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LEARNING OBJECTIVES

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

  • 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.

PATIENT PRESENTATION

Chief Complaint

“I think the dust is getting to me!”

HPI

Lilly Madison is a 17-year-old Caucasian girl 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 at night once a week during the past month. She states she especially becomes short of breath when she visits her father’s workshop (“Madison Custom Cabinetry”) and 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, and 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.

PMH

Asthma (previously documented as “mild persistent”) diagnosed at age 7; no prior history of intubations; hospitalized once in the past year for asthma exacerbation; one visit to the ED in the past 6 months; treated with oral systemic corticosteroids during last hospitalization and at 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.

FH

Mother 49 years old with HTN, migraine HA disorder, and asthma; (nonsmoker); father 50 years old (smoker) with HTN and type 2 DM; brother, age 21, healthy (smoker); twin sister, age 17, healthy (nonsmoker)

SH

No alcohol or tobacco use. Single, not sexually active. Lives at home with parents (father is a cabinet maker), twin sister, and two cats. Brother is currently away at college.

Meds

Flovent HFA 44 mcg, two puffs BID

Proventil HFA two puffs Q 4–6 H PRN shortness of breath, cough, wheezing

Propranolol 80 mg PO BID

Maxalt-MLT 5 mg PO PRN acute migraine

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