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Session 4

Session 4. Case Study Shompa. Shompa. 26 year old teacher attends for annual asthma review. Shompa: Presenting Complaint. Attends for annual asthma review; nocturnal symptoms during last month following cold virus States symptomatic when hill climbing What questions are you going to ask?.

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Session 4

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  1. Session 4 Case Study Shompa

  2. Shompa 26 year old teacher attends for annual asthma review

  3. Shompa: Presenting Complaint • Attends for annual asthma review; nocturnal symptoms during last month following cold virus • States symptomatic when hill climbing • What questions are you going to ask?

  4. Shompa: History of Presenting Complaint • Using SABA daily • On questioning symptomatic when hill climbing • Nocturnal symptoms • No acute attacks in last 2 years requiring oral steroids

  5. Shompa: Past Medical History • Asthma diagnosed age 6 years with after trial treatment • History eczema and hay fever, allergy to milk pre-school now resolved Family History: • Mother diagnosed with rheumatoid arthritis: DMARD • Father CHD and type 2 diabetes

  6. Shompa Medication: • Very low dose ICS; Clenil 100mcg bd • SABA 100mcgs 2p PRN Social History • Never smoked • Regular exercises • Alcohol 10 units per week • Lives alone What next?

  7. Shompa : Test Results • Current PEF 380 l/min • Best ever 490 l/min 4 years ago • Predicted 460 l/min • Pulse 64 regular • RR 18 • BP 118/68 • BMI 21 • ACT 16

  8. Shompa: Findings • Concerned re: symptoms especially nocturnal • PEF below best ever and predicted • ACT demonstrates poor control • Enjoys exercise and feels not as active as would like due to asthma symptoms • Adherence ICS good

  9. Shompa: plan • Increase ICS low dose – examples? • Education • PAAP: PEF or symptoms?

  10. Thank You

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