Week 2 Discussion: Health Assessment

DOMAIN: HISTORY
1a) Identify two (2) additional questions that were not asked in the case stud and should have been?
1b) Explain your rationale for asking these two additional questions.
1c) Describe what the two (2) additional questions might reveal about the patient’s health.

DOMAIN: PHYSICAL assessment
For each system examin in this case;
2a) Explain the reason the provider examin each system.
2b) Describe how the assessment findings would be abnormal based on the information in this case. If it is a wellness visit, based on the patient’s age, describe what assessment findings could be abnormal.
2c) Describe the normal findings for each system.Week 2 Discussion: Health Assessment
2d) Identify the various diagnostic instruments you would need to use to assess this patient.

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DOMAIN: ASSESSMENT (Medical Diagnosis)
Discuss the pathophysiology of the:
3a) Diagnosis and,
3b) Each Differential Diagnosis
3c) If it is a Wellness, type ‘Not Applicable’

DOMAIN: LABORATORY & DIAGNOSTIC TESTS
Discuss the following:
4a) What labs should be ordered in the case?
4b) Discuss what lab results would be abnormal.
4c) Discuss what the abnormal lab values indicate.
4d) Discuss what diagnostic procedures you might want to order based on the medical diagnosis.
4e) If this is a wellness visit, discuss what the U.S. Preventive Taskforce recommends for patients in this age group.

PLEASE READ CASE STUDY IN ORDER TO RESPOND TO THE QUESTION USE REFERENCES IN APA STYLE AND DO NOT USE REFERENCES OLDER THEN 5 YEARS AGO

I HAVE ATTACHED THE CASE STUDY TO THIS POST.Week 2 Discussion: Health Assessment

CASE STUDY

PLEASE READ COMPLETELY BEFORE ANSWERING THE QUESTIONS.

You are working in Dr. Wilson’s office. The first patient of the morning is Mr. Frank Dennison, a 40-year-old cisgender male.

As you and Dr. Wilson open the electronic medical record, you note past visits by Mr. Dennison for allergic rhinitis and refills of various antihistamines and nasal sprays. Then you look at today’s encounter which gives the following information:

Reason for visit: Cough for two months.

Vital signs:

· Temperature is 36.8 C (98.2 F)

· Pulse is 80 beats/minute

· Respiratory rate is 16 breaths/minute

· Oxygen saturation is 97%

· Blood pressure is 118/68 mmHg

· Height is 172.7 cm (68 in)

· Weight is 86.2 kg (190 lbs)Week 2 Discussion: Health Assessment

· Body mass index (BMI) is 28.9 kg/m2

Dr. Wilson asks you to “do a focused history, then let me know what you find.”

Before you go into the exam room, you review common conditions that can lead to a persistent cough.

Causes of Chronic Cough

Common causes of persistent cough include:

· Upper airway cough syndrome (UACS—previously called postnasal drip)

· Vocal cord dysfunction

· Asthma

· Gastroesophageal reflux disease (GERD)

· Medications such as angiotensin-converting enzyme inhibitors (ACE-inhibitors)

· Tobacco-related cough

· Post-infectious cough

· Chronic obstructive pulmonary disease (especially the chronic bronchitis type)

· Non-asthmatic eosinophilic bronchitis

Serious, less common causes of persistent cough include:

· Pulmonary conditions such as bronchogenic carcinoma of the lung, sarcoidosis, and tuberculosis

· Cardiac conditions such as congestive heart failure

 

Dr. Wilson has already obtained permission from the patient for you to see him.

You introduce yourself, and begin by asking:Week 2 Discussion: Health Assessment

“How may we help you today?”

Mr. Dennison responds, “I’ve had this nagging cough for two months.”

“Tell me more about your cough.”

“I don’t have a fever so I don’t think I have an infection. The cough is worse at night. In fact, I wake up some nights with coughing spells. Eventually, I cough up some clear mucous, and then I feel better. Sometimes I notice that my breathing gets noisy.”

“What kind of noise do you make when you are breathing?”

“It’s kind of a musical, whistling sound, especially when I breathe out.”

“How often do you notice this noisy breathing?”

“On one or two nights of the week, I will wake up coughing and get that noisy breathing at the same time. When I cough up some clear mucous, I feel better. I have never had the noisy breathing during the day. In fact, when I jog or bicycle, my breathing is fine.”

“Do you get any chest tightness or chest pain?”

“No.”

Week 2 Discussion: Health Assessment

Asthma is the most common cause of persistent cough and wheezing.

