NR 603 Week 2 Case Discussion: Pulmonary (Part One)
NR 603 Week 2 Case Discussion: Pulmonary (Part One)

1. 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.

2. 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.

3. Address Michelle's request for an antibiotic

Dr. Deering and class,

Primary Diagnosis:

Based on the presenting symptoms and assessment findings within this case study, the primary

diagnosis for Michelle is occupational asthma. Occupational asthma (OA), or work-related

asthma (WRA), is the most common occupational lung disease in the United States (Global

Initiative for Asthma [GINA], 2019). OA results from exposure to a stimulus, such as dust, grain,

flour, latex, insects, and mold, found in the workplace environment (Jolly et al., 2015). Exposure

to these types of allergens causes symptoms of asthma, including coughing, wheezing, chest

tightness, and shortness of breath (Dao & Bernstein, 2018). Nasal congestion and eye irritation

can also occur as a result of OA. In this case study, Michelle presents with shortness of breath

while she is at work. When she is not at work, she has relief and no longer experiences difficulty

breathing. Even on weekends when she is at home, she denies respiratory symptoms.

Individuals diagnosed with OA tend to have more symptomatic days and exacerbations of

asthma symptoms while they are exposed daily to a particular allergen in the workplace. Since

Michelle has a history of seasonal allergies, she is at an increased risk of developing

occupational asthma. One of the main risk factors for occupational asthma is atopy, which is

characterized by a sensitivity to allergens (Dao & Bernstein, 2018). Therefore, individuals with

atopy often have seasonal allergies, allergic skin rashes, and food allergies. In this case study,

Michelle has a history of seasonal allergies and has seen an allergy specialist.

Upon physical examination, Michelle was noted to have inspiratory and expiratory wheezing,

thin exudates to bilateral nares, and a pale, boggy mucosa. These findings are indicative of

inflammation within the respiratory mucosa from the irritant. The thin exudates within the nares

are related to allergic rhinitis, which is an inflammation caused by the immune system’s

response to an allergen (Pralong & Cartier, 2017). The wheezing is a result of airway narrowing

from bronchoconstriction or mucosal edema (Pralong & Cartier, 2017). Michelle’s respiratory

symptoms occur within a few hours of working in the bakery. She starts every morning baking

bread and pastries for the day as a Baker’s assistant. Therefore, it can be safe to assume that

Michelle is experiencing OA due to the type of flour used at the bakery. Even though staying

away from the irritant is the best way to improve outcomes, we must initiate some tests to

properly diagnose her before taking individuals away from work. In the office, Michelle had a

pulmonary function test (PFT) performed. Airflow obstructions occurs when FEV1/FVC is less

than 70%. Therefore, the result of FEV1/FVC 60% before the bronchodilator is indicative of

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airflow obstruction. After the bronchodilator was given, there was an increase of 15% in

FEV1/FVC. This is considered an appropriate bronchodilator response. The existence of airflow

obstruction coupled with a positive bronchodilator response is suggestive of asthma diagnosis

(Pralong & Cartier, 2017). Currently, Michelle experiences symptoms of shortness of breath and

wheezing five days a week within a few hours of working in the bakery. She denies

exacerbations at night, and is able to sleep through the night with no issues. Based on

Michelle’s frequency of symptoms and PFT results, she is considered a mild persistent


First-line Treatment Plan:

The treatment for occupational asthma is the same treatment for asthma. For mild persistent

asthma, inhaled corticosteroids (ICSs) are the preferred first line medication treatment (GINA,

2019). I would prescribe fluticasone propionate 88 mcg inhaled BID. Low dose ICS target the

small airways and reduce inflammation by decreasing activity of inflammatory cells and

mediators (Hollier, 2018). The reduction of inflammation will help decrease mucosal edema and

mucus production that cause rhinorrhea, cough, wheeze, and shortness of breath (Hollier,

2018). At the same time, a short-acting bronchodilator, such as albuterol, should be prescribed

to treat exacerbations. I would prescribe albuterol 2 puffs every 4-6 hours as needed for

shortness of breath. Short-acting bronchodilators are considered rescue inhalers, which help

dilate the bronchi in the lungs and increase airflow (GINA, 2019). Widening the airways will help

relieve breathing difficulties. Lastly, I would prescribe a leukotriene blocker, such as Singulair 10

mg daily, to prevent asthma symptoms and manage seasonal allergies. I would educate

Michelle to discontinue her current use of Zyrtec. Leukotriene antagonists block the release of

mast cells responsible for airway edema and inflammation (Hollier, 2018). This class of

medication will help reduce wheezing and runny nose from the inflammation.

While staying away from the irritant will drastically improve asthmatic symptoms, it may be

difficult for Michelle to quit this current job since she is temporarily working at the bakery for

financial reasons. Therefore, I would refer her to an allergist to have a skin prick testing done.

According to the American College of Occupational and Environmental Medicine (Jolly et al.,

2015), a skin prick testing is strongly recommended for diagnostic testing for occupational

asthma. Cereal flour, particularly wheat flour, is considered one of the most common types of

occupational asthma (Jolly et al., 2015). While there is a high probability that the flour used in

the bakery is the allergen, a skin prick test can help identify other allergens that may play a role

in Michelle’s occupational asthma. This includes rye, barley, rice, and oats. House dust mites,

storage mites, and fungus should also be checked (Jolly et al., 2015).

It is important to educate Michelle on ways to manage occupational asthma. Avoiding triggers is

the best way to treat OA. In this case, staying away from the type of flour used in baking breads

and pastries will help alleviate asthmatic symptoms. If this is not possible due to financial

reasons, taking medications to prevent symptoms and treating acute asthma episodes are

important educational topics. The goal of asthma self-management is to control and prevent

asthma attacks (Pralong & Cartier, 2017). Therefore, I would educate Michelle on a

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