NR 603 Week 2 Case Discussion: Pulmonary – Part 1 (GRADED)

NR 603 Week 2 Case Discussion: Pulmonary – Part 1 (GRADED) 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. 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. 3. Address Michelle's request for an antibiotic Dr. Deering and class, Primary Diagnosis: Based on the presenting symptoms and assessment findings within this case study, the primary diagnosis for Michelle is occupational asthma. Occupational asthma (OA), or work-related asthma (WRA), is the most common occupational lung disease in the United States (Global Initiative for Asthma [GINA], 2019). OA results from exposure to a stimulus, such as dust, grain, flour, latex, insects, and mold, found in the workplace environment (Jolly et al., 2015). Exposure to these types of allergens causes symptoms of asthma, including coughing, wheezing, chest tightness, and shortness of breath (Dao & Bernstein, 2018). Nasal congestion and eye irritation can also occur as a result of OA. In this case study, Michelle presents with shortness of breath while she is at work. When she is not at work, she has relief and no longer experiences difficulty breathing. Even on weekends when she is at home, she denies respiratory symptoms. Individuals diagnosed with OA tend to have more symptomatic days and exacerbations of asthma symptoms while they are exposed daily to a particular allergen in the workplace. Since Michelle has a history of seasonal allergies, she is at an increased risk of developing occupational asthma. One of the main risk factors for occupational asthma is atopy, which is characterized by a sensitivity to allergens (Dao & Bernstein, 2018). Therefore, individuals with atopy often have seasonal allergies, allergic skin rashes, and food allergies. In this case study, Michelle has a history of seasonal allergies and has seen an allergy specialist. Upon physical examination, Michelle was noted to have inspiratory and expiratory wheezing, thin exudates to bilateral nares, and a pale, boggy mucosa. These findings are indicative of inflammation within the respiratory mucosa from the irritant. The thin exudates within the nares are related to allergic rhinitis, which is an inflammation caused by the immune system’s response to an allergen (Pralong & Cartier, 2017). The wheezing is a result of airway narrowing from bronchoconstriction or mucosal edema (Pralong & Cartier, 2017). Michelle’s respiratory symptoms occur within a few hours of working in the bakery. She starts every morning baking bread and pastries for the day as a Baker’s assistant. Therefore, it can be safe to assume that Michelle is experiencing OA due to the type of flour used at the bakery. Even though staying away from the irritant is the best way to improve outcomes, we must initiate some tests to properly diagnose her before taking individuals away from work. In the office, Michelle had a pulmonary function test (PFT) performed. Airflow obstructions occurs when FEV1/FVC is less than 70%. Therefore, the result of FEV1/FVC 60% before the bronchodilator is indicative of airflow obstruction. After the bronchodilator was given, there was an increase of 15% in FEV1/FVC. This is considered an appropriate bronchodilator response. The existence of airflow obstruction coupled with a positive bronchodilator response is suggestive of asthma diagnosis (Pralong & Cartier, 2017). Currently, Michelle experiences symptoms of shortness of breath and wheezing five days a week within a few hours of working in the bakery. She denies exacerbations at night, and is able to sleep through the night with no issues. Based on Michelle’s frequency of symptoms and PFT results, she is considered a mild persistent asthmatic. First-line Treatment Plan: The treatment for occupational asthma is the same treatment for asthma. For mild persistent asthma, inhaled corticosteroids (ICSs) are the preferred first line medication treatment (GINA, 2019). I would prescribe fluticasone propionate 88 mcg inhaled BID. Low dose ICS target the small airways and reduce inflammation by decreasing activity of inflammatory cells and mediators (Hollier, 2018). The reduction of inflammation will help decrease mucosal edema and mucus production that cause rhinorrhea, cough, wheeze, and shortness of breath (Hollier, 2018). At the same time, a short-acting bronchodilator, such as albuterol, should be prescribed to treat exacerbations. I would prescribe albuterol 2 puffs every 4-6 hours as needed for shortness of breath. Short-acting bronchodilators are considered rescue inhalers, which help dilate the bronchi in the lungs and increase airflow (GINA, 2019). Widening the airways will help relieve breathing difficulties. Lastly, I would prescribe a leukotriene blocker, such as Singulair 10 mg daily, to prevent asthma symptoms and manage seasonal allergies. I would educate Michelle to discontinue her current use of Zyrtec. Leukotriene antagonists block the release of mast cells responsible for airway edema and inflammation (Hollier, 2018). This class of medication will help