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NURS 5002 Case Study #4

Refer to Case Study Grading Guidelines and Grading Rubric for a complete description of requirements and
grading criteria. To make the case study as real as possible, while you are working through the case study
do not look ahead at the information provided.

You are working in a Family Practice office and Cheryl, a 42 yo female with c/o wheezing and SOB is the
next patient. Her chart reveals the following:

PMH SH MEDS
Acute bronchitis X2 -1 ppd smoker Alesse
UTI Social alcohol
Obesity 2-3 cups coffee/day PRN:
2-3 diet soda/day Acetaminophen
Lives with boyfriend Ibuprofen
Works full-time Famotidine

FH
Mother HTN, GERD NKDA
Father HTN, asthma, DM

As you prepare for this visit what are your primary concerns? What is her oxygen saturation level,
respiratory rate, and is she in any acute distress? How long has she been having these symptoms?
Anything that makes the symptoms better or worse? Any associated factors with the above mentioned
symptoms, such as cough, chest or back pain? Has she been around anyone that has been sick or had
similar symptoms? What treatments, if any, has she tried at home, and did they relieve symptoms
temporarily? How long ago did Cheryl have her last physical examination? How is her blood pressure?
(She has a strong family history of hypertension with two first degree relatives, she is obese, consumes a
lot of caffeine daily, smokes, and takes oral contraceptives [combined with smoking increases risk of
hypertension].) How is her blood sugar? (She has a first degree relative with diabetes, she is also obese,
and we do not know typical diet other than social alcohol use, she consumes daily coffee [cream or
sugar?], and diet soda.)
Based on the medications listed, what are your concerns? Taking Aleese combined with smoking,
advanced age (42), obesity, and possibly hypertension could lead to very serious, possibly grave side
effects. According to Drugs.com (2016c), the risk of serious cardiovascular side effects increases with age
and with extent of smoking (in epidemiologic studies, 15 or more cigarettes per day was associated with a
significantly increased risk) and is quite marked in women over 35 years of age (p.6). Some of these side
effects include heart attack, thromboembolism, and stroke, and hypertension and increase significantly
with underlying risk factors such as obesity, hypertension, and diabetes (Drugs.com, 2016c). Smoking in
combination with oral-contraceptive use has been shown to substantially increase mortality rates
associated with circulatory disease in women over 35 (Drugs.com, 2016c). How long has she been taking
this medication? According to Drugs.com (2016c), studies have shown taking oral contraceptives for five
or more years in persons age 40-49, have increased risk of having a heart attack for nine years after
discontinuation of the medication.

Upon Assessment of the patient you find the following information:

Cheryl is having trouble breathing with some wheezing since she has started walking this Spring to lose
weight. She has been walking outside and started with about 10-15 minutes three times per week. When
she started increasing her time walking she noticed it was getting harder to breathe and at times she
would wheeze. She initially thought it was due to the warmer weather and her just being overweight. She
has never really exercised and has a job that limits activity and is mostly at a desk.

ROS
- orthopnea, chest pain, dizziness, indigestion, diarrhea, N/V, recent weight change, HA, sore throat,
+ occasional cough more prominent while walking, productive at times with clear sputum, some ankle edema after
walking,

Physical Exam
Patient is alert and oriented in NAD
EENT PEERLA, posterior pharynx slightly red with postnasal discharge, nasal mucosa pink; no adenopathy
appreciated; TMs without bulging or retractions bilaterally
Heart RRR without murmur, rubs or clicks; no carotid bruits auscultated; pedal pulses 1+, radial pulses 2+, ankles
large with small amount of edema (non-pitting)
Lungs sounds course but CTA bilat anterior and posterior
Abdomen large, round, soft, non-tender; bowel sounds present x4 quads; no masses palpable; unable to palpate
liver border;

