SAQ1

Question 1

WHAT IS THE MOST LIKELY DIAGNOSIS AND WHY (5 MARKS)

Roman, 28-year-old man w/SOB
Roman reports that over the last year, he notices that he has episodic shortness of breath, especially during activity. The shortness of breath resolves eventually when he sits down, and takes deep breaths.
He also had an episode of feeling short of breath when it was very cold outside. He notices it is worse at night and very early in the morning. In the last month, he has woken up once with symptoms.
During the episodes of shortness of breath, he admits to wheezing and has some palpitations and chest tightness.
He denies coughing, fevers, anxiety.
His family history is negative for respiratory conditions including asthma, lung cancer and no history of eczema or hay fever.
Roman denies a personal history of hay fever. He does report chronic dry skin since childhood, but has never been diagnosed with eczema. Otherwise, he is healthy and had all childhood immunizations. He takes no medications and has no allergies.
Roman smokes 3-4 cigarettes a weekend, just socially. He works as an auditor. He walks to work and plays football several times a week for exercise.
Physical Exam
On examination, HR is 92, BP is 120/65, RR 16, O2 sat 99% on Room air, T 37.2.

General obs/CVS/Resp/ENT all normal (NAD)

Answer 1

Most likely - Asthma

Why?

1) increasing SOB with activity that resolves upon resting and deep breaths
2) SOB worsened by cold weather
3) Diurnal variation (symptoms present early morning and night)
4) SOB associated with wheezing and chest tightness
5) Suffers from eczema (one of the conditions from the atopic triad)

Question 2

Outline a suitable drug treatment plan (that includes 2 medications) for Roman and explain to Roman how to take the medications. (5 marks)

Answer 2

SABA (salbutamol)
Reliever inhaler
Symptomatic treatment - shake before using, take 1/2 puffs as and when required when symptoms come on (e.g.- SOB, wheezing)

ICS (beclamethasone) - low dose
Preventer inhaler
Prevention treatment - shake before use and take 2 puffs twice a day (morning and evening)
Rinse mouth after use

Can use a spacer - benefits of spacer:

• reduces adverse effects (w/ICS - oral candidiasis)
• more medication targeted directly to the lungs where it is needed, rather than absorbed in the mouth/throat
• less coordination required - may be easier to use

Question 3

Describe the mechanism of action for the medications you have chosen in your treatment plan (5 points)

Answer 3

SABA MOA

• B2 receptors are found in the smooth muscle of the bronchi
• SABA activates these B2 receptors leading to the relaxation of the smooth muscle in the bronchi
• This improves airflow in the constricted airways
• This in turn reduces the asthma symptoms (e.g.- SOB, chest tightness)

ICS MOA

• corticosteroids activate specific receptors which in turn alters the transcription of genes - pro-inflammatory proteins are downregulated whilst anti-inflammatory proteins are upregulated
• this reduces mucosal inflammation, widens the airways and reduces mucous secretion
• this improves asthma symptoms and reduces the asthma exacerbations

Question 4

Explain the side effects of the medications you have chosen in your treatment plan (5 points).

Answer 4

SABA

• Tachycardia
• Palpitations
• Anxiety +/- tremor
• Muscle cramps

ICS

• oral candidiasis
• hoarse voice

Question 5

Roman returns to the clinic 1 month later with his asthma journal. He is using all of his medications you suggested as prescribed. In the last 2 weeks, he has woken up 5 times with shortness of breath and needed to use an inhaler. You think he needs escalation of treatment.

What is the next step in treatment escalation?

Answer 5

continue use of SABA as and when required for symptomatic treatment of asthma

continue use of low dose ICS (2x - morning + evening)

add LTRA (nice)
add LABA (BTS)

Question 6

-

Answer 6

-

Question 7

What are the 2 most common adverse effects associated with LTRAs?

Answer 7

headache

abdominal pain