Other causes of wheezing to consider include:

· Chronic obstructive pulmonary disease

· Congestive heart failure

· Foreign body aspiration

· Persistent bronchitis

· Pulmonary embolism

· Upper airway cough syndrome

· Vocal cord dysfunction

 

Co-morbid Conditions of Asthma

Conditions that may require treatment to improve the control of asthma include:

· Gastroesophageal reflux disease (GERD)

· Obesity or overweight

· Obstructive sleep apnea

· Rhinitis or sinusitis

· Stress and depression

As you proceed to take the rest of Mr. Dennison’s history, you continue to consider the diagnosis of asthma. Bearing this in mind, you ask Mr. Dennison about his past medical history:

“I see that you have a history of allergic rhinitis. How is that going?”

“My allergies were doing okay, but I have been having trouble the past three to four months. I’m sneezing a lot and congested in the nose a lot. I have a lot of clear drainage; occasionally there is a light yellow tinge to the drainage.”

“What medications do you take for this?”

“I’m supposed to take cetirizine and fluticasone nasal spray every day. But, to be honest, I only take them about two-thirds of the time. Sometimes, I get too busy and forget them. I’m also supposed to get allergy shots regularly, but I haven’t received one in several months.”Week 2 Discussion: Health Assessment

“Why haven’t you been receiving your allergy shots regularly?”

“I’ve been struggling to get to my appointments to receive the shots due to my new job schedule.”

“Let’s discuss some options to help you take your medications and receive your shots.”

“Okay.”

Through these questions, you realize Mr. Dennison’s allergic rhinitis is not under ideal control. You wonder if treating his allergic rhinitis would help control his cough and wheezing.

Next, you wish to see if he has an underlying sinusitis since that also is a co-morbid condition of asthma that could explain some of his symptoms.

 

Week 2 Discussion: Health Assessment

Fever (D), headache (F), facial pain (B), toothache (in the maxillary teeth) (I), failure to respond to decongestants (C), and double worsening (the pattern of initial improvement from a viral infection followed by an acute worsening) (G)are all symptoms consistent with acute sinusitis, though none are pathognomonic for the condition. Clear nasal discharge (A) is not typical of acute sinusitis. Gradual worsening in the first five days after the onset of a URI (E) is fairly typical for the common cold, not sinusitis. Nasal congestion lasting more than 12 weeks (H) is consistent with chronic sinusitis, not acute.

· In acute sinusitis, the nasal discharge is opaque and mucopurulent, not clear. (Clear drainage may be associated with allergies).

· Many viral upper respiratory infections will gradually worsen over the five days. In acute bacterial sinusitis, patients have symptoms for a minimum of seven to 10 days following a viral URI (or initially improve following a URI, then worsen).Week 2 Discussion: Health Assessment

· Nasal congestion or obstruction persisting for more than 12 weeks would be associated with chronic sinusitis, not acute sinusitis.

TEACHING POINT

Symptoms of Acute Sinusitis

In an early paper, Williams described hallmark symptoms of acute sinusitis to include a history of colored nasal drainage, a limited response to decongestants, a maxillary toothache, purulent secretions observed on physical examination, and an abnormal transillumination of the sinuses, when he reported validation of a clinical rule predicting the probability of acute sinusitis in 1992.

In a more recent review of the evidence, the American Academy of Otolaryngology – Head and Neck Surgery Foundation (AAO-HNS) updated guidelines (2015) define acute sinusitis as having purulent or colored nasal drainage, along with either nasal congestion/blockage and/or facial pain/pressure for a duration of less than four weeks. These guidelines also describe other diagnostic criteria of acute sinusitis including the failure to improve after 10 days or the development of fever. Finally, they also note that some patients with acute sinusitis may describe improving after a typical viral upper respiratory infection and then feeling worse again (“double-worsening” sign).

Week 2 Discussion: Health Assessment

You know that Mr. Dennison has had chronic nasal symptoms (sneezing, nasal congestion, and drainage) for three to four months, so it is unlikely that he has acute sinusitis. Dr. Wilson asks you to consider a different hypothetical scenario.

“What if Mr. Dennison presented with one week of upper respiratory symptoms including nasal congestion and drainage? On the day the symptoms began, he had a low-grade fever that has now resolved. His nasal congestion persisted and he has now had yellow nasal drainage for five days with associated mild headaches. On exam, he is afebrile and in no distress. Examination of his tympanic membranes and throat are normal. Examination of his nose is unremarkable although a slight amount of yellowish-clear drainage is noted. There is tenderness when you lightly percuss his maxillary sinuses.”