VS
BP 132/84 P 86 RR 20 O2 Sat 98%
Ht. 54 Wt. 195 lbs

What other question(s) would you like to ask Cheryl to assist with your diagnosis? What other
information would you like to have had? Is the shortness of breath and wheezing consistent or to the
symptoms come and go? Does anything make the symptoms better or worse? Do symptoms completely
resolve with rest? Are these symptoms experienced at any other times besides while walking (at rest, at
night)? Any associated chest discomfort or pains? Is the ankle edema only after walking, or have you
noticed it at any other times, such as standing for periods? Is it pitting or non-pitting and does it get better
with elevation of the feet/ legs? Any pain or redness noticed in the legs? There is an increase in risk of
developing cardiovascular problems and thrombosis in persons over 40 taking oral contraceptive while
smoking (Drugs.com, 2016c). Any jugular vein distension? Shortness of breath when lying down?
Congestive heart failure can manifest with this (MedlinePlus, 2016a). History of heart murmur? Have you
ever had group A beta-hemolytic streptococci that was untreated for a length of time or rheumatic fever?
Valvular problems can manifest as heart failure (Brashers, 2014). Any problems with seasonal allergies in
the past? Have you noticed stuffy or runny nose, sneezing, itchy eyes? Allergens such as pollen (in the
Spring of the year) can cause similar symptoms. Have you ever had these or similar symptoms in the
past? With previous episodes of acute bronchitis, how long did symptoms last and when was the last
episode? Chronic bronchitis is defined as hypersecretion of mucus and chronic productive cough lasting at
least 3 months for at least 2 consecutive years (Brashers & Huether, 2014, p. 1267). Common symptoms
involved with chronic bronchitis include decreased exercise tolerance, wheezing, and shortness of breath
(Brashers & Huether, 2014, p. 1267). With assessment, was any clubbing noted? This could possibly be
an indication of how long respiratory problems have been occurring.

DIFFERENTIATION OF DISEASE (may add other columns if needed)

Add 4th potential disease based on symptoms.


