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Olivia, aged 16 years, has been seeing you for a number of years for her asthma. Up until now it has been well controlled on a budesonide–formoterol (200/6 μg) turbuhaler preventer, one inhalation twice a day. Today Olivia presents alongside her mother, who is worried that Olivia’s asthma control has worsened over the past year. Olivia has had multiple exacerbations, particularly with viral infections, and her performance with netball has progressively dropped off. She also has a persistent wet cough that is different from her usual asthma cough and that does not always go away when she takes her salbutamol. As the consultation begins, Olivia’s mother announces that she is also worried that her daughter is smoking, which Olivia fervently denies. 1.What further history would you seek? 2.Is it important to address the issue of vaping with Olivia? What are some important considerations regarding the adverse effects of vaping? 3.During Olivia’s next consultation, what would be your approach to assessing Olivia’s general wellbeing? 4.You want to explore whether Olivia has developed nicotine dependence. Is this an issue for adolescents? How would you go about assessing for it? 5.What is the relationship between vaping, nicotine and mental health in adolescents? 6.How do you proceed in formulating a management approach to help Olivia quit vaping? 7.You are aware of Olivia’s likely nicotine dependence. What considerations are there for using cessation pharmacotherapy in an adolescent patient? 8.Olivia acknowledges the rapport that has developed across your recent consultations. She asks if you can be a part of her ‘quit support network’. What role do you play in providing follow-up? #Week14_Case5

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Georgina, a single woman aged 38 years, has made an appointment to see you because she ‘can’t get into her psychiatrist for another three weeks’. Georgina’s mother is her main carer, and has joined her daughter in the consult. Both confirm that Georgina had been doing well after a recent lengthy admission to the nearby psychiatric inpatient unit, after a relapse of psychosis. Georgina has a history of paranoid schizophrenia since late adolescence and has been trialled on multiple antipsychotics. Her recent admission resulted in a successful trial of clozapine and she was ‘the best ever ... since adolescence’. She has been compliant with her medications, has had weekly full blood examinations as per the clozapine protocols and has not used any illicit substances. Georgina’s mother states, ‘I just don’t understand. She was so stable and the psychiatrist told us she should continue to improve in her functioning ... but she has gone backwards really quickly.’ Georgina has started experiencing auditory hallucinations again, become suspicious and is now thought disordered. 1.What further questions would you ask Georgina or her mother? 2.What questions would you like to ask Georgina about her smoking? 3.What is the likely cause of Georgina’s deteriorating mental state? 4.What are the options of care for Georgina’s presenting problem? 5.What NRT options are available and what would you recommend to Georgina? 6.What are the alternative options for Georgina? 7.Is varenicline safe to use in people who are tobacco dependent and have a significant mental illness? 8.What advice do you give Georgina regarding her clozapine therapy while commencing varenicline? **#Week14_Case4

#Smoking #Breastfeeding

#Smoking #Pregnancy