Case scenarios asthma.doc

Case Scenarios: Asthma
Case #1 Scot is a 14 year old male whose asthma worsens in the spring and fall. He uses Flovent most days and Ventolin as needed. His most pressing concern is shortness of breath and chest tightness, with more cough at night after games. He is a very good player whose girlfriend prospects are being sorely affected by this. He went to the emergency room once already this year because of his asthma. Discussion Points: Case Scenarios: Asthma
Case #2 Sheila’s name appears for the second time in two weeks in the appointment book. Her asthma has been causing trouble lately: she experiences almost daily symptoms, her sleep is disturbed because of asthma three times a week, and she is not able to attend her regular exercise classes. She’s been prescribed daily ICS for six months and uses Ventolin for breakthrough wheezing, chest tightness and breathlessness. Discussion Points: Case Scenarios: Asthma
Case #3 Marty and Sara have a four year old female with asthma and allergies, one of which causes an anaphylactic reaction to peanuts. The first time that their child was exposed to peanuts (that they know of), Sara had to rush her in to emergency because of a severe difficulty in breathing, swollen mouth, red itchy skin and flushed face. Marty arrived at the emergency department in time to help take their daughter home. Marty refuses to ensure there is an epipen available when he is providing child care because he does not believe that their daughter had an anaphylactic reaction; he feels that Sara overreacted. Discussion Points: Case Scenarios: Asthma
Case #4 Peter is in his first year at University. He was diagnosed with asthma as a child and has controlled it with use of daily ICS and as needed rescue medications. At a recent party where there was cigarette smoke in the environment, he became extremely short of breath and started coughing. After a couple of puffs of his rescue medication, he felt much better and was able to stay at the party an additional three hours. Later at home, he collapsed while taking a shower. His mother heard him fall, and he was rushed to the local hospital. Upon discharge, the hospital staff recommended he see an asthma educator. Discussion Points: Case Scenarios: Asthma
Case #5 Kae is a 13 year old female who was diagnosed with asthma at the age of two. She has been referred to the asthma educator because, since she turned 13, she has been experiencing an episodic increase in breathing difficulties. These episodes are short-term and semi-regular. Her current prescriptions include daily Pulmicort and as needed Bricanyl. Discussion Points: Case Scenarios: Asthma
Case #6 Vayda is a 3 year old female whose parents’ main concern is the terrible parents who let their sick kids of to Vayda’s daycare. Ever since she was 1 year of age when she started at the daycare, Vayda catches everything, and they all go to her chest. Between colds she is a pristine angel and a perfect image of her mother. Vayda’s colds last 2-3 weeks with nasal drip, cough and wheeze. She has been given several antibiotics for bronchitis. Discussion Points: Case Scenarios: Asthma
Case #7 Gary is a 28 year old attending respiratory clinic day at his doctor’s office. Review of his file indicates he is on the following medications: Advair 250 ug ii BID; Spiriva I OD; Combivent neb QID; Ventolin as needed. Today’s spirometry is within normal limits, and has not changed since he began coming to the clinic three years ago. Discussion Points: Case Scenarios: Asthma
Case #8 Ruth is a 28 year old female with asthma who is just recovering from a bad cough. Upon further questioning, she indicates that she develops this cough several times per year – sometimes with a cold, sometimes in the absence of a cold. The cough usually lasts 2 – 3 weeks, sometimes longer, and is dry, hacking and leaves her weak and hoarse. She complains of trouble catching her breath after a coughing spell, can be short of breath and has sore chest muscles afterward. Sometimes her nose becomes red and itchy. Discussion Points: Case Scenarios: Asthma
Case # 9A Mary is a 67 year old widow who shares her apartment with two cats. She has had asthma since childhood and is currently taking Symbicort daily with Bricanyl as needed. However she is experiencing a persistent daily cough and wakes up at night because of her cough. Discussion Points: Management options based on current level of severity and control - inhaler technique - stage of change re: environmental control - questions needed to assess PER - processes to be employed Case Scenarios: Asthma
Case # 9B Through questioning, Mary has reluctantly indicated that her asthma has gotten worse since she purchased the cats (as kittens) when her husband passed away 3 years ago. Numerous discussions with Mary re: environmental control with emphasis on finding a new home for the cats has resulted in Mary having allergy testing which was positive for cats and indoor molds. Mary has, again reluctantly, agreed to put an ad in the newspaper to find a new home for her pets. Discussion Points: - stage of change - questions needed to assess PER - processes to be employed Case Scenarios: Asthma
Case # 9C Again, after months of discussion, three ads in the newspaper, and numerous interviews with potential foster homes for her cats, Mary delivered her pets to their new owners. Mary spent many long days cleaning her apartment: having her carpets and upholstered furniture professionally cleaned, washing her walls; and otherwise attempting to remove traces of her cats from everywhere. She admits to noticing an improvement of her symptoms: she no longer wakes up at night because of her cough, and she realized she was able to clean more than she anticipated before stopping for a rest. Discussion Points: - stage of change - questions needed to assess PER - processes to be employed Case Scenarios: Asthma
Case # 9D A recent phone call from a very short of breath Mary has elicited the following information (between gasps for air) from Mary: she took time to visit her cats two weeks ago in their new home and felt very concerned about the care that they were receiving. After much soul-searching Mary decided to ask the owners if she could buy back her cats. Mary welcomed her cats back into her apartment one week ago, with a little celebration of their favorite treats. Discussion Points: - stage of change - questions needed to assess PER - processes to be employed - what to expect in ER Case Scenarios: Asthma
A 40-year-old woman comes to the family practice clinic for a routine annual visit. She reports a 6-month history of progressively severe episodic shortness of breath, cough, wheeze and chest tightness. You question her about associated symptoms, the timing and frequency of the symptoms, and triggering or exacerbating factors. You ask about environmental exposures in the home and workplace and any temporal associations of the symptoms with such exposures, including any change in severity of symptoms on weekends or holidays, as is your routine for patients with new-onset or worsening asthma. She reports that symptoms typically worsen in the evenings and that they cleared while she was at home over the Christmas holidays. You note from your records that at the time of her previous visit she was working at an electronics factory, and you question her more closely about possible exposures to chemicals at work, but she is unsure what compounds are used. The results of a physical examination are normal. Case Scenarios: Asthma
Short snappers (can be used as role play or discussion): 1. Fifteen year old female with a 10-year history of asthma, confidently enters the counseling room and sits down. Mother is present during the session and often adds to daughter’s narrative. 2. 65 year old with asthma has just been given a new prescription and says to you, “This doesn’t make any sense to me – can you explain it?” 3. 76 year old very intelligent female with asthma and a history of arthritis. You are reviewing MDI technique. 4. 62 year old male diagnosed with asthma as a child. He is currently using an MDI and does not understand why his doctor gave him a spacer to use with it.


Biomass accumulation and potential nutritiveP.H. Robinson , S.R. Grattan , G. Getachew , C.M. Grieve ,a Department of Animal Science, University of California, Davis, CA 95616, USA b Department of LAWR, University of California, Davis, CA 95616, USA c USDA-ARS Salinity Laboratory, 450 W. Big Springs Road, Riverside, CA 92507, USA d Department of Plant Science, California State Unive

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