Michael, a 10-year-old African American male, presented to the emergency department experiencing an asthma exacerbation with trouble breathing, wheezing, fever, anxiety and respiratory distress. His oxygen saturation was low at 89%. He has a history of asthma triggered by weather changes and uses his albuterol inhaler frequently. He also experiences seasonal allergic rhinitis. His evaluation showed high blood pressure and occasional wheezing on examination. He was diagnosed with an asthma exacerbation and seasonal allergic rhinitis.

1. ASTHMA
Case Study
group V
CASE STUDY PRESENTATION

2. This case presents a patient with hardly controlled asthma
that remains refractory to treatment despite use of
standard-of-care therapeutic options. For patients such as
this, one needs to embark on an extensive work-up to
confirm the diagnosis, assess for comorbidities, and finally,
to consider different therapeutic options. The discussion also
tackle how asthma occurs on children.

3. CASE STUDY ASTHMA
PATIENT NAME: MICHAEL TARNEY
ADDRESS: 1636 AIRFLOW LANE
AGE: 10 YEARS OLD
SEX: MALE
HEIGHT: 4'8
WEIGHT: 40Kg
RACE: AFRICAN AMERICAN
ALLERGIES: NO UNKNOWN DRUG ALLERGIES
DESCRIPTION:

4. Michael is a 10 y-o African American male who was seen in the
ED yesterday evening, 12/5, during an asthma exacerbation,
Micahel had an uneventful day at school and was working in
homework when he began to experience trouble breathing. On
the arrival at the ED, Michael was only able to answer question
with single words and had an oxygen saturation of 89%
CHIEF COMPLAINT

5. 01
The patient is a 10 y-o
child, 40 kg in weight,
142.24 cm (4'8) in height.
Therefore, he is having a
BMI of about
19.8kg/m2(87% at risk of
overweight).
02
He experienced asthma
attack(asthma
exacerbation) at night
causing to run him in ED. It
is known that asthma gets
worse at night.
03
The patient had a O2
saturation of 89% during the
emergency, can barely talk
and breathe. Since it was
nighttime, oxygen levels in
blood are lower during
sleep due to a mildly
reduced level of breathing.
Below 88% is a cause of
concern.
In this section, we aim to answer the questions that significantly contribute to our
clinical case such as, what is known about the patient? Why did the patient seek
medical health? Mainly the pathophysiology of the patient.

6. HISTORY OF PRESENT ILLNESS
Michael self-treated his breathing difficulty with an albuterol inhaler
that carries in his pocket wherever he goes. His mother reports that he
is using his inhaler at least three to four times every week for the past
few months. She states she had to obtain refills every 2 weeks. This is
Michael’s second reported ED visit this past month due to difficulty
breathing, Michael’s last visit symptoms included watery eyes and
stuffy nose. These symptoms are not present at this visit, however, his
mother became concerned when he was disinterested in dinner and
experienced trouble speaking.

7. The patient’s mother states that his son always carries Albuterol inhaler in his
pocket and he is puffing 3 to 4 times every week. But according to her, she is refilling
his son’s inhaler every two weeks, means he consumes a lot, it is possible that the
patient is puffing 4-8 times a day.
In his last visit, it was observed that he has symptoms of watery eyes and stuffy
nose, possible occurrence of allergic rhinitis. However, it is not observed in his
current visit.
The patient was also disinterested during dinner and experienced trouble
speaking. Possible that the patient appears anxious and had moderate
respiratory distress.
1.
2.
3.
This section show the previous situation/s of the patients before his current visit on
the Emergency Department. This may help more on the observation of the
pathophysiology of the patient’s disease.

8. PAST MEDICAL HISTORY
Michael had four visits since he was 5 for upper respiratory
illness associated with wheezing. All of the visits have
occurred in the early fall. With each of these episodes
except the latest one he was sent home on an antibiotic
and albuterol inhaler. His mother states his episodes of
breathing problems are becoming frequent. His
vaccinations are up to date. The rest of his past medical
history is negative except for three episodes of otitis media
between ages 1 and 3 years.

