Asthma

Case Study Assignment
Instructions: Read the case study and answer the questions that are included at the end of this document and in Sakai. Make sure you support your answers with details/data from the case presentation. All answers need to be submitted to the corresponding assignment in the “Test & Quizzes” tab in Sakai.

Asthma Case Study
Patient’s Chief Complaints
“I feel like I can’t breathe and it’s getting worse.”
History of Present Illness
Doug is a 27 yo man, who presents to the nurse practitioner at the Family Care Clinic complaining of increasing SOB, wheezing, fatigue, cough, stuffy nose, watery eyes, and postnasal drainage—all of which began four days ago after he spent the weekend completing outdoor chores (i.e., mowing, preparing a garden). Three days ago, he began monitoring his peak flow rates several times a day. His peak flow rates have ranged from 200 to 240 L/minute (baseline, 340 L/minute) and often have been at the lower limit of that range in the morning.
Three days ago, he also began to self-treat with frequent doses of his albuterol MDI. He reports that usually his albuterol inhaler provides him with relief from his asthma symptoms, but as time goes on, this is no longer a sufficient treatment for his asthmatic episodes.

Past Medical History
• Born prematurely at 24 weeks gestation secondary to maternal intrauterine infection; weight at birth was 2 lbs, 0 ounces; lowest weight following delivery was 1 lb, 9 ounces; spent 2½ months in neonatal ICU and was discharged from hospital 2 weeks before mother’s original due date
• Diagnosed with asthma at age 18 months
• Moderate persistent asthma since age 19
• Has been hospitalized 3 times (with 2 intubations) in the past 3 years for acute bronchospastic episodes and has reported to the emergency room twice in the past 12 months
• Perennial allergic rhinitis × 15 years
• Gastroesophageal reflux
Family History
• Both parents living
• Mother 51 yo with H/O cervical cancer and partial hysterectomy
• Father 50 yo with H/O perennial allergic rhinitis and allergies to pets, asthma
• No siblings
• Paternal grandmother, step-grandfather and maternal grandmother are chain smokers but do not smoke around the patient
Social History
• No alcohol or tobacco use
• Married with two biological children and one stepson
• College graduate with degree in business, currently employed as a business development consultant with private firm
• There are no pets in the home at this time

Review of Systems
• Reports feeling unwell overall, “4/10”
• Denies H/A and sinus facial pain
• Eyes have been watery
• Denies decreased hearing, ear pain, or tinnitus
• Throat has been mildly sore
• (+) SOB and productive cough with clear, yellow phlegm for 2 days
• Denies diarrhea, N/V, increased frequency of urination, nocturia, dysuria, penile sores or discharge, dizziness, syncope, confusion, myalgias, and depression
Medications
• Ipratropium bromide MDI 2 inhalations QID
• Triamcinolone MDI 2 inhalations QID
• Albuterol MDI 2 inhalations every 4–6 hours PRN
Allergies
• Grass, ragweed, and cats → sneezing and wheezing
Physical Examination and Laboratory Tests
General
• Agitated, WDWN white man with moderate degree of respiratory distress
• Loud wheezing with cough
• Eyes red and watery
• Prefers sitting to lying down
• SOB with talking
• Speaks only in short phrases as a result of breathlessness
Vital Signs
BP 150/80 RR 24 HT 5′10″
P 115 T 100.2°F WT 212
lbs
Pulsus paradoxus 20
O2
Sat 92%
(room air)
Skin

• Flushed and diaphoretic
• No rashes or bruises
HEENT
• Extraocular movements intact (EOMI)
• PERRLA
• Fundi benign, no hemorrhages or exudates
• Conjunctiva erythematous and watery
• Nasal cavity erythematous and edematous with clear, yellow nasal discharge
• Hearing intact bilaterally
• Tympanic membranes visualized without bulging or perforations
• Auditory canals without inflammation or obstruction
• Pharynx red with post-nasal drainage
• Uvula mid-line
• Good dentition
• Gingiva appear healthy
Neck/Lymph Nodes
• Neck supple
• Trachea mid-line
• No palpable nodes or JVD noted
• Thyroid without masses, diffuse enlargement, or tenderness
Chest/Lungs
• Chest expansion somewhat limited
• Accessory muscle use prominent
• Diffuse wheezes bilaterally on expiration and, occasionally, on inspiration
• Bilaterally decreased breath sounds with tight air movement
Heart
• Tachycardia with regular rhythm
• No murmurs, rubs, or gallops
• S1 and S2WNL
Abdomen
• Soft, NT/ND
• No bruits or masses
• Bowel sounds present and WNL
Genitalia/Rectum
Deferred
Musculoskeletal/Extremities
• ROM intact in all extremities

• Muscle strength 5/5 throughout with no atrophy
• Pulses 2+ bilaterally in all extremities
• Extremities clammy but good capillary refill at 2 seconds with no CCE or lesions
Neurological
• Alert and oriented to place, person, and time
• Thought content: appropriate
• Thought process: appropriate
• Memory: good
• Fund of knowledge: good
• Calculation: good
• Abstraction: intact
• Speech: appropriate in both volume and rate
• CNs II–XII: intact
• Fine touch: intact
• Temperature sensation: intact
• Vibratory sensation: intact
• Pain sensation: intact
• Reflexes 2+ in biceps, Achilles, quadriceps, and triceps bilaterally
• No focal defects observed
Laboratory Blood Test Results
Na 139
meq/L Hb 13.6 g/dL Monos 6%
K 4.4
meq/L Hct 41% Eos 3%
Cl 105
meq/L Plt 292 ×
103/mm3 Basos 1%
HCO3 26 meq/L WBC 8.9 ×
103/mm3 Ca 8.8
mg/dL
BUN 15 mg/dL Segs 51% Mg 2.5
mg/dL
Cr 0.9 mg/dL Bands 2% Phos 4.1
mg/dL

Glu (non- fasting) 104
mg/dL Lymphs 37%

Peak Flow
175 L/min

Arterial Blood Gases
• pH = 7.55
• PaCO2 = 30 mm Hg
• PaO2 = 65 mm Hg
• HCO3- = 24 mEq/L

[Case adapted from: Bruyere, H. (2009). 100 Case studies in pathophysiology. Philadelphia, PA: Lippincott.]

Question 1:
Identify 2 risk factors that have likely contributed to Doug’s development of asthma and 2 risk factors that likely contribute to his current clinical presentation/recurrent exacerbations. (4 total points; 1 point for each correct risk factor identified)

Question 2:
What type of hypersensitivity reaction is asthma? Explain why. (2 points)

Question 3:
Based on Doug’s clinical presentation/manifestations, summarize what is occurring with the initial/early and late immune responses. How is the underlying pathophysiology occurring associated/linked with the clinical manifestations present in this case. (4 points)

Question 4:
Review Doug’s ABG and provide your interpretation of the results of this test (e.g., normal/acidotic/alkalotic, respiratory or metabolic, compensated)? Considering the pathophysiology occurring and clinical manifestations, what likely contributed to these ABG results? (3 points)

Question 5:
How could Doug’s asthma lead to cellular injury within his body? Hint: Think of the “most common” cause of
cellular injury and how this might affect the airway. (2 points)