Case Study 1

1
Case Study 1

• Juanita J.

2
Juanita J History

• 39-year-old African-American woman who developed
  asthma 3 years ago. Has had chronic cough for the
  past 6 months. The cough is worse at night,
  interrupts sleep, is usually non-productive.
  Patient experiences occasional wheezing, worse at
  night
• Variety of empiric pharmacologic interventions
  have not alleviated the cough
• mucolytic agents
• proton-pump inhibitors
• Past medical history no autoimmune disease, did
  not see doctor before developing asthma
• Family history Sister has asthma
• Habits non-smoker
• Allergies experiences hives after taking aspirin

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Juanita J History (cont)

• No smokers or pets in the home
• Profession paralegal
• Current medications
• Regularly uses albuterol, MDI, especially at
  night. The last canister of albuterol, MDI lasted
  3 weeks
• Current maintenance regime is budesonide, 360
  mcg, twice daily
• Primatene Mist (racemic epinephrine)
• Lisinopril, 20 mg, daily
• Ibuprofen for menstrual cramps
• Homeopathic asthma medication
• St Johns Wort

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Juanita J Physical Exam and Work-up

• PE afebrile apical pulse 80/min BP 130/80
  RR 12/min
• HEENT
• Moderate edema of the pale nasal turbinates
• No visible polyps
• Tympanic membranes appear normal
• Posterior oropharynx is normal except for mild
  cobblestoning
• No conjunctivitis
• Extraocular motions are intact
• No sinus tenderness on percussion of sinuses
• Chest exam is clear to percussion and
  auscultation
• Overweight (BMI 28)
• Remainder of exam is unremarkable
• Radiographic imaging of the sinus cavities has
  revealed no abnormalities

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What is the Severity of Juanita Js Asthma?

• Daily coughing and wheezing
• 6 month duration
• Nightly symptoms
• Multiple inhaler uses per day
• Severity classification severe persistent asthma

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What is the Control of Juanita Js Asthma?

• Symptoms present throughout day
• Nightly awakenings (gt 4/week)
• Inhaler used several times daily
• Control classification very poorly controlled
• Current impairment daily and nocturnal symptoms

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Juanita J Spirometry Results

• FEV1 2.5 liters (70 predicted)
• FVC 3.6 liters
• FEV1/FVC 69

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Juanita J Adherence Issues

• Owns a peak flow meter but does not know where it
  is
• Admits skipping budesonide doses regularly
• Has major distrust for the health care profession
  and was not seeing a doctor at all until she
  developed asthma.
• Heard that some asthma medicines can kill you
• Has strong feelings about taking too much
  medicine.
• Using unspecified homeopathic formulation that is
  good for asthma. (recommended by cousin who
  also has asthma)
• What adherence issues need to be addressed with
  Juanita?

9
Juanita J Signs of Depression

• Has been feeling down because of some personal
  problems at home and at work
• Recently began taking St. Johns Wort (Hypericum
  perforatum) to elevate her mood

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Juanita J Discussion Points

• How can we address Juanitas distrust of the
  health care profession?
• What adherence issues need to be addressed with
  Juanita?
• Characterize Juanitas current impairment
• Characterize Juanitas current and future risk
• Make a problem list for Juanita
• Make a differential diagnostic list for Juanita
• What diagnostic evaluation would you pursue for
  Juanita?
• What therapeutic options would you consider for
  Juanita?