9. 1
It was stated
that all his visits
have occurred in
the early fall.
Thus, the weather
had triggered his
disease causing
him in that
situation.
Michael
developed his
asthma when
he was 5.
Albuterol was
given.
2 3
Otitis media was
observed in his age
of 1-3 years, a
reason for the
patient on taking
antibiotics during
the previous time.
This maybe
irrelevant in his
current situation for
his HEENT seems
normal.
In this section, we sought the possible etiology of the main
disease, and other disease/s.

10. Tobacco: Denies
SOCIAL HISTORY
Illicit drug use: Denies
Alcohol: Denies
Caffeine use: 1
Coke per day

11. 1. Caffeine can increase heart rate that may lead to respiratory
distress.
2. Coke contains caffeine causes asthma exacerbation in patient
with asthma. Also, long term exposure to caffeine can lead to
hypertension, aortic stiffness, and atherosclerosis.
The explanation on how the patient’s consumes caffeine and cocaine
affects more on the negative side of the disease. Etiology of the
disease may also observe.

12. FAMILY HISTORY
Father has multiple allergies and high
blood pressure. Mother denies any health
problems. Three siblings all healthy by
report.

13. 01
It is possible to develop
asthma at any age,
children with asthmatic
parents are at an
increased risk of getting
it when they’re younger.
Asthma can be inherited
but not in a larger
probability. Environment
of the children may be
the main cause of his
disease.
02
03
Allergies can
be inherited.
High blood
pressure
cannot be
inherited.
This part sought to investigate whether the patient inherited his disease.

14. REVIEW OF SYSTEM
Occasional wheezes noted on auscultation.
Wheezing is a symptom of asthma. (Checked
during physical examination).
1.
INSIGHTS AND RESEARCH:

15. PHYSICAL EXAMINATION
GEN: Michael stage appropriate for age; appears anxious;
moderate respiratory distress
VS: On ED administration: BP 120/75mmHg, HR 150 bpm, RR 23
rpm, T 38 oC, Wt 40kg
HEENT: PERRLA, oral cavity without lesions. Bilateral TM
unremarkable.
CHEST: Occasional expiratory wheezes bilaterally.

16. 1. The patient experienced anxiety caused by his asthma, or in other way,
he had asthma attack which caused him to panic.
2. The patient has high blood pressure (120/75 mmHg). As normal ranges
for 10 y-o children must 95-110 systolic, 60-70 diastolic. . A short-term high
blood pressure is possible in this case because his anxiety was present
during his time in ED.
3. The patient currently experiencing fever due to his signs, evident in his
temperature for about 38.5 degrees.
In this section, the following may show the positive or normal findings of signs
and symptoms of the patient.

17. 4. HEENT are normal.
5. The most common cause of recurrent wheezing are
asthma and COPD, which both cause narrowing and
spasms in the small airways of his lungs.
6. His neuro is normal which refers to a person’s level of
awareness of self, place time and situation. Meaning that
the patient is conscious during his visit to the ED.

18. LAB AND DIAGNOSTIC TEST
Hemoglobin 15 g/dL – NORMAL (The healthy range for hemoglobin for men is 13.2 to 16.6 grams
per deciliter)
1.
2. Hematocrit 45% - NORMAL (Normal hematocrit level vary based on age and race. Normal
levels for men ranges from 41% - 50%)
3. Platelets 260,000/mm2 – NORMAL (The mean normal platelet count is between 250, 000 and
20,000 cells/mm3)
4. WBC 8000/mm3 - NORMAL (A normal white blood cell count is between 4,500 and 11, 000 cells
per cubic millimeter)
5. DIFF 60% PMN – NORMAL (Normal neutrophils results: 40% to 60%)
6. Lymphocytes 28% - NORMAL (Normal Lymphocytes: 20% to 40%)
The following were the result of the patient’s clinical examination prior to his
laboratory result/ diagnostic result. The results were explained below.