Week 2 Discussion: Health Assessment

The patient in the hypothetical example above is presenting with symptoms consistent with acute viral rhinosinusitis (the common cold). Low-grade fever is common at the onset of a cold, but it does not typically return unless a complication arises. Thick nasal discharge (irrespective of yellow or green discoloration) is common in acute rhinosinusitis and can persist for days to weeks after the onset of a cold. Tenderness of the maxillary sinuses on exam is a common and nonspecific exam finding. Though commonly performed, it does not meaningfully help to distinguish between a common cold and acute bacterial sinusitis. In the setting of a cold, prescribing antibiotics (B or C) would be inappropriate. Observation and reassurance (A) is the appropriate step in this case.Week 2 Discussion: Health Assessment

Since the arrival of the SARS-COV2 virus in late 2019, clinicians need to also consider COVID-19 as a cause of such symptoms. The initial treatment of a mild case of COVID-19 (as described here) involves rest, observation, and symptomatic treatment, much like for the common cold. However, for public health reasons, it would also be important to obtain a diagnostic test for SARS-COV2 infection in such a case. Such patients would need to self-isolate while awaiting the results and while waiting for symptoms to resolve. Positive cases would need to continue self-isolation, and close contacts would need to quarantine for 14 days from the time of last exposure.Week 2 Discussion: Health Assessment

TEACHING POINT

Distinguishing Viral Rhinosinusitis From Acute Bacterial Sinusitis

According to the American Academy of Otolaryngology – Head and Neck Surgery Foundation guidelines (2007) on sinusitis, making the distinction between a lingering viral upper respiratory infection that affects the nose and sinuses (viral rhinosinusitis) or an early acute bacterial sinusitis can be difficult.

A patient is more likely to have viral rhinosinusitis if the duration of symptoms is fewer than 10 days and the symptoms are not worsening. In this case, you should continue to observe the patient and reassure him or her that antibiotics are not necessary at this time.

Week 2 Discussion: Health Assessment

You and Dr. Wilson turn your attention back to Mr. Dennison.

By definition, nasal symptoms lasting more than 12 weeks are not acute sinusitis. So you consider chronic sinusitis and recall what you know about the symptoms of chronic sinusitis and you realize with the patient’s chronic nasal congestion and mucopurulent drainage, he may have chronic sinusitis. There may be additional physical signs and diagnostic tests that will be needed later to confirm this.

TEACHING POINT

Symptoms of Chronic Sinusitis

According to the AAO-HNS updated guidelines (2015), patients with chronic sinusitis have similar symptoms to patients with acute sinusitis, but they last at least 12 weeks. They must have two of the following symptoms:

· Nasal obstruction or congestion

· Mucopurulent drainage (anterior, posterior, or both)

· Facial pain, pressure, or fullness

· Decreased sense of smell

They must also have signs of inflammation on physical examination or radiological studies that will be discussed later.

However, according to the AAAAI/ACAAI Practice Parameter Update (2014), some patients with chronic sinusitis may have “subtle” symptoms such as only a mild increase in nasal congestion.

Week 2 Discussion: Health Assessment

“Do you have any other chronic conditions; have you had hospitalizations or surgeries?”

Mr. Dennison replies, “I have no other chronic conditions, I have never been hospitalized, and I have not had any surgeries.”

“Do you take any medications other than the ones we have discussed?”

“No.”

“Do you have any allergies to any medications, particularly aspirin?”

“I’m not allergic to any medications. I have occasionally used aspirin in the past without difficulty.”

“Have you ever smoked cigarettes or cigars or chewed tobacco?”

Mr. Dennison responds, “Never.” You tell him, “That’s great, since smoking might make your current symptoms worse.”

Mr. Dennison reports no alcohol or drug use. He lives with his wife and two children, who are all healthy. His father is deceased, but had allergic rhinitis and asthma.

You remember that there are still some potential asthma comorbid conditions to ask about such as overweight and obesity, gastroesophageal reflux disease, obstructive sleep apnea, stress and depression. You review his current weight and BMI and note that his current BMI classifies him as overweight, but not obese. You ask Mr. Dennison this series of questions and discover the review of systems is negative:

· “Have you ever had any symptoms of heartburn?”Week 2 Discussion: Health Assessment

· “Has your wife ever commented on the way you sleep—snoring a lot or breathing unusually?”

· “How are you doing emotionally; are you stressed or depressed?”

You explain that you would like Mr. Dennison to change into a gown while you go discuss your findings thus far with Dr. Wilson. And, when you return in a moment, you will perform a physical exam.

You find Dr. Wilson in the hallway and give him a synopsis of the history you’ve obtained from Mr. Dennison.

TEACHING POINT

Asthma and Aspirin

It is important to ask about aspirin in particular, as 21% of adults who have asthma have aspirin-induced asthma and should avoid NSAIDs.

 

Based on what you know about the patient so far, write a one- to three-sentence summary statement to communicate your understanding of the patient to other providers.

