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You are working in a Family Practice office and Cheryl, a 42 yo female with c/o wheezing and SOB is the
next patient. Her chart reveals the following:
PMH SH MEDS
Acute bronchitis X2 -1 ppd smoker Alesse
UTI Social alcohol
Obesity 2-3 cups coffee/day PRN:
2-3 diet soda/day Acetaminophen
Lives with boyfriend Ibuprofen
Works full-time Famotidine
FH
Mother HTN, GERD NKDA
Father HTN, asthma, DM
As you prepare for this visit what are your primary concerns? What is her oxygen saturation level,
respiratory rate, and is she in any acute distress? How long has she been having these symptoms?
Anything that makes the symptoms better or worse? Any associated factors with the above mentioned
symptoms, such as cough, chest or back pain? Has she been around anyone that has been sick or had
similar symptoms? What treatments, if any, has she tried at home, and did they relieve symptoms
temporarily? How long ago did Cheryl have her last physical examination? How is her blood pressure?
(She has a strong family history of hypertension with two first degree relatives, she is obese, consumes a
lot of caffeine daily, smokes, and takes oral contraceptives [combined with smoking increases risk of
hypertension].) How is her blood sugar? (She has a first degree relative with diabetes, she is also obese,
and we do not know typical diet other than social alcohol use, she consumes daily coffee [cream or
sugar?], and diet soda.)
Based on the medications listed, what are your concerns? Taking Aleese combined with smoking,
advanced age (42), obesity, and possibly hypertension could lead to very serious, possibly grave side
effects. According to Drugs.com (2016c), the risk of serious cardiovascular side effects increases with age
and with extent of smoking (in epidemiologic studies, 15 or more cigarettes per day was associated with a
significantly increased risk) and is quite marked in women over 35 years of age (p.6). Some of these side
effects include heart attack, thromboembolism, and stroke, and hypertension and increase significantly
with underlying risk factors such as obesity, hypertension, and diabetes (Drugs.com, 2016c). Smoking in
combination with oral-contraceptive use has been shown to substantially increase mortality rates
associated with circulatory disease in women over 35 (Drugs.com, 2016c). How long has she been taking
this medication? According to Drugs.com (2016c), studies have shown taking oral contraceptives for five
or more years in persons age 40-49, have increased risk of having a heart attack for nine years after
discontinuation of the medication.
Cheryl is having trouble breathing with some wheezing since she has started walking this Spring to lose
weight. She has been walking outside and started with about 10-15 minutes three times per week. When
she started increasing her time walking she noticed it was getting harder to breathe and at times she
would wheeze. She initially thought it was due to the warmer weather and her just being overweight. She
has never really exercised and has a job that limits activity and is mostly at a desk.
ROS
- orthopnea, chest pain, dizziness, indigestion, diarrhea, N/V, recent weight change, HA, sore throat,
+ occasional cough more prominent while walking, productive at times with clear sputum, some ankle edema after
walking,
Physical Exam
Patient is alert and oriented in NAD
EENT PEERLA, posterior pharynx slightly red with postnasal discharge, nasal mucosa pink; no adenopathy
appreciated; TMs without bulging or retractions bilaterally
Heart RRR without murmur, rubs or clicks; no carotid bruits auscultated; pedal pulses 1+, radial pulses 2+, ankles
large with small amount of edema (non-pitting)
Lungs sounds course but CTA bilat anterior and posterior
Abdomen large, round, soft, non-tender; bowel sounds present x4 quads; no masses palpable; unable to palpate
liver border;
VS
BP 132/84 P 86 RR 20 O2 Sat 98%
Ht. 54 Wt. 195 lbs
What other question(s) would you like to ask Cheryl to assist with your diagnosis? What other
information would you like to have had? Is the shortness of breath and wheezing consistent or to the
symptoms come and go? Does anything make the symptoms better or worse? Do symptoms completely
resolve with rest? Are these symptoms experienced at any other times besides while walking (at rest, at
night)? Any associated chest discomfort or pains? Is the ankle edema only after walking, or have you
noticed it at any other times, such as standing for periods? Is it pitting or non-pitting and does it get better
with elevation of the feet/ legs? Any pain or redness noticed in the legs? There is an increase in risk of
developing cardiovascular problems and thrombosis in persons over 40 taking oral contraceptive while
smoking (Drugs.com, 2016c). Any jugular vein distension? Shortness of breath when lying down?
Congestive heart failure can manifest with this (MedlinePlus, 2016a). History of heart murmur? Have you
ever had group A beta-hemolytic streptococci that was untreated for a length of time or rheumatic fever?
