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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

All

PCN (rash)

ROS

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

Physical ExaminationGen

Well-developed, well-nourished white female appearing stated age in NAD

VS

BP 110/68, HR 78, RR 16, T 37°C; Wt 58 kg, Ht 5′5″

HEENT

PERRLA; mild oral thrush present on tongue and buccal mucosa

Neck/Lymph Nodes

Supple; no lymphadenopathy or thyromegaly

Lungs/Thorax

No intercostal retractions or accessory muscle use with respirations; good air movement; mild expiratory wheezes bilaterally

CV

RRR; no MRG

Abd

Soft, NTND; (+) BS

Ext

Normal ROM; peripheral pulses 3+; no CCE

Neuro

A&O × 3. Cranial nerves II-XII grossly intact. No focal weakness or loss of sensation.

Labs

 

 

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Na 136 mEq/L Hgb 14 g/dL WBC 6.0 × 103/mm3
K 3.6 mEq/L Hct 42%  PMNs 56%
Cl 99 mEq/L RBC 5.0 × 106/mm3  Bands 1%
CO2 27 mEq/L Plts 192 × 103/mm3  Eosinophils 3%
BUN 18 mg/dL    Basophils 2%
SCr 0.6 mg/dL    Lymphocytes 33%
Glu 98 mg/dL    Monocytes 5%
Ca 9.3 mg/dL    

 

 

Assessment

A 17-year-old girl with uncontrolled chronic asthma and mild oral thrush

 

 

 

 

 

 

 

Develop a Care Plan

3.a. What are the goals of pharmacotherapy in this case?

3.b. What nondrug therapies might be useful for this patient?

3.c. What feasible pharmacotherapeutic alternatives are available for treating this patient’s chronic asthma?

3.d. Write an individualized, patient-centered, team-based care plan to optimize medication therapy for this patient’s asthma and other drug therapy problems. Include specific drugs, dosage forms, doses, schedules, and durations of therapy.

 

3.e. What alternatives would be appropriate if the initial care plan fails?

 

Implement the Care Plan

 

4.a. What information should be provided to the patient to enhance adherence, ensure successful therapy, and minimize adverse effects?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SCIENCE
HEALTH SCIENCE
NURSING
NSG 5510

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