DISEASE #1 DISEASE #2 DISEASE #3 Disease #4
CHF Asthma Bronchitis Exercise- Induced
Asthma (Exercise-
Induced
Bronchoconstriction)
Pathophysiology Systolic heart failure Chronic inflammatory Acute bronchitis: Bronchoconstriction
causes the heart to not be disorder of the bronchial infection or triggered by strenuous
able to eject blood out of mucosa causing bronchial inflammation of the exercise resulting from
the heart like it should. hyperresponsiveness, airways or bronchi. inflammation and
Diastolic heart failure constriction of the Chronic bronchitis: mucous production in
occurs when the heart airways, and variable (hypersecretion of the airways.
muscles get stiff and does airflow obstruction that is mucus and chronic
not allow the heart to reversible. Mainly productive cough that
properly fill with blood. genetic inheritance, other continues for at least 3
Congestive heart failure causes include allergen or months of the year for at
occurs when the pumping air pollution exposure, least 2 consecutive
becomes less effective, living in an urban area, years) Airway
and blood backs up into tobacco smoke, recurrent inflammation causes
other parts of the body, viral respiratory tract infiltration of
such as lungs, liver, infections, esophageal neutrophils,
gastrointestinal tract, and reflux, and obesity. macrophages, and
extremities. Airway epithelial lymphocytes into the
Uncontrolled exposure to antigen bronchial wall
hypertension can lead to initiates both an innate (Brashers & Huether,
stiffening and eventually and an adaptive immune 2014, p. 1267).
weakening heart muscle response in sensitized
(MedlinePlus, 2016a). individuals (Brashers &
Huether, 2014, p. 1264).
Early asthmatic response:
Antigen exposure to the
bronchial mucosa
activates dendritic cells
(antigen-presenting cells)
to present the antigen to
CD4+T cells, which
differentiate into Th2
cells (Brashers &
Huether, 2014, p. 1264).
Th2 cells release several
cytokines, stimulating
further responses
ultimately resulting in
production of antigen-
specific IgE, direct tissue
injury and airway
scarring,
bronchoconstriction and
airway remodeling,
exaggerated immune
response, and further
innate and adaptive
immune responses. IgE
antigen binding ultimately
results in vasodilation,
increased capillary
permeability, mucosal
edema, bronchospasm,
tenacious mucus
secretion, and narrowing
of airways and obstruction
of airflow.
Late asthmatic response:
Begins 4-8 hours after the
early response.
Chemotactic recruitment
of lymphocytes,
eosinophils, and
neutrophils during the
acute response causes a
latent inflammatory
response. Airway
obstruction increases
resistance to airflow and
decreases flow rates,
especially expiratory flow.
Impaired expiration
causes air trapping,
hyperinflation distal to
obstruction and increased
work of breathing
(Brashers & Huether,
2014, p. 1264).
Continued air trapping
increases lung pressures
which decreases perfusion
of alveoli.
Hyperventilation is
triggered by receptors
causing hypoxemia.
Continued hypoxemia
causes PaCO2 to decrease
and pH to increase leading
to respiratory alkalosis.
With prolonged attack the
lungs and thorax become
hyperexpanded due to
increased air trapping,
causing strain on
respiratory muscles. Tidal
volume falls, CO2
increases, leading to
respiratory acidosis which
signals respiratory failure.
Left ventricle backs up
due to the severe
hyperinflation causing
compromised cardiac
output as well.
Signs/Symptoms At first symptoms may Between attacks patients Acute bronchitis: Coughing, wheezing,
only occur with activity are asymptomatic and Cough, fever, chills, and shortness of breath,
and include: cough, pulmonary function is malaise. feeling of tightness or
fatigue/ weakness, loss of normal. Viral: non-productive pain in chest, and
appetite, need to urinate Beginning of an attack: cough (aggravated by fatigue during
at night, tachycardia, chest constriction, cold, dry, or dusty air), exercise. Symptoms
irregular heart rate/ expiratory wheezing, chest discomfort from may begin during or
palpitations, shortness of dyspnea, nonproductive continuous effort of start after exercise, left
breath with activity or cough, prolonged coughing. untreated symptoms
with lying down, expiration, tachycardia, Bacterial: productive may last 30 minutes or
enlarged liver or and tachypnea. cough, pain behind the longer.
abdomen, ankle/ foot Severe attack: use of sternum aggravated by
edema, waking from respiratory accessory coughing
sleep short of breath, muscles, inspiratory and Chronic bronchitis:
weight gain especially expiratory wheezing, and decreased exercise
rapid unexplained, decrease in systolic blood tolerance, wheezing,
jugular vein distension, pressure more than 10 shortness of breath,
crackles noted upon mmHg (pulsus productive cough,
auscultation of lungs paradoxus), hypoxemia, decreased pulmonary
(MedlinePlus, 2016a). and respiratory alkalosis. function, hypoxemia
may occur with
exercise, and frequent
pulmonary infections
occur with advanced
disease.
Treatments: Medications include: Prevention/ management Acute bronchitis- Viral: Short-acting beta
beta-adrenergic blocker, is essential: teaching on rest, aspirin, humidity, agonists (such as
loop diuretic, potassium- avoidance of allergens and and cough suppressant albuterol) or additional
sparing diuretic, ACE irritants causing asthma. (such as codeine) medication such as
inhibitor, anticoagulant, Mild (intermittent): short- Acute bronchitis- ipratropium.
calcium channel blocker, acting beta-agonist Bacterial: rest, aspirin, Long term control
digitalis glycoside, inhalers. humidity, and antibiotics medications such as
nitrates, angiotensin II Persistent: anti- Chronic bronchitis: inhaled
receptor agonist, inflammatory bronchodilators (long- corticosteroids,
antiarrhythmic, medications, inhaled acting inhaled combination inhalers
(Drugs.com, 2016e). corticosteroids, and anticholinergics or long- containing
Teaching on knowing leukotriene antagonists. acting inhaled beta corticosteroid and
when symptoms are agonists), chest physical long-lasting beta
worsening, limiting salt therapy, during the late agonist, or leukotriene
and fluids, and taking stages continuous modifiers.
ibuprofen and naproxen oxygen therapy, oral Warm up before
may worsen symptoms corticosteroids, exercise and cool
(MedlinePlus, 2016a). extensive teaching such down afterward, the
as nutritional longer time spent
counselling, respiratory doing this the better.
hygiene, recognition of Use short-acting
early signs of infection, asthma control
and techniques to medications
relieve dyspnea approximately 10-15
Acute exacerbation of minutes prior to
chronic bronchitis: exercise.
antibiotics and Be aware of triggers,
corticosteroids, and may such as cold or dry air.
need assistance of Breathe in through
mechanical ventilation nose or use a mask or
wear a scarf over
mouth to warm and
humidify inspired air.
Use caution when
exercising outdoors
when the air is
polluted with pollen or
around freshly cut
grass or fields.
Avoid strenuous
exercise if having
respiratory symptoms
such as cold or illness.
Complications: End-stage heart failure If bronchospasm is not Complication of acute Has the potential to
leading to need for heart reversed (status bronchitis is chronic develop into life
transplant (MedlinePlus, asthmaticus), hypoxemia bronchitis. threatening breathing
2016a). worsens, expiratory flow Considerable problems. Can also
decreases further, and irreversible airway result in lack of
effective ventilation damage is present with beneficial exercise,
decreases. PaCO2 chronic bronchitis. poor performance in
develops and acidosis activities you might
develops, if not otherwise enjoy.
immediately treated
PaCO2 levels will
continue to rise and levels
greater than 70 mmHg
along with a silent chest
are signs of impending
death will occur.
References (Drugs.com, 2016e; (Brashers & Huether, (Brashers & Huether, (Mayo Clinic Staff,
MedlinePlus, 2016a) 2014) 2014) 2014)
What is your choice for
the given scenario?
What is the rationale for the 4th potential disease that you chose? Exercise induced asthma is different from regular asthma. Her
symptoms seem to fit with exercise-induced bronchoconstriction more than other diseases looked up, such as thrombosis, myocardial
insufficiency, valvular dysfunctions and acute pulmonary hypertension.

