Part I—The Grandparents Arrive

Questions

1. What factors can trigger an asthmatic episode?

Ans. Asthmatic episode mostly triggered by allergens like pollen grains, dust, pets, etc. It
may be triggered by some irritants like air pollution, smoking, wood fire, chemical
irritants.
Other reasons are severe exercise especially in cold air, an emotional breakdown like
severe anxiety, fear, anger, crying and sometimes by a respiratory illness like cold, sore
throat, etc.

2. What do you think triggered the asthmatic episode in this case?

Ans. Stuffed toy bear is the cause of asthmatic episode in this case because it was old and
never washed.

3. Imagine that you are performing a lab in which you are monitoring breathing in a student
volunteer. Draw a graph, with time on the horizontal axis and breathing movements on the
vertical axis. Draw a line to show the results you would expect for a healthy student,
assuming that inhaling produces an upward deflection of the line and exhaling produces a
downward deflection of the line.

Ans -

4. Draw a second line to show the results you would expect from someone having an
asthmatic episode. Pay close attention to the slopes of the lines (the rate of air movement)
and the amplitude of the waves (the amount of air flowing in and out of the lung during
each breath).
Ans -

5. Which of the airways (trachea, bronchi, and bronchioles) do not contain rings of cartilage,
and are therefore more likely to collapse?

Ans. Bronchioles do not contain the rings and therefore more prone to collapse.

6. Why is air flow restricted during an asthmatic episode?

Ans. In response to allergens, lower respiratory tract becomes inflamed and swollen. This
swelling causes airflow restricted.

7. Why is wheezing usually worse when asthmatics exhale?

Ans. In asthma, there is swelling due to inflammation of respiratory tract present, so there
is narrowing of respiratory tract occurs. When patients of asthma exhale, there is more
narrowing of bronchioles occur, and they collapse while in inspiration bronchioles size
increases, so, wheezing sound worsens when asthmatics exhales.

Part II—That Night

Questions

1. Do you think that this episode is simply a bad asthmatic attack?

Ans: - No

2. What could have brought on this episode?

Ans. The bed on which Barbara and John were sleeping was the sleeping spot of the muffy
(cat), and proteins found in a pet's dander, hair, fur, skin flakes, saliva and urine can
cause an allergic reaction or aggravate asthma symptoms in some people.

3. What symptoms indicate that this may be something else?

Ans- Pain in the chest and neck and its radiation down to left arm.

4. With the above symptoms in mind, do you wish to speculate about Barbara’s condition?

Ans. It may be angina attack as there is a pain in the neck and chest and pain radiating to
left arm and also wet sticky hand present. But as the Barbara has a history of asthma, and
there is the presence of labored breathing, it may be an attack of asthma with anxiety
episode.

Part III—The Hospital

Questions

1. Is Barbara’s heart rate normal?

Ans. Yes, but on higher side.

2. Is Barbara’s blood pressure normal?

Ans. No, it shows hypotension.

3. What can you conclude from these two observations?

Ans. Barbara has hypotension with normal heart rate. It may be due to myocardial
infarction or may be anxiety induced.

4. What two parameters are responsible for creating the movement (filtration and
reabsorption) of fluid across the capillary wall?

Ans: - For filtration blood hydrostatic pressure

For reabsorption blood osmotic pressure

5. Draw a diagram of a capillary and label arteriole at one end and venule at the other. With
pressure on the vertical axis, draw two lines to show how the two parameters (Question # 4)
vary along the length of the capillary?
6. Why does a lack of movement create swelling in Barbara’s legs?

Ans. A lack of movement creates swelling in Barbara’s legs because for the back pressure

of blood flow from leg to heart relies on pressure created by the movement of muscles.

7. Why is swelling restricted to her legs? Why didn’t her arms swell?

Ans. Barbara’s lack of muscle activity in her legs caused the blood to build-up

into her veins leading to swelling of her legs.  This is why swelling was restricted to her leg
s. Barbara’s arms didn’t swell because she is more likely to move them in a car than her le
gs. 

8. If you were the doctor, what tests would you perform?

Ans. Blood investigations like ABG, CBC, LFT, RFT, Trop T, CK-MB Radiological investigation
like USG leg, cardiac testing like ECG, 2D echo.

Part IV—Tests, Tests, and More Tests

Questions
1. What do the ECG and the blood levels of creatine phosphokinase-2 and troponin-I tell you
about the likelihood that Barbara had a heart attack?

Ans. ECG, CPK 2, Trop-I are normal, so heart attack is very unlikely.

2. Why are Barbara’s arterial PO2, PCO2, and pH values different from normal?

Ans. Lower PO2 and higher PCO2 show the respiratory problem which is due to asthma
and pH shows acidosis, so it is showing respiratory acidosis.

3. Are your ideas consistent with her blood pressure and heart rate?

Ans. Higher heart rate may be due to hypoxia. In hypoxia, heart rate increases to
compensate the oxygen supply to the tissue or compensate the lower bp. Lower bp may
be due to pulmonary embolus.

4. What conditions cause contraction of the bronchiole smooth muscle?

Ans: - Asthma

5. What conditions cause contraction of the (pulmonary) arteriole smooth muscle?

Ans: - Pulmonary Hypertension

6. Why did the doctor ask for a CT scan and ultrasound of Barbara’s legs?

Ans: - CT scan to see if there is any complication of hip replacement and USG for the DVT
and to see the condition of leg valves.

7. With Barbara’s symptoms in mind, and the tests that were performed, do you wish to
speculate about her condition?

Ans: - Barbara may have pulmonary embolism which is a common complication of hip
replacement surgery.

Part V—A Few Days Later

Questions

You should consult the Internet for this last group of questions.
1. What would a V/Q scan tell the doctor about air flow through the affected part of the
lung?

Ans: - A ventilation–perfusion (VQ) scan is a nuclear medicine scan that uses radioactive

material to examine airflow or ventilation.
2. What would a V/Q scan tell the doctor about pulmonary blood flow to the affected part
of the lung?

Ans: - V/Q scan tells about Blood flow in the lungs. The aim of the scan is to look for
evidence of any blood clot in the lungs, called pulmonary embolism.

3. Why should Barbara not take aspirin or ibuprofen?

Ans: - Aspirin or ibuprofen is NSAIDS which are contraindicated in asthmatic patients

because they can precipitate asthma.

4. How does Warfarin control the clotting time of blood?

Ans: - Warfarin acts by inhibiting the synthesis of vitamin K-dependent clotting factors II,
VII, IX, & X, which are the most important components of clotting. Vitamin K acts as an
essential cofactor for the post ribosomal modification of these clotting factors.

5. If Muffy the cat ate Warfarin, which is used as rat poison, what would be the vet’s
treatment?

Ans. Activated charcoal orally and i.v infusion of Vit K