Jazz Case study 7

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MEDICAL MYSTERY FOR CHAPTER 7

HER STORY
Caroline’s primary complaint was a cough that hadn’t let up since a bout of influenza 18 months earlier. She sometimes
woke up coughing, making it difficult for her to get a good night’s rest. Caroline works as a customer service rep, and
her supervisor has commented that she sometimes sounds breathless and wheezy on the phone. Because she had little
energy and felt short-winded, Caroline had given up her nightly walks and had subsequently gained weight. Also, her
eyes sometimes felt itchy and watery, and she was experiencing rhinorrhea. Recently, Caroline had experienced some
chest pain, and she wondered whether she had a heart problem.

Concerned about the chest pain, Caroline went to see a cardiologist. After performing an electrocardiogram (EKG)
and an echocardiogram, he had ruled out heart disease. Still, Caroline was worried about her coughing and her
breathing difficulties. Her grandmother—a lifelong smoker—had died of emphysema, and Caroline was haunted by
memories of her gasping for air.

Since Caroline wasn’t a smoker, the cardiologist thought that emphysema was unlikely but that some of her
symptoms might be the result of allergic rhinitis. He suggested that she see an allergist and referred her to my office.

THE EVALUATION
I thought Caroline might have allergies as well as adult-onset asthma. I performed a spirometer test and did scratch
tests to see whether Caroline was allergic to dust mite allergens, pollen, pet dander, grass, or other common allergens.

The scratch tests revealed that Caroline was in fact allergic to all these allergens, and the pulmonary function test
using a spirometer showed that she wasn’t able to achieve full exhalation, which often indicates asthma.

THE DIAGNOSIS
At that point, I was fairly certain that Caroline had asthma, though diagnosing asthma in adults is complicated
because the symptoms mimic chronic obstructive pulmonary diseases such as emphysema or chronic bronchitis. In
order to confirm the diagnosis, I needed to see how Caroline responded to asthma medications: An improvement in
her symptoms would enable me to make a definitive diagnosis.

THE TREATMENT
The fact that Caroline periodically had tightness in her chest and breathing trouble made it likely that she had been
suffering mild asthma attacks without realizing it. I wanted to help her feel better on a regular basis and avert a life-
threatening attack. As I explained to Caroline, asthma is characterized by constriction of the airways as well as
inflammation of the bronchial tubes.

To reduce the inflammation, I prescribed two drugs: an inhaler containing a drug called fluticasone (Flovent) and a
pill called montelukast (Singulair). I also prescribed albuterol (Proventil), a short-acting drug that, when inhaled,
opens the airways. I also suggested that Caroline lose some weight. Although being overweight does not cause
asthma, it can make symptoms worse by limiting lung capacity.

In addition, I recommended regular exercise. To do that, I suggested that Caroline use the albuterol 5–20 minutes
before exercising on days when she felt asthmatic. I also suggested that she stay with low-impact activities, such as
walking on an indoor track, away from allergens, or swimming. I advised her to use a HEPA (high-efficiency
particulate air filter) air purifier in her bedroom and to sleep with the windows closed.

CASE CLOSED
When Caroline came back to see me a month later, she was no longer wheezing, coughing, or experiencing
tightness in the chest, so I told her that the asthma diagnosis was on target. Although she was initially shocked at
this diagnosis (like many others, Caroline never knew that asthma can strike adults), she was pleased to be able to
resume her nightly walks, with help from the albuterol. When I saw Caroline again 3 months later, she had lost 5
pounds, and her asthma was under control.

Discussion Questions
1. What is emphysema?

2. What did the spirometer measure?

3. What is bronchorrhea?

4. Albuterol is a short-acting spray that expands the opening of the passages into the lungs. What is the medical
term for this type of medicine?