Valvular problems can manifest as heart failure (Brashers, 2014). Any problems with seasonal allergies in
the past? Have you noticed stuffy or runny nose, sneezing, itchy eyes? Allergens such as pollen (in the
Spring of the year) can cause similar symptoms. Have you ever had these or similar symptoms in the
past? With previous episodes of acute bronchitis, how long did symptoms last and when was the last
episode? Chronic bronchitis is defined as hypersecretion of mucus and chronic productive cough lasting at
least 3 months for at least 2 consecutive years (Brashers & Huether, 2014, p. 1267). Common symptoms
involved with chronic bronchitis include decreased exercise tolerance, wheezing, and shortness of breath
(Brashers & Huether, 2014, p. 1267). With assessment, was any clubbing noted? This could possibly be
an indication of how long respiratory problems have been occurring.
Why did you make this choice? Give good rational for your decision. Although her symptoms could fit in any of these categories,
and more in-depth questioning and assessment is needed for more accurate diagnosis, exercise-induced asthma seems to fit all of the
symptoms given at this time. Exercise-induced asthma is a more acute condition, rather than the other more chronic conditions listed.
It is a very real possibility of having the other disease processes such as CHF, asthma, or chronic bronchitis. Since these conditions
are more chronic, it makes since to me to choose the more acute condition first, treat that condition, educate on the importance of
follow up if symptoms persist and do not get better with treatment and go from there. If intervention for exercise-induced asthma does
not relieve symptoms, additional testing should be implemented and investigated further. Anxiety and uncertainty can be mentally
exhausting if a wrong diagnosis is made, especially a diagnosis of a serious, chronic condition. Therefore my first choice for
diagnosis would be exercise-induced asthma.
Indications Prevention and relief of Maintenance and Asthma, exercise- Treatment of asthma.
bronchospasm with treatment of asthma as induced
reversible obstructive prophylactic therapy and bronchoconstriction, and
airway disease and for treatment of asthma allergic rhinitis.
prevention of exercise in patients requiring oral
induced bronchospasm corticosteroid therapy
For use in patients 4 years (may reduce or eliminate
old and older. need for oral
corticosteroids). For use
in patients 6 years old
and older.
Side Effects Common side effects Candida albicans The most common Candida albicans
include: palpitations, chest infection, adverse reactions infection,
pain, tachycardia, tremor, immunosuppression include: upper immunosuppression
and nervousness. causing increased respiratory infection, causing increased
Others include: heartburn, infections, fever, headache, infections,
nausea/ vomiting, stomach hypercorticism and pharyngitis, cough, hypercorticism and
ache, diarrhea, unusual adrenal suppression, abdominal pain, adrenal suppression,
taste, hypertension, reduction in bone mineral diarrhea, otitis media, reduction in bone
urticaria, angioedema, density, effects on influenza, rhinorrhea, mineral density,
arrhythmias (a-fib, SVT, growth, glaucoma, and and sinusitis. Other effects on growth,
extrasystoles), headache, bronchospasm. Others symptoms include: glaucoma, and
lightheadedness, agitation, include: headache, abdominal pain, fatigue, bronchospasm.
nightmares, sleeplessness, irritability, anxiety, dyspepsia, dental pain,
hyperactivity, aggressive depression, faintness, gastroenteritis,
behavior, throat irritation, fatigue, moodiness, headache, dizziness,
hoarseness, oropharyngeal numbness, vertigo, influenza, cough,
edema, discoloration of nausea/ vomiting, congestion, ALT
teeth, epistaxis, cough, dyspepcia, upset elevation, AST
and muscle cramps. stomach, heartburn, elevation, and pyuria.
May produce paradoxical constipation, diarrhea,
bronchospasm, ECG gas, abdominal fullness,
changes (flattening of the gastroenteritis, oral
T wave, prolonged QT moniliasis, edema,
interval, ST segment myalgia, abdominal pain,
depression). neck pain, loss of smell,
sore throat, dry throat,
glossitis, mouth
irritation, throat
irritation, phlegm,
bronchitis, laryngitis,
voice alteration,
hoarseness, pharyngitis,
rhinitis, increased cough,
cold symptoms, sinus,
nasal or chest congestion,
sinus drainage, sinusitis,
epistaxis, urinary tract
infection, capillary
fragility, enlarged lymph
nodes, palpitations,
hypertension,
tachycardia, chest pain,
dizziness, insomnia,
migraine, erythema
multiforme,
conjunctivitis, blurred
vision, eye discomfort,
eye infection, ear pain,
taste alteration, eczema,
puritis, acne, urticaria,
dysmenorrhea, and
vaginitis.
