Case Review Three - American Lung Association

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Section 5: Case Review
Case Review
Review the pulmonary function results and select the correct basic interpretation.
Choose from the following answers:
1.
2.
3.
4.
Normal
Mild to moderate obstruction
Severe obstruction
Severe obstructive ventilatory defect, cannot exclude a concomitant restrictive
defect
5. Restrictive ventilatory defect, long volumes necessary for confirmation
6. Uninterpretable, does not meet acceptability criteria
Pulmonary Function Case 1A:
Test
Meas
Pred
% Pred
FVC
2.20
2.58
85
FEV1
1.79
1.85
97
FEV1/FVC
.81
.72
FEF25-75%
1.82
2.23
82
PEF
5.67
5.20
109
Answer:
1
Section 5: Case Review
Case Review
Review the pulmonary function results and select the correct basic interpretation.
Choose from the following answers:
7.
8.
9.
10.
Normal
Mild to moderate obstruction
Severe obstruction
Severe obstructive ventilatory defect, cannot exclude a concomitant restrictive
defect
11. Restrictive ventilatory defect, long volumes necessary for confirmation
12. Uninterpretable, does not meet acceptability criteria
Pulmonary Function Case 1B:
Test
Meas
Pred
% Pred
FVC
5.08
4.94
103
FEV1
2.66
3.58
74
FEV1/FVC
.52
.72
FEF25-75%
1.40
3.47
40
PEF
6.49
9.10
71
Answer:
2
Section 5: Case Review
Case Review
Review the pulmonary function results and select the correct basic interpretation.
Choose from the following answers:
13.
14.
15.
16.
Normal
Mild to moderate obstruction
Severe obstruction
Severe obstructive ventilatory defect, cannot exclude a concomitant restrictive
defect
17. Restrictive ventilatory defect, long volumes necessary for confirmation
18. Uninterpretable, does not meet acceptability criteria
Pulmonary Function Case 1C:
Test
Meas
Pred
% Pred
FVC
4.09
4.25
96
FEV1
1.95
2.88
68
FEV1/FVC
.48
.68
FEF25-75%
.48
2.65
18
6.27
8.06
78
PEF
Answer:
3
Section 5: Case Review
Case Review
Review the pulmonary function results and select the correct basic interpretation.
Choose from the following answers:
19.
20.
21.
22.
Normal
Mild to moderate obstruction
Severe obstruction
Severe obstructive ventilatory defect, cannot exclude a concomitant restrictive
defect
23. Restrictive ventilatory defect, long volumes necessary for confirmation
24. Uninterpretable, does not meet acceptability criteria
Pulmonary Function Case 1D:
Test
FVC
Meas
3.02
Pred
3.41
FEV1
1.23
2.53
FEV1/FVC
.41
.74
FEF25-75%
.41
2.77
15
3.95
6.10
65
PEF
% Pred
88
49
Answer:
4
Section 5: Case Review
Case Review
Review the pulmonary function results and select the correct basic interpretation.
Choose from the following answers:
25.
26.
27.
28.
Normal
Mild to moderate obstruction
Severe obstruction
Severe obstructive ventilatory defect, cannot exclude a concomitant restrictive
defect
29. Restrictive ventilatory defect, long volumes necessary for confirmation
30. Uninterpretable, does not meet acceptability criteria
Pulmonary Function Case 1E:
Test
Meas
Pred
% Pred
FVC
3.00
4.79
63
FEV1
2.54
3.28
77
FEV1/FVC
.85
.69
FEF25-75%
3.25
2.97
109
PEF
9.12
8.92
102
Answer:
5
Section 5: Case Review
Case Review Two
9:15 a.m. Emergency Department
Kate Wind is a 10-year-old female admitted to the emergency department with the diagnosis of asthma. This
patient had one prior admission for asthma at this facility in the past year. On physical examination, the following
is noted:
Patient complains of shortness-of-breath, chest “tightness,” and feeling “very tired.” States she has
taken two Proventil treatments in the last hour. Neither has decreased her symptoms. She has had cold
symptoms for seven days. Mom states that Kate is breathless while talking and she is communicating
only in short phrases. Has a constant, dry, tight, non-productive cough. Her peak-flow rate (PEFR) is
167. Her baseline predicted peak flow is 270.
History (obtained from patient and mother):
Diagnosed with asthma two years ago; Has problems in spring and fall in association with seasonal “hay fever”
and asthma symptoms becomes more frequent. She has been using her Proventil MDI every four hours for the
past week. She normally uses her MDI infrequently, except during early spring and fall. She has been
complaining of a continual daytime cough for the past 24 hours and her night cough has become frequent. Cared
for at the local health clinic and not seen by one physician. She has had two to three office visits for asthmatic
episodes over the past year. She is not on any daily medications. She has a peak- flow meter but doesn’t have a
written plan. She is allergic to several strains of pollen and mold. She lives in a wooded area and they use a
wood burning stove to heat their home in the wintertime.
