Asthma Case Scenario

Introduction

As future nurse practitioners you will need to critically think through various pathways to establish differential diagnoses that ultimately lead to your final treatment plan.

The following case will take you through a visit with an adult patient. Use the information provided, along with acquired knowledge from course materials and clinic experience, to complete the case scenario.

Calvin Lewis is a 20-year-old African American male who comes to your clinic for the first time complaining of asthma-type symptoms.

Calvin Intro Transcript

Critical Questions

What are at least five questions critical to ask when assessing an asthmatic patient to determine severity of symptoms?

Questions you should ask include:

How often do you need to use your rescue inhaler per week?
How often do you awake with a cough, shortness of breath, or wheezing in a week?
How many times have you sought emergency care for an asthma attack in the last 12 months?
How much does your asthma interfere with your daily activities?
How often do you experience asthma symptoms per week?

Calvin Responds Transcript

Calvin’s Personal and Medical Information

Personal

Works at a local pizza shop making and delivering pizza
Lives in the inner city with his mother and grandmother
House is old, has carpeting, and has roaches
Lives with two cats
Being around cats makes his eyes and nose watery and itchy
No air-conditioning
Smokes half a pack of cigarettes/day

Medical

History of oral steroids at least four times/year
Has not been hospitalized for asthma but had at least four ER visits this year due to asthma
Chest a little tight today, but states this is normal for him
Takes albuterol at least twice a day
Refills albuterol twice a month
Nighttime symptoms 3 to 5 times/week
Wheezing daily
Peak flow today 340 l/min
Predicted should be 570 l/min
Supposed to be taking Fluticasone 110, 1 puff BID, and loratadine 10 mg PO QA

Physical Examination

After gathering Calvin's information through patient questioning, you gather additional data from both your examination and pharmacist statements.

Vital Signs

Heart rate: 68
Respiratory rate: 24
Blood pressure: 128/72
Temperature: 98 degrees F
Weight: 60 kg
Pulse oximeter: 95% on room air

You check his breathing and you notice that his chest is tight. He has trouble taking full breaths, and he is wheezing.

What other systems would you want to examine and why?

You should also examine the following systems.

EENT: The upper respiratory system is key, especially given Calvin’s suspected allergic response to his grandmother’s cats. Look for signs of allergic response, such as swollen eyes, red conjunctivitis, allergic shiners, otitis effusion showing fluid buildup in the ears secondary to eustachian tube defect with swollen nasal sinuses, blue and boggy nasal turbinate, clear rhinitis, cobblestone appearance to the back of the throat, or visual postnasal sinus drip.

Skin: Look for signs of allergic response, such as eczema that is part of the allergic triad.

Heart: Listening to heart sounds should be part of all physical examinations.

Based on the history and physical examination, what would you order for Calvin and why?

Nebulizer inhalation treatment: See if wheezing responds. You do not want to send Calvin out of the office with wheezing to this severity.
Prednisone 20 mg tablets, 3 tablets per oral route once in office, to help stop inflammation response in lungs that is causing wheezing.
You could order a chest x-ray if you suspect pneumonia or other pathology. Would not be of much benefit for asthma exacerbation alone. If you order a chest x-ray, it demonstrates hyperinflation. It is not necessary.
Because you are in a clinic, Calvin is a known asthmatic, and you have his peak flow meter readings, you can use them to determine his asthma severity. Pulmonary function testing is not completed in office and would not add to your diagnosis at this time.

Diagnosis

Based on the information you have gathered, what questions should you be reflecting on to determine a correct diagnosis?

Questions you should reflect on include:

Does Calvin actually have asthma?
Does it explain the entire clinical picture?
Is Calvin taking his medication properly?
Is Calvin compliant to treatment?
Are you prescribing adequate anti-inflammatory asthma?
Are allergies or sinusitis contributing?
Is the home environment or workplace contributing?
Are there barriers to care that need to be addressed?

Look back at all the information you have gathered and consider the severity of Calvin’s symptoms.

How frequent are Calvin’s symptoms?

Classification of Severity

How often does he have nighttime awakenings?

Classification of Severity

How often does he use short-acting beta-agonist for symptom control?

Classification of Severity

How much does asthma interfere with his normal activity?

Classification of Severity

What is his lung function?

Classification of Severity

What is your final diagnosis for Calvin and why?

Correct Diagnosis

The correct diagnosis is severe-persistent asthma and allergic rhinitis. Review the asthma severity chart in Asthma: Clinical Manifestations and Management to help with your diagnosis.