2 months with associated wheezing but no chest pain, shortness of breath, or fever.

The ideal summary statement concisely highlights the most pertinent features without omitting any significant points. The summary statement above includes:

Epidemiology and risk factors: 40-year-old nonsmoker, history of allergic rhinitis.

Key clinical findings about the present illness using qualifying adjectives and transformative language:Week 2 Discussion: Health Assessment

· Cough productive of clear sputum

· Worse at night

· Present for two months

· Associated wheezing

· No chest pain, shortness of breath, or fever.

· Dr. Wilson applauds your thorough history.

· He then asks you, “Given what you know so far, what parts of the physical exam do you want to focus on?”

· TEACHING POINT

· Physical Exam – Persistent Cough

Eyes The eye examination may show signs of allergic conjunctivitis.
Ears The examination of the ears should be performed as part of the examination of a patient with nasal symptoms but may be normal.
Nose Nose examination may show swollen nasal turbinates and pallor of the nasal mucosa consistent with allergic rhinitis. Clear, watery nasal drainage may also be present in patients with allergic rhinitis.Week 2 Discussion: Health Assessment
Sinuses Percussing the frontal and maxillary sinuses may be useful in assessing sinus tenderness that may indicate the possibility of an acute or chronic sinus infection.
Throat Throat examination may reveal erythema or streaking, which may be a clue that the patient has upper airway cough syndrome.
Neck Examining the neck for lymphadenopathy may show signs of infection.
Chest/Lungs The lung examination may show wheezing. However, the absence of wheezing does not rule out asthma or other cardiac or pulmonary conditions. The lung examination may also show rales or other lung abnormalities that are suggestive of congestive heart failure or pneumonia.
Cardiovascular The cardiac examination could show extra heart sounds (S3 or S4), which would suggest congestive heart failure.
Abdomen The examination of the abdomen is unlikely to be helpful in this patient.
Extremities In examining the extremities, one can look for clubbing, cyanosis, or edema. Clubbing is not a finding in patients with asthma, but if present, may be a sign of other pulmonary or cardiac conditions. Cyanosis is unlikely to be present in patients seen in the office setting, but if present, may indicate a hypoxic pulmonary or cardiac condition. If edema is present, it may be a sign of congestive heart failure. Week 2 Discussion: Health Assessment
Skin The skin examination may show eczema, since eczema and asthma may coincide.
Mental status Mood and affect may help you determine if there is underlying depression.

 

 

After you and Dr. Wilson have discussed which parts of the exam to focus on, you knock on the door to make sure he is ready for you and re-enter the room to examine Mr. Dennison.

You find:

Physical Exam

Vital Signs:

· Temperature is 36.8 C (98.2 F)

· Pulse is 80 beats/minute

· Respiratory rate is 16 breaths/minute

· Oxygen saturation is 97% on room air

· Blood pressure is 118/68 mmHg

· Height is 172.7 cm (68 in)

· Weight is 86.2 kg (190 lbs)Week 2 Discussion: Health Assessment

· Body mass index (BMI) is 28.9 kg/m2

Eyes: Normal sclerae and conjunctivae. No discharge or “allergic shiners” are present.

Ears: Tympanic membranes are normal.

Nose: Swelling of the inferior turbinates, pallor of the nasal mucosa with some clear drainage present.

Sinuses: No frontal or maxillary sinus tenderness.

Throat: Normal appearing; no signs of postnasal drainage.

Neck: No jugular venous distension with the head of the exam table elevated to 45 degrees; normal carotid pulses; normal thyroid; no lymph nodes.

Chest: No respiratory distress; normal, symmetrical expansion of the lungs; all areas resonant to percussion; mild scattered wheezes heard throughout.

Cardiovascular: Normal S1 and S2 without murmurs. No S3 or S4 heard.

Skin: No skin lesions. No areas of eczema seen.

Extremities: No clubbing, cyanosis, or edema.

Mental status: Oriented to time, place, and situation. An appropriate range of effect.

After concluding the physical examination, you inform Mr. Dennison that you will present your findings to Dr. Wilson. You ask him to remain in his gown because when you return with Dr. Wilson, he will want to confirm your physical exam findings.Week 2 Discussion: Health Assessment

When you find Dr. Wilson, you present your physical exam findings to him. He asks you what you are currently thinking about for a differential diagnosis.

 

Dr. Wilson replies, “What do you think we should do next to narrow the differential?”

 

What is the best test you should do at this point? Choose the single best answer.

Spirometry (D) findings will help us rule in or rule out several of the diagnoses on the differential; the other tests are not indicated at this time.