1. What is the symptom severity level?
2. Which signs and symptoms indicate this severity classification?
6
Section 5: Case Review
Case Review Three
Timmy Tubes is being seen in the pediatrician’s office for a well visit. He is a six-year-old white male who lives
with his mom, dad and three siblings. Timmy’s mom is under a lot of stress raising four children and taking care
of husband who was recently diagnosed with throat cancer. Dad spends the daytime at hospice so she can work
as a unit clerk at the local hospital. Timmy was diagnosed with asthma at the age of three. His recent medication
plan was: Singulair 5 mg 1 tab p.o. at bedtime and Flovent 44 mcg, 2 puffs BID. He has not been taking either
medication on a daily basis. Mom says she is having a difficult time caring for her family, let alone trying to give
Timmy medications daily. She reports that he coughs daily and he is not able to play a sport because the
symptoms interfere, he is unable to participate in an event without coughing, wheezing and stopping to catch his
breath. He wakes up two to three nights every week with coughing/wheezing. He is taking his albuterol via a
nebulizer twice a day and occasionally three times a day, especially when he is playing hard in the neighborhood.
He doesn’t have any rescue medication at school. Mom is called if he needs a treatment because they only have
one machine and Timmy is not carrying it to school. He also complains of runny nose, itchy watering eyes and
sneezing. These symptoms seem to be year round. He has not been tested for allergies. He used to track peak
flow but has not done this in six months. They don’t even know where the device is. They have two cats and a
dog in the house.
He presents today with inspiratory and expiratory wheezing. Timmy reports he feels great. He is coughing in the
office. He performed a peak flow and it was 150. His baseline, according to mom is, 200.
1. What is the symptom severity level?
2. Which signs and symptoms indicate this severity classification?
7
Section 5: Case Review
Case Review Four
Carey Cough is a 50-year-old white male. He is working three jobs to make ends meet. He owns the family farm.
He works in a pizza shop making pizza and at the local movie theater and on the farm where he plants and
harvests crops, mills wood and takes care of the horses. He states that being around horses makes his eyes and
nose watery and itchy. He has not been tested for allergies.
This is Cary Cough’s first visit with the asthma educator in the family practice office. He has been seeing this
doctor for 10 years. He has a history of being on oral steroids at least four times a year. He has not been
hospitalized but has had frequent emergency department visits. He has a peak-flow meter but has not tracked it
in two years. Carey reports that his chest is a little tight today, but he states this is normal for him. He takes his
albuterol two times a day. He has frequent nighttime symptoms. He complains of wheezing daily. His peak flow
today was 370. His normal should be 570. He is supposed to be taking Pulmicort – 2 puffs twice a day, but he
takes it as needed; Claritin 10 mg tab daily; and Singulair 10 mg tab at bedtime. He states with his work
schedule, it is hard for him to remember to take his medications but he does take the Singulair. He also admits to
smoking half a pack of cigarettes a day. Breath sounds reveal expiratory wheezing.
1. What is the symptom severity level?
2. Which signs and symptoms indicate this severity classification?
8
Section 5: Case Review
Case Review Five:
DeeDee Double is a 17-year-old African American. She was diagnosed with asthma at the age of two. Her
mother and grandma have asthma. She has used a peak-flow monitor in the past but has not tracked it in the
past month. Her personal best she reports is 460. Today she reached 380.
She has been hospitalized in the past for her asthma. Mom is recently unemployed and they no longer have
insurance coverage, so and they have difficulty getting their medications filled. They are living with their
grandparents and five other relatives. DeeDee and her mother sleep in the basement on a very old couch. There
are four people in the household who smoke in the car and at home. DeeDee states that she is doing pretty well
right now. She states that she uses albuterol maybe once a week. She notices her asthma is usually triggered
when she gets home from school and with weather change and upper respiratory infections. Her treatment plan
includes Flovent 44 mcg and albuterol prn. She admits she is not being compliant with taking Flovent. DeeDee
wakes up coughing three to four times a month at night.
1. What is the symptom severity level?
2. Which signs and symptoms indicate this severity classification?
9
Section 5: Case Review
CASE REVIEW ANSWER SHEET
Case Review 1A – Normal
The FEV1, FVC, and FEV1/FVC are normal. The flow-volume loop is normal. This is a normal spirogram.
Case Review 1B – Uninterpretable, does not meet acceptability criteria
The volume-time plot reveals a poor start to the test, an irregular upstroke on expiration and a poorly sustained
plateau that all indicate variable effort. This test is uninterruptable as it fails acceptability criteria.
Case Review 1C – Mild-to-moderate obstruction
The FEV1 is mild to moderately reduced (68% predicted), the FVC is normal and the FEV1/FVC is reduced. This
spirogram demonstrates mild-to-moderate obstruction.
Case Review 1D – Severe obstruction
The FEV1 is significantly reduced, FVC is normal and the FEV1/FVC is reduced. This spirogram demonstrates
severe obstruction.
Case Review 1E – Restrictive ventilatory defect, long volumes necessary for confirmation
The FEV1 is mildly reduced, the FVC is moderately reduced and the FEV1/FVC is high. The flow-volume loop is
narrow but of normal shape. This suggests a restrictive defect.
Case Review Two
Symptom severity level: Severe persistent asthma
Signs and symptoms indicating severity level:
Constant daytime cough
Frequent nighttime cough
Case Review Three
Symptom Severity level: Moderate persistent asthma
Signs and symptoms indicating severity level:
Daily cough
Nighttime symptoms two to three times a week
Peak flow 75% of predicted
10
Section 5: Case Review
Case Review Four
Symptom severity level: Severe persistent asthma
Signs and symptoms indicating severity level:
Frequent nighttime symptoms
Case Review Five
Symptom severity level: Mild persistent asthma
Signs and symptoms indicating severity level:
Peak flow 83% of predicted
Wakes up coughing three to four times a month at night
11
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