# Clinical Cases: Respiratory Conditions in Primary Care ## Case 1: Adult-Onset Asthma ### Patient Demographics - **Age:** 34 years old - **Sex:** Female - **Occupation:** Elementary school teacher ### Chief Complaint "I've had this cough for 2 months that won't go away, and sometimes I feel like I can't catch my breath." ### History of Present Illness Ms. Jennifer Rodriguez is a 34-year-old woman presenting with a persistent dry cough for 2 months. The cough is worse at night and early morning, and she wakes up coughing 2-3 times per week. She also reports episodes of chest tightness and shortness of breath, particularly when exercising or going out in cold air. She has noticed occasional wheezing. Symptoms began after a viral upper respiratory infection 2 months ago. She tried over-the-counter cough suppressants without relief. No fever, hemoptysis, or weight loss. No heartburn or post-nasal drip symptoms. She had childhood asthma that "resolved" by age 12 and hasn't needed an inhaler since then. ### Past Medical History - Childhood asthma (ages 5-12) - Allergic rhinitis - Eczema as a child ### Family History - Mother: Asthma - Father: Allergic rhinitis - Sister: Eczema ### Social History - Never smoker - No pets at home currently - Lives in an older apartment building - Works in an elementary school (dust, viral exposures) ### Physical Examination - **Vital Signs:** BP 118/74 mmHg, HR 76, RR 16, SpO2 98% on room air, BMI 24 - **General:** Well-appearing, speaks in full sentences - **HEENT:** Nasal mucosa pale, boggy; clear rhinorrhea; no sinus tenderness - **Neck:** No lymphadenopathy - **Lungs:** Faint end-expiratory wheezes bilaterally, no crackles, good air movement - **Cardiovascular:** Regular rate and rhythm ### Clinical Image ![Metered-dose inhaler](case_01_image.jpg) *Image: A metered-dose inhaler (MDI), the most common delivery device for asthma medications. Proper inhaler technique is essential for effective drug delivery to the airways.* **Image Source:** Wikimedia Commons **Attribution:** Newbie, Public Domain **URL:** https://commons.wikimedia.org/wiki/File:Inhaler.jpg ### Outpatient Workup - Spirometry: FEV1 78% predicted, FEV1/FVC 0.68 (reduced) - Post-bronchodilator spirometry: FEV1 improved to 92% predicted (18% improvement) - Peak flow: 380 L/min (predicted 450 L/min) - Chest X-ray: Normal - Allergy testing: Positive for dust mites, mold, grass pollen ### Assessment and Diagnosis 1. **Asthma, newly diagnosed (recurrence of childhood asthma)** - Compatible history, physical exam with wheezing, spirometry showing reversible obstruction 2. **Allergic rhinitis** - Contributing to asthma symptoms 3. **Classification: Mild persistent asthma** - Symptoms >2 days/week, nighttime awakenings 3-4x/month, FEV1 >80% predicted ### Management Plan **Asthma Controller Therapy:** - Start low-dose inhaled corticosteroid (ICS): Fluticasone 88 mcg 2 puffs twice daily - Provide rescue inhaler: Albuterol MDI 2 puffs every 4-6 hours as needed - Spacer device with MDI for improved delivery - Demonstrate and observe inhaler technique **Allergic Rhinitis:** - Intranasal corticosteroid: Fluticasone nasal spray 1-2 sprays each nostril daily - Consider adding antihistamine if inadequate response **Asthma Action Plan:** - Green zone: Symptoms controlled, continue controller medication - Yellow zone: Increased symptoms, use rescue inhaler, increase controller if needed - Red zone: Severe symptoms, use rescue inhaler, seek emergency care - Provide written action plan **Trigger Avoidance:** - Dust mite precautions: Allergen-proof bedding covers, wash bedding in hot water weekly - Address mold exposure in apartment if present - Avoid cold air triggers: Scarf over mouth/nose in cold weather - Flu vaccination annually **Monitoring:** - Provide peak flow meter for home monitoring - Assess symptom control with ACT (Asthma Control Test) score ### Follow-Up - Return in 4-6 weeks to assess response - Repeat spirometry in 3 months - Step down therapy if well-controlled for 3 months - Step up if not controlled (add LABA or increase ICS) ### Teaching Points 1. **Asthma diagnosis:** Episodic symptoms of wheeze, cough, chest tightness, and dyspnea with documented variable airflow limitation (spirometry showing >12% improvement with bronchodilator or positive methacholine challenge). 2. **Adult-onset asthma:** Can occur at any age. Prior childhood asthma is a risk factor for recurrence. Other risk factors include allergies, occupational exposures, and viral infections triggering airway hyperresponsiveness. 