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NR 603 Week 2 Part 1 and 2 B. Ingram
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- NR 603 Week 2 Part 1 And 2 B. Ingram
NR 603 Week 2 Part 1 and 2 B. Ingram
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Week 2: Case Discussion Pulmonary – Part 11. 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.
Diagnosis: Mild to moderate persistent asthma with episodes of shortness of breath (SOB).
ICD code: J45.30 Asthma
The Global Initiative for Asthma (GINA) 2020 defines asthma as a chronic airway inflammation
characterized by respiratory symptoms such as SOB, cough, wheezing and tightness of the chest, along
with a variable expiratory airflow limitation. A diagnosis can be confirmed by asking about recent
respiratory symptoms and by performing a pulmonary function test (PFT). A diagnosis of asthma can be
diagnosed with the patients’ respiratory symptoms and a FEV1 greater than 12% difference between a
pre-and-post bronchodilator PFT (GINA, 2020).
Rationale: Considering the patients history of seasonal allergies, a recent visit to an urgent care with
complaints of SOB and now the assessment of the PFT results in the office can assist in the diagnosis.
The patient’s physical exam presents slight wheezing on inspiration and forced expiration with
wheezing that does not clear with forceful coughing. The patients pre-PFT resulted in a FEV1/FVC of
60% and the post PFT resulted in a FEV1/FVC of 75%, which is greater than a 12% improvement
indicating a diagnosis of asthma as per the GOLD guidelines (GINA, 2020).
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.
Medications:
GINA (2020) no longer recommends only starting with a SABA only treatment but a SABA and an ICS
containing controller treatment. So, the initial therapy for Michelle would include a daily low dose ICS
and SABA.
Inhaled corticosteroid- Fluticasone propionate 88 mcg, IH 1 puff daily. Fluticasone is an
inhaled corticosteroid that suppresses inflammation, reduces airway hyperresponsiveness
and controls asthma symptoms like shortness of breath.
SABA- Albuterol sulfate: PROAIR HFA 108 mcg/puff Sig: 2 puff PO Q4-6 hours as needed for
SOB. Albuterol is a Short acting beta 2 agonist that rapidly relaxes the muscle lining of the
airways thereby allowing an increase in airflow and decreasing shortness of breath and
cough.
Labs:
No labs are needed at this time. (GINA, 2020).
Education:
Create an asthma action plan and educate the patient on the steps required if symptoms
worsen or when to seek emergency care. The patient will be given a copy (GINA, 2020).
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, Michelle should be educated on the use of the prescribed medications and how to
administer them to herself.
Viral infections, allergens at home or work, tobacco smoke, exercise, and stress can
exacerbate symptoms. Follow the asthma action plan when symptoms worsen. If unrelieved
by action plan, go to the nearest emergency room for treatment.
Referrals:
Michelle does not currently need a referral currently. If her symptoms do not improve, worsen, or
she experiences an increase in symptoms, then a referral should be considered.
Follow up:
Michelle should follow up in 2 weeks to evaluate the effectives of the newly prescribed medications
and any possible side effects she may be experiencing.
She should then follow up in 3 months to assess and monitor her asthma symptoms and assess if a
step up in therapy in warranted or even a step down (NIH, 2021).
3. Address Michelle's request for an antibiotic.
Normansell et. al, 2018 explains that although antibiotics are sometimes included in the treatment is
acute asthma exacerbations, antibiotics are only prescribed when clear signs, symptoms, or laboratory test
results are suggestive of bacterial infections. These symptoms include persistent daily symptoms greater than
14 days, fever, shortness of breath, and ineffective medication management.
Reference:
Asthma Care Diagnosing and Managing Asthma (2021). National Institutes of Health. Retrieved from:
https://www.nhlbi.nih.gov/files/docs/guidelines/asthma_qrg.pdf
Global Initiative for Asthma (GINA). (2020). Global Strategy for Asthma Management and Prevention. Retrieved
from: https://ginasthma.org/wpcontent/uploads/2020/06/GINA-2020-report_20_06_04-1-wms.pdf
Normansell, R., Sayer, B., Waterson, S., Dennett, E. J., Del Forno, M., & Dunleavy, A. (2018). Antibiotics for
exacerbations of asthma. The Cochrane database of systematic reviews, 6(6), CD002741.
https://doi.org/10.1002/14651858.CD002741.pub2
Week 2: Case Discussion Pulmonary – Part 2
1. Determine appropriate treatment plan for Michelle. Discuss medications, doses, Durable Medical
Equipment, and any testing, and apply these directly to her case. Provide your rationale with
evidence.
Treatment plan: Testing- According to the Infectious Diseases Society of America (2018) there
are multiple options for diagnostic testing of influenza however, the ideal diagnostic test should
produce rapid, accurate results with high sensitivity and high specificity to detect the influenza viruses
in respiratory specimens at reasonable cost. Michelle has tested positive for Influenza A in the office
and because she has a history of Asthma, treatment should begin as soon as possible. A
nasopharyngeal swab is a rapid testing method often used in outpatient settings to confirm the
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