reduce wheezing and runny nose from the inflammation. While staying away from the irritant will drastically improve asthmatic symptoms, it may be difficult for Michelle to quit this current job since she is temporarily working at the bakery for financial reasons. Therefore, I would refer her to an allergist to have a skin prick testing done. According to the American College of Occupational and Environmental Medicine (Jolly et al., 2015), a skin prick testing is strongly recommended for diagnostic testing for occupational asthma. Cereal flour, particularly wheat flour, is considered one of the most common types of occupational asthma (Jolly et al., 2015). While there is a high probability that the flour used in the bakery is the allergen, a skin prick test can help identify other allergens that may play a role in Michelle’s occupational asthma. This includes rye, barley, rice, and oats. House dust mites, storage mites, and fungus should also be checked (Jolly et al., 2015). It is important to educate Michelle on ways to manage occupational asthma. Avoiding triggers is the best way to treat OA. In this case, staying away from the type of flour used in baking breads and pastries will help alleviate asthmatic symptoms. If this is not possible due to financial reasons, taking medications to prevent symptoms and treating acute asthma episodes are important educational topics. The goal of asthma self-management is to control and prevent asthma attacks (Pralong & Cartier, 2017). Therefore, I would educate Michelle on a personalized asthma action plan. I would include education on how to take each medication to prevent asthma episodes, as well as to treat acute asthma attacks. I would educate Michelle on when to use rescue inhalers and the symptoms associated with an acute asthma attack. A return demonstration of inhaler use is imperative for Michelle since this is her first time using inhalers. Side effects of ICS, leukotriene blockers, and short-acting bronchodilators should be educated as well. Side effects include: heart palpitations, dry mouth, headaches, nausea, vomiting, cough, and stomach pain (Hollier, 2018). I would like to follow-up with Michelle in 4 weeks to evaluate her response to treatment. If she is able to control symptoms during the 4 week follow-up, I would then follow-up with her in three months. It is important for Michelle to record asthma control. This entails whether she experiences less asthmatic symptoms, quick relief from rescue inhalers, little to no side effects of asthma medication, and no interruption in daily activities. However, if she experiences shortness of breath unrelieved by short-acting bronchodilators or chest pain, she will need to be instructed to go to the emergency room. If the frequency and severity of asthma increases within the next two weeks, I would instruct her to return to the office and I will reassess her and evaluate for additional treatment. For example, if Michelle reports using rescue inhalers more than 2 times a week, I would need to add a long-acting inhaled bronchodilator to better manage her asthma symptoms. If Michelle’s symptoms are very severe to the point where she cannot perform her daily activities or complete her job duties, the discussion of completely removing herself from the workplace must be encouraged. Addressing Michelle’s Request for Antibiotics: While antibiotics are one of the greatest advances in medicine, overprescribing has certainly been an issue due to increased bacterial resistance. Like many people, Michelle feels that antibiotics have helped treat her symptoms before. Therefore, it is no surprise that she would request to have another antibiotic prescription. In this case, I would tell her: “Michelle, antibiotics would not be an appropriate treatment in your case. Even though it may have made you feel better when you went to the urgent care a few weeks ago, this is an allergic response to something in your current workplace. Antibiotics are prescribed to treat bacterial infections. Even for common colds, which are usually viral, we do not prescribe antibiotics because they have no effect on viruses. Overuse of antibiotics can actually make bacteria stronger and resistant to medications. This makes it harder for us to treat any future bacterial infections if they are resistant. In your particular case, your asthma symptoms are triggered by an allergen, not from bacteria. Therefore, our focus should be improving your asthma symptoms through medication and preventing future asthma attacks.” In Michelle’s case, it is important to explain to her that this is an allergic response. Therefore, an antibiotic is not indicated. The treatment for asthma should be focused on alleviating symptoms, avoiding triggers, and preventing the progression of asthma. References Dao, A., & Bernstein, D.I. (2018). Occupational exposure and asthma. Annals of Allergy, Asthma, & Immunology, 120(5), 468-475. doi:10.1016/.2018.03.026 Global Initiative for Asthma. (2019). Pocket guide for asthma management and prevention. Retrieved from