another noninvasive diagnostic tool that is used to identify conditions of the lungs such as pneumonia, pulmonary edema, pulmonary effusion, lung mases or nodules (Papadakis, M & McPhee, S. 2020). It uses small amount of radiation to create an image of the structures within the chest as a beam of radiation passes through the body. As a result, a black and white image is created. Asthma is not diagnosed using a radiographic image, however, it can be very useful in ruling out other lung diseases.
3. Ancillary Laboratory Tests
A. Cardiac Panel- A cardiac panel identifies abnormal cardiac enzymes and cardiac markers. It is useful in identify cardiac emergencies such as STEMI’s. It can be use in conjunction with an EKG to assess the heart condition. A negative cardiac panel rules out a cardiac event.
B. Complete Blood Count – A CBC is important when providing care for a patient reporting shortness of breath. Although a CBC can identify eosinophilic asthma, it can also identify other conditions such as anemia which can cause shortness of breath and fatigue (Papadakis, M & McPhee, S. 2020).
C. Basic Metabolic Panel (BMP) – A BMP can provide information about the body’s fluid and electrolyte balance. Electrolytes, like potassium, play a role in cardiac health. Hyperkalemia and hypokalemia can affect the heartbeats and cause arrythmias. Ruling electrolyte imbalance is necessary.
4. Peak Expiratory Flow- A peak flow is a handheld device that measures how well air flows out the lungs. Peak expiratory flow (PEF) can be an important aspect of asthma management. It can help identify early signs of an asthma attack or when medication is no longer producing optimal results and might require changes. PEF monitoring can establish peak flow variability and quantify asthma severity, can be very useful in new adult onset asthma as baseline condition is crucial (Papadakis, M & McPhee, S. 2020).
Medical management of Adult Onset Asthma generally consists of pharmacological interventions. Medications can generally be divided into two different categories, the reliever and the controller (Papadakis, M & McPhee, S. 2020). Relieving medication act primarily by promoting direct relaxation on bronchial smooth muscles while controlling medication helps to attenuate airway inflammation and are taken daily independent of symptoms. (Papadakis, M & McPhee, S. 2020).
For this case scenario, pharmacological management consists of prescribing Albuterol, a Beta-adrenergic agonist (SABA). SABAs are considered the rescue therapy of asthma patients making them extremely important and accessible to all asthma patients. According to Papadakis, M & McPhee, S. (2020) “SABAs are the most effective bronchodilators during exacerbations and provide immediate relief of symptoms”. For those with mild to moderate symptoms, one-two inhalations of a SABA would suffice, however, “severe exacerbations frequently require higher doses: 6–12 puffs every 30–60 minutes of albuterol by MDI with an inhalation chamber or 2.5 mg by nebulizer provide equivalent bronchodilation” (Papadakis, M & McPhee, S. 2020).
Albuterol comes in tablet form, immediate and extended release, oral solution and inhaled solution. Immediate release tablet comes in 2 mg and 4 mg with usual prescription of 2-4 mg PO tid-qid; Max of 32 mg/day (Papadakis, M & McPhee, S. 2020). Extended release tablets come in 4 mg and 8 mg, with usual prescription of 4-8 mg ER PO q 12h; Max of 32 mg/day. Do not cut, crush, or chew ER tablets (Papadakis, M & McPhee, S. 2020). Oral solution comes in 2mg/5ml and would follow the immediate release order (Papadakis, M & McPhee, S. 2020). Inhaled albuterol MDI comes in 90 mcg per actuation. For bronchospasm the order usually is for 2 puffs inhaled q 4-6h prn (Papadakis, M & McPhee, S. 2020). Prescription for this patient would be as follow:
Abuterol 90 mcg 2 puffs inhaled q 4-6h prn shortness of breath wheezing
Using the table above, from CURRENT Medical Diagnosis & Treatment 2020, patient falls under Step 1 where SABA PRN is the only recommended pharmacological intervention.
The prognosis of asthma is not well described, however, when well-managed, life expectancy can be as long as someone without asthma. Different factors such as smoking, persistent presence of irritants and lifestyle choices can play a role. Education will be necessary to inform patients of the DO’s and Don’ts after an asthma diagnosis has been given. In recent months, there has been increase awareness associated with asthma patients being more susceptible to other illness such as COVID-19.