Diagnostic testing for persistent cough:

Spirometry as test information Spirometry is useful to evaluate for obstructive lung disease such as asthma or COPD, or restrictive lung disease such as idiopathic pulmonary fibrosis.

Week 2 Discussion: Health Assessment

 

“So,” says Dr. Wilson, “We agree that a spirometry test is the best to confirm the diagnosis of asthma. He will go to the hospital’s pulmonary function laboratory for that test and it will take us a few days to get that result. Now, let’s go talk with Mr. Dennison.”

Why Spirometry is Necessary for Diagnosis

Objective assessments of pulmonary function are necessary for the diagnosis of asthma because history and physical are not reliable means of excluding other diagnoses or determining the extent of lung impairment. Without spirometry, clinicians generally can identify a lung abnormality as obstructive, but have a poor ability to assess the degree of airflow obstruction or predict if it is reversible. Furthermore, pulmonary function tests do not correlate directly with symptoms.

Week 2 Discussion: Health Assessment

You return to the examination room and Dr. Wilson confirms your physical findings.

Then, you sit down across from Mr. Dennison and tell him, “At this point, it sounds like the coughing and whistling noises that you are making at night may be due to asthma. Asthma is actually very common. It is a chronic breathing problem caused by swelling of the airways in the lungs. It can’t be cured, but it can be prevented and controlled. We would like to perform a simple test to confirm whether or not you actually do have asthma.”

Mr. Dennison nods and asks you to tell him about the test.

Mr. Dennison appreciates your evaluation and agrees to do the spirometry test in the next few days. He asks what medications he should take for the persistent cough and his allergic rhinitis in the meantime.Week 2 Discussion: Health Assessment

TEACHING POINT

Spirometry

Spirometry measures how much air the patient can inhale and exhale, as well as how fast the patient can exhale. For this test, the patient breathes into a mouthpiece attached to a recording device called a spirometer. The information collected by the spirometer will be printed out on a chart called a spirogram. The test is repeated at least three times to make sure that it is reliable. First, a baseline sample is obtained. Then, the patient is given a bronchodilator. Once this is given, the patient will perform the same tests again to provide pre- and post-bronchodilation data.

What are the best medications to offer the patient at this point?

Inhaled bronchodilator such as albuterol

Nasal corticosteroid such as fluticasone

Oral antihistamine such as cetirizine

Week 2 Discussion: Health Assessment

Before a diagnosis of asthma is confirmed, it is reasonable to offer patients a short-acting inhaled bronchodilator such as albuterol. While a Cochrane review (2015) did not find evidence to support the use of beta2-agonists routinely in patients with a cough, it did acknowledge that “quicker resolution of cough with beta2-agonists were those with a higher proportion of people wheezing at baseline.”

You ask Mr. Dennison to take his cetirizine and nasal fluticasone inhaler every day so you can see their effect on his allergic rhinitis and he agrees to do so.

You also explain that you will be giving him a new medication, an albuterol inhaler, two puffs four times per day as needed to control his cough, while you are waiting for the spirometry test.

You explain this is an inhaled medication, and it is more effective and easiest to use a spacer device with the inhaler. You give Mr. Dennison a handout on how to use an inhaler and spacer.

Week 2 Discussion: Health Assessment

The following week, Mr. Dennison returns for his follow-up visit.

He reports his allergic rhinitis is about the same with some sneezing and clear nasal drainage, but he is now taking his cetirizine pills and his inhaled fluticasone nasal inhaler regularly as prescribed.

He also reports that he continues to have cough and wheezing on two nights during the past week. The cough and wheezing were relieved by using the albuterol inhaler. He reports no fever, colored sputum, or any sign of infection.

On exam, the pertinent findings are:

Vital signs:

· Temperature is 36.7 C (98 F)

· Blood pressure is 110/72 mmHg

· Pulse is 76 beats/minute

· Respiratory rate is 16 breaths/minute

· Height is 172.2 cm (68 in)

· Weight is 86.2 kgs (190 lbs)Week 2 Discussion: Health Assessment

· Body mass index (BMI) is 28.9 kg/m2

Nose: Swelling of the inferior turbinates, pallor of the nasal mucosa with some clear drainage present.

Chest: No respiratory distress; normal, symmetrical expansion of the lungs; all areas resonant to percussion; all areas clear to auscultation, no abnormal sounds heard.

You then excuse yourself and leave the room. You proceed to present your findings to Dr. Wilson.

 

 

 

Given the key findings of the case so far, which of the following is the most likely diagnosis at this point? Choose the single best answer.

Week 2 Discussion: Health Assessment

Asthma

In this patient, the FEV1 value increases by 18% and the percent predicted FEV1 increases by 11% after the bronchodilator is given, consistent with a diagnosis for asthma (A).