19. 7.Monocytes 3% - NORMAL (Normal Monocytes: 2% to 8%)
8.pH 7.4 – NORMAL (Human blood has a normal pH range of 7.35 to 7.45)
9.PaO260 – LOW (Partial pressure for oxygen must range to 75 to 100 mmHg), if the
PaO2 level is lower it means that the person is not getting enough oxygen.
10.PaCO245 – HIGH (Partial pressure for carbon dioxide must range to 38 to 42 mmHg).
An elevated PaCO2 reflects alveolar hyperventilation meaning there is an absolute
decrease in ventilation.
11.Cardiac monitor: Sinus tachycardia – the patient’s heart beats faster than normal.
Sinus tachycardia is an ADR of albuterol.
12.CXR – within normal limit.

20. DIAGNOSIS
Asthma
exacerbation
1.
2. Seasonal
allergic rhinitis
PRIMARY: OTHERS:
Sinus tachycardia
1.
2. Temporary fever
3. High blood pressure
The following are the diagnostic both given and suggested.

21. The table below shows the past medication of Michael and next the table
are explanation on the reason of taking those medication.

22. ALBUTEROL
·Relevance to the patient: Michael had been suffering from asthma. Albuterol is
used to treat or prevent bronchospasm in patient with asthma.
·Dispensed from
September 2 by Dr. Diller and Mark. Another prescription containing albuterol
from different physician on October 4. continuously taking on October 30 given
by another physician named Mark.
·Direction are always the same as; inhale 2 puffs of albuterol inhaler every 6
hours as needed.
·The patient refill at least 12 times.
·ADR: Excessive intake of patient with Albuterol caused Sinus Tachycardia.
The following shows the different drugs taken by the patient on his
past visits. The information and reason of him taking these medicines
are indicated.

23. BIAXIN
·Relevance to the patient: As the patient’s asthma getting worse,
Clarithromycin (Biaxin) helps to suppress bronchial
hyperresponsiveness associated with eosinophilic inflammation in
patient with asthma.
·Dispensed from October 4 by physician Shaw with a quantity of 100mL.
Never refilled nor continue.
·Direction to the patient: Take one teaspoon twice a day.

24. CEFTIN
·Relevance to the patient: Cefuroxime was effective for
our patient since it is used to treat infection on the
lungs.
·Dispensed from September 2 by physician Diller. The
drug has a quantity of 100 mL
·Direction to the patient: take one teaspoon twice a day.

25. CEDAX
·Relevance to the patient: This drug is a cephalosporin antibiotic
that treats bacterial infections of the lungs and ears of the patient
since it was stated that he suffered from otitis media.
·Dispensed from September 2 by his physician Mark. The drug
dispensed contain a quantity of 120mL.
·Direction to the patient: take two teaspoon everyday.

26. NON PHARMACEUTICAL RECOMMENDATION/
RECOMMENDATION ON THE PATIENT'S LIFESTYLE
The following are the on non pharmaceutical recommendation prior to the
patient aged 10 year-old suffering from asthma and other allergies.
.
-Don't skip doctor's appointments.
-Take medications as prescribed and refill prescriptions before they run out.
-Prioritize good sleep and relaxation. Not just for managing asthma or allergies, but for overall
health as well, getting enough sleep is essential. Regular sleep deprivation makes it difficult for a
person to control their immune system, which is crucial for maintaining lung health.
-Try to keep your weight in a healthy range.
-Patients should balance calorie intake with physical activity to maintain a normal body mass index
and waist circumference.
-Although living a healthy lifestyle that includes exercise is great for your lungs, it can also cause
some types of asthma.

27. -Be sure to control your asthma before working out.
-Before exercising, warm up for at least 10 minutes. Walking or other low-
intensity exercises can be used for this.
- Avoid intake of caffeine and stop consuming excessive amount of coke.
-When working out, keep triggers at bay. You should keep an eye out for and be
monitored for any dust, pollen, animal fur, or other triggers that cause you
breathing issues.
-You can manage your asthma by drinking water, which is beneficial in a variety
of other ways as well. Staying hydrated keeps your mucus thinner, improving
digestion and breathing.
-Avoid foods that are high in sugar or fried fats as well as foods that you are
aware cause allergies. Both intensify the production and thickening of mucus.
-Make plant-based foods your primary source of food.