Why did you make this choice? Give good rational for your decision. Although her symptoms could fit in any of these categories,
and more in-depth questioning and assessment is needed for more accurate diagnosis, exercise-induced asthma seems to fit all of the
symptoms given at this time. Exercise-induced asthma is a more acute condition, rather than the other more chronic conditions listed.
It is a very real possibility of having the other disease processes such as CHF, asthma, or chronic bronchitis. Since these conditions
are more chronic, it makes since to me to choose the more acute condition first, treat that condition, educate on the importance of
follow up if symptoms persist and do not get better with treatment and go from there. If intervention for exercise-induced asthma does
not relieve symptoms, additional testing should be implemented and investigated further. Anxiety and uncertainty can be mentally
exhausting if a wrong diagnosis is made, especially a diagnosis of a serious, chronic condition. Therefore my first choice for
diagnosis would be exercise-induced asthma.

COMPARISON OF MEDICATIONS (may add other columns if needed)

MEDICATION #1 MEDICATION #2 MEDICATION #3 MEDICATION #4


Proventil HCA Aerospan Singulair Advair
Class/Type of med Beta2-adrenergic Corticosteroid Leukotriene inhibitor Synthetic
antagonist, bronchodilator corticosteroid and
Long acting beta
agonist (LABA)
Mechanism of Action Stimulation of beta- Marked anti- Cysteinyl leukotrienes, Corticosteroids have
adrenergic receptors of inflammatory activity, such as LTD4, are a wide range of
intracellular adenyl inhibiting both products of arachidonic actions on multiple
cyclace, which causes the inflammatory cells (such metabolism and released cell types (such as
conversion of adenosine as mast cells, from various cells, such mast cells,
triphosphate (ATP) to eosinophils, neutrophils, as mast cells and eosinophils,
cyclic adenosine macrophages, and eosinophils. CystLt1 neutrophils,
monophosphate (cyclic lymphocytes) and release receptors are found in macrophages, and
AMP). Increased cyclic of inflammatory human airways and have lymphocytes) and
AMP levels are associated mediators (such as been associated with release of
with bronchial smooth histamine, eicosanoids, pathophysiology of inflammatory
muscle relaxation. leukotrienes and asthma and allergic mediators (such as
cytokines) involved in rhinitis. Medication histamine,
allergic or non-allergic binds with CystLt1 eicosanoids,
mediated inflammation. receptors and inhibits leukotrienes and
action of LTD4 at the cytokines) involved
receptor without agonist in inflammation.
activity. LABA has been
shown more selective
for beta2-
adrenoceptors than
beta2-adrenergic
antagonists such as
albuterol. Stimulation
of beta2-adrenergic
receptors of
intracellular adenyl
cyclace, which causes
the conversion of
adenosine
triphosphate (ATP) to
cyclic adenosine
monophosphate
(cyclic AMP).
Increased cyclic AMP
levels are associated
with bronchial
smooth muscle
relaxation.

