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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 signs and symptoms of uncontrolled asthma.

  • Identify potential causes of uncontrolled asthma, and recommend preventive measures.

  • Formulate a patient-specific therapeutic plan (including drugs, route of administration, and appropriate monitoring parameters) for management of a patient with chronic asthma.

  • Develop a self-management action plan for improving control of asthma.

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PATIENT PRESENTATION

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Chief Complaint

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“Please don’t tell me we have to get rid of the cats!”

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HPI

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Shiloh Eddingfield is a 17-year-old female who presents to her primary care provider for follow-up and evaluation regarding her asthma. During her visit, she reports having had to use her albuterol MDI approximately 3–4 days per week over the past 2 months, but over the past week she admits to using albuterol once daily. She reports being awakened by a cough three nights during the last month. She states she especially becomes short of breath when she exercises, although she admits that her shortness of breath is not always brought on by exercise and sometimes occurs when she is not actively exercising. In addition to her albuterol MDI, which she uses PRN, she also has a fluticasone MDI, which she uses “most days of the week.” She indicates that her morning peak flows have been running around 300 L/min (personal best = 400 L/min) over the past several weeks.

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PMH

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  • Asthma (previously documented as “mild persistent”) diagnosed at age 7; no prior history of intubations; hospitalized twice in the last year for poorly controlled asthma; three visits to the ED in the last 6 months; treated with oral systemic corticosteroids during both hospitalizations and at each ED visit

  • Migraine headache disorder (without aura; diagnosed at age 15); currently taking prophylactic medication; has had only one migraine attack in the last year

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FH

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Mother 47 years old with HTN, migraine HA disorder; father 48 years old (smoker) with HTN and type 2 DM; brother, age 21 (smoker); twin sister, age 17 (nonsmoker).

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SH

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No alcohol or tobacco use. Single, sexually active. Lives at home with parents (father is a cabinet maker), twin sister, and two cats. Brother is currently away at college.

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Meds

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  • Flovent HFA 44 mcg, two puffs BID

  • Proventil HFA two puffs Q 4–6 H PRN shortness of breath

  • Yaz one PO daily

  • Propranolol 80 mg PO BID

  • Maxalt-MLT 5 mg PO PRN acute migraine

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All

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PCN (rash)

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ROS

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Denies fever, chills, headache, eye discharge or redness, rhinorrhea, sneezing, sputum production, chest pain, palpitations, dizziness or confusion

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Physical Examination

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Gen
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Well-developed, well-nourished ...

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