NR 603 Week 2 Case Discussion Pulmonary
- Part 2 Follow up Visit Complete Solution
Question 1
Michelle G. is a 40-year-old baker’s assistant with a history of occupational asthma, well-
controlled on low-dose inhaled corticosteroid (ICS), montelukast 10 mg daily, and albuterol PRN
(1–2 times/week). She presents with a 2-day history of fever (101–102°F), productive cough
with white sputum, and increased shortness of breath. Influenza A is confirmed positive. What
is the most likely primary acute diagnosis?
A. Community-acquired pneumonia
B. Acute bronchitis
C. Influenza A with asthma exacerbation
D. Pulmonary embolism
Correct Answer: C
Rationale: The patient has confirmed Influenza A by rapid test, fever, cough, and new-onset
wheezing/dyspnea. Her history of asthma and current wheezing indicate an asthma
exacerbation triggered by influenza. Community-acquired pneumonia would present with focal
crackles and consolidation on imaging; acute bronchitis lacks the systemic influenza symptoms;
pulmonary embolism would present with pleuritic chest pain, tachycardia, and hypoxemia
disproportionate to exam findings.
Question 2
Which feature of Michelle’s presentation most strongly supports the diagnosis of asthma
exacerbation rather than a fixed obstructive process?
A. Fever of 101.4°F
B. Inspiratory and expiratory wheezing
C. History of childhood eczema
D. Productive cough with white sputum
Correct Answer: B
Rationale: Inspiratory and expiratory wheezing indicates reversible bronchoconstriction and
airway inflammation, the hallmark of asthma exacerbation. Fever suggests infection (the
,trigger). Childhood eczema supports an atopic phenotype but does not indicate acute
reversibility. Productive cough can occur with both asthma and COPD.
Question 3
Based on GINA guidelines, which assessment finding would classify Michelle’s exacerbation
as moderate?
A. Speaks in single words, O₂ saturation 88%
B. Speaks in phrases, O₂ saturation 94%, mild work of breathing
C. Silent chest, respiratory rate 8
D. O₂ saturation 92%, ability to lie flat without dyspnea
Correct Answer: B
Rationale: GINA classifies moderate exacerbation as speaking in phrases, O₂ saturation 90–
95%, respiratory rate increased but <30, heart rate 100–120, and no accessory muscle use.
Michelle’s presentation (RR 24, O₂ sat 94%, speaks in sentences/phrases, mild work of
breathing) fits moderate severity. Single words with O₂ <90% indicates severe; silent chest is life-
threatening.
Question 4
Which of the following is the most appropriate initial diagnostic test for Michelle at this visit?
A. Chest X-ray
B. Sputum culture
C. Rapid influenza antigen test
D. D-dimer
Correct Answer: C
Rationale: Michelle presents with influenza-like illness (fever, cough, myalgias) during a
known influenza outbreak at her workplace. Rapid influenza testing is the first-line diagnostic
and is essential for guiding antiviral therapy. Chest X-ray is not routinely indicated in
uncomplicated asthma exacerbation unless pneumonia is suspected. Sputum culture is not first-
line for influenza. D-dimer is used for PE evaluation, which is not the primary concern here.
,Question 5
Michelle’s influenza rapid test is positive. According to CDC guidelines, which of the following
patients should receive antiviral treatment for influenza?
A. Only those with confirmed high-risk conditions
B. Only those presenting within 24 hours of symptom onset
C. All patients with confirmed or suspected influenza, regardless of risk factors
D. Only hospitalized patients
Correct Answer: C
Rationale: The CDC recommends antiviral treatment for all patients with confirmed or
suspected influenza who are within 48 hours of symptom onset, regardless of risk factors. For
high-risk patients (including those with asthma) who present >48 hours after onset, treatment
can still be considered. Michelle has asthma (a high-risk condition), so she should receive
antivirals even if she presents after 48 hours.
Question 6
Which medication is contraindicated in Michelle’s current management?
