Asthma Case Study

ASTHMA CASE STUDY 2 Subjective Complaint: “I need a refill for my inhaler” History: 25 year old male seen in clinic for first time; recently moved and is establishing primary care. Reports his asthma has never been under control despite using many different inhalers. Has never seen an asthma specialist and has never had a written asthma action plan. Current: Has symptoms 2-3 days per week, about 2-3 nighttime awakenings per month and uses SABA 3 days per week. Smokes a pack of cigarettes a day. No other health problems reported. Objective Examination is normal except for soft expiratory wheezes. When asked to demonstrate the use of his current inhaler, he demonstrated poor technique, Assessment Mild Persistent Asthma not well controlled Plan Rationale This patient has shown that his use of inhalers is not effective and since this is his first visit to my clinic, I would start him on step 1 of the stepwise approach for managing asthma in youths over 12 years of age and adults (National Heart, Lung, and Blood Institute, 2007). Patient education would be given on proper use of the inhaler prescribed and proper technique would need to be demonstrated by the patient at every appointment until consecutive and effective use of the inhaler is visualized by office staff. I would not step up his treatment plan until proper use was established. I would also perform the lung function tests of FEV1, FVC, and PEF. These pulmonary function tests would be used to determine asthma severity and to monitor effectiveness of treatment (Rosenthal & Burchum, 2018)