Indications Prevention and relief of Maintenance and Asthma, exercise- Treatment of asthma.
bronchospasm with treatment of asthma as induced
reversible obstructive prophylactic therapy and bronchoconstriction, and
airway disease and for treatment of asthma allergic rhinitis.
prevention of exercise in patients requiring oral
induced bronchospasm corticosteroid therapy
For use in patients 4 years (may reduce or eliminate
old and older. need for oral
corticosteroids). For use
in patients 6 years old
and older.
Side Effects Common side effects Candida albicans The most common Candida albicans
include: palpitations, chest infection, adverse reactions infection,
pain, tachycardia, tremor, immunosuppression include: upper immunosuppression
and nervousness. causing increased respiratory infection, causing increased
Others include: heartburn, infections, fever, headache, infections,
nausea/ vomiting, stomach hypercorticism and pharyngitis, cough, hypercorticism and
ache, diarrhea, unusual adrenal suppression, abdominal pain, adrenal suppression,
taste, hypertension, reduction in bone mineral diarrhea, otitis media, reduction in bone
urticaria, angioedema, density, effects on influenza, rhinorrhea, mineral density,
arrhythmias (a-fib, SVT, growth, glaucoma, and and sinusitis. Other effects on growth,
extrasystoles), headache, bronchospasm. Others symptoms include: glaucoma, and
lightheadedness, agitation, include: headache, abdominal pain, fatigue, bronchospasm.
nightmares, sleeplessness, irritability, anxiety, dyspepsia, dental pain,
hyperactivity, aggressive depression, faintness, gastroenteritis,
behavior, throat irritation, fatigue, moodiness, headache, dizziness,
hoarseness, oropharyngeal numbness, vertigo, influenza, cough,
edema, discoloration of nausea/ vomiting, congestion, ALT
teeth, epistaxis, cough, dyspepcia, upset elevation, AST
and muscle cramps. stomach, heartburn, elevation, and pyuria.
May produce paradoxical constipation, diarrhea,
bronchospasm, ECG gas, abdominal fullness,
changes (flattening of the gastroenteritis, oral
T wave, prolonged QT moniliasis, edema,
interval, ST segment myalgia, abdominal pain,
depression). neck pain, loss of smell,
sore throat, dry throat,
glossitis, mouth
irritation, throat
irritation, phlegm,
bronchitis, laryngitis,
voice alteration,
hoarseness, pharyngitis,
rhinitis, increased cough,
cold symptoms, sinus,
nasal or chest congestion,
sinus drainage, sinusitis,
epistaxis, urinary tract
infection, capillary
fragility, enlarged lymph
nodes, palpitations,
hypertension,
tachycardia, chest pain,
dizziness, insomnia,
migraine, erythema
multiforme,
conjunctivitis, blurred
vision, eye discomfort,
eye infection, ear pain,
taste alteration, eczema,
puritis, acne, urticaria,
dysmenorrhea, and
vaginitis.
Complications Should be used with Contraindicated for use Should be used in Cases of asthma
caution in patients with in status asthmaticus or caution and only when related death have
known cardiovascular acute episodes of asthma. benefits outweigh risk in been reported, do not
disorders such as Bronchospasm may patients who have use in patients who
hypertension, cardiac occur. experienced agitation, can be adequately
arrhythmias, and coronary May cause localized aggressive behavior, controlled on other
insufficiency, because of infections with Candida anxiousness, depression, long-term asthma
potential ECG changes albicans or Aspergillus disorientation, control medications,
(flattening of the T wave, niger in mouth, pharynx, disturbance in attention, such as low or
prolonged QT interval, ST and/ or larynx. hallucinations, suicidal medium dosed
segment depression). Corticosteroids can cause tendencies, and inhaled
Should be used in caution immunosuppression, use insomnia. corticosteroids.
in patients with in caution with May cause eosinophilia Contraindicated in
convulsive disorders, immunocompromised and phenylketonuria. use with primary
hyperthyroidism, and patients. Inform patients Drug/ drug interactions treatment of status
diabetes. who have not been involve: theophylline, asthmaticus.
Should be administered vaccinated for or prednisone, oral Excessive beta-
with extreme caution in previously had contraceptives, digoxin, adrenergic
patients who are currently chickenpox, measles, or warfarin, terfenadine, stimulation has been
taking or have taken other communicable thyroid hormones, associated with
MAOI or tricyclic diseases to avoid sedatives, NSAIDs, seizures, angina,
antidepressants within the exposure. Use in benzodiazepines, hyper/hypotension,
past two weeks, may extreme caution in decongestants, and tachycardia,
significantly increase the patients with suspected cytochrome P450 arrhythmias,
cardiovascular side or untreated tuberculosis, enzyme inducers. nervousness,
effects. viral, bacteria, fungal, or headache, tremor,
Should not use a beta- parasitic infections, nausea, dizziness, and
agonist with a beta worsening of the fatigue.
blocker, beta blockers will infection may occur. Effects bone density,
block effects and have the Death from adrenal growth, may cause
potential to cause severe insufficiency have cataracts or
bronchospasm in occurred in patients who glaucoma,
asthmatic patients. were on long term hypokalemia,
Causes decrease in serum systemic corticosteroids hyperglycemia,
digoxin levels. and transitioned to
When taking a beta- inhaled corticosteroids,
agonist along with non- because they are not as
potassium sparing systemically available
diuretics, hypokalemia and hypothalamic-
and ECG changes may pituitary-adrenal function
worsen. was compromised.
Pregnancy risk category Decrease in bone mineral
C. density have been
Has the potential to inhibit associated with long term
uterine contractions use of inhaled and oral
during labor if given in corticosteroids.
high doses. However it When administered to
has not been approved for pediatric patients, may
use in preterm labor, has cause reduction in
the potential to cause growth velocity.
maternal pulmonary Long term administration
edema. of inhaled corticosteroids
have been associated
with glaucoma and
cataract formation.
Pregnancy risk category
C.
Reference (Drugs, 2016d) (Drugs.com, 2016b) (Drugs.com, 2016f) (Drugs.com, 2016a)