A. Oseltamivir
B. Prednisone
C. Aspirin
D. Acetaminophen
Correct Answer: C
Rationale: Aspirin is contraindicated in asthmatic patients due to the risk of aspirin-
exacerbated respiratory disease (AERD), a severe bronchospasm triggered by NSAIDs.
Additionally, aspirin should be avoided in children and adolescents with influenza due to Reye’s
syndrome risk. Oseltamivir, prednisone, and acetaminophen are all appropriate.
Question 7
Michelle’s influenza symptoms began 2 days ago. What is the treatment window for oseltamivir
in this patient?
A. 24 hours
B. 48 hours for all patients, but can be extended for high-risk patients
, C. 72 hours
D. No time limit
Correct Answer: B
Rationale: Oseltamivir is most effective when started within 48 hours of symptom onset.
However, for high-risk patients (including those with asthma, diabetes, or immunocompromise)
who present >48 hours after onset, antiviral treatment is still recommended. Michelle is at 48–
72 hours and has asthma, so treatment is indicated.
Question 8
Which finding on Michelle’s physical exam would indicate that her asthma exacerbation
is severe rather than moderate?
A. Respiratory rate of 24
B. O₂ saturation of 94% on room air
C. Use of accessory muscles and inability to speak full sentences
D. Inspiratory wheezing
Correct Answer: C
Rationale: Severe asthma exacerbation is characterized by accessory muscle use, speaking
in single words, agitation, O₂ saturation <90%, and PEF <50% predicted. Moderate exacerbation
(Michelle’s current state) includes speaking in phrases, mild work of breathing, O₂ sat 90–95%,
and no accessory muscle use.
Question 9
What is the most likely trigger for Michelle’s current asthma exacerbation?
A. Occupational flour exposure
B. Influenza A infection
C. Montelukast nonadherence
D. Seasonal allergies
Correct Answer: B
Rationale: Michelle’s asthma was well-controlled until she developed influenza-like
symptoms. Influenza is a well-known trigger for asthma exacerbations due to viral-induced
airway inflammation, increased mucus production, and bronchial hyperresponsiveness. Her
occupational exposure is chronic, not acute, and she has been controlled on her regimen.
- Part 2 Follow up Visit Complete Solution
Question 1
Michelle G. is a 40-year-old baker’s assistant with a history of occupational asthma, well-
controlled on low-dose inhaled corticosteroid (ICS), montelukast 10 mg daily, and albuterol PRN
(1–2 times/week). She presents with a 2-day history of fever (101–102°F), productive cough
with white sputum, and increased shortness of breath. Influenza A is confirmed positive. What
is the most likely primary acute diagnosis?
A. Community-acquired pneumonia
B. Acute bronchitis
C. Influenza A with asthma exacerbation
D. Pulmonary embolism
Correct Answer: C
Rationale: The patient has confirmed Influenza A by rapid test, fever, cough, and new-onset
wheezing/dyspnea. Her history of asthma and current wheezing indicate an asthma
exacerbation triggered by influenza. Community-acquired pneumonia would present with focal
crackles and consolidation on imaging; acute bronchitis lacks the systemic influenza symptoms;
pulmonary embolism would present with pleuritic chest pain, tachycardia, and hypoxemia
disproportionate to exam findings.
Question 2
Which feature of Michelle’s presentation most strongly supports the diagnosis of asthma
exacerbation rather than a fixed obstructive process?
A. Fever of 101.4°F
B. Inspiratory and expiratory wheezing
C. History of childhood eczema
D. Productive cough with white sputum
Correct Answer: B
Rationale: Inspiratory and expiratory wheezing indicates reversible bronchoconstriction and
airway inflammation, the hallmark of asthma exacerbation. Fever suggests infection (the
,trigger). Childhood eczema supports an atopic phenotype but does not indicate acute
reversibility. Productive cough can occur with both asthma and COPD.
Question 3
Based on GINA guidelines, which assessment finding would classify Michelle’s exacerbation
as moderate?
