Week 2: Case Discussion: Pulmonary Part One
Setting: A free medical clinic that provides health care for the under-insured.
Your next patient, Michelle G., age 40, is a regular of the clinic and the last patient of the day. The chart states she is here for recent episodes of shortness of breath.
You enter the room and Michelle G is dressed in work clothes, standing up looking at a health poster on the wall. You introduce yourself and ask her what brings her to the clinic today. \”I think I may have a cold. I\’ve been having a hard time breathing on and off lately.\”
HPI: \”I notice I\’m short of breath mostly at work but by the time I get home feel fine. No episodes of shortness of breath on the weekends that I can recall. But a few hours back at work and I start to feel like I cannot catch my breath again. A few months ago this happened and it was so bad I left work and went to urgent care where they gave me a breathing treatment of some kind and sent me home on an antibiotic. I would like you to give me another antibiotic. She denies sputum. No new allergy triggers noted. She denies heartburn.
PMHx: Michelle G. reports her overall health as good.
Childhood/previous illnesses: eczema as a child
Chronic illnesses: Has seasonal allergies, spring is her worst season. Was seen by an allergy specialist ten years ago, Took allergy shots for five years with great results, now only takes Zyrtec when needed.
Surgeries: Cholecystectomy
Hospitalizations: childbirth x 3.
Immunizations: up-to-date on all vaccinations.
Allergies: Strawberries-Rash; erythromycin- severe GI upset.
Blood transfusions: none
Drinks alcohol socially, smoked 1 pack per week for 3 years in her 20\’s. Denies illicit drug use.
Sleeps 6 to 7 hours a night. Exercises four to five days per week.
Current medications: Multivitamin, Zyrtec
Social History: Married, lives with husband and 3 children. Worked in advertising up until 18 months ago when she got laid off. In order to help with the household finances she took a job as a Baker\’s assistant at an Artisan Bread Bakery. She arrives at 4 a.m. every morning to begin baking breads/pastries for the day.
Family History: Children are healthy- daughter currently has a sinus infection. Parents are deceased. Mother at age 80 from congestive heart failure. Father died at age 82 from lung cancer, diagnosed when metastasized to brain. PGM: died from unknown causes, PGF: Stroke at age 82. MGM: died at 83, had HTN, atherosclerosis and many heart attacks. PGF: died at 71 from complications of COPD.
PE: Height 5\’10\”, Weight 140 pounds
Vital signs : BP 130/70, T 98.0, P 75, R 18 Sao2 98% on RA
General: 40-year-old Caucasian female appears stated age in no apparent distress. Alert, oriented, and cooperative. Able to speak in full sentences and does not appear breathless. Skin: Skin warm, dry, and intact. Skin color is pale pink, no cyanosis or pallor.
HEENT: Head normo-cephalic. Hair thick and distribution even throughout scalp.
Eyes: Sclera clear. Conjunctiva: white, PERRLA, EOMs intact.
Ears: Tympanic membranes gray and intact with light reflex noted. Pinna and tragus non-tender
Nose: Nares patent with thin white exudate noted. Mucosa appears boggy and pale. Deviated septum noted. Sinuses non-tender to palpation.
Throat: Oropharynx pink, moist, no lesions or exudate. Tonsils 1+ bilaterally. Teeth in good repair, no cavities noted. Tongue smooth, pink, no lesions, protrudes in midline. Neck supple. No cervical lymphadenopathy or tenderness noted. Thyroid midline, small and firm without palpable masses.
Lungs: Lungs clear to auscultation bilaterally. Respirations unlabored. Slight wheezing noted inspiration and on forced expiration. Wheezing does not clear with forced cough.
CV: Heart S1 and S2 noted, RRR, no murmurs noted, no displaced PMI. Peripheral pulses equal bilaterally, no peripheral edema
Abdomen: Abdomen round, soft, with bowel sounds noted in all four quadrants. No organo-megaly noted.
Diagnostic Testing:
Review of the patient\’s EMR reveals an old CXR from last winter when she had Bronchitis.
CXR Report: 11/7/2016
This is a PA and lateral chest radiograph on Ms. Michelle X, performed on 11/7/16. Clinical information: low grade fever, productive cough, malaise.
Findings: Cardio-mediastinal silhouette is normal. B/L lung fields are clear. There are no effusions. The bony thorax appears normal. No opacities or fluid. Diaphragm normal.
Impression: Normal chest radiograph without pathology.
Click here to view CXR (Links to an external site.) (Links to an external site.)
You suspect an obstructive/restrictive process and order Pulmonary Function Testing
Pre-Bronchodilator Challenge- FEV1/FVC 60%, FVC decreased
Post Bronchodilator Challenge- FEV1/FVC 75%
Discussion Questions Part One:
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.
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.
Address Michelle\’s request for an antibiotic.
Differential Diagnosis and Primary Care
Student’s Name
Institutional Affiliations
Differential Diagnosis and Primary Care
One of the crucial roles of primary care physicians is to make an accurate diagnosis. The process of selecting treatment interventions for a patient begins after the physician has identified the actual cause or causes of existing symptoms (Singh et al., 2017). In primary care, healthcare professionals usually document a patient’s therapeutic information in a Subjective, Objective, Assessment, and Plan (SOAP) note. The information guides the physician to identify possible conditions and the actual diagnosis of a patient’s problems (Sudarsan et al., 2021). The purpose of this assignment is to analyze a SOAP note for Michelle G., identify her primary diagnosis, and document a treatment plan.