Patient will be instructed to stay current with vaccinations such as influenza and pneumonia, when of age, in order to prevent triggering asthma flare-ups. Avoiding known allergens is important. This patient is appropriate for a Nurse Practitioner (NP) as a provider in an Urgent Care setting. The NP is able to provide enhance care and education for asthma control, prescribe medication for acute phase or management of the diagnosis. Patients with moderate to severe asthma may require referral to a specialist, the NP must be able to discern which patients require referrals. In this case, the patient will need to see their PCP for follow up visits at periodic intervals in order to assess their asthma control and to modify treatment plan if needed (Papadakis, M & McPhee, S. 2020). In the UC setting, the patient will receive information of what is asthma, medications and devices, and an asthma action plan, however, the PCP will be able to provide the patient with additional resources available, such as Asthma Education in Home Visits and a home exposure assessment (Center of Disease Control and Prevention. 2020).
The patient’s PCP can refer them to a Pulmonologist if asthma worsens. A pulmonologist referral is appropriate since they specialize in diseases that affect the lungs, upper airway, thoracic cavity and chest wall (Allergy & Autoimmune Disease, 2020). A pulmonologist can better treat moderate to severe asthma. Depending on the severity of the asthma, a pulmonologist can then refer the patient to an allergist-immunologist to better treat the patient. An allergist-immunologist can help identify allergy and asthma triggers (Allergy & Autoimmune Disease, 2020).
FOLLOW UP CARE/REFERRAL:
Follow up care will include visit with PCP in seven days. Patient with also need planned follow up visits with PCP at periodic intervals in order to assess asthma control and to modify treatment plan if needed. Patient will be instructed to return if symptoms do not improve or if experiencing nausea, vomit, headache or severe pain. Call 911 or seek emergency services if experiencing worsening trouble breathing or shortness of breath unresolved with prescribed medication, swelling of the face/tongue, or feeling of closing of the airway.
This patient is also overdue for a pap-smear and would benefit from a woman health referral. According to Womenshealth.Gov. 2020, pap-smears should be done every 3 years between the ages of 21-29, unless there is a history of sexual transmitted diseases/infections.
Patient education will consist on aftercare instructions following an asthma diagnosis. Education will include a comprehensive explanation of what adult onset asthma is, signs symptoms to monitor, medication regimen, side effects of the medication, and when to seek medical help. Patient will be instructed to carry rescue medication with them at all times. If asthma symptoms are not resolved with the use of prescribed medication, seek medical help.
Asthma and Allergy Foundation of America. 2020. Adult Onset Asthma. Retrieved from https://asthmaandallergies.org/asthma-allergies/adult-onset-asthma/
Allergy & Autoimmune Disease. 2020. Allergies and Asthma. Retrieved from https://www.thermofisher.com/diagnostic-education/hcp/us/en/allergic-asthma-diagnosis-treatment.html?gclid=CjwKCAjwxev3BRBBEiwAiB_PWOhfkXM_jkHEuunydfoTfE33PoorxhiWQownL7wnSumtbLhOHbweDxoCbEcQAvD_BwE&cid=idd_standard_adwords_0120&ef_id=CjwKCAjwxev3BRBBEiwAiB_PWOhfkXM_jkHEuunydfoTfE33PoorxhiWQownL7wnSumtbLhOHbweDxoCbEcQAvD_BwE:G:s&s_kwcid=AL!8552!3!389636482731!b!!g!!%2Bdiagnose%20%2Basthma!6890339487!83463654207
Baldwin, Gran., Nastoff, Teresa., & Wade Pharagood. 2008. Environmental Triggers of Asthma. Retrieved from https://www.atsdr.cdc.gov/hec/csem/asthma/docs/asthma.pdf
Brashers, Valentina & Rote, Neal. 2018. Pathophysiology 8th ed. Elsevier. Cleveland, Ohio.
Center of Disease Control and Prevention. 2020. Strategies for addressing Asthma in Homes. Retrieved from https://www.cdc.gov/asthma/pdfs/Asthma_In_Homes_508.pdf
Papadakis, M & McPhee, S. 2020. Current 2020 Medical Diagnosis and Treatment 59th ed. Mc Graw Hill. E-book conversion
Pawankar R, Holgate S, Canonica G, at el. World Allergy Organization. White Book on Allergy (WAO). 2011. Retrieved from http://www.worldallergy.org/UserFiles/file/WAO-White-Book-on-Allergy_web.pdf
Uptodate. 2020. Acute Coronary Syndrome. Retrieved from https://www.uptodate.com/contents/acute-coronary-syndrome-terminology-and-classification
Wedo, Benjamin. 2019. Pulmonary Embolism (Blood Clot in the Lung). Retrieved from https://www.medicinenet.com/pulmonary_embolism/article.htm
Womenshealth.Gov. 2020. Pap Smear. Retrieved from https://www.womenshealth.gov/a-z-topics/pap-hpv-testsy