JR is a 17-year-old Caucasian girl who presents to her primary care…

JR 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 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. She also complains of mild oral thrush on tongue and buccal mucosa

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

Allergies

PCN (rash)

1. What subjective and objective information indicates the presence of uncontrolled chronic asthma?
2. Assess this patient’s level of asthma control based on the subjective and objective information available.
3. Make a list of the patient’s drug therapy problems and prioritize them. Include assessment of medication appropriateness, effectiveness, safety, and patient adherence.
4. What are the goals of pharmacotherapy in this case?
5. What nondrug therapies might be useful for this patient?
6. Make 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.
7. What information should be provided to the patient to enhance adherence, ensure successful therapy, and minimize adverse effects?