Primary Diagnosis
A primary diagnosis is a health condition that best matches a patient’s symptoms, recent history, and physical exam results. The primary diagnosis for Michelle is Occupational Asthma. Her symptoms, exam results, and recent history adequately support the presence of occupational asthma. Recent history indicates that Michelle has been having a hard time breathing on and off lately. Michelle further reports that she has noticed that she is short of breath mostly at work but feels fine by the time she gets home. She denies episodes of shortness of breath on the weekends when she has not gone to work. According to Bepko & Mansalis (2016), any event that occurs at the place of work and contributes to a health condition is known as an occupational illness. As Tiotiu et al. (2020) explain, occupational asthma is a lung disorder commonly diagnosed among workers in industrialized countries. Patients with occupational asthma normally present with typical asthma symptoms when they are at the workplace while the symptoms subside when they move to a different setting. Symptoms that usually occur in patients with occupational asthma whenever they are at work include difficulty breathing or shortness of breath, chest tightness, cough, and wheezing (Bush, 2019; Bepko & Mansalia, 2016). Michelle starts to feel like she cannot catch her breath again a few hours after reporting to work. She indicates that her symptoms were so bad a few months ago that she had to leave work to seek treatment in a hospital from where she was given an antibiotic. She denies heartburn, sputum, or new allergy triggers. A history of bronchitis is a risk factor for the development of asthma (Bush, 2019). Michelle has a history of bronchitis as documented in her electronic medical records.
Primary care physicians must always combine subjective assessment data with results of objective assessment. In addition to the subjective information discussed above, objective data provided in the SOAP note further supports Occupational Asthma as Michelle’s diagnosis. For instance, head, eyes, ears, nose, and throat (HEENT) assessment data indicates that her nose has nares patent with thin white exudates. The nasal mucosa also appears boggy and pale. She also has a deviated septum. Physical exam results of the lungs show slight wheezing during inspiration and on forced expiration. Wheezing does not clear with forced cough. A lateral chest radiograph performed on Michelle shows that her chest is normal without pathology. Additional clinical information indicates that Michelle has low-grade fever, productive cough, malaise. These results confirm the presence of asthma (Bush, 2019; Bepko & Mansalia, 2016). From the Pulmonary Function Test, it is discovered that Michelle has decreased forced expiratory volume to forced vital capacity ratio (FEV1/FVC) before using a bronchodilator. As reported by Sears (2017), asthma patients normally have decreased FEV1/FVC ratio due to a decline in lung function caused by the disease.
Management Plan
Pharmacological/First-Line Treatment: The first-line treatment for occupational asthma is the same as that of genera asthma. According to the American Academy of Family Physicians clinical practice guidelines, patients with occupational asthma should be treated with anti-inflammatory medications such as inhaled bronchodilators, corticosteroids, and leukotriene modifiers (Bepko & Mansalis, 2016). Drugs from these three classes are first-line treatments for occupational asthma and will help to relieve Michelle’s symptoms. An example of inhaled bronchodilator that the physician can administer to Michelle is salbutamol. This drug acts as an agonist of beta-2 receptors thereby improving lung function. It will helps to address breathing difficulties or shortness of breath (Sears, 2017).
Labs: Perform peripheral blood eosinophil count to determine the presence of eosinophils in the airway and their association with breathing difficulties (Bush, 2019).
Education: Michelle’s symptoms are triggered by some irritants like smoke or gases at the bakery. The best education for her is to completely avoid being at the workplace as this is the best way to eliminate her current symptoms. It is also important to educate her to adhere to the recommended treatment regimen (Bepko & Mansalis, 2016).
Referrals: Refer Michelle to a pulmonologist or a lung specialist for further assessment and guidance (Price et al., 2017).
Follow-Up: Encourage Michelle to make a follow-up visit to the clinic after two weeks of drug use for clinical evaluation (Tiotiu et al., 2020).
Addressing Michelle’s Request for an Antibiotic: Advice Michelle that her symptoms are not caused by a bacterial infection and thus, an antibiotic is not an appropriate treatment (Bush, 2019).
References
Bepko, J. & Mansalis, K. (2016). Common Occupational Disorders: Asthma, COPD, Dermatitis, and Musculoskeletal Disorders. American Family Physician, 93(12):1000-1006. https://www.aafp.org/afp/2016/0615/p1000.html
Bush, A. (2019) Pathophysiological mechanisms of asthma. Frontiers in Pediatrics, 7, 68. doi: 10.3389/fped.2019.00068
Price, D., Bjermer, L., Bergin, D. A., & Martinez, R. (2017). Asthma referrals: a key component of asthma management that needs to be addressed. Journal of Asthma and Allergy, 10, 209–223. https://doi.org/10.2147/JAA.S134300
Sears, M. R. (2017). Lung function decline in asthma. European Respiratory Journal, 30, 411-413; doi: 10.1183/09031936.00080007
Singh, H., Schiff, G. D., Graber, M. L., Onakpoya, I., & Thompson, M. (2017). The global burden of diagnostic errors in primary care. BMJ Quality & Safety, 26, 484-494.
Sudarsan, P., Gowda, M. B. A., Anusha, R. J., Balu, D., Sadagoban, G. K., & Borra, S. S. (2021). Development and validation of A-SOAP note: Assessment of efficiency in documenting patient therapeutic records. Journal of Applied Pharmaceutical Science, 11(10):001–006.
Tiotiu, A. I., Novakova, S., Labor, M., Emelyanov, A., Mihaicuta, S., Novakova, P., & Nedeva, D. (2020). Progress in occupational asthma. International Journal of Environmental Research and Public Health, 17(12), 4553. https://doi.org/10.3390/ijerph17124553