A. Speaks in single words, O₂ saturation 88%
B. Speaks in phrases, O₂ saturation 94%, mild work of breathing
C. Silent chest, respiratory rate 8
D. O₂ saturation 92%, ability to lie flat without dyspnea
Correct Answer: B
Rationale: GINA classifies moderate exacerbation as speaking in phrases, O₂ saturation 90–
95%, respiratory rate increased but <30, heart rate 100–120, and no accessory muscle use.
Michelle’s presentation (RR 24, O₂ sat 94%, speaks in sentences/phrases, mild work of
breathing) fits moderate severity. Single words with O₂ <90% indicates severe; silent chest is life-
threatening.
Question 4
Which of the following is the most appropriate initial diagnostic test for Michelle at this visit?
A. Chest X-ray
B. Sputum culture
C. Rapid influenza antigen test
D. D-dimer
Correct Answer: C
Rationale: Michelle presents with influenza-like illness (fever, cough, myalgias) during a
known influenza outbreak at her workplace. Rapid influenza testing is the first-line diagnostic
and is essential for guiding antiviral therapy. Chest X-ray is not routinely indicated in
uncomplicated asthma exacerbation unless pneumonia is suspected. Sputum culture is not first-
line for influenza. D-dimer is used for PE evaluation, which is not the primary concern here.
,Question 5
Michelle’s influenza rapid test is positive. According to CDC guidelines, which of the following
patients should receive antiviral treatment for influenza?
A. Only those with confirmed high-risk conditions
B. Only those presenting within 24 hours of symptom onset
C. All patients with confirmed or suspected influenza, regardless of risk factors
D. Only hospitalized patients
Correct Answer: C
Rationale: The CDC recommends antiviral treatment for all patients with confirmed or
suspected influenza who are within 48 hours of symptom onset, regardless of risk factors. For
high-risk patients (including those with asthma) who present >48 hours after onset, treatment
can still be considered. Michelle has asthma (a high-risk condition), so she should receive
antivirals even if she presents after 48 hours.
Question 6
Which medication is contraindicated in Michelle’s current management?
A. Oseltamivir
B. Prednisone
C. Aspirin
D. Acetaminophen
Correct Answer: C
Rationale: Aspirin is contraindicated in asthmatic patients due to the risk of aspirin-
exacerbated respiratory disease (AERD), a severe bronchospasm triggered by NSAIDs.
Additionally, aspirin should be avoided in children and adolescents with influenza due to Reye’s
syndrome risk. Oseltamivir, prednisone, and acetaminophen are all appropriate.
Question 7
Michelle’s influenza symptoms began 2 days ago. What is the treatment window for oseltamivir
in this patient?
A. 24 hours
B. 48 hours for all patients, but can be extended for high-risk patients
, C. 72 hours
D. No time limit
Correct Answer: B
Rationale: Oseltamivir is most effective when started within 48 hours of symptom onset.
However, for high-risk patients (including those with asthma, diabetes, or immunocompromise)
who present >48 hours after onset, antiviral treatment is still recommended. Michelle is at 48–
72 hours and has asthma, so treatment is indicated.
Question 8
Which finding on Michelle’s physical exam would indicate that her asthma exacerbation
is severe rather than moderate?
A. Respiratory rate of 24
B. O₂ saturation of 94% on room air
C. Use of accessory muscles and inability to speak full sentences
D. Inspiratory wheezing
Correct Answer: C
Rationale: Severe asthma exacerbation is characterized by accessory muscle use, speaking
in single words, agitation, O₂ saturation <90%, and PEF <50% predicted. Moderate exacerbation
(Michelle’s current state) includes speaking in phrases, mild work of breathing, O₂ sat 90–95%,
and no accessory muscle use.
Question 9
What is the most likely trigger for Michelle’s current asthma exacerbation?
A. Occupational flour exposure
B. Influenza A infection
C. Montelukast nonadherence
D. Seasonal allergies
Correct Answer: B
Rationale: Michelle’s asthma was well-controlled until she developed influenza-like
symptoms. Influenza is a well-known trigger for asthma exacerbations due to viral-induced
airway inflammation, increased mucus production, and bronchial hyperresponsiveness. Her
occupational exposure is chronic, not acute, and she has been controlled on her regimen.
