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LEARNING OBJECTIVES

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After completing this case study, the reader should be able to:

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  • Recognize the signs and symptoms of an acute asthma exacerbation.

  • Formulate therapeutic end points based on the initiation of a pharmacotherapy plan used to treat the acute asthma symptoms.

  • Identify appropriate dosage form selection based on the patient’s age, ability to take medication, or adherence to technique.

  • Determine an appropriate home pharmacotherapy plan, including discharge counseling, as the patient nears discharge from a hospital setting.

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PATIENT PRESENTATION

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Chief Complaint

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“My daughter has had a bad fever, and now she is having trouble breathing, and albuterol doesn’t help.”

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HPI

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Terri Collins is an 8-year-old African-American girl who presents to the ED with a 2-day history of fevers, malaise, and nonproductive cough. The mother gave acetaminophen and ibuprofen to help control the fever. Mother stated that “a lot of other kids in her class have been sick this fall, too.” Terri started having trouble breathing the morning of admission, and the mother gave her albuterol, 2.5 mg via nebulization twice within an hour. Terri still sounded wheezy to the mother after the albuterol, and Terri stated it was “hard to breath.” Terri was previously well controlled regarding asthma symptoms. Previous clinic notes reported symptoms during the day only with active play at school or at home and rare nighttime symptoms. She uses PRN albuterol to help with symptoms after playing. Her assessment in the emergency department revealed Terri to have labored breathing, such that she could only complete four- to five-word sentences. She had subcostal retractions, tracheal tugging with tachypnea at 54 breaths/min. Her other vital signs were a heart rate of 160 bpm, blood pressure of 115/59, temperature of 38.8°C, and a weight of 22.7 kg. The initial oxygen saturation was 88%, and she was started on oxygen at 1 L/min via nasal cannula. Bilateral expiratory and inspiratory wheezes were noted on examination. A chest x-ray revealed a right lower lobe consolidation consistent with pneumonia and possible effusion. After receiving three albuterol/ipratropium nebulizations, her breath sounds and oxygenation did not improve; so she was started on albuterol via continuous nebulization at 10 mg/hour, and her oxygen was titrated to 3 L/min. She was also given a dose of 25 mg IV methylprednisolone and a dose of 600 mg IV magnesium sulfate. Terri was then transferred to the PICU for further treatment and monitoring.

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PMH

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Asthma; last hospitalization 4 years ago, and has had two courses of oral corticosteroids in the past year

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FH

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Asthma on father’s side of the family

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SH

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Lives with mother, father, and two siblings, both of whom have asthma. There are two cats and a dog in the home. Father is a smoker, but states ...

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