TEACHING POINT

Differential of Obstructive Lung Disease With Reversible Findings

Most Likely Diagnosis

Based on spirometry findings of obstructive lung disease and improvement following treatment with inhaled bronchodilator, asthma is the most likely diagnosis.

The National Asthma Education and Prevention Program defines reversibility as an increase in the FEV1 value of > 200 mL and an increase > 12 % from baseline or an increase > 10% of the percent predicted FEV1.

Reversible obstructive findings on spirometry is the distinctive diagnostic abnormality in patients with asthma, especially early in the course. Patients with chronic, severe asthma may have less or no reversibility of their obstructive findings, very similar to patients with chronic obstructive pulmonary disease.

Less Likely Diagnoses

· Patients with nonasthmatic eosinophilic bronchitis will respond to inhaled corticosteroids like patients with asthma, but they will have a normal spirometry and normal chest x-ray. The diagnostic finding for this condition is sputum eosinophilia on induced sputum or bronchial wash obtained at bronchoscopy.Week 2 Discussion: Health Assessment

· Patients with vocal cord dysfunction may have flattening of the inspiratory loop on spirometry, but do not typically have reversible obstructive findings on spirometry like patients with asthma. The diagnostic finding of this condition is visualizing abnormal vocal cord movement during an episode of wheezing.

· Symptoms of chronic obstructive pulmonary disease, like those of asthma, should improve following treatment with bronchodilators and inhaled corticosteroids. Obstructive findings seen on spirometry with this condition, however, should not be reversible.

· Patients with gastroesophageal reflux disease typically present with either heartburn symptoms or findings of esophagitis on upper endoscopy. Even if asymptomatic, reflux can trigger bronchoconstriction and serve as an exacerbating factor for patients with asthma. If a patient with asthma fails to improve with standard treatment, it is reasonable to consider whether gastroesophageal reflux is present.

 

Dr. Wilson tells you, “In order to establish a diagnosis of asthma, you need to determine whether specific criteria are present. You have determined this is the case for Mr. Dennison via a detailed medical history; a focused physical exam; and spirometry that demonstrates reversible obstruction. Hence, you can now officially give Mr. Dennison the diagnosis of asthma, and there are several things we need to consider before we can decide on appropriate treatment options.”Week 2 Discussion: Health Assessment

You tell Dr. Wilson, “In my history and physical I was able to rule out comorbid conditions such as: gastroesophageal reflux disease (GERD), obesity, obstructive sleep apnea, stress, and depression. It appears that Mr. Dennison does have rhinitis or sinusitis which may aggravate his asthma, and we will need to address this. He also is overweight and we should address that at some point also.”

Dr. Wilson replies, “You are right that we will need to address his rhinitis/sinusitis, identify factors that precipitate his asthma, and assess his knowledge and skills for self-management — but we’ll talk more about all that later. Right now I’d like to talk about how to classify the severity of his asthma, since that will help us determine the appropriate treatment.”

Dr. Wilson asks you,

 

“How severe is Mr. Dennison’s asthma?”

After studying the chart for a moment, you reply, “For Mr. Dennison, the best information we have are the frequency of his nighttime awakenings and lung function findings. Due to his nighttime awakenings more than once a week but not nightly, and his FEV1 (60% to 80% of predicted), his severity is moderate persistent.”

TEACHING POINT

Establishing a Diagnosis of Asthma

1. Episodic symptoms of airflow obstruction or hyperresponsiveness are present.

2. This obstructive airflow is at least partially reversible.

3. Alternative diagnoses are excluded.Week 2 Discussion: Health Assessment

TEACHING POINT

Classifying Asthma Severity

The National Asthma Education Program Expert Panel Report 3 contains a chart that describes the components and classification of asthma severity including:

· Frequency of symptoms

· Frequency of nighttime awakenings

· Frequency of short-acting beta2 agonist use for symptom control

· Interference with normal activity

· FEV1 value

· FEV1/FVC ratio

TEACHING POINT

Initial Evaluation of Asthma

According to the National Asthma Education and Prevention Program Expert Panel Report 3 (2007), there are four key tasks in an initial evaluation of asthma including:

1. Classify asthma severity.

2. Assess the patient’s knowledge and skills for self-management.

3. Identify and control environmental factors and comorbid conditions that may aggravate asthma.

4. Offer appropriate medications.

“Good. Next,” Dr. Wilson says, “let’s choose the appropriate medications based on his severity of asthma. But before we do that, let’s consider the pathophysiology you are trying to affect with treatment.”

