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Comprehensive Assessment and Management for Breathless Shop Owner

This case study explores the annual asthma review of a 62-year-old shop owner with worsening breathlessness. The patient presents with early morning cough and difficulty keeping up with physical activities. The history of a previous acute attack and family history of lung problems raises concerns. The next steps include spirometry reversibility testing, considering asthma-COPD overlap, adding LABA/LAMA medication, smoking cessation support, and further investigations like CXR, FBC, and ECG. Education and the development of a personalized self-management plan are also essential.

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Comprehensive Assessment and Management for Breathless Shop Owner

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Presentation Transcript

  1. Session 4 Case Study Trevor

  2. Trevor 62 year old shop owner attends for annual asthma review

  3. Trevor: Presenting Complaint • Attends for annual asthma review; appears breathless • States breathlessness worse early morning, associated with early morning cough • What questions are you going to ask?

  4. Trevor: History of Presenting Complaint • Using SABA x 4 daily • On questioning symptomatic early morning, when climbing stairs or hills. Finds keeping up with peers on golf course difficult, now using buggy • No nocturnal symptoms • Acute attack last winter requiring oral steroids and antibiotics

  5. Trevor: Past Medical History • Asthma diagnosed age 24 years with variable PEF 25% • History eczema • Hypertension Family History: • Mother died age 76 years “lung problems” • Father died MI. Both life long smokers

  6. Trevor Medication: • Low dose ICS; Clenil 200mcg bd • SABA 100mcgs 2p PRN Social History • Smoker 40 cpd 50 years • Rarely exercises • Alcohol 30 units per week • Married What next?

  7. Trevor: Test Results • Current PEF 480 l/min • Best ever 510 l/min last year • Predicted 540 l/min • Pulse 72 regular • RR 20 • ACT 14 • BP 148/96 • BMI 32

  8. Trevor: Findings • SOBOE slowly increasing • No haemoptysis • PEF below best ever and predicted • Modified lifestyle • Adherence ICS good

  9. Trevor: plan • Spirometry reversibility • Re-consider diagnosis – Asthma-COPD overlap • Consider adding LABA/LAMA • Smoking cessation • CXR, FBC, consider other bloods and ECG • Education • PAAP/COPD self management plan: PEF or symptoms?

  10. Thank You

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