Margaret A. Fitzgerald

Managing Bronchospasm with Short-Acting Beta2-Agonists

The Nurse Practitioner • September 2006 47 ver 20 million people in the United States are affected by asthma, a chronic condition of the airways that manifests as recurrent episodes of coughing, wheezing, breathlessness, and chest tightness. In children, males are more likely than females to develop asthma, but the incidence of asthma in females increases during adolescence and adulthood. While there is some evidence to support a hereditary component for asthma, environmental factors such as pollutants, infections, and cold or dry air are often the most significant triggers for the initiation of airway hyperresponsiveness that results in the symptoms. The following case study is based on an office visit made by a patient with symptoms typical of an acute asthma exacerbation with moderate, persistent disease. None of the original information was altered; however, some hypothetical information was added for instructional purposes.

Restless leg syndrome: iron important.

Mr. J is a 55-year-old man who presents with a 6-month history of progressive fatigue and a 3-month history of “legs that hop all over the place when I am sitting in the evening or trying to get to sleep.” He was last seen by another primary care provider about 2 years ago and was told he was in good health. His daily medications include a multivitamin and a fullstrength aspirin. Currently, he denies any new life stress other than sleep disturbance. A review of his systems is noncontributory with the exception of intermittent upper gastrointestinal upset, or “heartburn” he attributes largely to dietary indiscretion. He denies the presence of melena or frank blood in stool. He does not smoke and drinks one to two beers on two occasions in an average week. He is not physically active and works as an accountant. On physical examination, findings show his body mass index at 34 kg/m and blood pressure at 152/98. The rest of his physical examination is within normal limits. Using a validated scale, Mr. J’s report of involuntary leg movement meets diagnostic criteria for restless leg syndrome (RLS).

Nonalcoholic fatty liver disease.

• Screen using AST/ALT and GGT in obese children (>95th for BMI) starting between the ages of 10 and 12 • New evidence indicates that normal ALT in children is <30 • Consider screening Black/African-American children less often unless there is a family history or blended heritage from a higher-risk group • Repeat AST/ALT and GGT annually in higher-risk children if they are continuing to gain excess weight or have a family history of NAFLD or Type 2 diabetes What do I do if the ALT is elevated? Below is an algorithm we developed for Health4Life, a multidisciplinary obesity clinic at Children’s Healthcare of Atlanta. In NAFLD, the AST should be lower than the ALT, and the GGT should be only mildly elevated. If the AST is higher or the GGT is very high, consider other diseases.