TEACHING POINT

Asthma Pathophysiology and Treatment

Pathophysiology

Asthma is a chronic inflammatory disease of the airways that involves many cells, in particular mast cells, eosinophils, T lymphocytes, macrophages, neutrophils, and epithelial cells. This chronic inflammation leads to airway hyperresponsiveness and limitation of airway flow (obstruction). The persistence of inflammation can lead to airway edema. Long-term inflammation can lead to airway remodeling and permanent loss of lung function.

Treatment

Since inflammation is the primary pathologic mechanism in asthma, maintenance medication that reduces inflammation is first-line therapy.Week 2 Discussion: Health Assessment

If a patient is acutely wheezing, he or she may need quick-acting rescue medications that focus on bronchodilation and opening up the airways.

Question

According to the National Asthma Education and Program guidelines, there is more than one option for maintenance medication to treat the severity of Mr. Dennison’s asthma. From the list below, which are recommended options to use as maintenance medication for Mr. Dennison’s moderate persistent asthma?

Combination of a low-dose inhaled corticosteroid and a long-acting beta2 agonist inhaler

Medium-dose inhaled corticosteroids

 

“All right,” declares Dr. Wilson, “now that we’ve determined the severity of Mr. Dennison’s asthma and come up with an initial treatment plan to present to him, let’s talk about some of the other things we’ve already touched on that we should bring up with him, where should we start?”

You respond, “We can identify any factors that precipitate Mr. Dennison’s asthma by asking him about allergens and irritants. And we can instruct him to avoid allergens, irritants, and getting a cold—which could exacerbate his asthma.”

Dr. Wilson informs you that “Mr. Dennison has had allergy tests in the past and has known allergies to dust mites and certain pollens.”

 

Dr. Wilson says, “What else can Mr. Dennison do to improve his allergic rhinitis?”

“It would help,” you reply, “if he could take his nasal corticosteroids and oral antihistamines regularly, as directed. And get his allergy shots regularly, too.”

“Yes,” says Dr. Wilson, “we will have to talk with him to see how we can work together on this.”

“He has chronic nasal congestion and mucopurulent drainage; should we treat Mr. Dennison for chronic sinusitis?” you ask.

Dr. Wilson responds, “It is a possibility that he has chronic sinusitis in addition to allergic rhinitis—and both of these are exacerbating his asthma. But, more testing will be needed to establish if he has clinical signs of chronic sinusitis.”

 

According to current immunization guidelines, what immunizations should you offer to Mr. Dennison?

According to the CDC Immunization guidelines, Mr. Dennison should receive the influenza vaccine (B) and tetanus, diphtheria, acellular pertussis vaccine (E) if due. Due to his asthma (chronic lung disease), he should also be offered the pneumococcal polysaccharide (PPSV) vaccine (D).

 

As you walk back to the patient’s room, Dr. Wilson shows you the handout he has just printed, “My Asthma Plan.” He says, “One good way by which to educate Mr. Dennison on how he should manage his asthma is to complete this asthma action plan with him.”

Week 2 Discussion: Health Assessment

First page of “My Asthma Plan”

· The top of the sheet contains a summary of the patient’s long-term controller and quick-relief medications and their dosages and instructions on use.

· The bottom of the sheet contains sections defining three levels of asthma control: Green Zone (doing well), Yellow Zone (getting worse) and Red Zone (medical alert). For each zone, there is a description of important symptoms to be aware of or look out for and levels of peak flow readings that correspond to the different zones. At the bottom of the Red Zone section is a short description of what symptoms should prompt the patient to call 911 and go to the emergency department.

Second page of “My Asthma Plan”

The second page summarizes environmental factors that may make asthma worse. According to the Plan, these are best addressed while the patient is in the Green Zone, to prevent future exacerbations of the asthma.

 

You reenter Mr. Dennison’s room and Dr. Wilson confirms your physical examination findings for this follow-up visit. He then informs Mr. Dennison that the spirometry test shows there is some decrease in lung function, but improvement with the bronchodilator medication. He explains to Mr. Dennison that the test proves that he has asthma, which is a chronic illness, but treatable with different medications.

You tell Mr. Dennison, “I need to do another measurement of your lung function. This is called a peak flow reading. It is simple to do and I will teach you how to do it, since we want to ask you to do peak flow readings twice per day at home, until we establish good control of your asthma.”

You give Mr. Dennison a handout on  how to perform a peak flow reading . After he finishes reading the handout, you view the American Lung Association  video  together.

Week 2 Discussion: Health Assessment

Mr. Dennison’s peak flow reading is 450 L/minute, which is below the expected reading of 600 L/minute for someone of his age and height. You reassure him that this may improve as his asthma is treated and better controlled.

You proceed to write in 450 L/minute as his Personal Best Peak Flow reading on the “My Asthma Plan” form and make the appropriate calculations of the peak flow reading cutoffs for each zone.