Complications Should be used with Contraindicated for use Should be used in Cases of asthma
caution in patients with in status asthmaticus or caution and only when related death have
known cardiovascular acute episodes of asthma. benefits outweigh risk in been reported, do not
disorders such as Bronchospasm may patients who have use in patients who
hypertension, cardiac occur. experienced agitation, can be adequately
arrhythmias, and coronary May cause localized aggressive behavior, controlled on other
insufficiency, because of infections with Candida anxiousness, depression, long-term asthma
potential ECG changes albicans or Aspergillus disorientation, control medications,
(flattening of the T wave, niger in mouth, pharynx, disturbance in attention, such as low or
prolonged QT interval, ST and/ or larynx. hallucinations, suicidal medium dosed
segment depression). Corticosteroids can cause tendencies, and inhaled
Should be used in caution immunosuppression, use insomnia. corticosteroids.
in patients with in caution with May cause eosinophilia Contraindicated in
convulsive disorders, immunocompromised and phenylketonuria. use with primary
hyperthyroidism, and patients. Inform patients Drug/ drug interactions treatment of status
diabetes. who have not been involve: theophylline, asthmaticus.
Should be administered vaccinated for or prednisone, oral Excessive beta-
with extreme caution in previously had contraceptives, digoxin, adrenergic
patients who are currently chickenpox, measles, or warfarin, terfenadine, stimulation has been
taking or have taken other communicable thyroid hormones, associated with
MAOI or tricyclic diseases to avoid sedatives, NSAIDs, seizures, angina,
antidepressants within the exposure. Use in benzodiazepines, hyper/hypotension,
past two weeks, may extreme caution in decongestants, and tachycardia,
significantly increase the patients with suspected cytochrome P450 arrhythmias,
cardiovascular side or untreated tuberculosis, enzyme inducers. nervousness,
effects. viral, bacteria, fungal, or headache, tremor,
Should not use a beta- parasitic infections, nausea, dizziness, and
agonist with a beta worsening of the fatigue.
blocker, beta blockers will infection may occur. Effects bone density,
block effects and have the Death from adrenal growth, may cause
potential to cause severe insufficiency have cataracts or
bronchospasm in occurred in patients who glaucoma,
asthmatic patients. were on long term hypokalemia,
Causes decrease in serum systemic corticosteroids hyperglycemia,
digoxin levels. and transitioned to
When taking a beta- inhaled corticosteroids,
agonist along with non- because they are not as
potassium sparing systemically available
diuretics, hypokalemia and hypothalamic-
and ECG changes may pituitary-adrenal function
worsen. was compromised.
Pregnancy risk category Decrease in bone mineral
C. density have been
Has the potential to inhibit associated with long term
uterine contractions use of inhaled and oral
during labor if given in corticosteroids.
high doses. However it When administered to
has not been approved for pediatric patients, may
use in preterm labor, has cause reduction in
the potential to cause growth velocity.
maternal pulmonary Long term administration
edema. of inhaled corticosteroids
have been associated
with glaucoma and
cataract formation.
Pregnancy risk category
C.
Reference (Drugs, 2016d) (Drugs.com, 2016b) (Drugs.com, 2016f) (Drugs.com, 2016a)
Why did you make this choice? Give good rational for your decision Albuterol is my first choice. Albuterol is a rescue inhaler that
is also beneficial for the disease process chosen, exercise-induced asthma. In my opinion, if only one medication is available the
medication that treats immediate acute symptoms such as bronchoconstriction should be a priority. As states by Drugs.com (2016d),
this medication is indicated for exercise-induced bronchospasm. It is recommended to teach patients to use the short-acting beta
agonists approximately 10-15 minutes before exercise if possible to prevent symptoms (Mayo Clinic Staff, 2014).
What are other potential choices you could make? Singulair would be my second choice. A leukotriene inhibitor such as Singulair is also
recommended for the treatment of exercise-induced bronchoconstriction, and will also help with seasonal allergy symptoms, such as the patients
physical exam findings of slightly red posterior pharynx and postnasal discharge (Drugs.com, 2016f; Mayo Clinic Staff, 2014).
References
Brashers, V. L. (2014). Alterations of cardiovascular function. In Brashers, V. L. & Rote, N. S. (Eds.), Pathophysiology: The biologic
basis for disease in adults and children (7th ed.) (pp. 1129-1193). Saint Louis, MO: Elsevier Mosby.
Brashers, V. L. & Huether, S. E. (2014). Alterations in pulmonary function. In Brashers, V. L. & Rote, N. S. (Eds.), Pathophysiology:
The biologic basis for disease in adults and children (7th ed.) (pp. 1248-1289). Saint Louis, MO: Elsevier Mosby.
Drugs.com [Internet]. (2016e). Medications for heart failure: Congestive heart failure. In Drugs.com, retrieved from:
http://www.drugs.com/condition/congestive-heart-failure.html
Mayo Clinic Staff (2014, October 14). Exercise-induced asthma. Retrieved from: http://www.mayoclinic.org/diseases-
conditions/exercise-induced-asthma/basics/symptoms/con-20033156
MedlinePlus [Internet]. Bethesda (MD): National Library of Medicine (US) (2016a). Heart failure: overview [last updated 2015,