February 2015 Pulmonary Case of the Month: Severe Asthma

Suresh Uppalapu, MD
Sunil Santhanakrishnan, MD
Rajeev Saggar, MD

Banner Good Samaritan Medical Center

Phoenix, AZ

History of Present Illness

A 50-year-old  African-American woman  with a history of asthma presented to the emergency department with a chief complaint of shortness of breath for 2 weeks. She reported some chest tightness, wheezing  and dry cough. She denied fever, chills, myalgias or arthralgias  at the time of admission.

PMH, SH and FH

In addition to asthma, she has a past medical history of type 2 diabetes mellitus, hypertension, and multiple sclerosis. She admitted to social smoking but states she quit 6 to 7 months ago. She denies alcohol, recreational drug use, or a family history of early coronary artery disease, strokes or cancers. 

Medications

• Montelukast 10 mg daily
• Salmeterol/fluticasone 250/50 inhaled twice a day
• Albuterol inhaler as needed for shortness of breath
• Metformin 500 mg bid.
• Dimethyl fumarate 240 mg bid.
• Omega 3 fish oil.
• Calcium carbonate 600 mg daily
• Naproxen 500 mg BID
• Lisinopril 10 mg daily
• Hydrochlorothiazide 25 mg daily.

Physical Exam

Vitals: Temperature 37.2º C, respiratory rate 33 breaths/min, heart rate 112 beats/min, blood pressure 152/80 mm Hg, SpO2 80% on room air but 98% on 3 liters/min by nasal cannula.

General: Mild respiratory distress.

Lungs: Diminished breath sounds diffusely with mild wheezing.

The rest of her exam was within normal limits.

Laboratory/EKG/Chest Radiography

White blood cells 8.1 X 10³ cells/microliter, hemoglobin 13.9 g/dL, hematocrit 41.7, platelets 289,000 cells/microliter.

Electrolytes blood urea nitrogen, creatinine, glucose, troponin, and brain naturetic peptide were within normal limits

EKG showed sinus tachycardia but was otherwise normal.

Chest x-ray was interpreted as normal.

A thoracic CT scan showed wispy infiltrates but no evidence of pulmonary embolism or other abnormalities.

Which of the following is appropriate management at this time? (Click on the correct answer to proceed to the second of four panels)

1. Bronchodilators
2. Discharge the patient to home
3. Intravenous corticosteroids
4. 1 and 3
5. All of the above

Reference as: Uppalapu S, Santhanakrishnan S, Saggar R. February 2015 pulmonary case of the month: severe asthma. Southwest J Pulm Crit Care. 2015;10(2):57-62. doi: http://dx.doi.org/10.13175/swjpcc010-15 PDF