His symptoms are severe persistent because he reports symptoms throughout the day; nighttime awakenings are moderate persistent with wakening 4 to 5 times a week but not nightly; beta-agonist use is severe persistent as use is now twice a day; interference is severe persistent, as he reports limitations to his daily activity and limiting his usual ability to be active on a daily basis now-very bothersome; and lung function is severe persistent—while not able to get pulmonary function testing, he is able to perform a peak flow. We know his expected is 570 but today he can only get to 340; this is a 16% reduction from his normal rate.

Also allergies because he reported an allergic response to his grandmother’s cats.

Treatment Plan

Review 2020 GINA Guidelines for the Global Strategy for the Management of Asthma, paying particular attention to Treating asthma to control and minimize risk, chapter 3.

What is your treatment plan for Calvin?

Your treatment plan should include:

A 5- to 7-day burst of oral steroids to address acute exacerbation—short-acting medication.
Renew Albuterol or short-acting inhaler for use with acute symptoms—short acting, rescue medication.
Step up therapy: First, add long-acting bronchodilator to Fluticasone. May also consider increasing Fluticasone to a high dose. High dose inhaled corticosteroid and long acting bronchodilator (or equivalent). Increase dosage of current Fluticasone to high dose strength, Fluticasone 220 mcg/spray 2 puffs BID. This may be accomplished by a combo therapy inhaler such as Advair.
Antihistamine and nasal steroid, sinus washes—address allergy triggers
Follow-up in two weeks. Discuss allergy skin testing and establish an asthma action plan.
Treatment options:
- Add Salmetrol LABA first then consider increasing inhaled steroids. Many options
- Fluticasone HFA: 44/110/220 mcg/spray (220, 2 puffs, BID)
- Fluticasone Diskus: 100, 250 mcg (250, 2 BID)
- Mometasone (Asmanex): 110/220 mcg DPI – start 220 mcg day, max 440 mcg/day (220, 2 BID)
- Budesonide (Pulmicort): 90/180 mcg DPI – 180-360 mcg BID (180, 2 BID)
- Combined:
  - Budesonide/formoterol (Symbicort): 80/4.5, 160/4.5 (160/4.5, 2 puffs BID)
  - Advair Diskus: 100/50, 250/50, 500/50 (1 puff BID)
  - Advair HFA: 45/21, 115/21, 230/21 (2 puffs BID)
  - LABA may increase risk of asthma related death in patients receiving salmeterol plus usual asthma treatment (SMART TRIAL). Consider combined therapy if patients not controlled on other asthma meds or if diagnosis warrants, initial treatment with two maintenance medications.
- Montelukast: 10 mg QPM (leukotriene inhibitor)
- Mometasone nasal (Nasonex): 50 mcg/nostril QD. 2 sprays QD. Review technique.
- Triamcinolone nasal (Nasacort AQ): 55 mcg/nostril QD: 1 to 2 sprays per day
- Peak flow monitoring: 60% of PB
  - Daily peak flow monitoring is recommended for moderate, severe, persistent asthma patients, aiding in the recognition of asthma triggers and assisting poor perceivers of an exacerbation or anyone who finds it helpful.

Patient Education

Explain Calvin’s diagnosis and treatment plan to him using simple language without medical jargon. In addition to your discussion of Calvin’s goals for asthma treatment, explain to the patient what asthma is, what the signs and symptoms of his asthma worsening are, and what should the patient do when experiencing various asthma symptoms. Include at least four points of patient education and specific instructions for the patient to follow up with you regarding worsening signs and symptoms.

Your description should be one the patient could understand if they were in fourth grade. Include at least one professional citation from a peer-reviewed source and use correct APA format.

What is your education plan for Calvin?

Your education plan should include:

Discuss Calvin’s goals for asthma treatment.
- Discuss Calvin’s concerns about medications and therapies for asthma.
- Inhaler instruction with a spacer/aero chamber.
- Medication education regarding the importance of long-term controllers.
- Education regarding daily symptoms and overuse of albuterol as indication of poorly controlled asthma.
- Peak flow meter and instruction
- Environmental education regarding cats, roaches, dust mites, and mold.
- Smoking cessation
- Discuss workplace as a possible trigger to asthma and discuss options at work to decrease exposure.
- Asthma Action Plan
Discussion barriers to care.
- No medical insurance: Social work consult? Sliding scale to pay for visits?
- Medications expense: Offer samples, investigate pharmaceutical medication assistance programs, simplify medication plan. Calvin may need resources.

Wrap Up

Congratulations! You have successfully treated Calvin for severe-persistent asthma and allergic rhinitis. You may repeat this scenario as often as desired to practice your treatment work.

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