Reference no: EM133221323
Sarah is a 66-year-old woman and a regular patient at your respiratory clinic for the past 4 years. She was diagnosed with COPD of moderate severity 3 years ago. She has had one severe exacerbation of her COPD in the last 6 months. She is an ex-smoker (10 cigarettes/day), she quit when she was diagnosed with COPD.
Her past medical history includes: Hypercholesterolaemia adequately controlled with atorvastatin 40 mg once daily, and osteopenia.
Sarah is a widow who lives with her daughter, son-in-law and granddaughter. She is a retired teacher but volunteers as a tutor at the local indigenous community service. Sarah is careful to take all her medicines daily and on time.
Her medications include:
- Indacaterol DPI 150 micrograms once daily
- Salbutamol pMDI 100 micrograms as needed
- Atorvastatin 40 mg once daily
She presents today for her annual influenza vaccination. When you enquire how she's been feeling, you learn that Sarah was discharged from hospital 2 weeks ago after a short stay to treat an infective exacerbation of her COPD. While Sarah is recovering well from the infection, she mentions she has been experiencing recurring headaches and a 'funny' heartbeat over the last week or so and wonders if these are side effects of her 'new puffer'. She denies overusing her salbutamol pMDI, saying she's only taken 'a few puffs' since discharge from hospital.
She was discharged from hospital with the following medication:
- Amoxicillin 500 mg three times daily for 5 days
- Prednisone 30 mg a day for 5 days
- Salbutamol 100 micrograms up to 10 actuations by inhalation via pMDI with spacer, as needed
- Budesonide/formoterol DPI (Symbicort Turbuhaler) 400/12 micrograms twice daily
Question One
You complete a quick assessment which includes: Heart rate 86 bpm and regular, on auscultation of breath sounds you hear odd scattered wheeze, no focal signs, Blood Pressure 134/86 mmHg, You complete an ECG which shows sinus rhythm, occasional supraventricular ectopic beats. No ischaemic changes.
Question One
Consider Sarah's recent medical history and medication, what may be contributing to her presenting symptoms of recurring headache and palpitations
Question Two
During her hospital admission Sarah was commenced on an Inhaled Corticosteroid + Long Acting Beta Agonist Fixed Dose Combination inhaler (Budesonide/formoterol DPI (Symbicort Turbuhaler) 400/12 micrograms twice daily)
Given your knowledge of these drugs and their use in COPD, what is the likely rationale behind this prescribing decision?
Question Three
Her GP ceases Sarah's prescription for indacaterol and explains to her why this is no longer needed. You update her MedicinesList.
When Sarah returns to see you for her Care Plan follow up, her palpitations and headache have resolved. However, she explains she feels more breathless on exertion and is convinced the new inhaler she started in hospital is not as strong as the one she was on before.
Assuming Sarah's breathlessness is not due to another infective exacerbation or cardiovascular cause, how would you suggest responding to her increase in symptoms?