28. -Keep an inhaler Naturally, you should keep your inhaler close by at all
times in case of emergencies. Maintain one wherever you will always have
easy access to it, such as in your purse, vehicle, gym bag, emergency kit,
etc.

29. PHARMACEUTICAL RECOMMENDATIONs BASED ON THE
DIAGNOSTIC OF THE PATIENT
The following are the on pharmaceutical recommendation prior to the patient aged
10 year-old suffering from asthma and some based on his diagnosis.
.
ALBUTEROL
The usual 2 puffs every six hours as needed may change into "one puff every six
hours as needed.". It was noticed that sinus tachycardia was developed due to the
excessive intake of patient with Albuterol, therefore, to lessen some side effects of
albuterol, the patient may change the method in which he take the drug or to lessen
the amount he takes.
We noticed that is hard for the patient to tolerate the side effects of albuterol, we
may reduce the recommended dose. Using one puff of albuterol rather than two
puffs will provide good relief of symptoms with fewer side effects.

30. CEFTIN
· Cefuroxime was effective for our patient since it is used to treat
infection on the lungs. We would also like the patient to continue this
medication since he is suffering from temporary fever. Dispense a quantity
of 100mL. Same direction as: take one teaspoon twice a day.
.
CAPTOPRIL
· Our patient was said to have a high blood pressure. For persistent
hypertension in children should generally begin with an ACE inhibitor. For
pediatric use, Captopril is used to treat high blood pressure. But in the case of
Michael, he suffered from anxiety which possibly cause a shorth-term high blood
pressure. Therefore, we would like to check his BP for the second time, if the
sign did not change then we can dispense him with this medication.

31. CETIRIZINE
· This medication is safe to treat allergic rhinitis in children; indicated
for seasonal allergies. Our patient may take 10 mg daily.
.

32. SUMMARY
Michael is a 10 y-o African American male who was seen in the ED, during an
asthma exacerbation, the symptoms observed are as follows: trouble breathing,
occasional wheezing, fever, anxiety and respiratory distress. On the arrival at the
ED, Michael was only able to answer questions with single words and had an
oxygen saturation of 89%. He is having a BMI of about 19.8 kg/m2 (87% at risk of
overweight). The patient's mother states that his son always carries Albuterol
inhaler in his pocket and he is puffing 3 to 4 times every week. In his last visit, it was
observed that he has symptoms of watery eyes and stuffy nose, possible
occurrence of allergic rhinitis.
Otitis media was observed in his age of 1-3 years, a reason for the patient on
taking antibiotics during the previous time. This maybe irrelevant in the current
situation for his HEENT seems normal.

33. The weather had triggered his disease causing him in
that situation, by that Albuterol was given. The patient did
not deny his consume on caffeine and everyday
consuming of coke which leads to some complications.
Father has multiple allergies and high blood pressure
that may inherited to Michael. Most common cause of
recurrent wheezing are asthma and COPD, which both
cause narrowing and spasms in the small airways of his
lungs. The patient has high blood pressure (120/75 mmHg).
His neuro is normal which means that he is conscious
during his visit to the ED.

34. All lab and diagnostic test at normal except for
PaO260 which is LOW it means that the person is not
getting enough oxygen and PaCO245 which is HIGH. An
elevated PaCO2 reflects alveolar hyperventilation
meaning there is an absolute decrease in ventilation. The
patient also develop sinus tachycardia which is the ADR
of albuterol. Primary diagnosis are Asthma exacerbation
and Seasonal allergic rhinitis. It was also evident that the
patient have sinus tachycardia , Temporary fever, High
blood pressure. The non pharmaceutical and
pharmaceutical recommendation for our patient to have
a faster rocovery is indicated through the previous slides.