What is your choice


for the given
scenario?
(place X in box)

Why did you make this choice? Give good rational for your decision Albuterol is my first choice. Albuterol is a rescue inhaler that
is also beneficial for the disease process chosen, exercise-induced asthma. In my opinion, if only one medication is available the
medication that treats immediate acute symptoms such as bronchoconstriction should be a priority. As states by Drugs.com (2016d),
this medication is indicated for exercise-induced bronchospasm. It is recommended to teach patients to use the short-acting beta
agonists approximately 10-15 minutes before exercise if possible to prevent symptoms (Mayo Clinic Staff, 2014).
What are other potential choices you could make? Singulair would be my second choice. A leukotriene inhibitor such as Singulair is also
recommended for the treatment of exercise-induced bronchoconstriction, and will also help with seasonal allergy symptoms, such as the patients
physical exam findings of slightly red posterior pharynx and postnasal discharge (Drugs.com, 2016f; Mayo Clinic Staff, 2014).

References

Brashers, V. L. (2014). Alterations of cardiovascular function. In Brashers, V. L. & Rote, N. S. (Eds.), Pathophysiology: The biologic

basis for disease in adults and children (7th ed.) (pp. 1129-1193). Saint Louis, MO: Elsevier Mosby.

Brashers, V. L. & Huether, S. E. (2014). Alterations in pulmonary function. In Brashers, V. L. & Rote, N. S. (Eds.), Pathophysiology:

The biologic basis for disease in adults and children (7th ed.) (pp. 1248-1289). Saint Louis, MO: Elsevier Mosby.

Drugs.com [Internet]. (2016a). Advair. In Drugs.com, retrieved from: http://www.drugs.com/pro/advair.html

Drugs.com [Internet]. (2016b). Aerospan. In Drugs.com retrieved from: http://www.drugs.com/pro/aerospan.html

Drugs.com [Internet]. (2016c). Alesse. In Drugs.com retrieved from: http://www.drugs.com/pro/alesse.html

Drugs.com [Internet]. (2016d). Albuterol. In Drugs.com retrieved from: http://www.drugs.com/pro/albuterol-aerosol.html

Drugs.com [Internet]. (2016e). Medications for heart failure: Congestive heart failure. In Drugs.com, retrieved from:

http://www.drugs.com/condition/congestive-heart-failure.html

Drugs.com [Internet]. (2016f). Singulair. In Drugs.com, retrieved from: http://www.drugs.com/pro/singulair.html

Mayo Clinic Staff (2014, October 14). Exercise-induced asthma. Retrieved from: http://www.mayoclinic.org/diseases-

conditions/exercise-induced-asthma/basics/symptoms/con-20033156
MedlinePlus [Internet]. Bethesda (MD): National Library of Medicine (US) (2016a). Heart failure: overview [last updated 2015,

April 20]. Retrieved from: https://www.nlm.nih.gov/medlineplus/ency/article/000158.htm