D.R. is a 27-year-old man, who presents to the nurse practitioner at the Family Care Clinic complaining of increasing SOB, wheezing, fatigue, cough, stuffy nose, watery eyes, and postnasal drainage—all of which began four days ago. Three days ago, he began monitoring his peak flow rates several times a day. His peak flow rates have ranged from 65-70% of his regular baseline with nighttime symptoms for 3 nights on the last week and often have been at the lower limit of that range in the morning. Three days ago, he also began to self-treat with frequent albuterol nebulizer therapy. He reports that usually his albuterol inhaler provides him with relief from his asthma symptoms, but this is no longer enough treatment for this asthmatic episode.
Case Study Questions
According to the case study information, how would you classify the severity of D.R. asthma attack?
Name the most common triggers for asthma in any given patients and specify in your answer which ones you consider applied to D.R. on the case study.
Based on your knowledge and your research, please explain the factors that might be the etiology of D.R. being an asthmatic patient.
Fluid, Electrolyte and Acid-Base Homeostasis:
Ms. Brown is a 70-year-old woman with type 2 diabetes mellitus who has been too ill to get out of bed for 2 days. She has had a severe cough and has been unable to eat or drink during this time. On admission, her laboratory values show the following:
Serum glucose 412 mg/dL
Serum sodium (Na+) 156 mEq/L
Serum potassium (K+) 5.6 mEq/L
Serum chloride (Cl–) 115 mEq/L
Arterial blood gases (ABGs): pH 7.30; PaCO2 32 mmHg; PaO2 70 mmHg; HCO3– 20 mEq/L
Case Study Questions
Based on Ms. Brown admission’s laboratory values, could you determine what type of water and electrolyte imbalance does she has?
Describe the signs and symptoms to the different types of water imbalance and described clinical manifestation she might exhibit with the potassium level she has.
In the specific case presented which would be the most appropriate treatment for Ms. Brown and why?
What the ABGs from Ms. Brown indicate regarding her acid-base imbalance?
Based on your readings and your research define and describe Anion Gaps and its clinical significance.
Full Answer Section
Etiology of D.R.'s Asthma: Several factors could contribute to D.R.'s asthma:
- Genetics: Family history of asthma increases the risk.
- Environmental factors: Exposure to secondhand smoke, air pollution, allergens during childhood can play a role.
- Respiratory infections: Repeated respiratory infections in early childhood can increase the risk.
- Atopy: Allergies to other substances like pollen or food can sometimes be linked to asthma.
Management Recommendations:
- Consult a doctor: A doctor can confirm the diagnosis and prescribe appropriate medications.
- Short-acting beta-agonists: Frequent albuterol use suggests dependence, and other medications like inhaled corticosteroids may be needed for long-term control.
- Inhaled corticosteroids: These reduce inflammation and prevent future attacks.
- Avoid triggers: Identify and avoid personal triggers as much as possible.
- Peak flow monitoring: Continue monitoring peak flow rates and report any significant changes to the doctor.
- Education: Understanding asthma triggers and management strategies is crucial for self-care.
Ms. Brown's Fluid, Electrolyte, and Acid-Base Imbalances
Water and Electrolyte Imbalance: Based on the lab values, Ms. Brown likely has hyponatremia (low sodium) and dehydration. Her symptoms of fatigue, confusion, and cough are consistent with this imbalance.
Potassium Level and Symptoms: Her potassium level (5.6 mEq/L) is slightly elevated, but not enough to cause significant clinical symptoms. However, if it goes higher, she could experience muscle weakness, cardiac arrhythmias, and even paralysis.
Treatment:
- Rehydration: Intravenous fluids are critical to replenish fluids and electrolytes.
- Sodium correction: Slow sodium correction will be necessary to avoid complications like cerebral edema.
- Insulin and glucose control: Managing her diabetes with insulin will help regulate her blood sugar and improve electrolyte balance.
Acid-Base Imbalance: Ms. Brown's ABGs show:
- Mild respiratory acidosis: Her PaCO2 is slightly elevated at 32 mmHg. This could be due to her weakened respiratory muscles from dehydration and illness.
- Metabolic compensation: Her HCO3– is also slightly elevated (20 mEq/L) to partially compensate for the acidosis.
Anion Gap: The anion gap is not provided in the case study. It is a calculated value used to identify unmeasured anions in the blood. However, based on her clinical picture and lab values, an anion gap metabolic acidosis is less likely in this case.
Clinical Significance of Anion Gap: A high anion gap can indicate various metabolic conditions like diabetic ketoacidosis, lactic acidosis, or uremia. Knowing the anion gap value and clinical context helps diagnose and manage underlying conditions.
Remember, this information is for educational purposes only and should not be used for self-diagnosis or treatment. Please consult a healthcare professional for proper medical advice.
Sample Answer
Asthma Attack Severity: Based on the information provided, D.R.'s asthma attack can be classified as moderate persistent. He experiences daily symptoms, has nocturnal symptoms for three nights in the past week, and his peak flow rates are consistently below his baseline despite regular albuterol use.
Common Triggers: There are many triggers for asthma, and they vary from person to person. Some potential triggers for D.R. based on the case study include:
- Infectious illness: The mention of a cough and fever suggests a possible viral or bacterial infection, a common asthma trigger.
- Allergens: While not explicitly mentioned, exposure to dust mites, pollen, mold, or pet dander could be triggers.
- Irritants: Smoke, strong odors, air pollution, or cold air could contribute to his symptoms.
- Emotional stress: Although not confirmed, emotional stress can also be a trigger for some people with asthma.