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NR 603 Week 2 Case Discussion: Pulmonary (Part One)
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NR 603 Week 2 Case Discussion: Pulmonary (Part One)
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NR 603 Week 2 Case Discussion: Pulmonary (Part One)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
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