Primary Diagnosis – Asthma
Asthma is an inflammatory disease that affects one’s airways (National Heart, Lung, and Blood Institute, 2017a). It is caused by inhaled substances that lead to the inflammation of the large and small airways, their swelling, and increased mucus production. Asthma is followed by such symptoms as shortness of breath, coughing, wheezing, and chest tightness. Moreover, many patients with asthma either have or had allergies and eczema (Postma & Rabe, 2015).
Rationale
The patient reports such symptoms as coughing and shortness of breath. Eczema is a child and allergic reactions are also indicative of asthma. Slight wheezing was noted during the examination. The results of Pulmonary Function Testing show signs of asthma (Johnson & Theurer, 2014). Michelle works at a bakery, where she is exposed to dust particles – a possible cause of an allergic reaction.
Secondary Diagnosis – COPD
Chronic Obstructive Pulmonary Disease (COPD) is a disease that involves small airways. It is a condition that becomes worse with time, first showing signs in individuals older than 40 years. The symptoms of COPD include wheezing, phlegm, cough, and shortness of breath (Postma & Rabe, 2015). COPD is also characterized by inflammation of the airways. The disease can be managed but not treated fully (National Heart, Lung, and Blood Institute, 2017b). Complications can cause increased mucus production, chest tightness, constant coughing.
Rationale
Michelle has such symptoms as shortness of breath and coughing. Family history shows grandfather with COPD complications. COPD history in the family may respond to the patient’s current problem. The patient’s age also corresponds to the time of the first symptoms’ appearance. The patient has a history of bronchitis, which could have complications. However, testing shows reversible obstruction.
Differential Diagnosis – Heart Failure
Heart failure is a condition where one’s heart does not pump blood sufficiently enough to support the body (McMurray et al., 2014). It usually becomes more evident with age and is prevalent in older patients. Its symptoms include coughing, shortness of breath, and tiredness. Other signs are acute pulmonary edema and swelling. The condition can become severe and require hospitalization.
Rationale
The patient’s family history has a number of heart-related issues – a mother with congestive heart failure, a grandfather with a stroke, grandmother with multiple heart attacks. Michelle has such symptoms as shortness of breath and coughing. However, she has no edema and no apparent swelling.
Medication
The treatment of asthma includes two parts – long-term and short-term medications. Long-term control medicines are corticosteroids, which usually have to be inhaled to deliver the components to one’s lungs (National Heart, Lung, and Blood Institute, 2017a). They are used to relieve swelling and inflammation. Medications for quick relief are inhaled short-acting beta2-agonists (National Heart, Lung, and Blood Institute, 2017a). They relax muscles and open up the airways.
An inhaled corticosteroid for long-term control treatment will help the patient to manage the condition and open up the airways (National Heart, Lung, and Blood Institute, 2017a). It is a usual type of treatment for asthma.
- Rx: QVAR 40 mcg/inhalation (Beclomethasone dipropionate)
- Sig: 320 mcg twice daily, one puff, Dispense 1, no refills.
An inhaled beta2-agonist for quick relief should provide Michelle with a way to minimize shortness of breath at work. It relaxes muscles and lets the air pass better (National Heart, Lung, and Blood Institute, 2017a). It should not be used often.
- Rx: Ventolin HFA/inhalation 90 mcg (Albuterol)
- Sig: 180 mcg every 4-6 hours for quick relief, two puffs, no more than 12 inhalations per day, Dispense 1, no refills.
Lab Tests
To eliminate the possibility of COPD one can advise a Full Pulmonary Function Test (Johnson & Theurer, 2014). The available test results already show a case of asthma, although other diagnoses should be tested. Further tests should be considered after follow-ups as they will reveal the effects of prescribed medicines.
Education
Michelle should limit her exposure to allergens and unfit environments. Her current workplace exposes her to asthma triggers. She should try to cover her face during work with a mask or other equipment. Furthermore, she should be aware of her clothes and skin getting covered in dust particles. She should start monitoring her condition by writing down her breathing and airflow (National Heart, Lung, and Blood Institute, 2017a). She should try to avoid stressful situations as they can make her condition worse. Michelle should use medicines responsibly and follow given instructions. Prescribed medications have side effects such as oral thrush – yeast-shaped fungus. She should rinse her mouth after inhalation and use a spacer or a holding chamber to avoid it (National Heart, Lung, and Blood Institute, 2017a). Other side effects may include a sore throat and cough. Quick-relief medicines also have side effects and should not be taken too often.
Referrals
If Michelle’s case gets worse, she can be referred to an asthma specialist. Future referrals should depend on the effects of prescribed treatment. The current diagnosis does not reveal any atypical symptoms or complications, and the patient does not have any issues with mental health that might interfere with the treatment process.
Follow-Up
Regular follow-ups should be scheduled to monitor the patient’s condition and see the effects of medications. The next appointment is two weeks unless the situation worsens. Subsequent follow-ups should be within a month to establish further treatment and tests (National Heart, Lung, and Blood Institute, 2017a).
References
Johnson, J. D., & Theurer, W. M. (2014). A stepwise approach to the interpretation of pulmonary function tests. Am Fam Physician, 89(5), 359-366.
McMurray, J. J., Packer, M., Desai, A. S., Gong, J., Lefkowitz, M. P., Rizkala, A. R.,… Zile, M. R. (2014). Angiotensin–neprilysin inhibition versus enalapril in heart failure. New England Journal of Medicine, 371(11), 993-1004.
National Heart, Lung, and Blood Institute. (2017a). Asthma. Web.
National Heart, Lung, and Blood Institute. (2017b). COPD, treatment options. Web.
Postma, D. S., & Rabe, K. F. (2015). The asthma–COPD overlap syndrome. New England Journal of Medicine, 373(13), 1241-1249.