TEACHING POINT

Peak Flow Requirements

Zone Level of control Peak Flow
Green Doing well > 80%
Yellow Getting worse 50%-79%
Red Medical alert < 50%

Question

Mr. Dennison is studying the “My Asthma Plan” and he asks you how he would feel when his peak flow reading is in the Red Zone. Which of the following are examples of symptoms and signs indicating he is in the Red Zone?

Gray or blue lips or fingernails

Peak flow reading that is < 50% of his personal best reading

Very short of breath, including when walking or talking

Week 2 Discussion: Health Assessment

After completing the peak flow cutoffs for the different zones, you go to the top of the form and begin explaining the medications to Mr. Dennison. You explain his long-term controller medications and quick-acting rescue medications. You elaborate that these are inhaled medications, and it is most effective and easiest to use a spacer device with the inhaler.

You further go on to explain:

· Environmental measures and other lifestyle measures that may be helpful (which are described on the second page of the asthma action plan).

· Recommendation that he go back to his allergist to consider restarting his immunotherapy for dust mites and other pollens.

You also remember that it is important to address his adherence with his medications for allergic rhinitis and explain, “I understand that you may get busy and forget to take your nasal corticosteroid and oral antihistamine for allergic rhinitis, but if we improve the control of your allergic rhinitis symptoms, this may also improve the control of your asthma symptoms. Is there any way we can help you remember to take these two medications more regularly?”

Mr. Dennison thanks you for letting him know the reason for taking the allergic rhinitis medications each day and promises to redouble his efforts to take these medications regularly.

 

Long-Term Effects of Uncontrolled Asthma

· Airway remodelling

· Airway smooth muscle hypertrophy

· Angiogenesis

· Inflammation

· Mucous hypersecretion

· Subepithelial fibrosis

The most concerning long-term effect is less reversibility of the airway obstruction with medication so it will be more difficult to control the patient’s asthma. This is why we want to treat patients early on with appropriate medication to control symptoms and prevent all of the long-term complications.

Week 2 Discussion: Health Assessment

Dr. Wilson, who has been listening to your conversation, then tells Mr. Dennison that he agrees with your plan. Dr. Wilson adds that he is still concerned about the possibility of a chronic sinusitis that may have triggered the asthma episodes.

Dr. Wilson informs Mr. Dennison that he will refer him for a CT scan of his sinuses to investigate whether he has a chronic sinus infection. He reminds Mr. Dennison to call to be seen acutely if he has persistent wheezing or his symptoms or the peak flow reading place him in the red zone of the asthma action plan.

Mr. Dennison has no further questions, so you both wish him well, shake his hand and leave the examination room.

 

It has been six months and you drop by Dr. Wilson’s office. He asks, “Remember, Mr. Dennison? Let me show you his CT scan of his sinuses.

“On his CT scan, you can see ethmoid sinus opacification and maxillary sinus mucosal thickening.”

Dr. Wilson informs you, “Mr. Dennison is doing much better now. He is taking the low-dose inhaled corticosteroid and long-acting beta2-agonist inhaler that we prescribed twice per day on a regular basis and he reports that he rarely wheezes. In addition, he is now taking his nasal corticosteroids each morning, irrigating his sinuses with saline on a daily basis and receiving his allergy shots regularly, so that his upper respiratory symptoms have also improved.”

TEACHING POINT

Treatment for Chronic Sinusitis

· All guidelines recommend maximizing treatment for allergic rhinitis, including regular use of nasal corticosteroids and, if indicated, allergen immunotherapy. There is no difference in the type, dose or delivery method of the nasal corticosteroid used.Week 2 Discussion: Health Assessment

· Current guidelines and a Cochrane review (2007) found that regular nasal saline irrigation is a useful adjunct in treating chronic sinusitis, though not as effective as nasal corticosteroids. A more recent Cochrane review (2016) notes that a large volume irrigation (150 mL) with hypertonic saline is more effective than placebo, “but the quality of the evidence is low for three months and very low for six months of treatment”.

· There is no compelling evidence to support the use of antibiotics in patients with chronic sinusitis. The AAAAI/ACAAI Practice Parameter Update (2014) indicates that antibiotics can be used for acute exacerbations of chronic sinusitis. A Cochrane review (2016) concluded that there was “very little evidence that systemic antibiotics are effective in patients with chronic rhinosinusitis”. A Canadian guideline recommended antibiotics for patients with chronic sinusitis only when there is pain or purulent discharge.

· Cochrane reviews (2016) also concluded that only low or low-quality evidence supports the use of short courses of oral steroids alone or as adjunct therapy in patients with chronic sinusitis. Week 2 Discussion: Health Assessment

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