3. **Asthma classification (GINA):** - Intermittent: Symptoms <2 days/week, no interference with activity - Mild persistent: Symptoms >2 days/week, some limitation - Moderate persistent: Daily symptoms, some limitation - Severe persistent: Symptoms throughout day, extremely limited 4. **Step therapy:** Start ICS for persistent asthma. Step up if not controlled (add LABA, increase ICS dose). Step down if well-controlled for 3+ months. --- ## Case 2: COPD Exacerbation in Primary Care ### Patient Demographics - **Age:** 67 years old - **Sex:** Male - **Occupation:** Retired construction worker ### Chief Complaint "My breathing has gotten worse over the past 4 days, and I'm coughing up more mucus than usual." ### History of Present Illness Mr. William Foster is a 67-year-old man with known COPD who presents with worsening dyspnea, increased cough, and change in sputum production over 4 days. His sputum has changed from white to yellow-green and increased in volume. He has been using his rescue inhaler every 2-3 hours instead of his usual 1-2 times daily. He slept sitting up last night due to breathlessness. He denies fever, but his wife notes he "feels warm." No chest pain, leg swelling, or hemoptysis. He has not had a COPD exacerbation requiring steroids or antibiotics in 8 months. He continues to smoke, though he has cut down to 5 cigarettes daily. ### Past Medical History - COPD, moderate (GOLD stage 2), diagnosed 5 years ago - Former smoker: 45 pack-years, currently smoking 5 cigarettes/day - Coronary artery disease, prior stent 3 years ago - Hypertension - Osteoporosis ### Current Medications - Tiotropium 18 mcg inhaled daily - Fluticasone/salmeterol 250/50 mcg 1 puff twice daily - Albuterol MDI PRN - Aspirin 81 mg daily - Atorvastatin 40 mg daily - Lisinopril 10 mg daily - Alendronate 70 mg weekly ### Family History - Father: COPD, lung cancer - Mother: Heart disease ### Social History - Current smoker (reduced from 1 pack/day to 5 cigarettes/day) - No alcohol - Widowed, lives with daughter - Uses home oxygen at night (2L NC) for nocturnal hypoxemia ### Physical Examination - **Vital Signs:** BP 142/88 mmHg, HR 98, RR 24, Temp 99.6F, SpO2 89% on room air (baseline 92-94%) - **General:** Appears uncomfortable, using accessory muscles, speaking in short phrases - **HEENT:** Normal - **Neck:** Elevated JVP to 8 cm - **Lungs:** Diffuse expiratory wheezes, decreased breath sounds at bases, prolonged expiratory phase, no crackles - **Cardiovascular:** Tachycardic, regular rhythm, no murmurs - **Extremities:** No edema, warm ### Assessment and Diagnosis 1. **COPD exacerbation, moderate severity** - Increased dyspnea, sputum volume, and sputum purulence (Anthonisen Type 1 - all 3 cardinal symptoms) 2. **Likely bacterial trigger** - Purulent sputum, low-grade fever 3. **COPD, GOLD stage 2** - Moderate, Group E (exacerbation history) 4. **Active tobacco use** - Ongoing harm ### Management Plan **Acute Exacerbation Treatment:** *Bronchodilators:* - Increase albuterol: Nebulizer 2.5 mg every 4 hours or MDI with spacer 4-8 puffs every 4 hours - Continue tiotropium *Systemic Corticosteroids:* - Prednisone 40 mg daily for 5 days - Short course adequate for most exacerbations *Antibiotics:* - Indicated given purulent sputum and all 3 Anthonisen criteria - Azithromycin 500 mg day 1, then 250 mg days 2-5 (5-day Z-pack) - Alternative: Amoxicillin-clavulanate or doxycycline *Oxygen:* - Maintain SpO2 88-92% - Increase home oxygen if needed during exacerbation **Decision: Outpatient vs. Inpatient:** - Patient has moderate exacerbation but is stable - No severe respiratory distress, confusion, or hemodynamic instability - Has support at home (daughter) - Can manage outpatient with close follow-up - Discuss warning signs requiring ED visit **Smoking Cessation:** - Reinforce importance, even during exacerbation - Offer varenicline when acute illness resolves - Provide quitline referral: 1-800-QUIT-NOW **Preventive Measures:** - Ensure influenza and pneumococcal vaccinations up to date - Discuss pulmonary rehabilitation when stable ### Follow-Up - Phone check in 24-48 hours to assess response - Return visit in 5-7 days or sooner if worsening - Indications to go to ED: Worsening dyspnea, confusion, unable to speak, SpO2 <88% on supplemental O2 ### Teaching Points 1. **COPD exacerbation definition:** Acute worsening of respiratory symptoms beyond normal day-to-day variation requiring change in therapy. Anthonisen criteria: increased dyspnea, increased sputum volume, sputum purulence. 2. **Treatment of exacerbations:** - Bronchodilators: Increase SABA frequency - Systemic corticosteroids: Prednisone 40 mg x 5 days (shorter courses as effective as longer) - Antibiotics: Indicated if purulent sputum present or need for mechanical ventilation 3. **Disposition decision:** Consider hospitalization for severe dyspnea, failure to respond to initial treatment, serious comorbidities, inadequate home support, or altered mental status. 4. **GOLD classification:** - Based on FEV1 and symptoms/exacerbation history - Group A: Low symptoms, low exacerbation risk - Group B: High symptoms, low exacerbation risk - Group E: Any exacerbation leading to hospitalization or ≥2 moderate exacerbations/year 5. **Smoking cessation:** Most important intervention to slow COPD progression. Address at every visit, even during exacerbations.